Clinical Briefs

By Louis Kuritzky, MD

Daily Vitamin E and Multivitamin-Mineral Supplementation and Acute RTI in Elderly Persons

Vitamin supplementation has been shown to improve cellular immune parameters, but whether vitamin E or multivitamins/minerals (MVIM) have an effect on clinical events has not been clearly elucidated. Since respiratory tract infections (RTI) may become especially consequential for senior citizens, the question of whether vitamin E or MVIM alter the frequency, severity, or duration or such infections is of great clinical relevance.

Graat and associates studied the effect of MVIM, containing traditional RDA levels of multiple vitamins and minerals, including zinc, selenium, iron, magnesium, copper, iodine, calcium, manganese, chromium, molybdenum, and silicium, as well as a separate vitamin E supplement of 200 mg. Study subjects (n = 652) were comprised of noninstitutionalized persons older than age 60 who were followed for 15 months. At baseline, a very small proportion of individuals had suboptimal serum levels of either ascorbic acid (6%) or alpha-tocopherol (1.3%).

MVIM supplementation demonstrated no clinically or statistically significant effect upon RTI incidence, severity, duration, number of symptoms, or restriction of activity. Vitamin E supplementation demonstrated worse outcomes than placebo in reference to illness severity, duration, symptoms, fever, and restriction of activity. Graat et al caution that not only do their data discourage employment of MVIM due to lack of efficacy, but also due to a deleterious effect of vitamin E. 

Graat JM, et al. JAMA. 2002;288: 715-721.

B-Type Natriuretic Peptide Levels and Outcome in Patients with Heart Failure

Brain natriuretic peptide (BNP) levels reflect the degree of cardiac ventricular wall stress and are useful to diagnose chronic heart failure (CHF), as well as differentiate other dyspnea syndromes (in which BNP levels are not elevated) from CHF. BNP levels correlate with severity of CHF, hence, in any one episode of CHF, their degree of elevation might provide prognostic information. Bettencourt and colleagues examined the relationship between hospital BNP levels (on admission and discharge) in persons with acute decompensation of CHF, and subsequent hospital CHF readmission or death.

All subjects (n = 43) received "standard" CHF treatment, including diuretics (furosemide, and in some cases, spironolactone) and ACE inhibitors. Subjects were followed for 6 months.

When patients were hospitalized for CHF, BNP levels typically decreased with treatment. After hospital discharge, in the group that remained event free during follow-up, the decline in BNP during hospitalization (47%) was much more substantial than the decline in persons who required readmission (17%). Patients whose BNP increased during the index admission were more than 3 times more likely to require readmission or die during follow-up. BNP, and its response to treatment, provides important prognostic information in persons with CHF. 

Bettencourt P, et al. Am J Med. 2002; 113:215-219.

Influence of Companions During Primary Care Medical Encounters

It is commonplace in primary care settings for patients to be accompanied by family, friends, or caretakers in the examining room during some portion or all of the clinician-patient interaction. The effect of the "third person" (3P) has received little literature scrutiny. Schilling and colleagues studied 226 adult medical encounters, approximately half of which included another accompanying adult who spent any portion of the visit in the examining room. Patients, companions, and clinicians rated the influence of the companion upon the visit. Aspects of the clinical encounter that were monitored included physician understanding, patient understanding, counseling time, length of visit, treatment, referrals, and number of tests ordered.

Physicians reported that having a companion present generally was either neutral to or increased physician and patient understanding. Almost universally, physicians perceived no effect upon treatments, referrals, or number of tests ordered whether a companion was present. On the other hand, 25-32% of physicians felt that the 3P caused an increase in the length of visit or time spent counseling. Although overall the presence of an adult companion may enhance physician and patient understanding, it appears to be potentially at the expense of greater time required for counseling and the visit itself.

Schilling LM, et al. J Fam Pract. 2002;51:685-690.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.