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Many of the elective arteria 23 generic 100 mg lasix otc, non-bariatric procedures on this rotation are performed using advanced laparoscopic techniques Jewish Hospital/Kindred Hospital Ph: (502) 587-4011 / Operating Room: (502) 587-4234 There are separate services of general surgery heart attack or panic attack cheap lasix 40mg line, thoracic blood pressure 80 over 60 buy generic lasix 100 mg on line, vascular surgery pulse pressure of 10 cheap lasix 100 mg line, transplantation, and cardiac surgery at this large teaching hospital. Residents are assigned to each of these services and all are under the supervision of the surgical staff members who are full time on clinical faculty members of this Department. Three surgical residents participate in the private general surgical service under the supervision of Dr. Christopher Jones, who is Director of the Surgical Education and Chief of Transplant at Jewish Hospital. In addition, there will be a large experience with general thoracic and vascular surgical patients on Thoracic and Vascular Associates’ private service (directed by Drs. Residents will also participate at Kindred Hospital, which is a subacute care facility located within Jewish Hospital. Residents will be responsible for the surgical needs of the hospital, which generally include chronic surgical conditions and wound care. Rural Surgical Experience Baptist Health Madisonville Ph: (270) 825-5100 / Operating Room: (270) 825-5115 Residents, midway through their residency training, will be assigned to this rotation at the Baptist Health facility in Madisonville, Kentucky, which is located approximately 150 miles west of Louisville. Mohan Rao, Director of Surgical Education, residents will work under several general surgeons at this facility to obtain a rich operative experience in a community rural setting. Owensboro Health Regional Hospital Ph: (270) 417-2000 / Operating Room: (270) 417-5500 Residents may also be assigned to this rotation at the Owensboro Health Regional Hospital in Owensboro, Kentucky, which is located approximately 110 miles west of Louisville. John Falcone and Chris Glaser, Director(s) of Surgical Education, the residents will work under several general surgeons in their group to obtain a rich operative experience in a community rural setting. In the near future, all chief residents must be assessed as competent in these areas prior to receiving certification for completion of residency training and undertaking the American Board of Surgery examinations. Surgical residents must demonstrate manual dexterity appropriate for their training level and be able to develop and execute patient care plans. Medical Knowledge about established and evolving biomedical, clinical, and cognate. Surgical residents are expected to critically evaluate and demonstrate knowledge of pertinent scientific information. Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care. Surgical residents are expected to critique personal practice outcomes and demonstrate recognition of the importance of lifelong learning in surgical practice. Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals. Surgical residents are expected to communicate effectively with other health care professionals, counsel and educate patients and families, and effectively document practice activities. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Surgical residents are expected to maintain high standards of ethical behavior, demonstrate a commitment to continuity of patient care, and demonstrate sensitivity to age, gender and culture of patients and other health care professionals. Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Surgical residents are expected to practice high quality, cost effective patient care, demonstrate knowledge of risk-benefit analysis, and demonstrate an understanding of the role of different specialists and other health care professionals in overall patient management. These attributes will be acquired over at least a 5-year training period by acquiring new knowledge through clinical experiences, reading current literature and major textbooks, attending bedside rounds and conferences, and preparing reports for presentation and publication. Knowledge of the clinical course of patient disease will be acquired by managing surgical patients both as inand out-patients, including management of the critically ill surgical patient. Most importantly, technical skill to perform operations and intra-operative decision-making will be acquired through observation and performance of a variety of surgical procedures within the realm of general surgery over the training period. The residents will record each operation performed or assisted, in an ongoing fashion, thereby preparing an operative log of case experience. Each resident is responsible for his/her own resident data collection for the duration of his/her residency. The ability to convey the clinical course of given patients will be developed by case presentations during walk rounds and conferences. The ability to interact appropriately with referring physicians and consulting physicians will be acquired by periodic communication with such physicians throughout the training period. This goal will be achieved by performance of initial patient assessment including history and physical and interpretation of routine laboratory tests and imaging studies. Additionally, assistance with, or performance of, certain operations will be carried out. Further knowledge of post-operative care will be learned by attending clinics and management of the patient in an ambulatory setting. It is our goal that residents will act as surgeon for some basic cases with proper supervision. These residents should be able to perform most complicated operations by the end of this year. The chief residents will be responsible for supervising all in-hospital patient care and for supervising outpatient care in the clinics. The chief resident will be responsible for preparing the morbidity and mortality reports presented at the Quality Improvement Conference pertaining to their own patients, as well as determining the autopsy status on each death and the status of the transplanted organs from those patients; the latter will be done in conjunction with the transplant coordinator. The chief resident will become familiar with quality assurance issues by having a seat on the Quality Assurance Committee at University Hospital. The chief resident will develop clinical decisionmaking skills by interacting directly with the attending surgeon for critically ill patients and those undergoing operation. The chief resident will supervise and assist the junior residents in critical patient care, as well as in performing certain operations. This will be accomplished in large part by an initial outpatient visit and formulation of a differential diagnosis, followed by appropriate laboratory and imagining workup, and finally by an elective operation and subsequent post-operative care. The residents are responsible for attending the Elective Surgery clinic every other Tuesday morning. This will be accomplished primarily by initial consultation through emergency room physician referral and involve resuscitation, workup algorithms, prioritization, operation, and perioperative critical care. Competence in directing multi-specialty management of critically ill surgical patients will be achieved by developing a close working relationship with physicians in many different specialties. The general surgery resident will assume primary responsibility for patient management under direction of faculty surgeons with an interest in trauma and critical care. The residents are also responsible for attending the Trauma Surgery Clinic every Tuesday morning. Practice-Based Learning and Improvement the skills to access information in Pub Med and relevant surgical literature attending quality improvement conference Interpersonal and Communication Skills interaction with the attending surgeon, chief resident, and medical students as appropriate. This will be achieved by both an inpatient and outpatient experience in management, by participation in several specialty clinics with diagnostic workup, medical clearance, surgery scheduling, operation and post-operative care. The residents will achieve competency in clinical management by mastering risk assessment in this group of challenging patients by thorough understanding of co-morbid medical illness. Residents on this service gain extensive exposure to the field of plastic surgery including pre and postoperative patient management, graduated operative experience, and a variety of conferences including didactics, journal club, and anatomy labs. Residents work closely with faculty and the plastic surgery fellows in all aspects of caring for these patients. The residents will also become competent in minimally invasive and catheter-based surgical techniques by close faculty supervision and extensive clinical experience. Competence in perioperative management will be achieved by initial daily patient visits and close communication with faculty in the clinical decision making on this group of patients with complex surgical disease. Residents are responsible for attending private general surgery clinic on Tuesday and Thursday. This includes elective primary bariatric patients, as well as re-operative and tertiary referral bariatric surgical patients. The resident will become competent in minimally invasive bariatric surgical procedures by close faculty supervision and extensive clinical experience. Competence in peri-operative management will be achieved by daily patient visits and close communication with faculty in the clinical decision-making on this group of patients. Residents will be responsible for attending preoperative and post-operative clinics. The resident will become through close faculty supervision and extensive clinical experience. Practice-Based Learning and Improvement the skills to access information in Pub Med and relevant surgical literature the knowledge of health care costs for common tests, imaging studies for both basic and complex surgical procedures. This includes elective patients, as well as re-operative and tertiary referral surgical patients. Competence in peri-operative management will be achieved by daily patient visits and close communication with faculty in the clinical decision making on this group of patients.

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The importance of out-of-office blood pressures for accurate prognosis is now supported by 5-8 several national and international guidelines blood pressure medication headache generic lasix 40mg online. Initial evaluation and classification of these patients is crucial because hypertension is mostly a silent disorder blood pressure chart template australia quality 100mg lasix, and patients are often asymptomatic for long periods of time prehypertension lower blood pressure proven lasix 40 mg. The goals for the initial evaluation of hypertensive patients include: estimating the average blood pressure (option A) heart attack test discount lasix 100 mg line, considering the overall cardiovascular risk status (option B), determining the presence or absence of target organ pathology (option C), and beginning the process of education that will lead the patient to recognize and collaborate in long-term risk reduction (option D). It is also an opportune moment to assess the patient for identifiable (secondary) hypertension. Choosing an appropriate cuff size is essential for accurate pressure readings; therefore, larger adult cuffs are mandatory for most large or obese patients (option A). During measurement, the patient should be seated comfortably, and pressures should be taken in both arms due to possible variability. Blood pressures can also be measured in the standing position (option B) 10 to assess for orthostatic hypotension, particularly in the elderly and in those with dizziness. Brachial artery pressures may fail to reflect central aortic pressures (option E), the latter of which is measured directly by invasive catheterization. It can thus measure blood pressure when a patient is awake during the day, as well as when the patient is sleeping during the night (option E). Studies suggest that the average level of ambulatory blood pressure 11 predicts risk of morbid events better than clinic blood pressure (option A). Ambulatory blood pressure monitoring is valuable for determining whether the patient’s usual pressure, in “real life,” is either higher or lower than the clinic pressure, thereby enabling the diagnosis of both white coat (option B) and masked hypertension (option C). Nevertheless, a careful and well-focused medical history and physical examination are the foundation for the initial appraisal of a hypertensive patient and his or her risk for cardiovascular disease, and these cannot be substituted by the use of this device (option D). Studies have shown that increased cardiovascular event rates were related to failure to intensify treatment, delays of more than 1. In general, the higher the blood pressure, the greater the need for shorter intervals between revisits. Therefore, while smoking cessation is important for cardiovascular prevention, 1 year is too long an interval for follow-up (option C). There is general agreement that in the absence of clues to identifiable hypertension, efficient use and appropriate selection of laboratory resources can be confined to those needed to define cardiovascular risk, to target organ pathology, and to establish a baseline for treatment (option E). Subsequently, appropriate treatment should focus on lifestyle improvement such as adherence to an adequate diet (option A) and increased exercise (option B), as well as prescription of antihypertensive drugs (option D). The most frequent adverse reaction to these drugs is hypokalemia, due to their effect on potassium excretion by the kidneys (option B). Loop-active diuretics are preferred over thiazides when renal function is impaired or in the presence of congestive heart failure, but they share similar adverse reactions, including hypokalemia (option C). Potassium-sparing diuretics, on the other hand, reduce potassium excretion by the kidneys and therefore do not cause hypokalemia (option A). They are valuable for treating primary aldosteronism or thiazide-related hypokalemia. However, the role of 15 beta-blockers in the management of coronary heart disease, especially angina, remains well accepted. Alpha-blockers may be combined with a beta-blocker for persons with highly variable blood pressure associated with tachycardia (option E). In addition, the treatment rates and drug responses vary across groups (option E). In addition, the coexistence of diabetes and hypertension confers a twoto threefold greater risk of future 18,19 cardiovascular disease compared to hypertension alone (option B). Although there is no blood pressure threshold for the diagnosis of hypertensive emergencies, most end-organ damage is noted with systolic blood pressures exceeding 220 mm Hg or diastolic blood pressures exceeding 120 mm Hg. The condition is usually related to a rapid increase in pressure from already high levels in established hypertension, perhaps related to poor adherence to antihypertensive medications. However, abrupt increases in pressure with threat to target organs may appear without prior warning as in some patients with pheochromocytoma or some forms of renal disease (eg, scleroderma renal crisis). For women with treated hypertension before pregnancy, pressure should be kept in the range of 120–160/80–105 mm Hg. Recommended drugs are methyldopa (option B), labetalol (option C), and nifedipine (option D) because these have acceptable evidence of safety in pregnancy. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Recent evidence on drug therapy of mild to moderate hypertension and decreased risk of coronary heart disease. Diagnostic and predictive accuracy of blood pressure screening methods with consideration of rescreening intervals: an updated systematic review for the U. European Society of Hypertension practice guidelines for ambulatory blood pressure monitoring. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Morbidity and mortality of orthostatic hypotension: implications for management of cardiovascular disease. Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin outcome study. Optimal systolic blood pressure target, time to intensification, and time to follow-up in treatment of hypertension: population based retrospective cohort study. Should beta blockers remain first choice in the treatment of primary hypertensionfi Treatment of hypertension in patients with coronary artery disease: a scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. Trends in hypertension prevalence, awareness, treatment, and control rates in United States adults between 1988-1994 and 1999-2004. Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus: Atherosclerosis Risk in Communities Study. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. The independent effect of type 2 diabetes mellitus on ischemic heart disease, stroke, and death: a population-based study of 13,000 men and women with 20 years of follow-up. Randomised trial of a perindopril-based blood pressure lowering regimen among 6105 individuals with previous stroke or transient ischemic attack. Initial assessment, surveillance, and management of blood pressure in patients receiving vascular endothelial growth factor signaling pathway inhibitors. American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Fetal and neonatal effects of treatment with angiotensinconverting enzyme inhibitors in pregnancy. Which of the following is not considered a component of the metabolic syndrome (MetS)fi Residual risk describes the remaining increased risk for atherosclerosis after the treatment of a specific risk factor 26-3. Which of the following is not a mechanism by which physical activity affects metabolismfi All of the above are mechanisms by which physical activity affects metabolism 26-4. Which of the following is considered the common starting pathway for the development of MetSfi What is the approximate annual risk of developing type 2 diabetes in a patient with obesity and MetSfi What is the most important factor when selecting a dietary intervention for a patient with MetSfi Which of the following procedures is associated with the least improvement in type 2 diabetesfi Specifically, the rationale and practical utility of MetS is to facilitate early diagnosis, risk stratification, and management of cardiometabolic risk factors. This topic is relevant, but it also remains controversial because many aspects remain unproven.

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Pathological disorders in captive cheetahs (Patologias de guepardos en cautividad) arteria carotida discount lasix 40mg fast delivery. In Iberian Lynx Ex Situ Conservation: An interdisciplinary Approach (Conservacion Ex Situ del Lince Iberico: Un Enfoque Multidisciplinar): 265-272 arrhythmia jokes lasix 100mg with amex. Hemato-Biochemical Analysis and Treatment Response to pulse pressure 45 buy 40 mg lasix with mastercard Enrofloxacin in Cats Affected with Feline Hemotropic Mycoplasma blood pressure medication bystolic side effects lasix 40mg on line. Oxalate nephrosis in captive cheetah National Zoological Gardens – Cheetah Conservation Fund. Beta Amyloid Deposition and Neurofibrillary Tangles Spontaneously Occur in the Brains of Captive Cheetah (Acinonyx jubatus). Anthrax in Europe: its epidemiology, clinical characteristics and role in bioterrorism. Seroprevalence of Neospora Caninum and Toxoplasma Gondii in Captive and Free-ranging Nondomestic Felids in the Unites States. Lungworm infections (Angiostrongylus vasorum, Crenosoma vulpis, Aelurostrongylus abstrusus) in dogs and cats in Germany and Denmark in 2003-2007. Comparison of Different Drying and Storage Methods on Quantifiable Concentrations of Fecal Steroids in the Cheetah. Characterization of the gastric immune response in cheetahs (Acinonyx jubatus) with Helicobacter-associated gastritis. Vaccine-induced protection against anthrax in cheetah (Acinonyx jubatus) and black rhinoceros (Diceros bicornis). A molecular epidemiologic investigation of Salmonella from a Meat Source to the Faeces of Captive Cheetah (Acinonyx jubatus). Ultrasonographic identification and characterization of spenic nodular lipomatosis or myelolipomas in cheetahs (Acinonyx jubatus). Evaluation of topical therapies for the treatment of dermatophyte-infected hairs from dogs and cats. Focal palatine erosion in captive and free-living cheetahs (Acinonyx jubatus) and other felid Species. A simple field method for spinal cord removal demonstrated in the cheetah (Acinonyx jubatus). Anna Kubber-Heiss, Institute of Pathology and Forensic Veterinary Medicine, University of Veterinary Medicine, A-1210 Vienna, Austria. A delay in the necropsy procedure, especially in the central nervous system can result in significant tissue autolysis and subsequent diagnostic difficulties. In the field where many necropsies are performed, suitable electric saws are mostly unavailable. A technically simple and rapid method for spinal cord removal, requiring only a straightforward tool has been devised. No necropsy induced structural damage has been noted on histo-pathological examination. Following standard necropsy procedures and evisceration of the carcass, the brain is removed and transected from the spinal cord at the level of the foramen magnum. The spinal column is separated from the remaining carcass and the paravertebral soft tissues and muscles are removed. The spinal column is then transected at the level of the intervertebral discs into approximately 15 cm. Spinal column, cheetah, Transected at the level of the intervertebral discs into approximately 15 cm. Individual segments now allow cranio – caudal visualization of the spinal cord within the spinal canal. In adult cheetahs a 250 mm long, 5-mm wide and 1 mm thick sterile, blunt metal blade is carefully inserted laterally to the spinal cord and into the spinal canal (fig. Spinal cord, cheetah, A 25-cm long, 5mm wide and 2-mm thick sterile, blunt metal blade is carefully inserted laterally of the spinal cord, into the spinal canal. The blade is moved dorsally and ventrally within the canal transecting the segmental nerves. Though not possible in all cases, it should be attempted to separate the dura mater from the epidural attachments in order to remove the spinal cord with the intact dura. Following this circumferential preparation, the spinal cord is grasped at one end with forceps and gently pulled out of the spinal canal while carefully removing persisting attachments (fig. Spinal cord, cheetah, the cord is grasped at one end with anatomic tweezers and gently pulled out of the spinal canal whilst carefully removing persisting attachments. If possible the spinal cord should be grasped by the dura mater to further reduce the possibility of artifacts. The process is repeated in each segment until the entire spinal cord has been removed. Once removed the spinal cord can be processed as required for further examination. However, this fragment should be frozen for possible viral isolation or biochemical and molecular studies. The cranial aspect of each spinal cord segment is marked with a small incision and placed in 10% buffered formalin. Small tight fitting containers, with an adequate volume of formaldehyde, help in avoiding post necropsy transport trauma to the cord. Special fixatives may be required for subsequent electron microscopy, immunocytochemistry or in-situ hybridization studies. The nervous tissue in juvenile animals contains more water and fewer lipids than in adult animals and therefore does not fix as well. The described tool is easily constructed from a flat stainless steel sheet in a simple workshop. Through variations in the size of the blunt edged blade this method can be adapted for various species and juvenile animals. Chris Walzer Research Institute of Wildlife Ecology, University of Veterinary Medicine Vienna Savoyenstrasse 1, 1160 Vienna, Austria chwalzer@eunet. Should only be provided if it is tube (2ml screw cap) containing 70% ethanol accompanied by a tissue sample. Bi obank addr esses If you would like to send usyour samplesthen please send themto the biobank hub relevant for your country. Philippe Helsen Address: Centre for Research and Conservation Royal Zoological Society of Antwerp Koningin Astridplein 20-26 2018 Antwerp, Belgium E-mail: Philippe. A huge “thank you” to the amazing Houston Host Committee led by the fabulous co-chair team of Bryan Hlavinka, Lou Weaver, Tamira “Augie” Augustine, Christina Canales Gorczynski and our very own Task Force staff of Russell Roybal, Sue Hyde, Daniel Pino and Mel Braman for their tireless passion, planning, persistence and sheer hard work to make this the biggest and best Creating Change ever. A lot of positive change has happened since our last conference: from historic and far-reaching Supreme Court decisions, to the passage of inclusive anti-discrimination legislation in states the length and breadth of our land. From policy changes that tear down barriers facing transgender people to the release of CeCe McDonald, unjustly imprisoned for simply defending herself in the face of racist, homophobic and transphobic slurs and physical attacks. Perhaps you, like me, have refected: wow, all these years of attending this conference, mobilizing, strategizing, and yes, celebrating our right to love and be ourselves is beginning to deliver big results. Yet every victory that we achieve makes clearer the inequalities that remain in our community, the painful gap between progress and true freedom. The truth is our work for equality, freedom and justice, for us and for all, is far from done. Let us also remember that we can still be fred at work for who we are and who we love. We can still be turned away at the polling station because of our gender identity and the color of our skin. That’s why we need the House to pass the Employment Non-Discrimination Act; fair immigration reform legislation; and to restore the heart of the Voting Rights Act. We must preserve, sustain and advance racial and economic justice, labor rights, reproductive freedom, pro-equality communities of faith, and so much more. We must intensify the fght for a whole range of issues, for the whole person, for freedom, equality and the pursuit of happiness for all people. So as we gather, let us recommit ourselves to the progressive movement and redouble our efforts to transform society.

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The relationship between serum 25-hydroxy-vitamin D levels and other variables related to blood pressure chart on age trusted 40 mg lasix calcium and phosphorus metabolism in the elderly blood pressure medication can you get off buy discount lasix 40 mg on line. Seasonal variations in serum levels of 25-hydroxyvitamin D and parathyroid hormone but no detectable change in femoral neck bone density in an older population with regular outdoor exposure pulse pressure and kidney disease purchase lasix 40 mg with mastercard. Age-related changes in the 25-hydroxyvitamin D versus parathyroid hormone relationship suggest a different reason why older adults require more vitamin D prehypertension home remedies 40mg lasix mastercard. Continuous decline in incidence of hip fracture: nationwide statistics from Finland between 1970 and 2010. Estimation of the dietary requirement for vitamin D in free-living adults >=64 y of age. Effects of a short-term vitamin D(3) and calcium supplementation on blood pressure and parathyroid hormone levels in elderly women. Development and validation of a vitamin D status prediction model in Danish pregnant women: a study of the Danish National Birth Cohort. Serum concentrations of vitamin D metabolites in vitamin D supplemented pregnant women. An outbreak of hypervitaminosis D associated with the overfortifcation of milk from a home-delivery dairy. Both high and low levels of blood vitamin D are associated with a higher prostate cancer risk: a longitudinal, nested case-control study in the Nordic countries. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. Vitamin D status of two groups of elderly in Oslo: living in old people’s homes and living in own homes. Introduction Vitamin E has traditionally been used as the common term for four tocopherols (fi-, fi-, fi-, and fi-tocopherol) and four tocotrienols (fi-, fi-, fi-, and fi-tocotrienol) that have been shown to have varying levels of biological activity in experimental animal studies (1). However, fi-tocopherol is the only form that is recognized to meet human requirements. Synthetic fi-tocopherol (also known as all-rac-fi-tocopherol or dl-fi-tocopherol) contains an equal mixture of eight diferent stereoisomers. This means that only fi-tocopherol in foods and 2R-fi385 tocopherols in vitamin E preparations contribute to vitamin E activity. Dietary sources and intakes Vegetable oils, vegetable oil-based spreads, nuts, seeds, and egg yolk are good food sources of vitamin E. The fi-tocopherol content is highest in sunfower oil followed by corn and rapeseed oil, olive oil, and soybean oil. In addition, vegetable oils contain variable amounts of other tocopherols and tocotrienols. On average, approximately half of the fi-tocopherol in the diet of Finnish adults was provided by cereal and bakery products and fat spreads, oils, and dressings (7). In recent dietary surveys from the Nordic countries, the mean dietary intake of vitamin E (fi-tocopherol) among adult populations varied between 7 mg and 10 mg per day (9–14). During pregnancy, intake of vitamin E is higher and most of women use supplements containing vitamin E (15–18). Physiology and metabolism the uptake, transport, and tissue delivery of fi-tocopherol involves molecular, biochemical, and cellular processes that are closely related with overall lipid and lipoprotein metabolism (21). The presence of bile salts and pancreatic enzymes and the formation of micelles are prerequisites for vitamin E absorption. However, knowledge of vitamin E absorption is incomplete, and both the amount of fat and the food matrix infuence 386 vitamin E absorption. In balance studies with small radioactive doses of fi-tocopherol, absorption in normal subjects has ranged between 55% and 79% (2, 22), whereas a much lower fgure of 33% was reported based on observed changes in plasma-labelled fi-tocopherol afer administration of a stable isotope-labelled dose of fi-tocopherol (23). The metabolism of vitamin E is tightly regulated, and unlike other fat-soluble vitamins there is no toxic accumulation in the liver. The major route of excretion of fi-tocopherol is in the faeces with small amounts excreted in urine (22). Although no tissue serves to store vitamin E, depletion of body vitamin E takes decades rather than weeks (25). Non-fi-tocopherols and tocotrienols are rapidly metabolized thereby preventing their tissue accumulation and limiting increases in their plasma concentrations (26). In human tissues, fi-tocopherol is the most common tocopherol and contributes about 90% of the total amount of tocopherols and tocotrienols in plasma (27) and 50%– 80% in other tissues (4). Recently, water-soluble fi-tocopheryl phosphate has been shown to appear in minute amounts in foods and tissues (28). The main biochemical function of fi-tocopherol has been suggested to be its antioxidant activity. As a chain-breaking antioxidant, fi-tocopherol might prevent the propagation of free radicals in membranes and in plasma lipoproteins (29). In addition, several other important biological functions, including modulation of cell signalling and gene expression, have been ascribed to vitamin E (30). Most of these enzymes are membrane bound or activated by membrane recruitment, especially those afecting cell proliferation, membrane trafcking, and metabolism of xenobiotics (24). Genes involved in the metabolism and excretion of vitamin E are regulated by fi-tocopherol itself. The ultimate biological function of vitamin E, however, remains to be elucidated (31). Evidence for decreased oxidative stress with fi-tocopherol supplementation in humans is inconsistent (32). The efect of vitamin E on biomarkers of oxidative stress appears to depend on the circumstances in which it is administered, most importantly on the level of baseline oxidative stress (33). Diferences in the individual responses to fi-tocopherol are also suggested to arise due to genetic factors (34, 35). High vitamin E intake has been associated with prolonged bleeding suggesting that large amounts of vitamin E might interfere with the blood clotting system especially with simultaneous use of aspirin or treatment with anticoagulants (36, 37). It is hypothesized that vitamin E intake can afect vitamin K status because they share the same metabolic pathways (38, 39). Vitamin E and chronic diseases Vitamin E has been proposed to play a role in several chronic diseases such as cardiovascular diseases, cancer, dementia, and other diseases associated with increased oxidative stress and infammation. Observational studies have provided some evidence suggesting a lower risk of coronary heart disease with higher intake of vitamin E, but randomized clinical studies do not, in general, provide support for a signifcant or clinically important efect of vitamin E supplementation on coronary heart disease (40, 41) or stroke (42). It did, however, result in a signifcant 24% decrease in cardiovascular deaths in women over the age of 65 years at baseline (43). Results from the same study showed that women supplemented with vitamin E also had a 21% lower risk for vascular thromboembolism (44). The signifcance of vitamin E in cancer prevention has been investigated in several clinical trials, none of which has provided evidence for overall protection from cancer (49). The decreased prostate cancer risk associated with a 50 mg daily dose of synthetic fi-tocopherol among middle-aged Finnish male smokers (50) has not been supported by fndings from other large-scale controlled trials (51). Results from observational studies on fi-tocopherol in cancer prevention are inconsistent (58). There is some evidence from observational studies to indicate a putative role of vitamin E in preventing cognitive impairment, but fndings from a few intervention studies have provided little support for this (59). In observational studies, the reduced risk of type 2 diabetes due to higher intake of antioxidants was mainly attributed to vitamin E (60), but such a benefcial efect of vitamin E supplementation has not been confrmed in randomized trials (61). Observational studies of vitamin E and the risk of cataracts and age-related maculopathy have shown mixed results. Only a very limited efect of vitamin E supplementation alone or in combination with other antioxidants on the incidence or progression of cataracts or age-related macular degeneration has been reported (62). Supplementation with fi-tocopherol above the recommended levels is suggested to improve immune function and decrease respiratory tract infections, especially in the elderly (63), but the results of a few randomized trials are inconsistent. Individual diferences in the efects of vitamin E supplementation on respiratory tract infections are suggested to be due in part to genetic factors (64). However, defciency can be caused by prolonged fat malabsorption, genetic defects in lipoprotein transport, or genetic defects in the hepatic fi-tocopherol transfer protein. In addition, premature and very low birth weight infants are in danger of defciency, and neurological disorders due to protein and energy malnutrition are suggested to be related to vitamin E defciency (25). In premature children, symptoms such as haemolytic anaemia, thrombocytosis, and oedema have been reported (65).


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