VITAMIN E AND RESPIRATORY TRACT INFECTIONS
Respiratory tract infections are prevalent in elderly individuals, resulting in increased morbidity, mortality, and use of health care services. Vitamin E supplementation has been shown to improve immune response in elderly persons. However, the clinical importance of these findings has not been determined. The objective of this study was to determine the effect of 1 year of vitamin E supplementation on respiratory tract infections in elderly nursing home residents. It was a randomized, double-blind, placebo-controlled trial conducted from April 1998 to August 2001 at 33 long-term care facilities in the Boston, MA, area. A total of 617 persons aged at least 65 years and who met the study’s eligibility criteria were enrolled; 451 (73%) completed the study. Vitamin E (200 IU) or placebo capsule was administered daily; all participants received a capsule containing half the recommended daily allowance of essential vitamins and minerals.

Main outcome measures were incidence of respiratory tract infections, number of persons and number of days with respiratory tract infections (upper and lower), and number of new antibiotic prescriptions for respiratory tract infections among all participants randomized and those who completed the study. Results showed that vitamin E had no significant effect on incidence or number of days with infection for all, upper, or lower respiratory tract infections. However, fewer participants receiving vitamin E acquired 1 or more respiratory tract infections (60% vs 68%; risk ratio [RR], 0.88; 95% confidence interval [CI], 0.76-1.00; P = .048 for all participants; and 65% vs 74%; RR, 0.88; 95% CI, 0.75-0.99; P = .04 for completing participants), or upper respiratory tract infections (44% vs 52%; RR, 0.84; 95% CI, 0.69-1.00; P = .05 for all participants; and 50% vs 62%; RR, 0.81; 95% CI, 0.66-0.96; P = .01 for completing participants.

When common colds were analyzed in a post hoc subgroup analysis, the vitamin E group had a lower incidence of common cold (0.67 vs 0.81 per person-year; RR, 0.83; 95% CI, 0.68-1.01; P = .06 for all participants; and 0.66 vs 0.83 per person-year; RR, 0.80; 95% CI, 0.64-0.98; P = .04 for completing participants) and fewer participants in the vitamin E group acquired 1 or more colds (40% vs 48%; RR, 0.83; 95% CI, 0.67-1.00; P = .05 for all participants; and 46% vs 57%; RR, 0.80; 95% CI, 0.64-0.96; P = .02 for completing participants). Vitamin E had no significant effect on antibiotic use. The investigators concluded that supplementation with 200 IU per day of vitamin E did not have a statistically significant effect of vitamin E supplementation on upper respiratory tract infections, particularly the common cold, that merits further invesitgation.

Meydani SN, Leka LS, Fine BC, et al. Vitamin E and respiratory tract infections in elderly nursing home residents. JAMA 2004;292:828-836.

EXTENDED OUTPATIENT REHABILITATION AFTER HIP FRACTURE
Hip fractures are common in the elderly, and despite standard rehabilitation, many patients fail to regain their prefracture ambulatory or functional status. The objective of this study was to determine whether extended outpatient rehabilitation that includes progressive resistance training improves physical function and reduces disability compared with low-intensity home exercise among physically frail elderly patients with hip fracture.

A randomized controlled trial was conducted between August 1998 and May 2003 among 90 community-dwelling women and men age 65 years or older who had had surgical repair of a proximal femur fracture no more than 16 weeks prior and had completed standard physical therapy. Participants were randomly assigned to 6 months of either supervised physical therapy and exercise training (n = 46) or home exercise (control condition; n = 44). The primary outcome measures were total scores on a modified Physical Performance Test (PPT), the Functional Status Questionnaire physical function subscale (FSQ), and activities of daily living scales. Secondary outcome measures were standardized measures of skeletal muscle strength, gait, balance, quality of life, and body composition. Participants were evaluated at baseline, 3 months, and 6 months. The results showed that changes over time in the PPT and FSQ scores favored the physical therapy group (P = .003 and P = .01, respectively). Mean change (SD) in PPT score for physical therapy was +6.5 (5.5) points (95% confidence interval [CI], 4.6-8.3), and for the control condition was +2.5 (3.7) points (95% CI, 1.4-3.6 points). Mean change (SD) in FSQ score for physical therapy was +5.2 (5.4) points (95% CI, 3.5-6.9) and for the control condition was +2.9 (3.8) points (95% CI, 1.7-4.0).

Physical therapy also had significantly greater improvements than the control condition in measures of muscle strength, walking speed, balance, and perceived health but not bone mineral density or fat-free mass. The investigators concluded that in community-dwelling frail elderly patients with hip fracture, 6 months of extended outpatient rehabilitation that includes progressive resistance training can improve physical function and quality of life and reduce disability compared with low-intensity home exercise.

Binder EF, Brown M, Sinacore DR, et al. Effects of extended outpatient rehabilitation after hip fracture. JAMA 2004;292:837-846.

RELIGION, SPIRITUALITY, AND ACUTE CARE HOSPITALIZATION
The impact of religion and spirituality on acute care hospitalization (ACH) and long-term care (LTC) in older patients before, during, and after ACH is not well known. Patients age 50 years or older who were consecutively admitted to the general medical service at Duke University Medical Center were interviewed shortly after admission (N = 811). Measures of religiosity were organized religious activity (ORA), nonorganizational religious activity (NORA), religiosity through religious radio and/or television (RTV), intrinsic religiosity, and self-rated religiousness. Measures of spirituality included self-rated spirituality and daily spiritual experiences (DSE). Primary outcome was number of ACH days during an average 21-month observation period. Secondary outcomes were times hospitalized and number of days spent in a nursing home or rehabilitation setting (collectively, long-term care: LTC). Race and sex interactions were examined. In the cross-sectional analysis, ORA was the only religious variable related to fewer ACH days and fewer hospitalizations, an effect that is fully explained by physical health status and that disappeared when examined prospectively. The number of LTC days was inversely related to NORA, RTV, and DSE, effects that were partially explained by social support but not by severity of medical illness. Interactions with race and sex were notable but reached statistical significance only among African Americans and women. In those groups, religious and/or spiritual characteristics also predicted future LTC use independent of physical health and baseline LTC status. The investigators concluded that relationships with ACH were weak, were confined to ORA only, and disappeared in prospective analyses. However, robust and persistent effects were documented for religiousness and/or spirituality in the use of LTC among African Americans and women.

Koenig HG, George LK, Titus P, et al. Religion, spirituality, and acute care hospitalization and long-term care use by older patients. Arch Intern Med 2004;164: 1579-1585.

RADIATION THERAPY ALONE VS WITH ANDROGEN SUPPRESSION FOR PROSTATE CANCER
Survival benefit in the management of high-grade clinically localized prostate cancer has been shown for 70 Gy radiation therapy combined with 3 years of androgen suppression therapy (AST), but long-term AST is associated with many adverse events. The objective of this study was to assess the survival benefit of 3-dimensional conformal radiation therapy (3D-CRT) alone or in combination with 6 months of AST in patients with clinically localized prostate cancer. A prospective randomized controlled trial of 206 patients with clinically localized prostate cancer were randomized to receive 70 Gy 3D-CRT alone (n = 104) or in combination with 6 months of AST (n = 102) from December 1, 1995, to April 15, 2001. Eligible patients included those with a prostate-specific antigen (PSA) of at least 10 ng/mL, a Gleason score of at least 7, or radiographic evidence of extraprostatic disease. The main outcome measures wereÊtime to PSA failure (PSA >1.0 ng/mL and increasing >0.2 ng/mL on 2 consecutive visits) and overall survival. After a median follow-up of 4.52 years, patients randomized to receive 3D-CRT plus AST had a significantly higher survival (P = .04), lower prostate cancer–specific mortality (P = .02), and higher survival free of salvage AST (P = .002). Kaplan-Meier estimates of 5-year survival rates were 88% (95% confidence interval [CI], 80%-95%) in the 3D-CRT plus AST group vs 78% (95% CI, 68%-88%) in the 3D-CRT group. Rates of survival free of salvage AST at 5 years were 82% (95% CI, 73%-90%) in the 3D-CRT plus AST group vs 57% (95% CI, 46%-69%) in the 3D-CRT group. The investigators concluded that the addition of 6 months of AST to 70 Gy 3D-CRT confers an overall survival benefit for patients with clinically localized prostate cancer.

D’Amico AV, Manola J, Loffredo M, et al. 6-month androgen suppression plus radiation therapy vs radiation therapy alone for patients with clinically localized prostate cancer. JAMA 2004;292: 821-827.