Pancreatic Enzymes Research Articles

Intestinal-Targeted Digestion of Heme Chloride by Forming Inclusion Complexes In Vitro.

Hemin, a heme-like compound with significant biological activity, shows promise as an iron supplement for humans. Nonetheless, its poor solubility in water greatly impedes its absorption and utilization. To surmount this obstacle, researchers have chosen various cyclodextrins with distinct cavity sizes and derivative groups to act as hosts, forming inclusion complexes with hemin chloride. Among these, γ-cyclodextrin has been identified as the optimal carrier, based on a thorough evaluation of its encapsulation efficiency, solubility, and molecular docking. Multiple characterization techniques further confirmed the formation of these inclusion complexes. Results from IEC-6 cell experiments indicated that the cytotoxicity of the inclusion complexes was lower than that of FeSO4. Static and dynamic gastrointestinal simulation digestion systems were established, and the results showed that the bioavailability of the inclusion complex was significantly higher than that of raw hemin. Additionally, only about 0.29% of hemin chloride is digested by gastric enzymes, whereas 9.52% is digested by pancreatic enzymes in the static gastrointestinal simulation digestion system, with similar outcomes observed in the dynamic system. These findings suggest that targeted digestion in the intestine significantly enhances the bioavailability of hemin chloride by forming inclusion complexes in vitro.

A50-year-old patient with pancreatitis revealing pancreatitis, panniculitis, and polyarthritis syndrome-acase report and review of the literature.

The combination of pancreatitis, panniculitis, and polyarthritis (PPP) is arare systemic syndrome that occurs in patients with acute or chronic pancreatitis or pancreatic malignancies. A50-year-old male patient presented with polyarthritis increasing for 1week and consequent inability to walk unaided. In addition, the patient had several isolated nodules on the lower extremities without any tenderness to pressure. Laboratory tests showed elevated pancreatic enzymes indicative of pancreatitis, which was thereafter confirmed by abdominal CT scan, with signs of chronic pancreatitis and concrements in the pancreatic duct. The diagnosis of panniculitis was established by dermatological consultation. Considering all these clinical features, PPP syndrome was diagnosed. In accordance with the pre-existing literature, oral glucocorticoid therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) were given but failed to improve pain and polyarthritis. In the further clinical course, due to the persistent increase in lipase and amylase, endoscopic retrograde cholangiopancreatography (ERCP) was performed, showing small concrements in the pancreatic duct. During the intervention, the pancreatic duct was widened, the small concrements were removed, and apancreatic duct stent was then implanted. Following ERCP, an instant decrease in pancreatic enzymes was observed, accompanied by aclear and sustained improvement of joint swellings and pain. With the typical triad of clinical findings in mind, one should consider PPP syndrome in the context of acute or chronic pancreatitis as well as in pancreatic malignancies. All involved disciplines (gastroenterology, dermatology, and rheumatology) should be familiar with this rare but severe condition. The prognosis depends on the extent of the functional deficit of the extremities and the progression of the underlying disease.

Image J as the quantification tool in endosonography strain elastography may be reflected in the disturbance of endocrine pancreatic dysfunction.

Pancreatic fibrosis is one of the main pathological features of chronic pancreatitis (CP), suggesting a strong relationship between CP and pancreatic ductal cancer. There was no available data about pancreatic fibrosis and pancreatic dysfunction in the early CP (ECP) using endosonography (EUS). Asymptomatic patients with pancreatic enzyme abnormalities (AP-P; n = 56) and patients with ECP (n = 21) were determined by the absence of abnormal findings on upper gastrointestinal endoscopy, abdominal ultrasonography, and abdominal computed tomography. An Olympus EUS (GF-UCT 260; Olympus) was used to perform EUS. Open software "Image J", developed by NIH, was used to measure the surface area fraction of the designated elastic blue region. The maximum value among the pancreatic head, pancreatic body, and pancreatic tail was defined as the ELST-blue score. The exocrine and endocrine pancreatic functions were evaluated using the N-benzoyl-l-tyrosyl-p-aminobenzoic acid (BT-PABA) test and homeostasis model assessment of β-cell function (HOMA-β) value, respectively. EUS score, lobularity, and hyperechoic foci/strands in patients with ECP were significantly (p < 0.001) higher than those in patients with AP-P. In addition, there were no significant differences in the BT-PABA test (73.1 ± 25.5, 68.5 ± 15.6) and HOMA-β (93.1 ± 67.4, 73.5 ± 139.7) between patients with ECP and AP-P. The ELST-blue score measured by image J as the quantification tool in EUS strain elastography in patients with ECP was significantly higher (p = 0.002) than that in patients with AP-P. Interestingly, the ELST-blue score was significantly associated with HOMA-β in patients with ECP. The ELST-blue score may be a useful tool for the evaluation of endocrine pancreatic dysfunction in the ECP.

The evaluation of postoperative exocrine pancreatic insufficiency in patients with benign and low-malignant pancreatic tumor: A multicenter, prospective, observational study

Objectives: We assess the incidence of exocrine pancreatic insufficiency (EPI) at different time points after pancreatic surgery and explore pancreatic enzyme replacement therapy's (PERT) efficacy. Background: EPI is characterized by inadequate pancreatic enzymes, resulting in maldigestion and abdominal symptoms. EPI is a common postoperative complication of pancreatic surgery, yet often overlooked by surgeons. There is no clear answer to when EPI occurs after pancreatic surgery nor the duration of PERT after partial pancreatectomy. Methods: Benign or borderline pancreatic tumor patients undergoing surgeries were recruited between December 2020 and November 2021 from 10 medical centers in China. The EPI Questionnaire (EPI-Q) was performed at discharge, and 3-, 6-, 9-, and 12-month follow-ups to evaluate the occurrence of EPI. Statistical analyses were performed to identify the occurrence of EPI and explore PERT's efficacy. Results: Of the 146 patients, 105 (71.9%) were female, and the median age was 49 (range 16-78 yrs). Symptoms of EPI patients were most pronounced within 3 months post-surgery (15.7%), while most patients recovered after 1 year (96.9%). There was a negative correlation between symptom score and time since surgery. Lack of PERT in the 3-month post-surgery was associated with higher symptom scores in pancreatoduodenectomy (PD) patients, while not in distal pancreatectomy (DP) patients. Conclusions: Generally, the high-occurrence period for postoperative EPI is within 3 months after resection in patients with benign or borderline pancreatic tumors, and most will gradually recuperate with time. PERT can improve symptoms in PD patients, while reduced PERT duration may be considered for DP patients.

Minimally invasive treatment of an internal pancreaticopleural fistula with massive pleural effusion: a case report

BackgroundA pancreatic duct rupture can lead to various complications such as a fistula, pseudocyst, ascites, or walled-off necrosis. Due to pleural effusion, pancreaticopleural fistula typically causes dyspnea and chest pain. Leaks of enzyme-rich pancreatic fluid forming a pleural effusion can be verified in a thoracocentesis following radiological imaging such as computed tomography or magnetic resonance tomography. While management strategies range from a conservative to endoscopic and surgical approach, we report a case with successful minimally invasive treatment of pancreaticopleural fistula and effusion.Case presentationWe present a case of a patient with pancreaticopleural fistula and successful minimally invasive surgical treatment. A 62-year old Caucasian man presented with acute chest pain and dyspnea. A computed tomography scan identified a left-sided cystoid formation, extending from the abdominal cavity into the left hemithorax with concomitant pleural effusion. Pleural effusion analysis indicated significantly elevated pancreatic enzymes. Magnetic resonance cholangiopancreatography revealed a rupture of the pancreatic duct and nearby fluid accumulation. Endosonography later confirmed proximity to the tail of the pancreas, suggesting a pancreatic pseudocyst with visible tract into the pancreas. We assumed a pancreatic duct rupture with a fistula from the tail of the pancreas transdiaphragmatically into the left hemithorax with a commencing pleural empyema. A visceral and parietal decortication on the left hemithorax and a laparoscopic distal pancreatectomy with splenectomy was performed. The suspected diagnosis of a fistula arising from the pancreatic duct was confirmed histologically.ConclusionPancreaticopleural fistulas often have a long course and may remain undiagnosed for a long time. At this point diagnostic management and therapy demand a high level of expertise. In instances of unclear symptomatic pleural effusion, considering an abdominal focus is crucial. If endoscopic treatment is not feasible, minimally invasive surgery should strongly be considered, especially when located in the distal pancreas.

Evaluation of Anti-Hyperlipidemic Activity of the Seeds Extracts of Ficus carica: In Vitro and In Silico Approaches.

Obesity and hyperlipidemia have become major disorders predominantly causing prevailing cardiovascular diseases and ultimately death. The prolonged use of anti-obesity drugs and statins for reducing obesity and blood lipid levels is leading toward adverse effects of kidneys and muscles, specifically rhabdomyolysis. The objective of this study is to evaluate potential of seeds of Ficus carica against hyperlipidemia. Various extracts and isolated compounds from fig seeds were analyzed and evaluated for their anti-hyperlipidemic potential. Methanol extract and its ethyl acetate fraction showed maximum pancreatic lipase inhibition of 61.93% and 86.45% in comparison to reference drug Orlistat. Four compounds isolated by HPLC-PDA technique were determined as Gallic acid, Catechin, Epicatechin, and Quercetin also showed strong potential to inhibit enzyme pancreatic lipase comparable to Orlistat. These isolated compounds were further analyzed for molecular docking and MM-GBSA studies. Three ligands, namely Quercetin, Epicatechin, and Catechin were found more effective against pancreatic lipase as these possessed docking scores (-9.881, -9.741, -9.410) higher to that of the reference ligand Orlistat (-5.273). The binding free energies of these compounds were -55.03, -56.54, and 60.35 kcal/mol, respectively. The results have shown that Quercetin has the highest binding affinity correlating with the highest inhibition of pancreatic lipase enzyme 1LPB. Hence, it is suggested that seeds of F. carica have promising anti-hyperlipidemic potential and foremost in reducing obesity.

A rare case of pancreatic pseudocyst-portal vein fistula in a patient with chronic pancreatitis.

A 60-year-old female with chronic pancreatitis and a history of splenectomy presented with epigastric pain, vomiting, and asthenia. Elevated pancreatic enzymes and CT imaging revealed a pseudocyst in the pancreatic head with suspected communication to the portal vein, confirmed by MR Cholangiopancreatography and endoscopic ultrasound (EUS). EUS-guided puncture revealed high amylase levels. Given her manageable symptoms, a conservative approach was adopted, leading to symptomatic relief and pseudocyst size reduction. Pancreatic pseudocyst-portal vein fistula is a rare pancreatitis complication, challenging to diagnose, with no gold-standard treatment. Endoscopic stenting offers a promising alternative to surgery for severe cases.

Groove pancreatitis – an unusual case of pancreatitis, case report

Groove pancreatitis is a rare form of chronic pancreatitis affecting the pancreaticoduodenal groove, leading to ductal stenosis and symptoms like abdominal pain, vomiting, and jaundice. It often coexists with cystic dystrophy of the duodenal wall (CDDW), marked by duodenal wall thickening and cyst formation. We report a case of a 36-year-old male with persistent abdominal pain and a history of acute pancreatitis, diagnosed with CDDW via MRI. Despite multiple endoscopic interventions, ductal access was challenging due to inflammation and conservative management with proton pump inhibitors and pancreatic enzymes provided symptom relief. Diagnostic tools include MRI, endoscopy, and EUS were administered. Management of groove pancreatitis still remains a challenge consisting of treatment ranging from conservative methods to surgical intervention for refractory cases, emphasizing a cautious, stepwise approach and lifestyle changes.

Exocrine pancreatic insufficiency in a child with STEC-HUS: a forgotten complication.

Exocrine pancreatic insufficiency (EPI) is an extremely rare complication of hemolytic uremic syndrome related to Shiga toxin-producing Escherichia coli (STEC-HUS) and, to our knowledge, only one patient has been reported to have received pancreatic enzyme replacement therapy (PERT). Furthermore, STEC-HUS is not usually included among EPI causes. We report a 4-year-old girl with STEC-HUS who required dialysis and 4days after admission developed acute pancreatitis (ACPAN) and diabetes mellitus (DM). Amylase and lipase normalized 15days later but on the 73rd day of admission, she presented abdominal discomfort, bloating, and bulky and malodorous stools with a low fecal elastase-1 level (FE-1) of 15.74µg/g confirming EPI diagnosis. She received 3months of PERT until normalization of FE-1 levels. In children with STEC-HUS with ACPAN or DM, a high index of suspicion for EPI is required, since its symptoms are often mild, nonspecific, or delayed. In addition, STEC-HUS should be further recognized as a cause of secondary EPI.

Porcine-derived pancreatic enzyme replacement therapy may be linked to chronic hepatitis E virus infection in cystic fibrosis lung transplant recipients

ObjectivesIn high-income countries hepatitis E virus (HEV) is an uncommonly diagnosed porcine-derived zoonoses. After identifying disproportionate chronic HEV infections in persons with cystic fibrosis (pwCF) postlung transplant, we sought to...

Effect Of Pentavalent Antimony Compounds On The İnflammatory, Hematological and Biochemical Parameters İn Patients With Cutaneous Leishmaniasis

Objective This study aimed to evaluate how systemic antimony treatment in cutaneous leishmaniasis (CL) patients affects biochemical, hematological, and inflammatory parameters in child and adult patient groups. Methods A total of 50 patients (29 adults, 21 children) who received systemic meglumine antimonate (MA) treatment in the skin and venereal diseases clinic between September 2022 and January 2024 and were diagnosed with CL by microscopic examination were included in the study. The medical records of the patients were examined retrospectively. Before and after treatment, neutrophil count, leukocyte count, lymphocyte count, hemoglobin concentration, platelet count, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), mean platelet volume (MPV), amylase, lipase, alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen and serum creatinine levels were recorded. Results In the children group, lymphocyte and platelet values decreased statistically significantly; and lipase value increased statistically significantly after treatment. In the adult group; hemoglobin, neutrophil, lymphocyte and leukocyte values decreased statistically significantly; ALT, AST, amylase, lipase, NLR and PLR values increased statistically significantly after treatment. Conclusion Based on the data in our study, it was stated that systemic meglumine antimonate treatment may lead to an increase in pancreatic enzymes and transaminases and bone marrow suppression. We also think that patients in the adult age group should be followed more closely regarding pancreatic enzymes and kidney function tests than the pediatric age group.

Selection strategy for endoscopic necrosectomy approaches of infected walled-off pancreatic necrosis: Analysis of 101 patients from a single center with long-term follow-up.

Endoscopic necrosectomy (EN) is a promising minimally invasive approach for treating infected walled-off pancreatic necrosis (WOPN). Multiple EN approaches are currently available, though criteria for selecting the optimal approaches are lacking. We aimed to propose a rational selection strategy of EN and to retrospectively evaluate its safety and effectiveness. Altogether 101 patients who underwent EN for infected WOPN at a tertiary hospital between June 2009 and February 2023 were retrospectively included for analysis. Demographic characteristics, details of the EN procedures, procedure-related adverse events, and clinical outcomes were investigated. Among these 101 patients with WOPN, 56 (55.4%) underwent transluminal EN, 38 (37.6%) underwent percutaneous EN, and seven (6.9%) underwent combined approach, respectively. Clinical success was achieved in 94 (93.1%) patients. Seven (6.9%) experienced procedure-related adverse events, and seven (6.9%) died during the treatment period. During a median follow-up of 50 months, 5 (5.3%) of the 94 patients had disease recurrence, 17.0% (16/94) had new-onset diabetes mellitus, and 6.4% (6/94) needed oral pancreatic enzyme supplementation. The clinical success rate, procedure-related adverse event rate, and long-term follow-up outcomes were not significantly different among the three groups. High APACHE-II scores (≥15) and organ failure were identified as factors related to treatment failure. A selection strategy for EN approaches, based on the extent of necrosis and its distance from the gastrointestinal lumen (using a threshold of 15 mm), is safe and effective for treating infected WOPN in both short-term and long-term outcomes.

Dual amylase/glucosidase inhibition, antilipolytic and antiproliferative potential of the aerial parts of Pistacia atlantica, Pistacia lentiscus and Pistacia terebinthus on a obesity related-colorectal cancer cell line panel

Abstract Pistacia species (P. spp) have been used as a treatment for various diseases, including diabetes and inflammation. This study aimed to identify the main components of flavonoids in Pistacia species and evaluate the effect of aqueous extracts of P. spp on pancreatic enzymes and on cancer cells associated with obesity in colon and rectum. HPLC was used to identify the major components of flavonoids. The potent inhibitory effect of Pistacia species against pancreatic α-amylase, α-glucosidase and lipase was examined. The antiproliferative efficacy of the plant extract against several colorectal cancer cell lines were then measured. The main flavonoids component found in Pistacia species are quercetin-3-β-D-glucoside, rutin, kaempferol and vitexin. The starch blockade IC50 (µg/mL) of Pistacia species in a descending order were: P. lentiscus leaves: 1.09±0.01; P. atlantica leaves: 0.96±0.09 and P. atlantica fruits: 0.48±0.02. Pistacia species exerted promising inhibition effect for pancreatic lipase (PL). Besides the aglycones of P. atlantica leaves, all the tested aqueous extracts exerted appreciably novel antiproliferative activity against the tested colorectal cancer cell lines. This study provides useful indication for the Pistacia species as a potential novel therapeutic agent against diabesity and cancer.

Serum Biochemistry and Haematology Alterations in Sled Dogs Before and After a Race

Abstract Long-distance sled dogs are known for their great endurance and ability to run several hundred kilometres over the course of a few days. There are several factors to consider when selecting a team of high-performing sled dogs, including their physique, body score condition, appetite, paws, and ability to adapt to unknown environments and situations. The most common breed used in sled dog racing, Alaska Huskies, are known for their great work diligence, and determined mindset. It has previously been researched how well these dogs endure such intense physical activity using observation of behavioural patterns, physical examinations, and the analysis of alterations in blood parameters. This study aimed to evaluate serum chemistry and haematology alterations in dogs before and after completing a 300 km race in Norway. Changes were observed in haematology and serum chemistry between pre- and post-race blood sampling. Significant increases were observed in the white blood cell count, haemoglobin in blood and creatine phosphokine activity in serum (CK), and significant decreases were seen in the electrolytes (e.g., chlorides, potassium), cholesterol levels, liver (e.g., alkaline phosphatase) and pancreatic enzymes (α-amylase, lipase), and total red blood cell count. Several other parameters were measured, and resulted in insignificant changes. Our results indicated that long-distance racing, in fact, has an impact on the physiology of the dog, influencing muscular system, the gastrointestinal tract, electrolyte balance and haematopoiesis among others.

Long-Term Vonoprazan and Acotiamide-Refractory Patients With Functional Dyspepsia Partly Exhibit Pancreatic Enzyme Abnormalities.

Although a new potassium-competitive acid blocker (P-CAB)vonoprazan has been developed in Japan, no data are available regarding long-term vonoprazan or vonoprazan and acotiamide combination treatment in patients with functional dyspepsia (FD). A total of 73 consecutive patients with FD diagnosed according to the Rome III classification were enrolled. Forty-two patients with FD were treated with vonoprazan monotherapy and thirty-one patients with FD were treated with vonoprazan and acotiamide combination therapy for 24 weeks. The levels of five pancreatic enzymes were measured, and the overall treatment efficacy (OTE) was defined as the ratio of FD patients with improved or unchanged in all items of GSRS and FD symptom scores after the treatment. Treatment with vonoprazan monotherapy and vonoprazan and acotiamide combination therapy significantly improved FD symptoms. There were no significant differences in OTE between patients treated with vonoprazan monotherapy (42.9%) and those treated with vonoprazan and acotiamide combination therapy (52%). There were no significant differences in duodenal eosinophilic infiltration between the improved and unimproved groups treated with vonoprazan alone and vonoprazan and acotiamide combination therapy, respectively. In contrast, there was a significant difference (P = 0.004) in the ratio of pancreatic enzyme abnormalities between the improved and unimproved patients treated with vonoprazan monotherapy and those treated with vonoprazan and acotiamide combination therapy. Long-term vonoprazan alone or vonoprazan and acotiamide combination therapy significantly improved each FD symptom. The OTE in patients treated with vonoprazan alone or vonoprazan and acotiamide combination therapy was only 50%. Long-term vonoprazan and acotiamide combination therapy may differentiate patients with pancreatic enzyme abnormalities from those with FD.

Small intestinal bacterial overgrowth (SIBO) - Therapy, nutrition, microbiome

SIBO (small intestinal bacterial overgrowth) is defined by bacterial overgrowth or colonization of the small intestine in combination with gastrointestinal symptoms such as bloating, nausea, pain, diarrhoea, malabsorption and food intolerance. SIBO can be caused by various mechanisms such as reduced intestinal motility, altered gastrointestinal anatomy, reduced gastric acid or pancreatic enzyme production, altered bile acid metabolism, or immune defects. Accordingly, SIBO often develops secondary to different underlying diseases.Diet has a fundamental influence on the composition of the intestinal microbiome and is therefore also a potential pathomechanism in SIBO. Furthermore, food intolerances are common in SIBO patients. However, both aspects have so far been insufficiently investigated. Nevertheless, elemental diets, carbohydrate-reduced diets, as well as pre- and probiotics are potential therapy options.This article provides a summary of current knowledge on the pathophysiology, diagnosis and treatment of SIBO, with particular emphasis on the role of nutrition and the microbiome.

The clinical outcomes and healthcare resource utilization in IgG4-related disease: a claims-based analysis of commercially insured adults in the United States.

IgG4-related disease (IgG4-RD) can affect nearly any organ and is often treated with glucocorticoids, which contribute to organ damage and toxicity. Comorbidities and healthcare utilization in IgG4-RD are poorly understood. We conducted a cohort study using claims data from a US managed care organization. Incident IgG4-RD cases were identified using a validated algorithm; general population comparators were matched by age, sex, race/ethnicity and index date. The frequency of 21 expert-defined clinical outcomes associated with IgG4-RD or its treatment and healthcare-associated visits and costs were assessed 12 months before and 36 months after the index date (date of earliest IgG4-RD-related claim). There were 524 cases and 5240 comparators. Most cases received glucocorticoids prior to (64.0%) and after (85.1%) the index date. Nearly all outcomes, many being common glucocorticoid toxicities, occurred more frequently in cases vs comparators. During follow-up, the largest differences between cases and comparators were seen for gastroesophageal reflux disease (prevalence difference: +31.2%, P < 0.001), infections (+17.3%, P < 0.001), hypertension (+15.5%, P < 0.01) and diabetes mellitus (+15.0%, P < 0.001). The difference in malignancy increased during follow-up from +8.8% to +12.5% (P < 0.001). Some 17.4% of cases used pancreatic enzyme replacement therapy during follow-up. Over follow-up, cases were more often hospitalized (57.3% vs 17.2%, P < 0.01) and/or had an emergency room visit (72.0% vs 36.7%, P < 0.01); all costs were greater in cases than comparators. Patients with IgG4-RD are disproportionately affected by adverse outcomes, some of which may be preventable or modifiable with vigilant clinician monitoring. Glucocorticoid-sparing treatments may improve these outcomes.

Exokrinní pankreatická nedostatečnost – klinická praxe roku 2024

Summary Exocrine pancreatic insufficiency (EPI) is characterized by insufficient secretion of pancreatic digestive enzymes. According to the mechanistic theory, the lack of pancreatic enzymes in the small intestine does not ensure the digestion of food, which is mainly associated with the lack of essential fatty acids and liposoluble vitamins and, as a result, leads to the inability to ensure the nutritional and metabolic needs of the organism. In diagnostics, the standard is determination of fecal elastase. This determination is simple, the limitation is the low sensitivity to determine possible changes in pancreatic function already in the so-called initial stages of the dis ease. An alternative to fecal elastase testing is the use of breath tests using a mixture of triglycerides, radioactively labeled with carbon C13. Although the test is non-invasive, it is time-consuming and more difficult to access. The clinical symptoms of EPI are mainly those related to microbial digestion and subsequent malabsorption/maldigestion of micro- and macronutrients. In addition to the subjective feeling of bloating, borborygmy or osmotic diarrhea, low levels of liposoluble vitamins and some trace elements are frequent findings. Osteoporosis or sarcopenia belong to the picture of EPI. In EPI therapy, diet therapy and pancreatic enzyme replacement are essential approaches. The principle is to administer an adequate dose, especially of pancreatic lipase: 40,000–50,000 units with main meals, with application during meals. Smaller meals (snacks) are substituted with half the dose. The optimal galenic form is capsules with a protective cover, against the inactivation of enzymes by gastric acid, before they enter the duodenum. The galenic form is capsules containing enzymes in microparticles, 1.0–2.0 mm in size, which are released from the capsule upon entering the duodenum. This is the so-called controlled synchronization of the liberalization of the enzymes contained in the capsule. EPI is an underdiagnosed and undertreated condition in the population. The control of patients must therefore include, in addition to the evaluation of the overall clinical condition, the monitoring of changes that may manifest malabsorption. It is recommended to monitor the nutritional status at least once a year, at regular intervals. Keywords exocrine insufficiency, maldigestion, malabsorption, fecal elastase, osteoporosis, osteopenia, pancreatic replacement, microparticle capsules

Effect of an Early Mobilization Program on Functional Capacity after Coronary Artery Bypass Surgery a Systemic Review

Phenylalanine function stabilized by lysine which found on lysosomal surface, that Phe necessary to regulate the synthesis or secretion of α-amylase, trypsin and lipase, where the Severe acute pancreatitis in a child with phenylketonuria. The phenylketonuria due to decreased lysine followed by lysosomal dysfunction that will be result of deficiency in phenylalanine function that will not form pancreatic enzymes and stomach enzyme and will be accumulated. The Lysosomal dysfunction will be result of accumulation of undigested polymer including inflammation which play important roles in pathophysiology, that reflect reduction in lysine acylation followed by reduction in aminoacyl tRNAs which promote Phe and E coli functions for activating protein and mRNAs synthesis, that will be followed by increasing in TNf-a synthesis (and reduction in VEGF-As ) which activate NK (not beings related to human immune proper function ) which regulated by the undigested polymers in random pathways stimulated by TNf-a functional pathway (activated by NLRP3 inflammasome. Retinoic acid is necessary to promote lysine acylation which regulate aminoacyl-tRNAs production regulated by mitochondrial enzymes, which regulate mRNA production by E coli (regulated by phenylalanine) that necessary to run antioxidant functions and cellular biosynthesis. Lysine acetylation so important to regulates the activity of Escherichia coli Sadenosylmethionine synthase. RNA (produced by E coli) is 2′-O-methylated demonstrated higher stability that can improve immune by promoting anti-inflammatory processes and improve myocardial functions, and adopt heart constriction by activating NR4As pathway. The antihypertensive pathway mechanism is: the Lysine ¬¬&gt;activate ATPase (stimulate retinoic acid “RA” ) ¬¬&gt;Lysine acetylation ¬¬&gt; promote Phe/ hydroxylase ¬¬&gt; followed by ¬&gt;activate Tyr/ hydroxylase ¬&gt;activate dopamine ¬&gt; activate NR4As pathway ¬&gt;GC-beta ¬&gt;activate both of Oxytocin and Nrf2 ¬&gt; Ang2-AT2 and VEGF-A productive functions ¬&gt;heme oxygenase ¬&gt;anti-inflammatory growth and processes. Lysine Methylation has important role in adopt hypertension through activating pervious Antihypertensive pathway mediated by Phe hydroxylase synthesis and Tyr hydroxylase production followed by activating both of dopamine and NR4As pathway. The oxidation of phenylalanyl-tRNA synthetase positively regulates translational quality control, and regulates the initiation of digestive enzyme mRNA translation, where consecutive AAA-lysines is paused for encoding Phe followed by ribosome sliding on homopolymeric A sequence. That lysine activates mitochondria function followed by promoting Phenylalanine and phenylalanine-tRNAs productions by translations within E coli, followed by Phe/ hydroxylase activate Tyr hydroxylase production which activate dopamine synthesis. And positively, Lysine is the most effective amino acid for activating all of ATPase, GTPase, and lysosomes, and E coli functions, where ATPase necessary for activating lysine Phosphorylation for activating lysosome digestion, followed by activating E coli through activating Phe hydroxylase production, while GTPase necessary for activating mitochondrial repairs, which act on pro-inflammation and cholesterol for activating estrogen production and activating the NR4As pathway which activate all of Oxytocin, Nrf2 followed by Ang2-AT2 and VEGF-A production and then followed by activating heme oxygenase and anti-inflammatory growth and processes that prevent LV-hypertrophy, and prevent coronary calcification.

A review of proton pump inhibitor use in cystic fibrosis and considerations for deprescribing.

Use of proton-pump inhibitors (PPIs) is common among people with cystic fibrosis (pwCF) both for the management of suspected GERD, as well as pancreatic enzyme replacement therapy augmentation. Despite their use, limited data exist to demonstrate a clinically significant impact of PPIs on key endpoints in pwCF. Furthermore, the advent of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy may modify the need for use. These notions, coupled with the potential for adverse outcomes associated with long-term PPI use in pwCF, should facilitate re-evaluation of long-term PPI use in pwCF and promote potential deprescribing. Despite limited data on PPI deprescribing in pwCF, it intuitively mirrors the existing guidance in adults in the general population, but with added consideration given to tapering strategy, and monitoring for CF-specific outcomes such as nutritional and respiratory status. The development of a monitoring and re-initiation plan is key to reducing deprescribing inertia. This review aims to summarize the evidence that details the concern for long-term use of PPIs and provide CF clinicians with rationale and guidance on how to approach deprescribing in their practice.