Portable droplet-based real-time monitoring of pancreatic α-amylase in postoperative patients

Postoperative complications after pancreatic surgery are frequent and can be life-threatening. Current clinical diagnostic strategies involve time-consuming quantification of α-amylase activity in abdominal drain fluid, which is performed on the first and third postoperative day. The lack of real-time monitoring may delay adjustment of medical treatment upon complications and worsen prognosis for patients. We report a bedside portable droplet-based millifluidic device enabling real-time sensing of drain α-amylase activity for postoperative monitoring of patients undergoing pancreatic surgery. Here, a tiny amount of drain liquid of patient samples is continuously collected and co-encapsulated with a starch reagent in nanoliter-sized droplets to track the fluorescence intensity released upon reaction with α-amylase. Comparing the α-amylase levels of 32 patients, 97 % of the results of the droplet-based millifluidic system matched the clinical data. Our method reduces the α-amylase assay duration to approximately 3 min with the limit of detection 7 nmol/s·L, enabling amylase activity monitoring at the bedside in clinical real-time. The presented droplet-based platform can be extended for analysis of different body fluids, diseases, and towards a broader range of biomarkers, including lipase, bilirubin, lactate, inflammation, or liquid biopsy markers, paving the way towards new standards in postoperative patient monitoring.

No Drain, No Problem: Serum-Based Marker Prediction of Clinically Relevant Postoperative Pancreatic Fistula

BACKGROUND

Postoperative day (POD) 1 drain amylase concentration (DAC) is considered the most accurate predictor for the development of a clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Recent studies have associated drain placement with negative postoperative outcomes. This study aims to evaluate multiple biochemical markers and their associations with CR-POPF development in order to identify a reliable, non-drain dependent alternative to DAC.

METHODS

This is a review of 53 consecutive PD patients between 2021 and 2022. Albumin, C-reactive protein (CRP), C-reactive protein-to-albumin ratio (CAR), DAC, white blood cell count, and procalcitonin values were compared by CR-POPF status. The discriminatory abilities of CAR, CRP, and DAC for CR-POPF were compared using receiver operating characteristic (ROC) curves.

RESULTS

Six of 51 included patients developed a CR-POPF. Receiver operating characteristic curve analysis produced an area under the curve of .977 for POD 1 DAC (cut-off 5131.0 IU/L, sensitivity 100%, specificity 95.5%), .858 for POD 1 CRP (cut-off 52.5 mg/L, sensitivity 100%, specificity 72.7%), and 1.000 for POD 3 CAR (cut-off 99.2, sensitivity and specificity 100%). POD 3 CAR produced a positive and negative predictive value of 100%.

CONCLUSION

The CAR and CRP provide early and accurate identification of patients with post-PD CR-POPFs. These markers offer a method of safe CR-POPF detection, when the gold standard DAC is unavailable, ultimately allowing for early intervention and patient rescue.

Age and incidence of occult pancreaticobiliary reflux in patients with benign gallbladder diseases

BACKGROUND

Occult pancreaticobiliary reflux (OPBR) has a significant correlation with diseases of the gallbladder and biliary system. This study examined the incidence of OPBR by age in patients with benign gallbladder diseases.

METHODS

We assessed 475 patients with benign gallbladder diseases who underwent surgery at Shanghai East Hospital from December 2020 to December 2021. Bile samples collected during surgery were tested for amylase. Patients with bile amylase >110 U/L (n = 64) were classified as the OPBR group; the rest (n = 411) as controls.

RESULTS

Of the participants, 375 had gallbladder stone (GS), 170 had gallbladder polyp (GP), and 49 had gallbladder adenomyomatosis (GA). The OPBR group was generally older, with OPBR incidence increasing with age, peaking post-45. Rates by age were: 4.9% (<35), 5.2% (35-44), 20.7% (45-54), 22.5% (55-64) and 17.6% (≥65), mainly in GS patients. ROC analysis for predicting OPBR by age yielded an area under the curve of 0.656, optimal cut-off at 45 years. Logistic regression indicated age > 45, GP, male gender, and BMI ≥ 24 kg*m-2 as independent OPBR predictors in GS patients. Based on these variables, a predictive nomogram was constructed, and its effectiveness was validated using the ROC curve, calibration curve and decision curve analysis (DCA). Further stratification revealed that among GS patients ≤ 45, concurrent GA was an OPBR risk; for > 45, it was GP and male gender.

CONCLUSIONS

The incidence of OPBR in GS patients is notably influenced by age, with those over 45, especially males without GP, being at heightened risk.

Evaluation of the effect of ozone disinfection on forensic identification of blood, saliva, and semen stains

Good laboratory practice minimizes the biological hazard posed by potentially infectious casework samples. In certain scenarios, when the casework sample is contaminated with highly contagious pathogens, additional safety procedures such as disinfection might be advised. It was previously proven that ozone gas treatment does not hamper STR analysis, but there is no data on how the disinfection affects other steps of the forensic analysis. In this study, we aimed to assess the interference of ozone disinfection with forensic tests used to identify biological stains. A dilution series of blood, saliva, and semen samples were pipetted onto cotton fabric and let completely dry. Half of the samples were subjected to ozone treatment, while the rest served as controls. All the samples were tested with specific lateral flow immunochromatographic assays and for specific RNA markers with quantitative real-time PCR. Additionally, luminol test was carried out on blood spots, Phadebas® Amylase Test on saliva stains, and semen stains were examined with STK Lab kit and light microscope following Christmas Tree or Hematoxylin-Eosin staining. Ozone treatment had no detrimental effect on the microscopic identification of sperm cells. Undiluted blood samples were detected with luminol and immunoassay, but at higher dilution, the sensitivity of the test decreased after disinfection. The same decrease in sensitivity was observed in the detection of semen stains using STK Lab kit from STK® Sperm Tracker, and in the case of the immunoassay specific for prostate-specific antigen (PSA). Ozone treatment almost completely inhibited the enzymatic activity of amylase. The sensitivity of antibody-based detection of amylase was also greatly reduced. RNA markers showed degradation but remained detectable in blood and semen samples after incubation in the presence of ozone. In saliva, the higher Ct values of the mRNA markers were close to the detection limit, even before ozone treatment.

Drain fluid volume combined with amylase level predicts clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: A retrospective clinical study

BACKGROUND AND AIM

Several indicators are recognized in the development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). However, drain fluid volume (DFV) remains poorly studied. We aimed to discover the predictive effects of DFV and guide clinical management.

METHODS

We retrospectively reviewed the clinical data of patients that received PD between January 2015 and December 2019 in a high-volume center. DFV was analyzed as a potential risk factor and postoperative short-term outcomes as well as drain removal time were compared stratified by different DFV levels. Receiver operating characteristic curves and area under curves (AUC) were compared for DFV alone and DFV combined with drain fluid amylase (DFA). Subgroup analysis of DFV stratified by DFA evaluated the predictability of CR-POPF.

RESULTS

CR-POPF occurred in 19.7% of 841 patients. Hypertension, postoperative day 3 (POD3) DFA ≥ 300 U/L, and POD3 DFV ≥ 30 mL were independent risk factors, while pancreatic main duct diameter ≥ 3 mm was a protective factor. POD3 DFV ≥ 30 mL increased the overall occurrences of CR-POPF and major complications (P = 0.017; P = 0.029). POD3 DFV alone presented a low predictive value (AUC 0.602), while POD3 DFV combined with DFA had a high predictive value (AUC 0.759) for CR-POPF. Subgroup analysis showed that the combination of POD3 DFV ≥ 30 mL and DFA ≥ 300 U/L led to higher incidences of CR-POPF (P = 0.003).

CONCLUSION

CR-POPF is common after PD, and high DFV combined with DFA may predict its occurrence and facilitate appropriate management.

Comparative Evaluation of Salivary Parameters in Tobacco Substance Abusers

BACKGROUND

Tobacco use by youth is ever-demanding, and it is increasingly distributed not only in India but also globally. Saliva is a complex oral bio-fluid, freely available, performing absolute tasks for maintaining oral health and homeostasis. It contains a plethora of significant constituents such as proline-rich proteins (PRPs), immunoglobulins, IgA, enzymes lysozyme, lactoferrin, peroxidases, amylase, etc. The basic ecological balance of the oral cavity is stabilized via salivary clearance by reduced aggregation and adherence of microorganisms by direct microbial activity. This balance of oral activity is also done by indirect mechanisms by immunological as well as non-immunological means and also by effectively regulating salivary pH flow rate. This institutional observational study was planned to assess and compare salivary parameters (pH, salivary flow rate), total proteins, α-amylase, calcium, phosphate, and IgA, of unstimulated whole saliva of both tobacco abusers and tobacco non-users.

METHODS

The Study consisted of 270 participants (Tobacco habit) group, n = 135 and Control (Healthy) group, n = 135 and were in the age range of 20-50 years. They were assessed for oral health status, followed by the analysis of salivary pH, flow rate, total proteins, amylase, calcium, phosphates, and IgA of unstimulated whole saliva.

RESULTS

Comparative evaluation of salivary parameters among groups found that varying tobacco abusers had increased salivary amylase, protein levels, and phosphate whereas decreased salivary pH, flow rate, IgA, and in the whole unstimulated saliva samples than those of non-tobacco users. This difference among groups was statistically significant. (p < 0.05), and calcium levels were not altered significantly.

CONCLUSIONS

This study concludes that salivary parameters are altered in tobacco abusers when compared to those of non-abusers, and it was more significant in smokeless tobacco abusers than in any other form of tobacco abuse.

Post-pancreatectomy Acute Pancreatitis in Distal Pancreatectomies - a Rare Bird According to the New Definition

BACKGROUND

Post-pancreatectomy acute pancreatitis (PPAP) is a recently identified clinical condition characterized by sustained elevated serum amylase levels for at least 48 h post-operatively, consistent radiological findings, and relevant clinical features. The purpose of this study was to determine the frequency of PPAP after DP, to investigate the rate of major complications in patients with sustained or transiently elevated serum amylase activity, and to explore the usability of CT as a prerequisite for the diagnosis of PPAP.

METHODS

This retrospective single-center observational study included consecutive patients 18 years or older who underwent DP at Karolinska University Hospital between 2008 and 2020. The two serum amylase levels on post-operative days (POD) 1 and 2 were correlated with post-operative major complications by logistic regression analyses.

RESULTS

Of the 403 patients who underwent DP, 14% (n = 58) had sustained elevated serum amylase levels according to PPAP criteria, and 31% (n = 126) had transiently elevated serum amylase levels on either POD1 or POD2. Of the patients with sustained elevated levels, 45% (n = 26) developed major complications, but less than 2% (n = 1) showed imaging findings consistent with acute pancreatitis. Of the 126 patients who exhibited only transiently elevated serum amylase on either POD1 or POD2, 38% (n = 48) developed major complications. The frequency of PPAP was 0.25% (n = 1).

CONCLUSION

These findings indicate that PPAP after DP is rare and that computed tomography has limited usability for diagnosing PPAP. The findings also suggest that transiently elevated serum amylase may be an early indicator of acute pancreatitis, especially when peaked.

Relationship between Salivary Amylase and Xerostomia in Intensity-Modulated Radiation Therapy for Head and Neck Cancer: A Prospective Pilot Study

Purpose. A single-institution prospective pilot study was conducted to the assess correlation between salivary amylase and xerostomia in patients with head and neck squamous cell carcinoma (HNSCC) treated with intensity-modulated radiotherapy (IMRT). Methods and materials. Serum saliva amylase, clinician-reported xerostomia (using Common Terminology Criteria for Adverse Events), and patient-reported xerostomia (using 8-item self-reported xerostomia-specific questionnaire) were prospectively collected at baseline, during treatment and thereafter. Correlations between variables were assessed by correlation matrices. Results. Twelve patients with locally advanced HNSCC formed the cohort. Eighty-three percent were male, 75% were smokers, 100% had clinical positive lymph nodes at diagnosis, and 42% received induction chemotherapy. All patients received IMRT with concurrent cisplatin-based chemotherapy. No grade ≥4 xerostomia was observed. Severe (G3) acute and late xerostomia occurred in five cases (41.7%) and two cases (16.7%), respectively. Patient-reported xerostomia scores were highly correlated with the clinician-reported scores (ρ = 0.73). A significant correlation was recorded between the concentration of amylase and the acute (ρ = −0.70) and late (ρ = −0.80) xerostomia. Conclusion. Preliminary results are encouraging. Prospective clinical trials are needed to define the value of salivary amylase in the management of HNSCC tumors.

A Degradable-Renewable Ionic Skin Based on Edible Glutinous Rice Gel

Traditional wearable devices are commonly nonrecyclable and nondegradable, resulting in energy waste and environmental pollution. Here, a household degradable and renewable ionic skin based on edible glutinous rice gel is developed for a strain, temperature and salivary enzyme activity sensor. This gel depends on intermolecular and intramolecular H-bonds among amylopectin and amylose, and this presents excellent skin-like properties, including stretchability, self-healing property, and adhesion to various substrates. The glutinous rice gel-based skin sensor can be used to monitor vital signs and physiological parameters such as body temperature and heart rate. The sensor also achieves specific speech recognition and detects temperature and body micromovements, which provides the potential to reconstruct language or sensory/motor functions. More importantly, because of the excellent biocompatibility and degradability, the sensor can directly detect the activity of human salivary amylase, which is useful for diagnosing pancreas-, kidney-, and spleen-related diseases in the elderly. Finally, the raw material of ionic skin that originates from traditional grains is degradable and renewable as well as it can be used to prepare household wearable devices. Hence, this work not only extends the application of wearable electronics in daily life but also facilitates health monitoring in the elderly and improves their quality of life.

Influence of ethnicity on biochemical markers of health and disease in the CALIPER cohort of healthy children and adolescents

Background Accurate pediatric reference intervals (RIs) for laboratory tests determined in a healthy pediatric population are essential for correct laboratory test interpretation and clinical decision-making. In pediatrics, RIs require partitioning by age and/or sex; however, the need for partitioning based on ethnicity is unclear. Here, we assessed the influence of ethnicity on biomarker concentrations in the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER) cohort of healthy children and adolescents and compared the results with the National Health and Nutrition Examination Survey (NHANES). Methods A total of 52 biomarkers were measured in a multiethnic population of 846-1179 healthy children (aged 5 to <19 years) upon informed consent. Biomarker concentrations were retrospectively compared between four major ethnic groups (i.e. Black, Caucasian, East Asian, and South Asian, determined by parental ethnicity). Retrospective results were verified prospectively using an additional 500 healthy pediatric samples with equal sample size across ethnicities. Ethnic-specific differences were assessed based on statistical significance and biological and analytical variations. Appropriate age-, sex-, and ethnic-specific RIs were calculated. Results Ethnic-specific differences were not observed for 34 biomarkers examined in the retrospective analysis, while 18 demonstrated statistically significant ethnic differences. Among these, seven analytes demonstrated ethnic-specific differences in the prospective analysis: vitamin D, amylase, ferritin, follicle-stimulating hormone (FSH), immunoglobulin A (IgA), immunoglobulin G (IgG), and immunoglobulin M (IgM). Analysis of select NHANES data confirmed CALIPER findings. Conclusions This is the first comprehensive Canadian pediatric study examining ethnic-specific differences in common biomarkers. While the majority of biomarkers did not require ethnic partitioning, ethnic-specific RIs were established for seven biomarkers showing marked differences. Further studies in other populations are needed to confirm our findings.

Various Modalities Accurate in Diagnosing a Disrupted or Disconnected Pancreatic Duct in Acute Pancreatitis: A Systematic Review

BACKGROUND

Severe pancreatitis may result in a disrupted pancreatic duct, which is associated with a complicated clinical course. Diagnosis of a disrupted pancreatic duct is not standardized in clinical practice or international guidelines. We performed a systematic review of the literature on imaging modalities for diagnosing a disrupted pancreatic duct in patients with acute pancreatitis.

METHODS

A systematic search was performed in PubMed, Embase and Cochrane library databases to identify all studies evaluating diagnostic modalities for the diagnosis of a disrupted pancreatic duct in acute pancreatitis. All data regarding diagnostic accuracy were extracted.

RESULTS

We included 8 studies, evaluating five different diagnostic modalities in 142 patients with severe acute pancreatitis. Study quality was assessed, with proportionally divided high and low risk of bias and low applicability concerns in 75% of the studies. A sensitivity of 100% was reported for endoscopic ultrasound and endoscopic retrograde cholangiopancreatography. The sensitivity of magnetic resonance cholangiopancreatography with or without secretin was 83%. A sensitivity of 92% was demonstrated for a combined cohort of secretin-magnetic resonance cholangiopancreatography and magnetic resonance cholangiopancreatography. A sensitivity of 100% and specificity of 50% was found for amylase measurements in drain fluid compared with ERCP.

CONCLUSIONS

This review suggests that various diagnostic modalities are accurate in diagnosing a disrupted pancreatic duct in patients with acute pancreatitis. Amylase measurement in drain fluid should be standardized. Given the invasive nature of other modalities, secretin-magnetic resonance cholangiopancreatography or magnetic resonance cholangiopancreatography would be recommended as first diagnostic modality. Further prospective studies, however, are needed.

Drain Amylase Levels in the Early Diagnosis of Gastric Leak after Laparoscopic Sleeve Gastrectomy

OBJECTIVES

Laparoscopic sleeve gastrectomy is gaining popularity as a bariatric option. Gastric leak is the most dreaded septic complication after this procedure. This study investigated levels of drain amylase that could be useful for predicting gastric leak before its clinical presentation.

SUBJECTS AND METHODS

This prospective observational study was carried out in 167 patients who underwent sleeve gastrectomy for morbid obesity between February 2014 and March 2020. Measurement of drain amylase levels (DALs) was adapted as a routine procedure. The results of the receiver operative characteristic (ROC) curve analysis revealed an optimal drain amylase levels cutoff point of 814.18 IU/L. Consequently, the DALs were classified as DALs &lt814.18 or DALs ≥814.18 for all subsequent analyses.

RESULTS

Gastric leak occurred in 6 patients. Drain amylase levels of 167 patients were tested. The mean value for patients without leak was 71.13 ± 72.11 IU/L; for patients with leak, it was 4,687 ± 6,670 IU/L (p &lt 0.001). Using ROC curve analysis, the mean ± standard error of the area under the curve for DALs on postoperative day 1 was 0.9927 ± 0.0075, CI = 0.978-1.00, and a cutoff level at 814.18 IU/L for predicting gastric leak achieved 83.33% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value 99.38%. All patients with a leak, but one, had a drain amylase level &gt;814.18 IU/L.

CONCLUSION

The determination of drain amylase levels after sleeve gastrectomy is a significant indicator of gastric leak with high sensitivity and specificity.

Bioactive compounds guided diversity of endophytic fungi from Baliospermum montanum and their potential extracellular enzymes

Baliospermum montanum (Willd.) Muell. Arg, a medicinal plant distributed throughout India from Kashmir to peninsular-Indian region is extensively used to treat jaundice, asthma, and constipation. In the current study, 203 endophytic fungi representing twenty-nine species were isolated from tissues of B. montanum. The colonization and isolation rate of endophytes were higher in stem followed by seed, root, leaf and flower. The phytochemical analysis revealed 70% endophytic isolates showed alkaloids and flavonoids, 13% were positive for phenols, saponins and terpenoids. Further, these endophytes produced remarkable extracellular enzymes such as amylase, cellulase, phosphates, protease and lipase. The most promisive three endophytic fungi were identified by ITS region and secreted metabolites were identified by gas chromatography-mass spectrometry (GC-MS/MS). The GC-MS profile detected twenty-five bioactive compounds from ethyl acetate extracts. Among endophytic fungi, Trichoderma reesei isolated from flower exhibited nine bioactive compounds namely, 2-Cyclopentenone, 2-(4-chloroanilino)-4-piperidino, Oxime-methoxy-Phenyl, Methanamine N-hydroxy-N-methyl, Strychane, Cyclotetrasiloxane, Octamethyl and 1-Acetyl-20a-hydroxy-16-methylene. The endophyte, Aspergillus brasiliensis isolated from root and Fusarium oxysporum isolated from seed produced nine and seven bioactive compounds, respectively. Overall, a significant contribution of bioactive compounds was noticed from the diverse endophytic fungi associated with B. montanum and could be explored for development of novel drug with commercial values.

Appraisal of different levels of soybean meal in diets on growth, digestive enzyme activity, antioxidation, and gut histology of tilapia (Oreochromis niloticus)

This study was designed to determine the effect of fishmeal (FM) replacement with soybean meal (SBM) in the diet of tilapia (Oreochromis niloticus). Growth, digestive enzyme activity, antioxidation, and gut histomorphology were assessed in the fish fed with five different formulated diets that increasingly replaced FM. The SBM0 contained 100% FM, followed by 25% (SBM25), 50% (SBM50), 75% (SBM75), and 100% (SBM100). Juvenile tilapia having weight and length of 6.6 ± 0.1 g and 5.4 ± 0.2 cm, respectively, were randomly divided into five treatment groups. Each group had 40 individual fish and fed to visual satiation for 90 days. Body weight gain and specific growth rate in fish fed with 25-75% SBM increased significantly (P < 0.01) compared with those in fish fed with SBM100. Fish having the same weight fed with diets SBM50, SBM75, and SBM100 showed a significantly (P < 0.01) longer intestine compared with those fed with SBM0 and SBM25. Villus height of the stomach and intestine was significantly (P < 0.01) greater in the fish fed with the diets SBM0, SBM25, and SBM50 compared with SBM75 and SBM100. Muscular thickness was inversely related with the increasing villus height. Protease activity increased significantly (P < 0.01) in the stomach, anterior intestine, and posterior intestine of fish fed with SBM0 compared with SBM100. In the stomach and anterior and posterior segments of the intestine, significantly (P < 0.01) higher lipase activity was observed in fish fed with the diets SBM0 and SBM25 compared with diet SBM100. In the stomach, anterior intestine, and posterior intestine, amylase activity was also significantly (P < 0.01) greater in SBM0 compared with SBM100. The antioxidant enzymes including superoxide dismutase and catalase of the liver were significantly (P < 0.01) higher in fish fed SBM100 compared with SBM0. These results suggest that the replacement of FM up to 75% with SBM could be possible considering the growth performances, gut health, and activities of digestive enzymes and antioxidant enzymes in O. niloticus.

Role of drain amylase levels assay and routinary postoperative day 3 abdominal CT scan in prevention of complications and management of surgical drains after pancreaticoduodenectomy

To asses drains amylase (DA) cut-offs for the risk of clinically relevant postoperative pancreatic fistula (POPF) and define the optimal timing of drains removal based on daily DA assay and abdominal CT scan finding after pancreatoduodenectomy (PD). Different algorithms able to identify patients at higher risk of POPF and to assess the optimal time for drains removal after PD have been proposed. The most accurate DA cut-offs in the assessment of the risk of clinically relevant POPF were retrospectively identified. Data from a prospective trial for optimal timing of drains removal were analyzed. Then, to validate the cut-offs identified in the first phase, they were applied to the patients enrolled in the prospective trial. Patients with POD1 DA ≥ 666 U/L were at higher risk of clinically relevant POPF (p 0.0001). POD3 DA value ≥ 252 U/L predicted 88% of clinical relevant fistulas. POD3 DA level ≥ 207 U/L was able to predict 68% of biliary fistulas. Patients with abdominal collection ≥ 5 cm, showed a significantly higher rate (60% vs. 23%, p < 0.001) of biliary fistula. Timing of drains removal did not influence complications. Drains amylase levels predict clinically relevant POPF. Drains should be maintained up to POD3; in case of POD1 DA levels < 666 U/L and POD3 DA levels < 252 U/L drains could be removed. In case of POD3 DA levels, ≥ 207 the routine use of abdominal CT scan in the same day could be justified to detect collections ≥ 5 cm and maintain drains beyond the POD3.

Is the measurement of drain amylase content useful for predicting pancreas-related complications after gastrectomy with systematic lymphadenectomy?

Many studies investigating postoperative pancreatic fistula (POPF) after gastrectomy, including studies measuring drain amylase content (D-AMY) as a predictive factor have been reported. This article reviews previous studies and looks to the future of measuring D-AMY in patients after gastrectomy. The causes of pancreatic fluid leakage are; the parenchymal and/or thermal injury to the pancreas, and blunt injury to the pancreas by compression and retraction. Measurement of D-AMY to predict POPF has become common in clinical practice after pancreatic surgery and was later extended to the gastric surgery. Several studies have reported associations between D-AMY and POPF after gastrectomy, and the high value of D-AMY on postoperative day (POD) 1 was an independent risk factor. To improve both sensitivity and specificity, attempts have been made to enhance the predictive accuracy of factors on POD 1 as well as on POD 3 as combined markers. Although several studies have shown a high predictive ability of POPF, it has not necessarily been exploited in clinical practice. Many problems remain unresolved; ideal timing for measurement, optimal cut-off value, and means of intervention after prediction. Prospective clinical trial could be imperative in order to develop D-AMY measurement in common clinical practice for gastric surgery.

Significance of Amylase Monitoring in Peritoneal Drainage Fluid after Splenectomy: A Clinical Analysis of Splenectomy in 167 Patients with Hepatolenticular Degeneration

Different kinds of complications after splenectomy in hepatolenticular degeneration patients with hypersplenism have been reported in the past decades, but studies on pancreatic fistula and the corresponding targeted prevention and treatment after splenectomy still remain much unexplored. The present work investigated the pathogenic factors of pancreatic fistula after splenectomy and the variation tendency of amylase in drainage fluid, aiming to verify the significance of monitoring amylase in the abdominal drainage fluid in the early diagnosis of pancreatic fistula after splenectomy. One hundred sixty-seven patients with hepatolenticular degeneration and hypersplenism who underwent splenectomy in the First Affiliated Hospital of Anhui University of Traditional Chinese Medicine from January 2016 to August 2018 were selected and analyzed. The amylase in the abdominal drainage fluid was monitored routinely after splenectomy. We also conducted the statistics on the incidence of different types of pancreatic fistula and analyzed the influence factors of pancreatic fistula formation. After splenectomy, biochemical fistula occurred in 11 patients (6.6%), grade B fistula in six patients (3.6%), grade C fistula in one patient (0.6%), and the incidence of pancreatic fistula was 4.2 per cent (biochemical fistula excluded). The amylase in the peritoneal drainage fluid was closely concerned with the incidence of pancreatic fistula according to our statistics. Furthermore, by analyzing the different influence factors of pancreatic fistula, Child-Pugh grading of liver function (P = 0.041), pancreatic texture (P = 0.029), degree of splenomegaly (P = 0.003), and operative method (P = 0.001) were supposed to be closely related to the formation of pancreatic fistula. Monitoring of amylase in peritoneal drainage fluid is regarded as an important physiological parameter in the early diagnosis of pancreatic fistula after splenectomy, which provides effective clinical reference and plays a significant role in preventing the occurrence and development of pancreatic fistula.

Seasonal variations of digestive enzymes in sea cucumbers (Holothuria tubulosa, G. 1788) under culture conditions

Sea cucumber, Holothuria tubulosa (Gmelin, 1788), is an economically valuable species due to its rich nutrients content that being exported in Turkey. However, culture of this species is difficult due to a lack of knowledge. The main objective of this study is to investigate seasonal activities of main digestive enzymes (protease, lipase, and amylase) for nutritional requirements. In this sense, sea cucumbers were stocked in the glass aquarium and sediment was 10 cm. It was replaced monthly and enriched (1% of the living individual weight) by dried Sargassum sp. Total protease and amylase enzymes have shown higher activity compared to lipase. All three enzyme activities were maximum in the summer and minimum in the winter. In summer, the highest measured total protease, amylase, and lipase activity values were 6.45 ± 0.66, 6.77 ± 0.72, and 2.78 ± 0.32 U/mg per protein, respectively. In winter, the lowest total protease, amylase, and lipase activity values were measured as 2.03 ± 0.16, 1.14 ± 0.14, and 0.12 ± 0.01 U/mg per protein, respectively. As a conclusion of the study, seasonal expression of the main digestive enzymes was strictly dependent on water temperatures and food abundance and also it was ideal to feed this species with food containing high protein and carbohydrate under appropriate temperatures for commercial culture.

2019 WSES guidelines for the management of severe acute pancreatitis

Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Association between salivary amylase enzyme activity and obesity in Saudi Arabia

Obesity is a significant public health concern that predisposes individuals to a high risk of premature mortality. Previous studies also reported that low serum concentrations of AMY1 have been associated with obesity. The aimed of the study to assess the relationship between salivary amylase (AMY1) activity and body mass index (BMI) in Saudi male and female adults in Riyadh. This study included a total of 200 (100 individuals who were overweight and obese and 100 who had normal body weight [control individuals]) Saudi participants aged 20 to 50 years old. They were recruited from physical fitness clubs and were school employees in Riyadh City. The dietary food intake was assessed using a 24-hour dietary recall. The activity of the AMY1 was measured using a microplate fluorescence reader. A significant (P ≤ .05) increase was observed in the incidence of hypertension, dyslipidemia, diabetes mellitus (DM), and family history of overweight and obesity in overweight and obese individuals than in the control individuals, and these were in parallel to the significant increase in weight, waist circumference (WC), hip circumference (HC), systolic blood pressure (SBP), diastolic blood pressure (DBP), and BMI. A significant (P ≤ .05) increase was also observed in the carbohydrate and total fat dietary intake of overweight and obese individuals in relation to the respective dietary reference intake (DRI) values. AMY1 activity was significantly lower than the reference values in the overweight and obese group. Furthermore, AMY1 activity was significantly (P ≤ .05) reverse with weight, WC, HC, and BMI in both males and females in the overweight and obese group. In conclusion, the Saudi overweight and obese population seems to be at risk of low AMY1, which correlates with their obesity.

Assessing abdominal pain in adults: a rational, cost-effective, and evidence-based strategy

The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. Emphasizing safe disposition over diagnosis, this issue identifies the important aspects of the history and physical examination, explores strengths and weaknesses of laboratory evaluations, and summarizes the pros and cons of the many types of imaging now available. With abdominal pain still the most common chief complaint seen in the emergency department, a new look at the evolution of assessment strategies is in order, such as new recommendations on the use of oral contrast, managing HIV patients on highly active antiretroviral therapy, maximizing use of bedside ultrasound, when and how to offer pain relief, and the value of serial examinations and observation to reduce costs and improve care.

Acute pancreatitis with abdominal bloating and distension, normal lipase and amylase: A case report

RATIONALE

Acute pancreatitis is an inflammatory disorder of the pancreas, and its correct diagnosis is an area of interest for clinicians. In accordance with the revised Atlanta classification, acute pancreatitis can be diagnosed if at least 2 of the following 3 criteria are fulfilled: abdominal pain; serum lipase (or amylase) activity at least 3 times the upper limit of normal; or characteristic findings of acute pancreatitis on contrast-enhanced computed tomography (CT) or, less often, magnetic resonance imaging or transabdominal ultrasonography. Diagnostic imaging is essential in patients with no or slight enzyme elevation. If enzymes are normal in cases with abdominal distension, there is clinical doubt about the diagnosis of acute pancreatitis, so an early CT scan should be obtained and other life-threatening disorders excluded.

PATIENT CONCERNS

A 50-year-old male presented with a 1-day history of abdominal bloating and distension. On physical examination, abdominal bulging and mild epigastric tenderness were detected. Laboratory evaluation showed normal amylase and lipase. There was no abnormality on abdominal ultrasound or CT of the abdomen and pelvis. On the fourth day of admission, CT of the abdomen and pelvis showed a hypodense lesion in the pancreas surrounded by a moderate amount of peripancreatic fluid.

DIAGNOSES

In accordance with the revised Atlanta classification, acute pancreatitis was diagnosed, based on the presence of abdominal pain, and the results of the CT scan of the abdomen and pelvis.

INTERVENTIONS

The patient was treated with fasting, gastrointestinal decompression bowel rest, intravenous rehydration, and somatostatin.

OUTCOMES

After 2 days of treatment, his abdominal distension was significantly relieved, and the patient was discharged on the seventh day of admission. At the 3-month follow-up, the patient had no recurrence of pancreatitis.

LESSONS

This case of abdominal distension could not be explained by common causes, such as ascites, bowel edema, hematoma, bowel distension, or ileus, which led us to suspect pancreatitis.

Addition of explicit guidance to acute pancreatitis guidelines increases compliance with amylase measurement recommendations

AIM

Hospital HealthPathways is an online database of local clinical guidelines produced by a dedicated team for use within Canterbury District Health Board (CDHB) hospitals. A 'Practice Point'-a bullet point making explicit a recommendation within the body of a clinical guideline-was added to the guideline for acute pancreatitis, instructing users to avoid serial measurements of serum amylase levels. The aim was to explore whether the addition of this Practice Point affected compliance with the amylase measurement recommendations.

METHOD

The number of serum amylase tests requested for patients admitted with acute pancreatitis by GPs and doctors working in the emergency department, general surgery and other departments was audited using the CDHB's online clinical information system. A data set from a six-month period ending three months prior to the addition of the Practice Point, collected for a previous study, was used with the author's permission as a control group. A new data set from a six-month period starting three months after the addition of the Practice Point formed the experimental group.

RESULTS

Compliance rose by 13% after the addition of the Practice Point. Before the Practice Point was added to the guideline, 82 of 126 total patients (65%) had amylase measured only once, on admission, in compliance with the Hospital HealthPathway guideline. After the addition of the Practice Point, 142 of 182 patients (78%) had one measurement of amylase. This improvement was seen where patients were referred directly by their GP to the general surgical teams and patients managed by other specialties. Variation in compliance seen over the six-month experimental group period was significant, but did not show a clear trend of either improvement or decay in compliance.

CONCLUSION

This supports the hypothesis that the simple intervention of clarifying a key point within a clinical guideline can have a significant positive effect on compliance. This is an important consideration for guideline authors and institutions publishing clinical guidelines, as poor compliance by clinicians is reported in studies. The intervention in this study is a simple change for guidelines based online, and the significant effect could contribute to improvement in patient-centred, financial and clinical domains.

Two-point measurement of amylase in drainage fluid predicts severe postoperative pancreatic fistula after gastric cancer surgery

BACKGROUND

Early identification of patients at risk of postoperative pancreatic fistula (POPF) allows appropriate management after gastrectomy. Although some reports have suggested a correlation between POPF and the concentration of amylase in drained abdominal fluid (D-AMY), this has not been proven to impact sufficiently on clinical decision-making. A sustained high level of D-AMY is often assumed to be due to unsatisfactory drainage or excessive pancreatic leakage. We assessed the clinical utility of measuring D-AMY on postoperative day (POD) 1 and POD3 for prediction of POPF.

METHODS

Starting in April 2014, 801 patients who underwent radical gastrectomy with prophylactic drain placement were consecutively enrolled. We routinely measured D-AMY on POD1 and POD3, and compared the incidence of problematic POPF and clinical factors including D-AMY. We also attempted to clarify whether such two-point D-AMY measurement was clinically useful for patient management after gastrectomy.

RESULTS

Fifty-one of the patients (6.4%) developed Clavien-Dindo grade III or worse POPF. Using D-AMY cutoffs of 2218 IU/L on POD1 and 555 IU/L on POD3, the patients were successfully classified. The highest risk group, in which D-AMY was higher than the cut-off value on both POD1 and POD3, showed a significantly high rate of occurrence (33/105, 31.4%) and high positive likelihood ratio (6.74). Multivariate analysis showed that classification into this highest risk group was an independent risk factor for development of severe POPF (odds ratio 15.2, 95% CI 7.92-29.0).

CONCLUSION

Two-point measurement of D-AMY may be an efficient tool for achieving individualized management of POPF following radical gastrectomy.

Predictive value of drain pancreatic amylase concentration for postoperative pancreatic fistula on postoperative day 1 after pancreatic resection: An updated meta-analysis

BACKGROUND

Postoperative pancreatic fistula (POPF) is a potentially fatal complication following pancreaticoduodenectomy. Early prediction and exclusion of POPF may be highly advantageous to enhance patient outcomes, and accelerate recovery. In this meta-analysis, we sought to assess the prediction of drain pancreatic amylase concentration on postoperative day 1 (DPA1) for POPF.

METHODS

By searching online databases up to April 2018, all researches mentioned DPA1 for detecting POPF were analyzed. STATA 12.0 was used to analyze pooled predictive parameters.

RESULTS

Seventeen studies were finally analyzed including 4676 patients in total. The pooled sensitivity and specificity of DPA1 were respectively 0.85 (95% CI: 0.71, 0.93), 0.80 (95% CI: 0.74, 0.85) to predict overall POPF, and 0.70 (95% CI: 0.53, 0.82), 0.88 (95% CI: 0.86, 0.90) to predict CR-POPF. If pretest probability was 50%, corresponding post-test (+) were respectively 81%, 86% for overall POPF and CR-POPF when DPA1 was above cutoffs, while the post-test (-) were respectively 16%, 26% when DPA1 was under cutoffs. In subgroup analysis, sensitivities of cutoff >5000 group, 1000< cutoff <5000 group, and cutoff <1000 group were respectively 0.65 (0.43-0.82), 0.82 (0.71-0.89), 0.87 (0.78-0.92); and specificities were respectively 0.88 (0.83-0.92), 0.83 (0.77-0.88), 0.71 (0.62-0.79). Positive LR was 5.5 (3.4-8.8), 4.8 (3.4-6.7), and 3.0 (2.3-4.0) respectively. Negative LR was 0.40 (0.22-0.72), 0.22 (0.13-0.37), and 0.19 (0.11-0.32) respectively.

CONCLUSION

DPA1, which has good sensitivity and specificity, is useful for predicting overall POPF and CR-POPF, according to the present studies. Meanwhile, it should be cautious to apply because there is a wide range in cutoffs between different studies.

Effects of single-point acupuncture (HT7) in the prevention of test anxiety: Results of a RCT

Background

The number of students using neuro enhancement to improve their performance and to prevent test anxiety is increasing. The acupuncture point Heart 7 (HT7) has been described as being prominent in reducing states of anxiety.

Methods

We conducted a randomized placebo-controlled, two-armed pilot trial to investigate the efficacy of a single-point acupuncture treatment at bilateral HT7 compared to sham laser acupuncture on test anxiety. Test anxiety was induced applying the standardised protocol of the Trier Social Stress Test. Outcome measures included saliva samples analysed for cortisol and amylase, anxiety questionnaires and heart rate variability.

Results

Twenty-five male subjects (age 28 ± 5 years) were allocated to either verum acupuncture (n = 12) or sham laser acupuncture (n = 13). Cortisol peaked 20 min after the stress test (2-fold, 18.11 ± 2 nmol/l) and amylase 10 min after (2-fold, 259 ± 49 U/ml) with no difference between groups. There were no differences between groups regarding either anxiety questionnaires or physiological parameters. Compared to reference data (3-fold increase in cortisol), increase in stress hormones and heart rate seemed somewhat reduced.

Conclusions

Acupuncture may be a possible approach for the treatment of anxiety. Due to the lack of a no control treatment group, we cannot determine the magnitude of possible specific needle effects at HT7 to promote specific effects in the neuroendocrine system. Finally this study only examines the efficacy of a single time treatment.

Evaluation of Drain Amylase Level after Pancreaticoduodenectomy with Special Reference to Delayed Pancreatic Fistula

Postoperative pancreatic fistula (PF) is a relatively frequent and occasionally fatal complication of pancreatoduodenectomy (PD). Several risk factors for PF have been reported, including high drain amylase level (D-AMY). Among the 140 consecutive patients who underwent PD, we analyzed 110 cases with D-AMY measurements over time after PD. According to the D-AMY change, we divided patients into five patterns and defined delayed PF cases. We analyzed clinical characteristics, including serum amylase and D-AMY, and examined the correlation between the period of drain insertion and PF grade. In 15 delayed PF cases, 12 cases were grade B or C, pancreatic cancer was less frequent, pancreatic ducts were smaller, and soft pancreas texture was more commonly observed. The D-AMY on postoperative day (POD) 1 was higher in cases of delayed PF compared with non-PF cases (P < 0.0001). In 28 cases with drain removal before POD 7, grade B or C PF was not observed afterward. The average D-AMY on POD 1 in cases with drain removal before POD 1 was significantly lower than in delayed PF cases. Although further studies are required to determine the most appropriate timing of drain removal, it is thought that intra-abdominal drains should be removed within seven days of PD in cases without signs of PF. On the other hand, delayed PF should be considered in cases of soft pancreas texture and/or high D-AMY on POD 1, even if D-AMY levels are low on POD 3 or decreasing on POD 5.

Drain amylase monitoring for early diagnosis of anastomotic leakage in sleeve gastrectomy An animal study

BACKGROUND

Sleeve gastrectomy(SG) is a popular bariatric surgery procedure with rare but dreaded complications. Although drain amylase levels are a reliable early predictor of anastomosis leakage in oesophagectomy and pancreaticoduodenectomy, for SG have not yet been studied. We aimed to monitor drain amylase levels to ascertain their applicability for early diagnosis of gastric leakage in SG.

METHODS

Twenty-four rats were randomly divided into three groups: Group A: only laparotomy and abdominal drain; Group B: laparotomy, SG, and drain; Group C: laparotomy, SG with fistula,and drain. On postoperative days 0,1,2,3, and 4, drain lavage samples were collected to measure amylase.

RESULTS

Groups were compared in pairs. Preoperative weights were not significantly different in any comparison. On postoperative days 0,1,2,3, and 4, drain amylase levels were found to be significantly lower in Group A than in Group B as well as in Group A than in Group C but were significantly higher in Group C than in Group B. For postoperative day 1, a receiver operating characteristic curve was done. Drain amylase levels over 1514 IU were statistically significant for leakage.

CONCLUSIONS

Drain amylase levels were significantly high in sleeve gastrectomy with fistula. This indicates that drain amylase level monitoring might be an easy and cheap alternative for determining staple-line leakage for high risk patients with Body Mass Index(BMI)>50kg/m2 in whom we cannot use radiological imaging.

KEY WORDS

Animal Experimental Study, Bariatric Surgery, Drain amylase, Sleeve gastrectomy, Staple-line leakage.

Salivary changes in type 2 diabetic patients

OBJECTIVE

this study was conducted to determine the effect of type 2 diabetes mellitus on salivary secretion of glucose, amylase and immunoglobulin A levels and also to fined out if saliva could be used as anon invasive method to monitor glycaemic control in type 2 diabbetes. This study was conducted on 40 human subjectes, They were 20 males and 20 females, their ages ranged from 35 years to 64 years,and they were divided into two groups, the first one is the patient group which contains 20 diabetic paient. (10 males and 10 females,aged between 38 years to 64 years). the second one is the control group which contains 20 healthy adult (10 males and 10 females,aged between 35 years to 60 years) they were age and sex matched. All studied group were subjected to clinical and laboratory investigation which includes post prandial blood glucose, HA1C, salivary glucose, salivary amylase, and salivary immunoglobulin A.

RESULTS

there was a highly significant increase in the level of post prandial blood glucose, HBA1C; Salivary glucose, Salivary amylase & Salivary immunoglobulin A in diabetic group compared with control group and There was a significant positive correlation between post prandial blood glucose and salivary glucose in diabetic group.

CONCLUSIONS

These results suggest that diabetes influences the composition of saliva and that saliva can be used as less painful,non invasive biomarker for monitoring the blood glucose concentration in the patients with diabetes mellitus.

Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Choledochoscopy and D-J Tube Drainage for Treating Choledocholithiasis

BACKGROUND This study aimed to assess the clinical short-term results of a primary closure following laparoscopic common bile duct exploration (LCBDE) combined with intraoperative choledochoscopy and D-J tube drainage for choledocholithiasis treatment. MATERIAL AND METHODS Twenty-five patients (14 women and 11 men) who underwent LCBDE with primary duct closure and D-J tube drainage for choledocholithiasis were retrospectively enrolled. The D-J tube (4.7F×14 cm) was removed using a duodenoscope if there was no bile leakage. Before discharge, patients were examined for blood amylase. After discharge or D-J tube removal, all patients were routinely assessed for complications. RESULTS Mean operating time was 135±46 min (range, 78-195 min). Mean intraoperative blood loss was 71±24 mL (range, 25-110 mL). Total hospital stay was 6-9 days (mean, 8.04±1.37 days). Two patients experienced intraoperative bile leakage, which was stopped with re-suturing. None of these patients experienced postoperative bile leaks. Three patients had slight elevation of serum amylase before discharge but without pancreatitis signs. The successful clearance rate of stones was 100%. During 1-year follow-up, no recurrence or severe complications occurred. CONCLUSIONS A primary closure following LCBDE combined with intraoperative choledochoscopy and D-J tube drainage is safe and feasible for choledocholithiasis treatment.

Salivary Markers for Quantitative Dehydration Estimation During Physical Exercise

Salivary markers have been proposed as noninvasive and easy-to-collect indicators of dehydrations during physical exercise. It has been demonstrated that threshold-based classifications can distinguish dehydrated from euhydrated subjects. However, considerable challenges were reported simultaneously, for example, high intersubject variabilities in these markers. Therefore, we propose a machine-learning approach to handle the intersubject variabilities and to advance from binary classifications to quantitative estimations of total body water (TBW) loss. For this purpose, salivary samples and reference values of TBW loss were collected from ten subjects during a 2-h running workout without fluid intake. The salivary samples were analyzed for previously investigated markers (osmolality, proteins) as well as additional unexplored markers (amylase, chloride, cortisol, cortisone, and potassium). Processing all these markers with a Gaussian process approach showed that quantitative TBW loss estimations are possible within an error of 0.34 l, roughly speaking, a glass of water. Furthermore, a data analysis illustrated that the salivary markers grow nonlinearly during progressive dehydration, which is in contrast to previously reported linear observations. This insight could help to develop more accurate physiological models for salivary markers and TBW loss. Such models, in turn, could facilitate even more precise TBW loss estimations in the future.

Amylase in drain fluid for the diagnosis of pancreatic leak in post-pancreatic resection

BACKGROUND

The treatment of people with clinically significant postoperative pancreatic leaks is different from those without clinically significant pancreatic leaks. It is important to know the diagnostic accuracy of drain fluid amylase as a triage test for the detection of clinically significant pancreatic leaks, so that an informed decision can be made as to whether the patient with a suspected pancreatic leak needs further investigations and treatment. There is currently no systematic review of the diagnostic test accuracy of drain fluid amylase for the diagnosis of clinically relevant pancreatic leak.

OBJECTIVES

To determine the diagnostic accuracy of amylase in drain fluid at 48 hours or more for the diagnosis of pancreatic leak in people who had undergone pancreatic resection.

SEARCH METHODS

We searched MEDLINE, Embase, the Science Citation Index Expanded, and the National Institute for Health Research Health Technology Assessment (NIHR HTA) websites up to 20 February 2017. We searched the references of the included studies to identify additional studies. We did not restrict studies based on language or publication status, or whether data were collected prospectively or retrospectively. We also performed a 'related search' and 'citing reference' search in MEDLINE and Embase.

SELECTION CRITERIA

We included all studies that evaluated the diagnostic test accuracy of amylase in the drain fluid at 48 hours or more for the diagnosis of pancreatic leak in people who had undergone pancreatic resection excluding total pancreatectomy. We planned to exclude case-control studies because these studies are prone to bias, but did not find any. At least two authors independently searched and screened the references produced by the search to identify relevant studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies. The included studies reported drain fluid amylase on different postoperative days and measured at different cut-off levels, so it was not possible to perform a meta-analysis using the bivariate model as planned. We have reported the sensitivity, specificity, post-test probability of a positive and negative drain fluid amylase along with 95% confidence interval (CI) on each of the different postoperative days and measured at different cut-off levels.

MAIN RESULTS

A total of five studies including 868 participants met the inclusion criteria for this review. The five studies included in this review reported the value of drain fluid amylase at different thresholds and different postoperative days. The sensitivities and specificities were variable; the sensitivities ranged between 0.72 and 1.00 while the specificities ranged between 0.73 and 0.99 for different thresholds on different postoperative days. At the median prevalence (pre-test probability) of 15.9%, the post-test probabilities for pancreatic leak ranged between 35.9% and 95.4% for a positive drain fluid amylase test and ranged between 0% and 5.5% for a negative drain fluid amylase test.None of the studies used the reference standard of confirmation by surgery or by a combination of surgery and clinical follow-up, but used the International Study Group on Pancreatic Fistula (ISGPF) grade B and C as the reference standard. The overall methodological quality was unclear or high in all the studies.

AUTHORS' CONCLUSIONS

Because of the paucity of data and methodological deficiencies in the studies, we are uncertain whether drain fluid amylase should be used as a method for testing for pancreatic leak in an unselected population after pancreatic resection; and we judge that the optimal cut-off of drain fluid amylase for making the diagnosis of pancreatic leak is also not clear. Further well-designed diagnostic test accuracy studies with pre-specified index test threshold of drain fluid amylase (at three times more on postoperative day 5 or another suitable pre-specified threshold), appropriate follow-up (for at least six to eight weeks to ensure that there are no pancreatic leaks), and clearly defined reference standards (of surgical, clinical, and radiological confirmation of pancreatic leak) are important to reliably determine the diagnostic accuracy of drain fluid amylase in the diagnosis of pancreatic leak.

Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial

PURPOSE

Studies on the impact of tapered-cuff tracheal tubes on rates of microaspiration and ventilator-associated pneumonia (VAP) in intubated patients have reported conflicting results. The aim of this study was to determine the influence of this shape of tracheal cuff on abundant microaspiration of gastric contents in critically ill patients.

METHODS

All patients intubated in the intensive care unit (ICU) and requiring mechanical ventilation for at least 48 h were eligible for this multicenter cluster-randomized controlled cross-over open-label study. The primary outcome was abundant microaspiration of gastric contents, defined by the presence of pepsin at significant level in >30% of tracheal aspirates. Quantitative measurement of pepsin and salivary amylase was performed in all tracheal aspirates during the 48 h following enrollment.

RESULTS

A total of 326 patients were enrolled in the ten participating ICUs (162 in the PVC tapered-cuff group and 164 in the standard-cuff group). Patient characteristics were similar in the two study groups. The proportion of patients with abundant microaspiration of gastric contents was 53.5% in the tapered-cuff and 51.0% in the standard-cuff group (odds ratio 1.14, 95% CI 0.72-1.82). While abundant microaspiration of oropharyngeal secretions was not significantly different (77.4 vs 68.6%, p = 0.095), the proportion of patients with tracheobronchial colonization was significantly lower (29.6 vs 43.3%, p = 0.01) in the tapered-cuff than in the standard-cuff group. No significant difference between the two groups was found for other secondary outcomes, including ventilator-associated events and VAP.

CONCLUSIONS

This trial showed no significant impact of tapered-cuff tracheal tubes on abundant microaspiration of gastric contents.

TRIAL REGISTRATION

ClinicalTrials.gov, number NCT01948635.

Pancreatic endometrial cyst mimics mucinous cystic neoplasm of the pancreas

Pancreatic cysts include a variety of benign, premalignant, and malignant lesions. Endometrial cysts in the pancreas are exceedingly rare lesions that are difficult to diagnose pre-operatively. This report describes the findings in a 43-year-old patient with a recent episode of acute pancreatitis who presented with a large cyst in the tail of the pancreas. Imaging demonstrated a loculated pancreatic cyst, and cyst fluid aspiration revealed an elevated amylase and carcinoembryonic antigen. The patient experienced an interval worsening of abdominal pain, fatigue, diarrhea, and a 15-pound weight loss 3 mo after the initial episode of pancreatitis. With concern for a possible pre-malignant lesion, the patient underwent a laparoscopic distal pancreatectomy with splenectomy, which revealed a 16 cm × 12 cm × 4 cm lesion. Final histopathology was consistent with an intra-pancreatic endometrial cyst. Here we discuss the overlapping imaging and laboratory features of pancreatic endometrial cysts and mucinous cystic neoplasms of the pancreas.

Amylase Zymography

Amylase zymography was carried out for the detection of amylases produced by a Geobacillus stearothermophilus strain isolated from the Thermal Center "Las Trincheras" in Venezuela. Zymography is an electrophoretic technique used to study hydrolases by means of thin gels containing copolymerized-specific substrates, under nonreducing conditions. In this study, 0.1% starch was incorporated into the gel as substrate. The formation of clear zones against a dark background in the gel stained with iodine indicated the presence of amylolytic activity. The thermophilic bacteria released several extracellular amylases to a selective growth medium supplemented with 1% soluble starch at 55 °C after 40 h incubation. The amylolytic enzymes showed an optimum temperature of 60 °C and an optimum pH at 6.0. The amylases were partially purified by cold acetone precipitation followed by two chromatographic techniques. These purified amylases showed different molecular masses which were determined by sodium dodecyl sulfate gel electrophoresis and confirmed by zymography.

Identification of in vivo Pellicle Constituents by Analysis of Serum Immune Responses

Human acquired enamel pellicle is composed of molecules that selectively adsorb from saliva onto tooth surfaces and provides a protective interface between the tooth enamel and the oral environment. To identify the micro-amounts of components present in pellicle, we immunized mice with in vivo-formed human acquired enamel pellicle and analyzed the serum immune responses. Selective reactivities of the serum (OD > 1.0 above background) against albumin, amylase, carbonic anhydrase II, sIgA, IgG, IgM, lactoferrin, lysozyme, proline-rich proteins, statherin, histatin 1, and mucous glycoprotein 1 were observed. We further confirmed the presence of proline-rich proteins, lactoferrin, lysozyme, and carbonic anhydrase II by probing in vivo pellicle with specific polyclonal anti-sera. The polyclonal antibody approach provided a powerful method for the identification of various pellicle proteins, including some which show mineral homeostasis or antimicrobial activity.

A proposal of "core enzyme" bioindicator in long-term Pb-Zn ore pollution areas based on topsoil property analysis

To study the effects of long-term mining activities on the agricultural soil quality of Mengnuo town in Yunnan province, China, the heavy metal and soil enzyme activities of soil samples from 47 sites were examined. The results showed that long-term mining processes led to point source heavy metal pollution and Pb, Cd, Zn and As were the primary metal pollutants. Polyphenoloxidase was found the most sensitive soil enzyme activity and significantly correlated with almost all the metals (P < 0.05). Amylase (for C cycling), acid phosphatase (for P cycling) and catalase (for redox reaction) activities showed significantly positive correlations (P < 0.05) with Pb, Cd, Zn and As contents. The correlations between soil enzymes activities and Cd, Pb and Zn contents were verified in microcosm experiments, it was found that catalase activity had significant correlations (P < 0.05) with these three metals in short-term experiments using different soils under different conditions. Based on both field investigation and microcosm simulation analysis, oxidoreductases activities (rather than a specific enzyme activity) were suggested to be used as "core enzyme", which could simply and universally indicate the heavy metal pollution degrees of different environments. And hydrolases (for C, N, P and S recycling) could be used as a supplement to improve correlation accuracy for heavy metal indication in various polluted environments.

Salivary profile in diabetic patients: biochemical and immunological evaluation

BACKGROUND

The aim of this study was to evaluate the biochemical and immunological characteristics of saliva from diabetic patients compared to non-diabetic adults.

METHODS

Eighty-eight diabetic adults and 39 non-diabetic adults (control) were included in the study. Glucose, urea, calcium, total protein and amylase were determined by a colorimetric method. The levels of secretory IgA and the IgA anti-Streptococcus mutans and anti-insulin IgA antibodies were measured by enzyme-linked immunosorbent assay (ELISA). Caries status was evaluated using the DMFT index.

RESULTS

Glucose, urea, calcium, anti-S. mutans IgA, total IgA, and anti-insulin IgA were significantly higher in diabetic patients, whereas total protein and amylase levels were lower in these patients. There was no positive correlation between blood and salivary glucose levels in either group. Diabetic patients had a higher DMFT index.

CONCLUSIONS

The present study showed for the first time that IgA levels in diabetic patients'saliva, shows correlation with systemic biochemical parameters. Thus the saliva is an useful tool to follow the systemic health status in these patients.

Sialendoscopy of Salivary Glands Affected by Sjögren Syndrome: A Randomized Controlled Pilot Study

PURPOSE

Sialendoscopy of the major salivary glands could alleviate the oral symptoms of Sjögren syndrome (SS) and restore salivary function. The aim of this pilot study was to evaluate the effect of sialendoscopy of the major salivary glands on salivary flow, saliva composition, and mouthfeel in patients with SS and to collect data for sample size analysis for a larger clinical trial.

MATERIALS AND METHODS

Twenty patients diagnosed with SS were randomly assigned to a nonintervention control group or a sialendoscopy group. Unstimulated whole saliva flow, stimulated whole saliva flow, Clinical Oral Dryness Score, Xerostomia Inventory score, and EULAR Sjögren's Syndrome Patient Reported Index score were obtained 1 week before (T0), 1 week after (T2), and 8 weeks after (T3) sialendoscopy. Unstimulated whole saliva was analyzed for amylase concentration, activity, and mucin 5B concentration. Amylase and mucin 5B output were calculated.

RESULTS

In the sialendoscopy group, unstimulated and stimulated whole saliva flows were numerically higher at T2 and T3 compared with T0. Xerostomia Inventory score was significantly lower in the sialendoscopy group at T2 compared with T0 (P = .03). Unstimulated and stimulated whole saliva flows were higher in the sialendoscopy group compared with the control group at T2 and T3 (not meaningful). Significant differences were found between groups for the EULAR Sjögren's Syndrome Patient Reported Index score at T2 (P = .03) and T3 (P = .001). Xerostomia Inventory score and Clinical Oral Dryness Score in the sialendoscopy group were lower compared with the control group at T2 (P = .02) and at T3 (P = .04), indicating less oral dryness.

CONCLUSION

This pilot study indicates a positive effect of sialendoscopy on some parameters, but it cannot yet be concluded that it has a positive effect on salivary flow in patients with SS. These preliminary results need to be verified in a randomized controlled trial with a larger sample and longer follow-up period.

Sphincter of Oddi Dysfunction and the Formation of Adult Choledochal Cyst Following Cholecystectomy: A Retrospective Cohort Study

To determine the causes underlying the formation of adult choledochal cyst.Anomalous pancreaticobiliary junction is the most widely accepted theory regarding the etiology of choledochal cyst. However, choledochal cysts have been found in patients in the absence of this anomaly. Because the number of adult patients with choledochal cyst is increasing, it is important to address this controversy.Bile amylase levels in the cysts of 27 patients (8 males and 19 females) who had undergone cholecystectomy were retrospectively evaluated.The average age of the 27 patients was 45.8 ± 10.1 years and the majority (85.2%) were diagnosed with Todani type I cysts. None of the patients had dilatation of the common bile duct prior to surgery. There were 6 (22.2%) patients with anomalous pancreaticobiliary junction. However, amylase levels did not significantly differ between patients with and without this anomaly (P = 0.251). According to bile amylase levels, pancreatobiliary reflux was present in 21 (77.8%) patients. The mean amylase level significantly differed in patients with pancreatobiliary reflux (23,462 ± 11,510 IU/L) and those without (235 ± 103 IU/L) (P < 0.001). In patients with pancreatobiliary reflux, only 4 patients had anomalous pancreaticobiliary junction. That is, the majority of patients (17/21, 81%) having pancreatobiliary reflux did not have an anomalous junction of the pancreatic and biliary ducts.Since the only explanation for pancreatobiliary reflux in patients with a normal pancreaticobiliary junction is sphincter of Oddi dysfunction, we proposed that the formation of adult choledochal cyst is mainly due to sphincter of Oddi dysfunction.

Distribution of islet hormones in human adult pancreatic ducts

BACKGROUND/AIMS

The source of insulin-secreting cells from adult duct system is attractive, but its clinical practice remains poorly understood. Here, we aimed at identifying the distribution of secreted hormone reactive cells in adult ducts.

METHODS

Consecutive pancreatic slices from nondiabetic subjects were subjected to immunohistochemistry and immunofluorescence to screen islet hormones (insulin; glucagon, Glu; somatostatin, Som; pancreatic polypeptide, PP) and exocrine biomarkers (cytokeratin 19, CK19; chromogranin A, CgA; amylase). All pancreatic sections were imaged using an optical or confocal microscope.

RESULTS

Immunostaining results showed that insulin was expressed in adult ducts, in which the cell count was more than other islet hormone immunoactive cells. CK19-positive cells are mainly distributed in the ducts, whereas CgA-labeled cells are localized in endocrine cells. The duct branches visibly exhibited cell populations that co-expressed islet hormones in exocrine cell populations.

CONCLUSIONS

In this report, our findings demonstrate that adult ductal cells that produce insulin may contribute to beta-cell proliferation.

Differences of starch granule distribution in grains from different spikelet positions in winter wheat

Wheat starch development is a complex process and is markedly difference by changes in spikelet spatial position. The present study deals with endosperm starch granule distribution and spatial position during filling development. The study was conducted with pure starch isolated from wheat (Triticum aestivum L.), Jimai20 and Shannong1391, at 7-35 days after anthesis (DAA). The results showed that grain number, spikelet weight and grain weight per spikelet in different spatial position showed parabolic changes. Upper spikelets had highest starch and amylose content followed by basal spikelets, then middle spikelets. The paper also suggested the volume percents of B-type and A-type granule in grain of middle spikelets were remarkably higher and lower than those of basal and upper spikelets, respectively. However, no significant difference occurred in the number percents of the two type granule. The ratio of amylase to amylopectin was positively correlated with the volume proportion of 22.8-42.8 µm, but was negatively related to the volume proportion of <9.9 µm. The results indicated that the formation and distribution of starch granules were affected significantly by spikelet position, and grains at upper and basal spikelet had the potential of increasing grain weight through increasing the volume of B-type granules.

Decontamination of orthodontic bands following size determination and cleaning

OBJECTIVE

To measure the effectiveness of ultrasonic cleaning for decontaminating orthodontic molar bands following size determination using a quantitative antibody capture assay technique.

DESIGN

A prospective, cross-sectional, clinical and laboratory investigation.

SETTING

The Orthodontic Department of the Charles Clifford Dental Hospital and the Microbiology Laboratory of the School of Clinical Dentistry, Sheffield.

PARTICIPANTS

Thirty-two patients about to start orthodontic treatment with fixed orthodontic appliances.

METHODS

Four first molar bands were tried in the mouth and then removed. They were randomly assigned either for no decontamination (control) or to be decontaminated in an ultrasonic cleaning bath for 15 minutes (experimental). The bands were placed in a predetermined volume of phosphate-buffered saline (PBS) and assayed by enzyme-linked immunosorbent assay (ELISA) for albumin, to detect the presence of blood and amylase, to detect the presence of saliva.

RESULTS

Fifty per cent of decontaminated molar bands showed detectable amounts of amylase, albumin or both. The quantity of detectable amylase was significantly reduced on the cleaned compared with uncleaned bands (P = 0.036); however, the reduction in the quantity of albumin was not statistically significant (P = 0.074).

CONCLUSIONS

Ultrasonic cleaning for 15 minutes reduces, but does not always eliminate, salivary proteins (amylase) from tried-in bands. It is less effective at removing serum protein (albumin). There is a need, therefore, to investigate effective means of cleaning organic material from orthodontic bands if they are to be adequately sterilized and reused.

Effect of repeated applications of buprofezin and acephate on soil cellulases, amylase, and invertase

The impact of repeated applications of buprofezin and acephate, at concentrations ranging from 0.25 to 1.0 kg ha(-1), on activities of cellulases, amylase, and invertase in unamended and nitrogen, phosphorous, and potassium (NPK) fertilizer-amended soil planted with cotton was studied. The nontarget effect of selected insecticides, when applied once, twice, or thrice on soil enzyme activities, was dose-dependent; the activities decreased with increasing concentrations of insecticides. However, there was a rapid decline in activities of enzymes after three repeated applications of insecticides in unamended or NPK-amended soil. Our data clearly suggest that insecticides must be applied judiciously in pest management in order to protect the enzymes largely implicated in soil fertility.

The role of endoscopic ultrasound in the management of intraductal papillary mucinous neoplasms

As the use of cross-sectional imaging increases so does the incidence of asymptomatic pancreatic cysts. Pancreatic neoplastic cysts can be broadly grouped into mucinous lesions and solid pseudopapillary neoplasms, which have malignant potential and serous lesions, which have negligible malignant potential. Non-neoplastic pancreatic cysts such as pseudocysts are not associated with malignant potential. It is important to identify those mucinous lesions with the highest potential of malignancy as identifying these lesions may allow prevention or early treatment of pancreatic carcinoma. The preoperative diagnosis of these cysts remains challenging with imaging alone often proving inadequate at making the diagnosis. Endoscopic ultrasound (EUS) can assess the morphology of cysts including identification of malignant characteristics of cysts as well as allowing aspiration of cyst fluid, which can be analysed for cytology, mucin, tumour markers, amylase and DNA analysis. Intraductal papillary mucinous neoplasms (IPMNs) can be subdivided into main duct IPMNs (MD-IPMN), branch duct IPMNs (BD-IPMN) and mixed type IPMNs which have feature of both the aforementioned. MD-IPMNs have the highest malignant potential and are often easier to identify on cross-sectional imaging due to the involvement of the main pancreatic duct. BD-IPMNs however can be difficult to distinguish from non-mucinous lesions such as pseudocysts, serous cyst adenomas and other benign cysts such as duplication cysts and in this group of lesions EUS is a valuable tool both to aid diagnosis and to identify BD-IPMNs, which should be considered for surgical resection.

Pepsin and amylase in oral and tracheal secretions: a pilot study

BACKGROUND

Endotracheal intubation increases the risk for microaspiration of secretions around the tube cuff. Pepsin has been used as a biomarker for gastric aspiration. Amylase is a newer proposed biomarker for aspiration of oral contents.

OBJECTIVE

To assess the presence of pepsin and amylase in paired oral-tracheal secretions of adult patients treated with mechanical ventilation.

METHODS

In this descriptive study, paired samples of oral and tracheal secretions were obtained from adult patients at baseline and again within 4 hours when a need for endotracheal suctioning was assessed. Assays of pepsin and amylase were processed in a specialty diagnostic laboratory.

RESULTS

The sample consisted of 10 men and 3 women with a median age of 56 years. The majority were intubated with a subglottic suction endotracheal tube (9 patients, 69%), receiving synchronized intermittent mandatory ventilation (10 patients; 77%), and receiving enteral feedings (11 patients; 85%) through a tube distally placed in the stomach (8 patients; 67%). Pepsin was present in oral secretions of 9 patients (69%), and in tracheal specimens of 7 patients (54%) at one or both sampling times. Amylase was detected in all patients' oral secretions and in tracheal secretions of 5 patients (38%) at one or both sampling times.

CONCLUSIONS

Many patients had pepsin, amylase, or both in tracheal aspirates. Pepsin was more commonly detected than was amylase. Although the relationship of this finding to long-term outcomes was not assessed, findings indicate that microaspiration of oral and gastric secretions occurs frequently.

Sex differences in upper respiratory symptoms prevalence and oral-respiratory mucosal immunity in endurance athletes

The purpose of this study was to examine sex differences in oral-respiratory mucosal immunity and the incidence, severity and duration of upper respiratory symptoms (URS) episodes in endurance athletes during a 16-week winter training period. Blood was collected from 210 subjects (147 men and 63 women) at the start and end of the study for determination of differential leukocyte counts. Timed collections of unstimulated saliva were obtained at the start and at 4-week intervals during the study period. Saliva samples were analysed for salivary antimicrobial peptides and proteins (AMPs). Weekly training and daily illness logs were kept using validated questionnaires. Training loads averaged 11 h/week of moderate-vigorous physical activity and were not different for males and females. The salivary concentration of lysozyme and lactoferrin (both P < 0.04) but not salivary immunoglobulin A (SIgA) or amylase were higher in males than females. Saliva flow rates were significantly higher in males than females (P < 0.03) and consequently so were the salivary secretion rates of lysozyme, lactoferrin and amylase (all P < 0.01) but not SIgA (P = 0.097). Total blood leukocyte, monocyte and lymphocyte counts were not different between the sexes but females had higher numbers of circulating neutrophils (P = 0.040). The average number of URS episodes was 0.6 +/- 0.8 (mean +/- SD) in males and 0.8 +/- 1.0 in females (P = 0.103) and the number of URS days was higher in females (4.7 vs 6.8 days, P < 0.02). The duration of URS episodes was longer in females (11.6 vs 15.5 days, P < 0.03). The findings of this study concur with recent reports of illness incidence at major competitive games indicating that female athletes may be more susceptible than their male counterparts to URS and that lower oral-respiratory mucosal immunity may, in part, account for this.