In the United States about 15 million units of blood are transfused annually. The recent FOCUS trial (Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip fracture Repair) enrolled over 2000 patients over age 50 with a mean age of 81.6 years. They were randomly assigned to two study groups once their post-operative hemoglobin level fell below 10 g per deciliter. In the liberal strategy group, transfusions were given to restore and maintain a hemoglobin level above 10 g; whereas in the restrictive group transfusions were given when the hemoglobin level fell below 8 g. The liberal strategy did not reduce the rate of death, or the ability to walk independently at 60 days, or the in hospital morbidity. The authors concluded that a more restrictive transfusion threshold in the absence of symptoms of anemia are reasonable in elderly patients at risk for cardiovascular events. Given the risks of blood transfusions and the emphasis on cost containment these conclusions seem reasonable. (N Engl J Med 365; 26: December 29, 2011.)

Vitamin supplements are a multi-million dollar industry in our society in spite of the fact that many foods, cereals and dairy products are vitamin fortified. As more data becomes available on vitamins more risks have arisen with supplementation. Vitamin E contained in vegetables, seed oils and nuts is mostly gamma-tocopherol in foods but in supplements is mostly alpha-tocopherol which may block the anti-oxidant effect of gamma-tocopherol. A large meta-analysis found that supplementation was associated with an increased risk of death and an increased of hemorrhagic stroke. It has not been found to decrease cardiovascular events and in men causes a statistically significant increase in the risk of prostate cancer. Vitamin A and beta-carotine, which is a potent source of Vitamin A, have been found to increase the risk of lung cancer and prostate cancer. Vitamin D is the one vitamin that many people especially the elderly and those with dark skin should take if living at northern latitudes. The latest U.S. recommendations are taking D3 600 IU/day for males and females 1-70 and 800 IU/day for men and women over 70. Some studies have even suggested that in older adults it may help prevent falls and therefore fractures. Vitamin C which is contained in citrus fruits, juices and green leafy vegetables has been found not to significantly reduce the risk of developing upper respiratory infections. In high doses of more than a gram a day, it may cause diarrhea and might cause kidney stones because of its increased urinary oxillated excretion. Vitamin B 12 found in meat, fish and dairy products is commonly deficient especially in older people who often have atrophic gastritis and poor absorption. Folate is especially important in women of child bearing age at a dose of 400 mgc/day, the amount that is contained in most multi vitamin preparations. The conclusion of this article is that healthy people living in developed countries such as the US and eating a normal diet probably get sufficient amounts of vitamins. Supplements are well established for women of child bearing age for folic acid and for vitamins D & B12 in the elderly. There is no good reason to take vitamins A, C, or E routinely. (The Medical Letter, Volume 53, Issue 1379/1380: December 12/26, 2011)

John J. Mohr, M.D.