Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial.

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.

Holocaust survivors: Health and longevity 70 years later.

BACKGROUND: Holocaust survivors (HS) alive today form a unique and disappearing population, whose exposure to systematic genocide occurred over 70 years ago. Negative health outcomes were widely documented prior to age 70. We examine the hypothesis that the experience of remote trauma continues to negatively affect health, functional status, and survival between the ages of 85-95. METHODS: The Jerusalem Longitudinal Study (1990-2022) followed a representative sample of Jerusalem residents born 1920-1921, at ages 85, 90 and 95. Home assessment included medical, social, functional, and cognitive status, and mortality data. Subjects were classified: (1) HS-Camp (HS-C): survived slave-labor, concentration, or death camps; (2) HS-Exposed (HS-E): survived Nazi occupation of Europe; (3) Controls: European descent, outside Europe during WWII. We determined Hazards Ratios (HR), adjusting for gender, loneliness, financial difficulty, physical activity, ADL dependence, chronic ischemic heart disease, cancer, cognitive deficits, chronic joint pain, self-rated health. RESULTS: At ages 85 (n = 496), 90 (n = 524), and 95 (n = 383) the frequency of HS-C versus HS-E versus Controls was 28%/22%/50%, 19%/19%/62%, and 20%/22%/58%, respectively. No consistent significant morbidity differences were observed. Mortality between ages 85-90 and 90-95 years was 34.9% versus 38% versus 32.0%, and 43.4% versus 47.3% versus 43.7%, respectively, with no significant differences in survival rates (log rank p = 0.63, p = 0.81). Five-year mortality adjusted HRs were insignificant for HS-C and HS-E between ages 85-90 (HR 0.87, 95% CI 0.54-1.39; HR 1.14, 95% CI 0.73-1.78) and ages 90-95 (HR 0.72, 95% CI 0.39-1.32; HR 1.38, 95% CI 0.85-2.23). CONCLUSIONS: Seventy years following their trauma and suffering during the Holocaust, the significant impairments of health, function, morbidity, and mortality which have accompanied survivors throughout their entire adult life, were no longer observed. Indeed, it is likely that survivors living >85 years old represent a uniquely resilient population of people, whose adaptation to adversity has accompanied them throughout their lives.

A before and after study of medical students' and house staff members' knowledge of ACOVE quality of pharmacologic care standards on an acute care for elders unit.

BACKGROUND: The Assessing Care of Vulnerable Elders (ACOVE) comprehensive set of quality assessment tools for ill older persons is a standard designed to measure overall care delivered to vulnerable elders (ie, those aged > or =65 years) at the level of a health care system or plan. OBJECTIVE: The goal of this research was to quantify the pretest and posttest results of medical students and house staff participating in a pharmacotherapist-led educational intervention that focused on the ACOVE quality of pharmacologic care standards. METHODS: This was a before and after study assessing the knowledge ofACOVE standards following exposure to an educational intervention led by a pharmacotherapist. It was conducted at the 29-bed Acute Care for Elders (ACE) unit of Maimonides Medical Center, a 705-bed, independent teaching hospital located in Brooklyn, New York. Participants included all medical students and house staff completing a rotation on the ACE unit from August 2004 through May 2005 who completed both the pre-and posttests. A pharmacotherapist provided a 1-hour active learning session reviewing the evidence supporting the quality indicators and reviewed case-based questions with the medical students and house staff. Educational interventions also occurred daily through pharmacotherapeutic consultations and during work rounds. Medical students and house staff were administered the same 15-question, patient-specific, case-based, multiple-choice pre-and posttest to assess knowledge of the standards before and after receiving the intervention. RESULTS: A total of 54 medical students and house staff (median age, 28.58 years; 40 men, 14 women) completed the study. Significantly higher median scores were achieved on the multiple-choice test after the intervention than before (median scores, 14/15 [93.3%] vs 12/15 [80.0%], respectively; P = 0.001). CONCLUSION: A pharmacotherapist-led educational intervention improved the scores of medical students and house staff on a test evaluating knowledge of evidence-based recommendations for pharmacotherapy in the elderly.

Elder Orphans Hiding in Plain Sight: A Growing Vulnerable Population.

Adults are increasingly aging alone with multiple chronic diseases and are geographically distant from family or friends. It is challenging for clinicians to identify these individuals, often struggling with managing the growing difficulties and the complexities involved in delivering care to this population. Clinicians often may not recognize or know how to address the needs that these patients have in managing their own health. While many such patients function well at baseline, the slightest insult can initiate a cascade of avoidable negative events. We have resurrected the term elder orphan to describe individuals living alone with little to no support system. Using public data sets, including the US Census and University of Michigan's Health and Retirement Study, we estimated the prevalence of adults 65 years and older to be around 22%. Thus, in this paper, we strive to describe and quantify this growing vulnerable population and offer practical approaches to identify and develop care plans that are consistent with each person's goals of care. The complex medical and psychosocial issues for elder orphans significantly impact the individual person, communities, and health-care expenditures. We hope to encourage professionals across disciplines to work cooperatively to screen elders and implement policies to prevent elder orphans from hiding in plain sight.

Themes from a grounded theory analysis of elder neglect assessment by experts.

PURPOSE: This paper describes one program that has developed a screening procedure for assessing elder mistreatment, with a special focus on elder neglect. The aim is to understand how expert neglect assessment teams process and diagnose complex geriatric cases referred for suspected elder neglect. What are the key themes that must be understood in order to determine if neglect should be suspected and confirmed? DESIGN AND METHODS: Transcripts of audio recordings of neglect assessment team meetings were analyzed by using grounded theory analysis. RESULTS: Four major themes emerged from the analysis of the transcripts. These themes were understanding the underlying health status of the elder and caregiver, understanding the socioeconomic and life circumstances of the dyad, credibility of data collected by others, and the consequences of the assessment outcome. IMPLICATIONS: These findings offer insight into the development of future clinical screening and assessment procedures used to make diagnoses about elder neglect, as well as the guidelines that govern neglect assessment. Understanding not only the high-risk signs and symptoms but also the context and consequences of neglect is critical. Future screening and assessment procedures should be developed with these data in mind.

Delirium outcomes in a randomized trial of blood transfusion thresholds in hospitalized older adults with hip fracture.

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.