The reverse-transcriptase inhibitor lamivudine (Zeffix, GlaxoSmithKline) is often used to treat chronic infection with hepatitis B virus (HBV) until resistance develops. Treatment may then be switched to the reverse-transcriptase inhibitor adefovir (Hepsera, Gilead), which has a lower frequency of resistance. Here, we describe three cases of primary adefovir resistance that were sensitive to tenofovir (Viread, Gilead). All three cases involved a rare HBV variant with a valine at position 233 of the reverse-transcriptase domain instead of isoleucine (rtI233V), as in the wild-type virus. This HBV variant also displayed resistance to adefovir and sensitivity to tenofovir in vitro.

Purpose of review Alterations in cognitive functions are common in the perioperative course. Although often unnoticed by physicians, these alterations might have distinct long-term consequences for the patient with regard to everyday functioning, self-dependency, and quality of life. In recent years, however, perioperative cognition has gained increased interest, both by clinicians and scientists, and knowledge of the preventive measures of postoperative cognitive decline has become mandatory for anesthetists and surgeons. Recent findings This review offers a brief overview of the current state of knowledge concerning perioperative changes in cognition, including its pathophysiology and prevention strategies. Summary Postoperative neurocognitive disorders are frequent complications, especially in elderly patients, with postoperative delirium being its most pronounced and acute postoperative form, predisposing the patient for long-term cognitive impairment. The incidence of postoperative cognitive decline can be reduced by implementing preventive measures during perioperative patient care as recommended by national and international guidelines.

he demographic trend in Germany means that an increasing number of elderly patients will undergo surgical procedures. More than 7 million inpatients aged 65 years or older underwent surgery in 2017 (e1). There is no standard definition for the age beyond which an individual is "old." In medicine, one often refers to individuals aged 65-75 years as the "young elderly" and 75-85 years as the "old elderly." Those aged over 85 years are occasionally referred to as "the aged" or "superelderly."With advancing age, risks that can have an adverse effect on the postoperative outcome in this patient group accumulate. A good postoperative outcome is defined not only by surgical success, but far more so by the preservation of performance, functionality, autonomy, and quality of life. Avoiding postoperative delirium (POD) is an important treatment goal. POD has serious sequelae for the patient's future life, including a loss of quality of life and independence, as well as increased morbidity and mortality. As a result, this frequent complication (incidence among patients ≥ 70 years: 30%-50%) has dramatic social, healthrelated, and socioeconomic consequences (1, e2-e4). MethodsThe evidence for the following recommendations on the perioperative care of older patients is primarily based on current guidelines, as well as on randomized controlled studies, meta-analyses, and systematic review articles (eTable). A search was carried out in PubMed, the guideline database of the Association of the Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF), and the Cochrane database. Preoperative PhaseThe importance of primary care physicians Elderly patients benefit from a good preclinical work-up for their pending surgery. Optimally, this is initiated by the primary care physician and includes, e.g., compensating nutritional deficits, treatment of anemia, or optimizing long-term medication (Box). By using the national medication plan, it is possible to avoid loss of information when switching medication from the outpatient to the inpatient sector. The primary care physician's knowledge of often pre-existing multimorbidity enables the potential specific benefits of surgical treatment to be weighed up against its disadvantages in advance and together with the SummaryBackground: Elderly patients are a growing and vulnerable group with an elevated perioperative risk. Perioperative treatment pathways that take these patients' special risks and requirements into account are often not implemented in routine clinical practice.Methods : This review is based on pertinent publications retrieved by a selective search in PubMed, the AWMF guideline database, and the Cochrane database for guidelines from Germany and abroad, meta-analyses, and Cochrane reviews.Results: The care of elderly patients who need surgery calls for an interdisciplinary, interprofessional treatment concept. One component of this concept is preoperative preparation of the patient ("prehabilitation"), which is be...

IntroductionHip fracture surgery is associated with high in-hospital and 30-day mortality rates and serious adverse patient outcomes. Evidence from randomised controlled trials regarding effectiveness of spinal versus general anaesthesia on patient-centred outcomes after hip fracture surgery is sparse.Methods and analysisThe iHOPE study is a pragmatic national, multicentre, randomised controlled, open-label clinical trial with a two-arm parallel group design. In total, 1032 patients with hip fracture (>65 years) will be randomised in an intended 1:1 allocation ratio to receive spinal anaesthesia (n=516) or general anaesthesia (n=516). Outcome assessment will occur in a blinded manner after hospital discharge and inhospital. The primary endpoint will be assessed by telephone interview and comprises the time to the first occurring event of the binary composite outcome of all-cause mortality or new-onset serious cardiac and pulmonary complications within 30 postoperative days. In-hospital secondary endpoints, assessed via in-person interviews and medical record review, include mortality, perioperative adverse events, delirium, satisfaction, walking independently, length of hospital stay and discharge destination. Telephone interviews will be performed for long-term endpoints (all-cause mortality, independence in walking, chronic pain, ability to return home cognitive function and overall health and disability) at postoperative day 30±3, 180±45 and 365±60.Ethics and disseminationiHOPE has been approved by the leading Ethics Committee of the Medical Faculty of the RWTH Aachen University on 14 March 2018 (EK 022/18). Approval from all other involved local Ethical Committees was subsequently requested and obtained. Study started in April 2018 with a total recruitment period of 24 months. iHOPE will be disseminated via presentations at national and international scientific meetings or conferences and publication in peer-reviewed international scientific journals.Trial registration numberDRKS00013644; Pre-results