The overall objective of this study was to examine the absorption and transport of vitamin E into plasma and bile using deuterium labeled tocopherol. In this experiment, we examined the relative contribution of newly absorbed ytocopherol and o-tocopherol to plasma and bile tccopherols. Two subjects undergoing operative common bile duct exploration were used for these studies. After undergoing common bile duct exploration for choledccholithiasis (gall stones within the common duct), a T-tube biliary drain was placed within the common duct until edema had resolved and normal bile flow had resumed Baseline blood and bile samples were taken prior to administering the tocopherols though a nasogastric tube. Prior to administration, the tccopherols were mixed with bile to promote solubilization. Subjects received three forms of deuterated tocopherol; ytocopherol (d2) (253 mg), RRR-a-tocopheryl acetate (d3) (173 mg), and allracemic-a-tocopheryl acetate (d6) (173mg). Endogenous a- and y-tocopherols (dO) were also measured. Blood and bile samples were obtained over time. Plasma lipoproteins were separated by rapid differential ultracentrifugation. Tocopherols in plasma, bile and lipoprotein fractions were extracted in hexane and quantitated by GC/MS with selected ion monitoring. All tccopherols were transported similarly in plasma with 46-62% in LDL, 17-35% in HDL with lesser amounts in chylomicrons and VLDL. y-tocopherol (d2) was enriched in bile compared to RRR-a-tocopherol (d3). Low levels of plasma y-tocopherol may be due to increased excretion into bile compared to a-tocopherol.

Vitamin E sufficiency has been an on-going concern in premature infants particularly in ameliorating retinal artery abnormalities and in preventing hemolytic anemia. Prenatal vitamin supplements contain vitamin E, but the majority of these contain all-rat-a-tocopheryl acetate at l S mg or less. Using deuterium-labeled isotopes of RRR- and all-rac'-a-tocopheryl acetate, the transport of tocopherol during pregnancy has been investigated. Fifteen pregnant subjects were recruited 5 days prior to delivery to receive 15, 30. 75, 150 or 3 00 mg daily of a 1:1 mixture of d3-RRR- and d6-all-rat-a-tocopheryl acetate. Maternal blood samples were obtained throughout the dosing period along with cord blood samples, at parturition. Plasma, red blood cell and lipoproteins were evaluated by GC/MS to distinguish between JO, d3 and c/6 tocopherols Relative bioavailability of d6 was greater in maternal plasma at delivery when compared to Je at all dose levels. Cord blood samples exhibited greater cK tocopherol when compared to dt>. At the lowest dose levels 15,30 and 75 mg, cti/Jb in cord blood was 3 42 ±1.96 and 2 26 ±0.44 for the higher doses, respectively. Evaluation of lipoprotein tocopherol content revealed that LDL and HDL are the main transport lipoproteins in maternal blood with HDL being the main carrier in cord blood. We conclude that RRRa-tocopheryl acetate is more bioavailable than the all-rac- form and at low dose levels is the form transported preferentially by the placenta.

Cytokine genes expression may play an important role in ischemia/reperfusion injury associated with acute myocardial infarction. We have recently observed that occlusion of left anterior descending coronary artery followed by reperfusion increased cardiac TNF-a mRNA expression in rats. The transcription factor NF-kB is a pleiotropic regulator of many genes involved in immuno and inflammatory responses. To elucidate the mechanisms of TNF-a mRNA expression induced by ischemia/reperfusion, we have investigated the activation of NF-kB in the ischemia/hypoxia cardiac myocytes in rats. Cardiac myocytes from adult rat ventricles were isolated by perfusion and incubation with buffer containing collagenase and hyaluronidase (Kao, 1980). The isolated cardiac myocytes were harvested and washed with modified Medium 199 containing 10% calf serum. The cells (2 x 107) were placed in microcentrifuge tubes, covered with mineral oil, and incubated at 37° C for 5 to 120 min. to establish the kinetics of ischemia/hypoxiainduced activation of NF-kB in cardiac myocytes. After incubation, nuclear proteins were extracted from the cardiac myocytes and NF-kB activation was determined by gel electrophoretic mobility shift assay. Ischemia/hypoxia resulted in the stimulation of DNA binding activities of NF-kB in the rat cardiac myocytes at 5 minutes, which peaked within 15 to 30 min. The activation of NF-kB binding to DNA in ischemia/hypoxia cardiac myocytes maintained up to two hours. These results are the first demonstration of ischemia/hypoxia stimulation of transcription factor NF-kB binding activity in the rat cardiac myocyte.

Sepsis and sepsis syndrome are significant causes of morbidity and mortality in critically ill patients. Despite technological and therapeutic advances in critical care, sepsis continues to be a pivotal factor in 20-50 % of deaths in surgical intensive care units. It is clear that alternative approaches to the prevention and/or treatment of sepsis must be found. Preclinical data indicate that macrophage activation with (1→3)-β-D-glucans will ameliorate sequelae associated with Gram-negative septicemia. Recent clinical data indicate that macrophage activation with (1→3)-β-D-glucans will significantly reduce septic morbidity and mortality in trauma and/or high-risk surgical patients. This work reviews the preclinical and clinical evaluation of (1→3)-β-D-glucans in the prevention of sepsis and septic sequelae.

Background: Transcription factor activation may be a pivotal step in the pathophysiology of sepsis syndrome and adult respiratory distress syndrome. This study investigated the activation of lung nuclear factor κB (NFκB) and nuclear factor interleukin-6 (NF-IL6) and how they correlate to proinflammatory cytokine expression and mortality in a murine model of cecal ligation and puncture (CLP). Methods: Polymicrobial sepsis was induced by CLP. Transcription factor activation was assessed at 0, 1, 2, 3, 4, 5, 6, 8, and 24 hours after CLP by the electrophoretic mobility-shift assay. Lung cytokine mRNA levels were established by reverse transcriptase-polymerase chain reaction. Results: CLP induced pulmonary NFκB activation at 3, 4, and 8 hours (p < 0.05). Lung NFκB activation peaked at 3 hours (533% vs. no surgery, 2,900% vs. sham treatment) after CLP. Supershift analysis revealed a predominance of p50 subunits in the lung nuclear extracts of septic mice 3 hours after CLP, indicating the presence of p50 homodimer. In contrast, liver nuclear extracts from septic mice indicated the presence of both p65 and p50 subunits at 3 hours. Lung NF-IL6 activation (p < 0.05) was observed at 4 hours (649% vs. no surgery, 296% vs. sham treatment) and 6 hours after CLP. Lung tumor necrosis factor-α mRNA levels were increased (p < 0.05) at all time intervals after CLP. Lung IL-6 mRNA levels were increased at 3, 6, and 8 hours after CLP. Conclusion: Early activation of lung NFκB and NF-IL6 and lung cytokine mRNA expression correlated with mortality in polymicrobial sepsis. Although IL-6 mRNA levels correlated with NFκB and NF-IL6 activation, tumor necrosis factor-α mRNA levels did not, in that they preceded transcription factor activation. These data suggest a potential role for NFκB and NF-IL6 activation in the initiation and propagation of acute lung injury.

Sepsis and sepsis syndrome are significant causes of morbidity and mortality in critically ill surgical patients. Despite technological and therapeutic advances in critical care, sepsis continues to be a pivotal factor in 20 to 50% of deaths in surgical intensive care units. It is clear that alternative approaches to the prevention and/or treatment of sepsis must be found. Preclinical data indicate that macrophage activation with ( I ->3)-D-gIucans will ameliorate sequelae associated with Gram-negative septicaemia. We and others have translated these preclinical observations to the clinical setting and have shown that macrophage activation with (l->3)-D-gIucans will significantly reduce septic morbidity and mortality in trauma and/or high-risk surgical patients. The precise mechanism(s) by which ( I->3)-D-glucans prevent or ameliorate infections have not been fully elucidated. However, recent data suggest the anti-infective efficacy of (l->3)-D-gIucans is attributable, in part, to macrophage activation induced by binding of (l->3)-D-gIucan to a specific receptor followed by modulation of macrophage pro-inflammatory cytokine expression. This article reviews the anti-infective potential of ( l-3)-D-glucans in the prevention of sepsis and septic sequelae.

One hundred and nineteen consecutive carotid endarterectomies (CEAs) performed on 86 patients have been reviewed. Thirty-three patients had bilateral CEAs. The indications were: (1) asymptomatic stenosis or ulceration (29%); (2) transient ischemic attack and amaurosis fugax (58%); and (3) reversible is chemic neurologic deficit and stroke (13%). Sixty percent of patients were shunted and 40% were not. There were 1 postoperative death in the first group and 2 strokes in each group. The overall stroke and death rates were 3.4% and 0.8% respectively. Eighty-eight percent and 83% of patients were alive and stroke free respectively during the forty-two-month follow-up period. The authors conclude that (1) CEA can be safely performed at a community hospital and (2) routine shunting or no shunting does not affect the patient's outcome.

Dectin-1 is the major macrophage receptor for β-glucans and generates a proinflammatory response through the recognition of these carbohydrates on fungal pathogens. We have examined the effects of cytokines and other agents on the expression and functions of dectin-1 in both resident and elicited murine peritoneal macrophages (Mφ). Dectin-1 expression was found to be highly up-regulated by GM-CSF and by the cytokines that induce alternative macrophage activation, IL-4 and IL-13. In contrast, IL-10, LPS, and dexamethasone, but not IFN-γ, down-regulated the expression of this receptor. Modulation of dectin-1 receptor levels correlated with the ability of these macrophages to bind zymosan and significantly affected the contribution of this receptor to the resultant proinflammatory response, as measured by the production of TNF-α, although some Mφ-specific differences were observed. These results correlate with the known effects of these cytokines and other agents on the ability of the immune system to recognize and respond to fungal pathogens.

Fungal infections in the critically ill patient are difficult to diagnose and are associated with a high mortality rate. A major obstacle to managing fungal infection is the lack of a reliable clinical assay that will rapidly identify patients with fungal sepsis. Glucans are polymers of glucose that are found in the cell wall of fungi and certain bacteria. Glucans are also released from the fungal cell wall into the extracellular milieu. Several studies have reported that detection of fungal glucan in serum or plasma is useful in the diagnosis of mycoses. However, recent studies have questioned the clinical utility of this assay. In this study, we examined serum glucan levels in intensive care unit (ICU) patients and attempt to correlate serum glucan levels with the presence of fungal infection. Following attainment of informed consent, serum was harvested from 46 ICU patients with confirmed fungal infections, confirmed bacterial infections, or no evidence of infection. Sera from eight healthy volunteers served as control. Serum glucan was assayed with a glucan-specific Limulus assay. Serum glucan levels were increased (69.6 ± 17 pg/ml; P < 0.001) in ICU patients versus the normal (11.5 ± 1.3 pg/ml) and noninfected ICU (27.4 ± 17 pg/ml) controls. However, serum glucan levels were not different in patients with confirmed fungal infections versus those with confirmed bacterial infections. Thus, serum glucan levels did not show a correlation with the presence of fungal infections and do not appear to be specific for fungal infections. However, the assay may be useful as a negative predictor of infection.

Aortogastric fistulas are a rare but usually fatal entity that presents as an acute gastrointestinal bleeding. The authors present the case of a 65-year-old man who had undergone a Nissen fundoplication and presented in the emergency room with syncope secondary to massive upper gastrointestinal tract bleed. Despite aggressive resuscitation and prompt operative intervention with repair of the gastric ulcer and closure of the aortic side of the fistula, he succumbed to the complications of hypovolemic shock. Overview of the pertinent literature with discussion of the most common causes of aortogastric fistulas as well as guidelines for intraoperative management are also presented.