Clinical shorts
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* Diane Kelsall

## Transfusion after hip surgery

A liberal transfusion strategy after hip surgery, as compared with a restrictive strategy, did not reduce rates of death, in-hospital morbidity or inability to walk independently at 60-day follow-up in older patients at high cardiovascular risk. This is the conclusion of a randomized controlled trial that included 2016 patients 50 years of age or older, with risk factors for or a history of cardiovascular disease, and whose hemoglobin level was below 100 g/L after surgery for hip fracture. The mean age of the population was 81.6 (range 51 to 103) years. Patients assigned to the liberal strategy group received one unit of packed red cells and blood as needed to maintain a hemoglobin level of 100 g/L or more after surgery. In the other group, patients received transfusions only if symptoms or signs of anemia developed or at the discretion of their physician if the hemoglobin level fell below 80 g/L. The rates of death or inability to walk independently were similar in the liberal strategy group compared with the restrictive strategy group (35.2% v. 34.7%; odds ratio 1.01, 95% confidence interval 0.84 to 1.22). The frequency of myocardial infarction, congestive heart failure or stroke also did not differ significantly. See *N Engl J Med* 2011;365:2453–62.

## Daily antiviral therapy for preventing genital herpes reactivation

Short episodes of subclinical shedding of herpes simplex virus type 2 (HSV-2) persist even with daily antiviral therapy at standard doses and high doses. In three complementary open-label crossover studies, 113 participants who had recurrent genital herpes and were HIV-seronegative were randomly assigned to receive antiviral therapy (acyclovir or valacyclovir) at standard or high doses, or no medication. Participants received the study medication for a specified period, had a one-week washout period, and then crossed over to the other study medication for the rest of the trial. The participants self-collected one genital swab four times daily during the study period. About 5.4% (*n* = 1272) of the 23 605 swabs collected were HSV-positive. The frequency of HSV shedding was significantly higher in the no-medication group (*n* = 384, 18.1%) than in the other groups. Although all doses of antiviral agents reduced the frequency of detection of HSV, breakthrough reactivation (usually one or two episodes per month) occurred at all drug doses. Most shedding episodes were asymptomatic. See *Lancet* 2012; DOI:10.1016/S0140-6736(11)61750-9.

## Yoga, stretching or a self-care book for back pain

Yoga classes are more effective than a self-care book, but not more effective than stretching classes, in improving function and reducing pain in patients with chronic low back pain. In a randomized trial comparing these three treatment options, 228 adults with at least three months of moderate to severe low back pain were randomized to receive 12 weekly classes of yoga or conventional stretching exercises, or a self-care book. All received usual medical care. Treatment response was assessed at 6, 12 (the primary outcome) and 26 weeks by telephone interview using the validated Roland Morris Disability Questionnaire (RDQ) for function, while bothersomeness of symptoms was self-rated using a 0 to 10 scale. At 12 weeks, the RDQ score had declined in all groups, indicating improvements in function. Compared with self-care, the yoga group reported better function at 12 weeks (mean difference −2.5, 95% confidence interval [CI] −3.7 to −1.3), as did the stretching group (−1.7, 95% CI −3.0 to −0.4). There were no differences in function or bothersomeness of symptoms between the yoga and stretching groups at any time point. See *Arch Intern Med* 2011;171:2019–26.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/184/2/211/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/184/2/211/F1)

Image courtesy of © 2012 Thinkstock

## Treating hypertension in people over 80 years of age

People over the age of 80 years with hypertension may gain benefit within a year after starting treatment. Although the randomized controlled trial HYVET (Hypertension in the Very Elderly Trial) showed that total mortality and cardiovascular events were reduced by treatment for hypertension in those 80 years of age or older with a systolic blood pressure of at least 160 mm Hg at baseline, the authors wondered how soon these benefits would be seen. Over 1700 participants in the HYVET study (91% of those eligible) agreed to participate in a one-year open-label extension. Participants who had been in the placebo arm were started on antihypertensive medications, while those who had been in the treatment arm continued on active treatment, aiming for systolic pressure below 150 mm Hg and diastolic pressure below 80 mm Hg. At the start of the extension, the difference in mean sitting blood pressure between the two groups was 14.3/4.2 mm Hg in favour of active treatment. By six months, the difference in blood pressure was not statistically significant, and by the end of one year, there were no significant differences in rates of stroke or cardiovascular events. Total mortality and cardiovascular mortality were lower in the group previously treated with the active drug (hazard ratio for total mortality 0.48, 95% confidence interval 0.26 to 0.87). See *BMJ* 2012; 344:d7541 doi:10.1136/bmj.d7541.