By S. Volkar. Davis College.
In sharing her thyroid disease treatment experience buy generic alesse 0.18 mg, one of Carla’s comments was indicative of grief order 0.18 mg alesse fast delivery. Based on the themes identified from the individual participant interviews buy online alesse, the following composite description provides answers 148 to the research questions: “What are the treatment experiences of women with thyroid disease? Women who develop thyroid disease experience a number of disturbing physical and emotional symptoms, sometimes years before obtaining a diagnosis. When reported to their doctors, symptoms are often considered to be “normal” aspects of aging, particularly when test results indicate no thyroid dysfunction. Nevertheless, many of the women in this study continued to report a feeling that “something is wrong” (Alicia). Whether they chose to believe that “doctor knows best” (Karen) or to pursue further information or a second opinion, these women sought support from others with similar experiences. Due to its convenience and wealth of information, the Internet is a popular medium for individuals seeking information or interaction with other people. Online support groups enable their members to interact anonymously, thus providing members with a safe and supportive environment in which to share their experiences, information, and resources. The women in this study found The Thyroid Support Group to be a reliable source for support and information about thyroid disease symptoms, treatment approaches, testing for thyroid disease, how to interpret such tests, and the names of recommended doctors. For the women in this study, dissatisfaction with one’s doctor seemed to result from feeling unheard and invalidated by one’s doctor, more so than misdiagnosis in general. When these women shared their concerns with their doctors, they trusted that 149 they would be listened to and taken seriously. When these women brought information to their doctors, they expected their doctors to review the information and to include their thoughts and concerns in the diagnostic and treatment planning processes. The women in this study felt disrespected when their doctors rushed or interrupted them. Feelings of distrust in doctors developed when these women felt dismissed or as if their doctors did not care about them––when their doctors seemed to view them and their experiences by “the numbers” (Michelle) rather than as people. For some of the women in this study, their dissatisfaction with their doctors lead to feelings of hopelessness. When the thoughts and concerns of the women in this study were considered––when they were taken seriously––they felt hopeful that they would someday feel well instead of constantly feeling tired, “foggy,” anxious, and depressed. According to the women in this study, not rushing or interrupting one’s patient demonstrates respect for the patient, which in turn, leads to respect for one’s doctor. In addition, including women with thyroid disease in the diagnostic and treatment planning processes encourages authentic communication and patient satisfaction. Many of the women in this study who did not feel heard or taken seriously by their doctors advocated for themselves––conducted research, sought new doctors, refused treatment, self-treated, and kept secrets if they believed it is necessary—including individuals who believed (at least at one point) that “doctor knows best. Some of these women in this study 150 feared not being taken seriously because they tend to show emotion as they describe their symptoms and share their experiences. The general culture of the medical profession seemed to devalue the experiences of the women in this study––labeling their symptoms as psychosomatic, as solely related to diet and exercise, or due to “women’s problems” for which there are clear treatment guidelines. When these women questioned their diagnosis or did not feel better after following their doctor’s orders, they were labeled as difficult––and sometimes even “fired” by their doctors (Anne). The women in this study who were aware of this discrepancy and brought it to the attention of their doctors because they were still not feeling well were often dismissed. Similarly, although synthetic thyroid medication is standard in treating hypothyroidism, it does not work for everyone. Some of the women in this study actually felt worse on synthetic thyroid medication than on no medication at all. The women who learned about natural thyroid treatments and who brought information about this option to the attention of their doctors were often told that such treatments are outdated or ineffective. Even the women who had taken natural thyroid medication in the past and felt better were told that natural thyroid medication was not a treatment option. But these women knew otherwise––they had learned from their own experiences or from others 151 like them that doctors who prescribe natural thyroid medication do exist. Through sharing with other women with thyroid disease, they had learned that it is possible that they might feel better taking natural thyroid medication. For some of the women in this study, financial difficulties, limited health insurance benefits, and geographic location sometimes interfered with finding a good doctor or the medication needed for thyroid disease. In addition, many of the women in this study had the impression that they were more knowledgeable about thyroid disease than their doctors. For the women whose doctors were receptive to a collaborative relationship, treatment planning ensued with shared information, respect for experience, patience, and the understanding that medication would be adjusted until the patients felt well. Some of the women with doctors who functioned in a more paternalistic manner were told to “get off Google” (April). Regardless of their relationship style, it seems that doctors (and their patients, in turn) might benefit from continuing education on thyroid disease––particularly considering its prevalence. Likewise, it seems prudent that research be conducted on the use of natural thyroid medication because of the many women in this study did not feel better while taking synthetic thyroid medication. Doctors who diagnose and treat women with thyroid disease are in a position to empower their patients (“I have chosen to stay with the physician because I believe he will listen to me. Based on the experiences of the women in this study, it seems that women with thyroid disease grieve their health and long to feel well again. They desperately wish for their experiences to be known and understood” “Listen to someone that is ‘living it’ and throw away the Synthroid book” (Carla). Summary In Chapter 4, I described the findings from this phenomenological study of female thyroid patients’ experiences of treatment and the doctor-patient relationship. Upon analyzing the participants’ interview transcripts, four themes emerged: (a) doctor-patient relationship, (b) patient self-advocacy, (c) doctor-patient communication, (d) and culture of the medical profession (see Appendix H). A review of the research literature in Chapter 2 revealed a significant gap specifically concerning the treatment experiences of women with thyroid disease diagnoses and the doctor-patient relationship. An understanding of how women with thyroid disease experience treatment and the doctor-patient relationship can enhance doctors’ knowledge of women’s health and chronic illness and can help to determine factors related to positive treatment outcomes. Between January 12, 2014 and February 5, 2014, I individually interviewed via online chat 16 female thyroid patients who were members of The Thyroid Support Group. This phenomenological study resulted in a rich description of the participants’ experiences with thyroid disease treatment and the doctor-patient relationship. Criterion sampling was used to recruit 16 participants who were female, who were aged 18 years and older, who had self-proclaimed thyroid disease diagnoses, and who were members of The Thyroid Support Group. Data were collected using an interview guide that I created, which was validated by an external panel of three experts in qualitative methods (see Appendix A). The four themes consisted of experiences surrounding (a) the doctor-patient relationship, (b) patient self-advocacy, (c) doctor-patient communication, (d) and the 154 culture of the medical profession. Appendix H presents the full list of themes and subthemes that emerged from the data analysis. Exploration of the manner in which people assign meaning to their thoughts, feelings, and actions is required for understanding human behavior (Marshall & Rossman, 2006, p. Thus, the participants’ experiences with thyroid disease treatment and the doctor-patient relationship were formed into textural-structural descriptions (see Appendix G) within the conceptual frameworks introduced in Chapters 1 and 2: phenomenology, social constructionism, and feminism. Both social constructionism and feminism emphasize individuals’ experiences in social contexts (Docherty & McColl, 2003; Fernandes et al. In the sample interviewed, participants shared their thoughts and experiences regarding the influence of gender, autonomy, knowledge, and communication on their perceptions of thyroid disease treatment and doctor-patient relationships.
Therapy may be directly observed in a medical ofce or clinic setting order alesse 0.18 mg overnight delivery, but can also be observed by an outreach worker in the feld (e alesse 0.18mg generic. Chapter 6: Treatment of Tuberculosis Disease 146 Incentives and Enablers Incentives and enablers should be used to ensure adherence to therapy (Figure 6 trusted 0.18mg alesse. Enablers are things that help the patient receive treatment, such as bus fare to get to the clinic. Chapter 6: Treatment of Tuberculosis Disease 147 Self-Administered Therapy Patients on self-administered therapy should be asked routinely about adherence at follow-up visits. Pill counts should be performed consistently, and urine or blood tests can be used periodically to check for the presence of urine drug metabolites or appropriate blood serum level of the drugs. In addition, the response to treatment should be monitored closely for all patients. Includes assigning responsibilities, conducting a regular systematic review of the case, and developing a plan to address barriers to adherence. A supervisor watches a health-care worker give a patient a bottle of prescribed pills. A physician sees the patient once a month and counts the remaining pills in the medication bottles. A health-care worker or another designated person watches the patient swallow each dose of the prescribed drugs. The nurse uses special urine tests to detect the presence of medicine in the patient’s urine. Can reduce the development of drug resistance, treatment failure, or relapse after the end of treatment. The remaining drugs are reserved for special situations such as drug intolerance or resistance. Cycloserine These drugs are reserved for special situations such as drug intolerance or resistance. Capreomycin ρ-Aminosalicylic acid Levofoxacin* Moxifoxacin* Gatifoxacin* Amikacin/Kanamycin* Ethionamide * Not approved by the U. Each treatment regimen consists of an initial 2-month treatment phase followed by a continuation phase of either 4 or 7 months (Table 6. Although these regimens are broadly applicable, there are modifcations that should be made under specifed circumstances (Tables 6. Each treatment regimen consists of an initial 2-month treatment phase followed by a continuation phase of either 4 or 7 months. Initial Phase The initial phase of treatment is crucial for preventing the emergence of drug resistance and determining the ultimate outcome of the regimen. Continuation Phase The continuation phase of treatment is given for either 4 or 7 months. For patients started on this regimen and found to have positive culture from the 2-month specimen, treatment should be extended an extra 3 months. Chapter 6: Treatment of Tuberculosis Disease 155 Treatment Completion Treatment completion is defned primarily as the ingestion of the total number of doses prescribed within the specifed time frame. The duration of therapy depends on the drugs used, the drug- susceptibility test results of the isolate, and the patient’s response to therapy (see Chapter 4, Drug-Susceptibility Thesting). The duration of therapy depends on the drugs used, the drug susceptibility test results of the isolate, and the patient’s response to therapy. Patients whose organisms were fully susceptible to the drugs being used should be instructed to promptly report the development of any symptoms, particularly prolonged cough, fever, or weight loss. Health-care providers are responsible for deciding whether to restart a complete course of treatment or to continue as intended. These decisions should be based on when the interruption occurred and the duration of the interruption. Chapter 6: Treatment of Tuberculosis Disease 158 Treatment Interruption During Initial Phase If the interruption occurred during the initial phase, the following guidelines apply (Figure 6. Start over from the beginning Can the initial No phase treatment Yes be completed within 3 Start over from months? Start initial phase Continue 4-drug regimen treatment from the beginning Can treatment No be completed Yes within required time frame for Start initial phase regimen? Indicate whether the following statements about the continuation phase of treatment are true or false. Continue treatment to had a lapse in therapy that was greater than 14 complete planned total days. Although all of these drugs cross the placenta, they do not appear to have teratogenic efects. The amount of pyridoxine in multivitamins is variable, but generally less than the needed amount. Every efort should be made to use a rifamycin-based regimen for the entire course of therapy in coinfected patients. Chapter 6: Treatment of Tuberculosis Disease 166 Of particular concern is the interaction of rifamycins with antiretroviral agents and other anti- infective drugs. Rifabutin, which has fewer drug-drug interactions due to its decreased induction of the cytochrome P450 system, may also be used in place of rifampin and appears to be equally efective, although the doses of the rifabutin and antiretroviral agents may require adjustments and should be administered with expert consultation. In addition, knowledge of the mechanisms of drug interactions can help predict the likelihood of an interaction, even if that specifc combination of drugs has not been formally evaluated. As new antiretroviral agents and more pharmacokinetic data become available, these recommendations are likely to be modifed. Notably, the serum concentrations of protease inhibitors are decreased during the latter stages of pregnancy. Tus, clinicians may consider regimens with fewer potentially hepatotoxic agents in patients with advanced or unstable liver disease. Clinicians may consider regimens with fewer potentially hepatotoxic agents in patients with advanced or unstable liver disease. Primary resistance occurs in persons who are initially exposed to and infected with resistant organisms. Drug resistance can be proven only by drug-susceptibility testing (see Chapter 4, Diagnosis of Tuberculosis Disease). There are several potential explanations for this occurrence, including the possibilities that the acid-fast organisms are nontuberculous and difcult to culture, that they are nonviable tubercle bacilli, or that there was laboratory error. The approach taken in such cases should be individualized on the basis of clinical and radiographic fndings. Young children should be treated with three (rather than four) drugs in the initial phase. If there is evidence of a slow or suboptimal response, the continuation phase should be prolonged to 7 months (a total of 9 months of treatment). A 6-month treatment regimen is recommended, unless the organisms are known or strongly suspected to be resistant to the frst-line drugs. Baseline Monitoring Before starting treatment, adult patients should have certain baseline blood and vision tests to help detect any underlying problems that may complicate treatment.
It causes a benign infection with only one or a few skin ulcers purchase alesse with american express, known as chiclero ulcer buy generic alesse 0.18mg on-line, chiclero ear purchase alesse discount, or bay sore. The lesion is usually located on the earflap or, less often, on the face or extremities. It begins with an ery- thematous papule that then ulcerates and, when the scab comes off, bleeds easily. The lesions on the earflap are deforming, tend to be chronic, and may last many years, while those on other parts of the body heal spontaneously in about six months. A distinctive feature of this form of cutaneous leishmaniasis is that it may spread to the lymph nodes, though this very rarely occurs. In Mexico, no cases of mucocuta- neous leishmaniasis have been detected, but two or three cases of cutaneous lesions that invaded the contiguous mucosa have been reported. The vectors are not espe- cially attracted to man, and the main victims tend to be people who spend a lot of time in the forest, the vector’s habitat, such as the gum tappers (chicleros)who work there during the rainy season when phlebotomine flies are plentiful. Human cases due to this agent are rare because the vec- tors are nocturnal and not normally anthropophilic, and they inhabit marshy areas where man does not ordinarily live. Around 30% of patients have diffuse cutaneous lesions characterized by thickening of the skin in the form of scattered plaques, papules, or nodules, found mainly on the face and legs. This diffuse form of leishmaniasis has been described in Venezuela, but it also occurs in other areas. Patients with diffuse cutaneous leish- maniasis are anergic and do not react to the Montenegro skin test. Healthy volunteers inoculated with parasites from patients with diffuse cutaneous leishmaniasis developed a localized lesion at the inoculation site which healed without sequelae. For that reason, the occurrence of this form is believed to be due more to deficient immune response in the host than to some special property of the parasite. The disease begins with a papular lesion on the face or extrem- ities that may develop into a painless ulcer that seldom heals spontaneously. A char- acteristic feature of this form is metastasis to the mucocutaneous parts of the body. A sizable proportion of untreated patients develop lesions on the nasal septum, mouth, nasopharynx, and, sometimes, even the anorectal region, penis, scrotum, and vulva. These metastases may occur simultaneously with the primary lesion or, more often, much later, and may cause severe destruction of the affected tissue, disfigur- ing the patient. Despite these descriptions, most clinical physicians indicate that it is very diffi- cult to differentiate between subspecies of leishmanias based only on the lesions they cause. The lesion begins as a papule on the exposed parts of the body (face and extremities), which develops into a wet ulcer. The disease lasts two to eight months, and fibrosis during spontaneous healing leaves a permanent scar. The initial papule develops slowly, and ulceration, when it occurs, is also slow to develop. Owing to the diffi- culty of identifying the parasite species, the etiologic agent of leishmaniasis in dogs is sometimes called simply L. Regardless of which species causes the infection, dogs often exhibit both cutaneous and visceral manifestations. In endemic areas, leishmaniasis may also occur in equines, which develop nodular lesions and sometimes scabs or ulcers, but only on or around the earflap. In Venezuela, of 116 donkeys examined, 28 had one or more ulcerous lesions and 17 (15%) had positive microscopy. Based on its behavior in hamsters and culture media, the authors classified the agent as L. Lesions consist of swellings with hair loss and, sometimes, ulcers, in which the pres- ence of amastigotes can be demonstrated. In these cases, the skin remains normal in appearance but the parasites are dispersed in the dermis. The parasites can be cultured from blood, viscera (spleen, liver), and apparently normal skin. Source of Infection and Mode of Transmission: In the Americas, the reservoirs of cutaneous leishmaniasis are generally rodents or edentate animals (Table 1). The infection is transmitted from one wild animal to another by means of phlebotomine flies of the genus Lutzomyia. Humans are infected accidentally by the bite of these phlebotomines when they enter enzootic areas in the jungle. However, Lainson (1983) suspected that dogs are actually a secondary host of this infection (uta) and that the primary host is a wild animal. In some areas of the Americas, the relative roles of the various infected animal species have not been clearly defined. Infected colonies of this desert or semidesert rodent have been found in Iran, the southern part of the former Soviet Union, and from northern Afghanistan to Mongolia. In north- western India and in Israel and Morocco, the reservoirs are Meriones spp. In Algeria, northwestern Libya, and Israel, Psammomys obesus serves as the reservoir, while in Ethiopia and Senegal, the reser- voirs are species of Mastomys, Tatera, and Arvicanthis. Lainson (1982) does not share that opinion, however, pointing out that person-to-person transmission is unlikely, since this agent causes few skin lesions in humans and those lesions con- tain only scant numbers of amastigotes. Humans are accidental hosts who acquire the infection when they enter enzootic forest areas for occupational purposes (e. Cutaneous leishmaniasis may be a serious problem in rural settlements within the jungle. Permanent human settlements in enzootic areas generate significant ecological changes, especially deforestation, replacement of wildlife with domestic animals, and replacement or modification in the prevalence of some insects as species better adapted to the new environment become dominant. These ecological changes also modify the epidemiology of cutaneous leishmaniasis: in Vale do Ribeira, São Paulo, Brazil, 80% of cutaneous leishmaniasis patients worked near their homes and had no contact with the jungle. The devastation of the natural environment altered the species composition of the phlebotomine population in that region and Psychodopygus intermedius—a species that prefers secondary growth, enters human dwellings, and is anthropophilic—became dominant (Tolezano et al. In the western-central region of Venezuela, the disease used to occur exclusively among the inhabitants of villages located near mountainous areas with dense vege- tation. However, cases have been diagnosed in several neighborhoods on the out- skirts of the city of Barquisimeto (Bonfante-Garrido et al. It is not yet known whether this was due to some ecological change, but the appearance of the disease in an urban environment shows that cutaneous leishmaniasis is not always sylvatic or rural and that its epidemiology is changing. Diagnosis: The simplest specific diagnostic method consists of confirming the presence of amastigotes in lesions. For that purpose, the lesion is cleaned with 70% alcohol to remove any necrotic matter. Then, a sample is taken from the edge or base of the lesion (nodule or ulcer of the skin or mucosa) by aspiration, scraping, or biopsy.
Soderstrom U order alesse without a prescription, Aman J cheap alesse 0.18mg amex, Hjern A (2012) Being born in Sweden increases the risk for type 1 diabetes – a study of migration of children to Sweden as a natural experiment generic 0.18 mg alesse overnight delivery. Ahlgren C, Oden A, Lycke J (2012) A nationwide survey of the prevalence of multiple sclerosis in immigrant populations of Sweden. Breslau J, Borges G, Tancredi D, Saito N, Kravitz R, Hinton L et al (2011) Migration from Mexico to the United States and subsequent risk for depressive and anxiety disorders: a cross- national study. Milo R, Kahana E (2010) Multiple sclerosis: geoepidemiology, genetics and the environment. Cabre P (2009) Environmental changes and epidemiology of multiple sclerosis in the French West Indies. Dean G (1967) Annual incidence, prevalence, and mortality of multiple sclerosis in white South-African-born and in white immigrants to South Africa. 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Dig Dis Sci 57(11):2955–2964 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 351 111. Hanski I, von Hertzen L, Fyhrquist N, Koskinen K, Torppa K, Laatikainen Thet al (2012) Environmental biodiversity, human microbiota, and allergy are interrelated. Hviid A, Svanstrom H, Frisch M (2011) Antibiotic use and inﬂammatory bowel diseases in childhood. Hemarajata P, Versalovic J (2013) Effects of probiotics on gut microbiota: mechanisms of intestinal immunomodulation and neuromodulation. Sotgiu S, Angius A, Embry A, Rosati G, Musumeci S (2008) Hygiene hypothesis: innate immunity, malaria and multiple sclerosis. Proc Natl Acad Sci U S A 109:5995–5999 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 353 150. Calcagni E, Elenkov I (2006) Stress system activity, innate and T helper cytokines, and susceptibility to immune-related diseases. Hayakawa M, Asahara T, Henzan N, Murakami H, Yamamoto H, Mukai N et al (2011) Dramatic changes of the gut ﬂora immediately after severe and sudden insults. Hagberg H, Gressens P, Mallard C (2012) Inﬂammation during fetal and neonatal life: implications for neurologic and neuropsychiatric disease in children and adults. Engelhardt B, Sorokin L (2009) The blood-brain and the blood-cerebrospinal ﬂuid barriers: function and dysfunction. Schwarcz R, Pellicciari R (2002) Manipulation of brain kynurenines: glial targets, neuronal effects, and clinical opportunities. Hertz-Picciotto I, Delwiche L (2009) The rise in autism and the role of age at diagnosis. Epidemiology 20(1):84–90 15 Microbiota, Immunoregulatory Old Friends and Psychiatric Disorders 355 188. Hallmayer J, Cleveland S, Torres A, Phillips J, Cohen B, Torigoe Thet al (2011) Genetic heritability and shared environmental factors among twin pairs with autism. Meyer U, Feldon J, Dammann O (2011) Schizophrenia and autism: both shared and disorder- speciﬁc pathogenesis via perinatal inﬂammation? Onore C, Careaga M, Ashwood P (2012) The role of immune dysfunction in the pathophysio- logy of autism. Margutti P, Delunardo F, Ortona E (2006) Autoantibodies associated with psychiatric disorders. Emanuele E, Orsi P, Boso M, Broglia D, Brondino N, Barale F et al (2010) Low-grade endotoxemia in patients with severe autism. Crespi B, Badcock C (2008) Psychosis and autism as diametrical disorders of the social brain. Arch Pediatr Adolesc Med 163(6):542–546 Chapter 16 M icrobiota-Gut-Brain Axis and Cognitive Function Melanie G. Gareau´ Abstract Recent studies have demonstrated a clear association between changes in the microbiota and cognitive behavior. This chapter will highlight recent ﬁndings in both human and animal studies indicating how changes in the composition and diversity of the microbiota can impact behavior and brain physiology in both disease states and in health. Cognitive behavior can not only be affected in cases of intestinal disease, but also manifests changes in extra-intestinal disease conditions. In laboratory animals cognition, or learning and memory, is assessed by speciﬁc behavioral tests (Table 16. Communication between the gut and the brain can occur via neuronal, endocrine and immunological pathways, highlighting the complexity in deciphering the speciﬁc mechanisms involved in mediating normal physiology and homeostasis . These mouse models involving the presence of an altered microbiota can be used independently or in combination to study the overall impact of pathology, and chronic disease in changing cognitive behavior. This review will focus on the role of the gut-brain-microbiota axis in mediating alterations in cognition in both human and animal studies and comparing normal and disease states. Microbiota and Cognition The microbiome has emerged in recent years as a leading factor in establishing normal physiology and function of the host as well as being a causative factor in numerous disease states when inappropriately altered . Changes in the intestinal microbiota, either due to inﬂammation, infection, or drugs—including administra- tion of antibiotics—can lead to extraintestinal effects, including changes in the brain. Alterations in behavior, including anxiety, depression and cognitive defects, 16 Microbiota-Gut-Brain Axis and Cognitive Function 359 Table 16. This supports the notion that the microbiota can regulate the development of the central response to stress, at least in rodents. In these studies, conventionalization of mice could normalize behavior, but only in early stages of life . These pilot studies revealed a change in brain neurotransmitter levels impacted by the microbiota, which could signiﬁcantly 360 M.
Vitamin E protects against lipid per- oxidation by acting directly on a number of oxygen radicals including sin- glet oxygen cheapest generic alesse uk, lipid peroxide products cheap 0.18mg alesse visa, and the superoxide radical to form the relatively harmless tocopherol radical alesse 0.18mg without a prescription. It has been suggested that vitamin E may only be effective in combination with vitamin C as the pro-oxidant activity of α-tocopherol 733 734 Part Three / Dietary Supplements is prevented by ascorbate acting as a co-antioxidant. The γ-tocopherol form of vitamin E is a more effective anti-inflammatory and a better quencher of reactive nitrogen oxide species generated in chronic inflammation. Important novel anti-prolifer- ative and neuroprotective effects of tocotrienols, which may be independent of their antioxidant activity, have also been described. Substantial quantities of vitamin E may be lost during storage, processing, and cooking. A control study on healthy volunteers con- firmed that the plasma concentration of vitamin E and plasma antioxidant activity in response to oral supplementation of vitamin E are markedly affected by food intake. As vitamin E is lipophilic, and its absorption is expected to be increased by food, vitamin E should be taken with meals. The most preva- lent form of vitamin E in plant seeds and their products is γ-tocopherol, yet α-tocopherol is the form usually supplied in supplements. Furthermore, although α-tocopherol is preferentially accumulated, γ-tocopherol has prop- erties not shared by α-tocopherol. Although the sys- tem of International Units for vitamin E has been officially discontinued for several decades, in practice, both systems continue to be used and dietary supplements tend to favor use of the discontinued system. As shown in Table 107-1, the advantage of the unit system is that the dose can be readily modified to whichever particular tocopherol supplement the clinician is using. The Food and Nutrition Board of the Institute of Medicine recently pub- lished a new daily dietary reference intake of 15 mg (35 mol) vitamin E for adults. Although the relative potency in humans is unproven, in animals the potency of natural versus synthetic vitamin E is 1. Furthermore, variations in the biologic activity of various homologous prob- ably reflect the ease with which each attaches to the lipid membrane. It is generally accepted that the requirement for vitamin E increases as the concentration of polyunsaturated fatty acids in the diet increases. Chapter 107 / Vitamin E 737 Store vitamin E supplements away from heat, direct light, and damp areas. In addition to epi- demiologic studies that suggest a benefit for high intakes of α-tocopherol, studies of supplementation in humans have clearly shown that α-tocopherol decreases lipid peroxidation, platelet aggregation, and functions as a potent anti-inflammatory agent. Various studies suggest clinical uses of vitamin E in daily doses of the following27: ● 50-1500 mg to prevent cardiovascular disease. Data from a study on volunteers suggested that smoking increased the disappearance of vitamin E from the plasma. Antipsychotic (neuroleptic) medication, used to treat people with chronic mental illnesses, is associated with a wide range of adverse effects, includ- ing movement disorders such as tardive dyskinesia. Small trials of uncer- tain quality indicate that vitamin E protects against deterioration of tardive dyskinesia, but there is no evidence that vitamin E improves symptoms. In fact, although basic science and animal studies have generally supported the hypothesis that vitamin E may slow the progression of atherosclerosis and observational studies, primarily assessing patients without established coro- 738 Part Three / Dietary Supplements nary heart disease, have largely supported a protective role of vitamin E, early primary and secondary prevention clinical trials have essentially failed to show a significant benefit from vitamin E. Vitamin E is helpful for secondary prevention of intermittent claudication, providing most benefit to those with the poorest collateral circulation and pedal blood flow. However, it should be noted that a review of clinical trials using vitamin E concluded there was insufficient evidence to determine whether vitamin E is an effec- tive treatment for intermittent claudication. Variations of insulin sensitivity are related to the long-chain polyunsaturated fatty acid content of the phospholipid mem- brane of skeletal muscle. Pharmacologic doses of vitamin E and C increase insulin-stimulated cellular uptake of glucose. Other potential uses for vitamin E involve inclusion as part of a larger nutritional protocol to prevent cancer. Vitamin E inclusive protocols signifi- cantly reduce the incidence of prostate, bladder, and stomach cancers, and prevent recurrences of colonic adenomas. Vitamin E, by antagonizing vitamin K and inhibiting prothrombin production, may increase risk of hemorrhagic strokes. Vitamin E supplementation may impair the hematologic response to iron and should be avoided in iron deficiency anemia. Large doses of iron or copper may increase the requirement for vitamin E, while zinc deficiency reduces vitamin E plasma levels. Vitamin C has a sparing effect on vitamin E, and moderate doses of vitamin E have a sparing effect on vitamin A. On the other hand, large doses of vitamin E may deplete vitamin A and increase the requirement for vitamin K. Vitamin E may enhance the anti-inflammatory effect of aspirin and decrease the dose of anticoagulant, insulin, and digoxin required. Plasma levels of vitamin E may be reduced by anti-convulsants, oral contraceptives, sucralfate, colestyramine, and/or liquid paraffin. In reality, clinical deficiency is rare, except in persons with fat malabsorption. Symptoms suggestive of vitamin E deficiency include arreflexia, psychologic syndromes, cognitive dysfunction, 740 Part Three / Dietary Supplements nystagmus, ataxia, muscle weakness, and sensory loss in the arms or legs. Bendich A, Mallick R, Leader S: Potential health economic benefits of vitamin supplementation, West J Med 166(5):306-12, 1997. Jialal I, Devaraj S, Kaul N: The effect of alpha-tocopherol on monocyte proatherogenic activity, J Nutr 131(2):389S-94S, 2001. Yoshikawa T, Yoshida N: Vitamin E and leukocyte-endothelial cell interactions, Antioxid Redox Signal 2(4):821-5, 2000. Iuliano L, Micheletta F, Maranghi M, et al: Bioavailability of vitamin E as function of food intake in healthy subjects: effects on plasma peroxide- scavenging activity and cholesterol-oxidation products, Arterioscler Thromb Vasc Biol 21(10):E34-7, 2001. Mahabir S, Coit D, Liebes L, et al: Randomized, placebo-controlled trial of dietary supplementation of alpha-tocopherol on mutagen sensitivity levels in melanoma patients: a pilot trial, Melanoma Res 12(1):83-90, 2002. Meydani M: Effect of functional food ingredients: vitamin E modulation of cardiovascular diseases and immune status in the elderly, Am J Clin Nutr 71(6 Suppl):1665S-8S, 2000. Brighthope I: Nutritional medicine tables, J Aust Coll Nutr Env Med 17:20-5, 1998. A critical and constructive review of epidemiology and supplementation data regarding cardiovascular disease and cancer, Biofactors 7(1-2):113-74, 1998. Brighthope I: Nutritional medicine—Its presence and power, J Aust Coll Nutr Env Med 17:5-18, 1998. Meydani M, Meisler J: A closer look at vitamin E: can this antioxidant prevent chronic disease, Postgrad Med 102(2):199-207, 1997. Primack A: Complementary/Alternative therapies in the prevention and treatment of cancer. Vitamin K is a fat-soluble vitamin obtained from bacteria in the bowel and from dietary sources such as liver, leafy green vegetables, and milk. Die- tary vitamin K includes phylloquinone (vitamin K1) and menaquinone (vitamin K2).