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Objective: Constipation is often inadequately treated in childhood, which can lead to psychological problems. This study aimed to evaluate the adequacy of prescribed drugs, dosing, usage, and responses to these drugs in children with functional constipation. Methods: This research comprised children who had consulted a pediatric gastroenterologist for functional constipation and had previously undergone constipation therapy. The name of the drug used, duration of drug usage, method of measurement, and what they took the drug with, the dose of drug, and response to the drug were recorded. Results: Eighty-seven percent of the patients had received lactulose treatment. Only 31% of the patients received a medication dose greater than 1 mL/kg. In 58.3% of cases, the duration of drug use was shorter than one month. There was not a response in 62.9% of cases, a partial response in 23.1%, and a full response in 13.8% of cases. When the patients were compared based on response, there was a significant difference in the duration of drug usage, what they drank the drug with, the daily dose of the drug, and the daily dosage per weight of the drug. Patients who measured the drug using a milliliter scale responded better. The response to the drug increased as the drug dosage per weight increased. Response was obtained in 73% of patients who had no response or partial response after drug or dose adjustments. Conclusion: For a comprehensive response, parents must be carefully taught the dosage of the drug and how to measure it. [ABSTRACT FROM AUTHOR]

Background: Hyponatremia portends a poor prognosis in decompensated cirrhosis and is an independent predictor of mortality. Multiple modalities have been evaluated in the management of hyponatremia, including albumin infusion. However, the effect of albumin infusion on the resolution of hyponatremia is unclear. We conducted a systematic review to explore the available literature on the use of albumin infusion in hyponatremia. Methods: We performed a comprehensive search up to 31st December 2022 using MEDLINE, EMBASE, and Scopus for studies reporting the effectiveness of albumin infusion in the resolution of hyponatremia. The impact of albumin infusion of any dose, administration frequency, and duration of therapy was recorded. The study protocol was prospectively registered (CRD42021245914). Results: The literature search yielded 1322 references after duplicate removal. Only seven studies (three randomized trials, three cohort studies, and one case series) satisfied the predefined selection criteria after a full-text review. While hyponatremia was clearly defined as serum sodium < 130 meEq/L in all studies, two studies explicitly defined hyponatremia resolution (serum sodium > 135 mEq/L). No differentiation was made between the types of hyponatremia. The strength of the albumin infusion used was 5% and 20%. All but one study reported significant improvement in hyponatremia with albumin infusion. A subgroup analysis showed albumin infusion improved 30-day survival (odds ratio 0.43, 95% CI 0.25–0.74, I2 = 0.) No studies reported adverse events or the impact of concomitant associations (diuretic withdrawal, lactulose use, sepsis). Conclusion: Despite available literature on the use of albumin infusion for the resolution of hyponatremia, the level of evidence remains low. Large prospective studies with pre-defined selection criteria and endpoints are required to generate the evidence. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Management of hepatic encephalopathy relies on self-titration of lactulose. In this feasibility trial, we assess an artificial intelligence--enabled tool to guide lactulose use through a smartphone application. METHODS: Subjectswith hepatic encephalopathy onlactulose captured bowelmovementpicturesduring lead-in and intervention phases. During the intervention phase, daily feedback on lactulose titration was delivered through the application. Goals were determined according to number of bowel movement and Bristol Stool Scale reports. RESULTS: Subjects completed the study with more than 80% satisfaction. In the lead-in phase, less compliant subjects achieved Bristol Stool Scale goal on 62/111 (56%) of days compared with 107/136 (79%) in the intervention phase (P50.041), while themost compliant subjects showed no difference. Severe/recurrent hepatic encephalopathy group achieved Bristol Stool Scale goal on 80/104 (77%) days in the lead-in phase and90/110(82%)days inthe intervention phase (P5NS), comparedwith89/143(62%)days and86/127 (68%) days in the stable group. DISCUSSION: Dieta application is a promising tool for objective Bowel Movement/Bristol Stool Scale tracking for hepatic encephalopathy and may potentially be used to assist with lactulose titration. [ABSTRACT FROM AUTHOR]

Lactulose-based hepatic encephalopathy treatment requires bowel movements/day titration, which is improved with Bristol stool scale (BSS) incorporation. Dieta app evaluates artificial intelligence (AI)-based BSS (AI-BSS) with stool images. Initially, controls (N 5 13) and cirrhosis patients on lactulose/not on lactulose (n 5 33) were trained on the app. They entered self-reported BSS (self-BSS) with AI-BSS communicated. Lactulose dose changes were tracked. A subset (n512) was retested with AI communication blocked. Most subjects were comfortable with the app. Self/AIBSS and lactulose dose/AI-BSS correlation increased with app use. AI-BSS communications improved insight into self-BSS over time. Dieta app to gauge stool AI characteristics was acceptable and increased insight into lactulose dose and BSS in cirrhosis. [ABSTRACT FROM AUTHOR]

Epilactose is a disaccharide composed of galactose and mannose, and it is currently considered an "under development" prebiotic. In this study, we described the prebiotic potential of epilactose by in vitro fermentation using human fecal inocula from individuals following a Mediterranean diet (DM) or a Vegan diet (DV). The prebiotic effect of epilactose was also compared with lactulose and raffinose, and interesting correlations were established between metabolites and microbiota modulation. The production of several metabolites (lactate, short-chain fatty acids, and gases) confirmed the prebiotic properties of epilactose. For both donors, the microbiota analysis showed that epilactose significantly stimulated the butyrate-producing bacteria, suggesting that its prebiotic effect could be independent of the donor diet. Butyrate is one of the current golden metabolites due to its benefits for the gut and systemic health. In the presence of epilactose, the production of butyrate was 70- and 63-fold higher for the DM donor, when compared to lactulose and raffinose, respectively. For the DV donor, an increase of 29- and 89-fold in the butyrate production was obtained when compared to lactulose and raffinose, respectively. In conclusion, this study suggests that epilactose holds potential functional properties for human health, especially towards the modulation of butyrate-producing strains. [ABSTRACT FROM AUTHOR]

Lactulose was produced from lactose using subcritical phosphate or carbonate buffer solution. Phosphate buffer with an initial pH of 8.0 accomplished the maximum yield of 29% at 120 °C. A long reaction time and high pH led to the rapid decomposition of lactulose and a large color change of the reaction solution. The formation of some monosaccharides, such as glucose, galactose, fructose, tagatose, talose, allulose, and sorbose, occurred due to the hydrolysis and isomerization reactions in the production of lactulose. These monosaccharides could be classified into two groups based on their time to arise and the reaction mechanism. The coloration of lactose was less than that of glucose and galactose, which are the constituents of lactose, due to degradants formed during their reaction in the subcritical phosphate buffer. Therefore, the application of a subcritical buffer solution would be suitable for the production of lactulose because of a small burden on the purification process. [Display omitted] • Lactose was converted to lactulose in subcritical phosphate buffer solution. • Buffer with an initial pH of 8.0 accomplished the maximum yield at 120 °C. • The maximum yield of 29% was obtained at 10 min as a reaction time. • The coloration of lactose was less than that of glucose and galactose. [ABSTRACT FROM AUTHOR]

Background: The bioavailability of the drug is influenced by the solubility of the drug in the biological fluids. Solubility and dissolution are the rate-limiting steps for the absorption and bioavailability of BCS class II drugs. Materials and Methods: In the current work, Efavirenz (EFV) has been selected as a model drug for the development and assessment of Solid Dispersion (SD) by solvent evaporation and fusion methods using sugar-based carriers like xylitol, Sorbitol, lactulose, and one nonsugar carrier surplus. First, the drug was assessed for solubility in various solvents. EFV Solid Dispersions (S.D.s) have been produced by solvent evaporation and fusion at different carrier ratios (1:0.5, 1:1, 1:1.5, 1:2, and 1:3). The prepared SDs were subjected to drug content uniformity, saturation solubility studies, and in vitro dissolution studies. Results: Preformulation investigations, such as FT-IR, proved that the excipient and drug molecules are binding with intermolecular hydrogen bonds. EFV was found to be more soluble in 7.4 pH phosphate buffer than in the other solvents. The saturation solubility of EFV was affected by carrier concentration and %yield, and in vitro drug dissolution studies were performed on the S.D.s. Pure EFV released 54.78% of the drug, whereas SDs by solvent evaporation method released 85.28± 1.84%-100.74±1.69% drug, and SDs prepared by fusion method released 76.65±0.98%-99.28±1.95% of the drug in 60 min. Conclusion: SDs of EFV prepared by solvent evaporation and fusion methods have improved the aqueous solubility of EFV, and, in turn, improved the in vitro drug release, and formulation with 1:1.5 drug-to-carrier ratio has been selected as an optimized formulation. [ABSTRACT FROM AUTHOR]

Background: Lactulose is a laxative which accelerates transit and softens stool. Our aim was to investigate its mechanism of action and use this model of diarrhea to investigate the anti‐diarrheal actions of ondansetron. Methods: A double‐blind, randomized, placebo‐controlled crossover study of the effect of ondansetron 8 mg in 16 healthy volunteers. Serial MRI scans were performed fasted and 6 h after a meal. Participants then received lactulose 13.6 g twice daily and study drug for a further 36 h. On Day 3, they had further serial MRI scans for 4 h. Measurements included small bowel water content (SBWC), colonic volume, colonic gas, small bowel motility, whole gut transit, and ascending colon relaxation time (T1AC), a measure of colonic water content. Key Results: Lactulose increased area under the curve (AUC) of SBWC from 0 to 240 min, mean difference 14.2 L · min (95% CI 4.1, 24.3), p = 0.009, and substantially increased small bowel motility after 4 h (mean (95% CI) 523 (457–646) a.u. to 852 (771–1178) a.u., p = 0.007). There were no changes in T1AC after 36 h treatment. Ondansetron did not significantly alter SBWC, small bowel motility, transit, colonic volumes, colonic gas nor T1AC, with or without lactulose. Conclusion & Inferences: Lactulose increases SBWC and stimulates small bowel motility; however, unexpectedly it did not significantly alter colonic water content, suggesting its laxative effect is not osmotic but due to stimulation of motility. Ondansetron's lack of effect on intestinal water suggests its anti‐diarrheal effect is not due to inhibition of secretion but more likely altered colonic motility. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion To compare polyethylene glycol 4000 versus lactulose in chronic constipation during pregnancy.Women at 28–32 weeks' gestation attending antenatal clinic for routine care were screened using the Rome IV chronic constipation criterion. Eligible women were approached and consented. Participants were randomized to oral polyethylene glycol (10 g/day) or lactulose (10 g/day) for 4 weeks. A bowel movement diary was kept and outcomes using the Patient Assessment of Constipation Symptoms questionnaire (PAC‐SYM), Patient Assessment of Constipation Quality of Life questionnaire (PAC‐QoL) and Bristol Stool Form Scale (BSFS), which were evaluated at the start and end of the four‐week period. Relative risks (RR) were determined for the coprimary outcomes of complete spontaneous bowel movement (CSBM) and PAC‐SYM mean score improvement (decrease in score of >1 from the baseline).A total of 4323 women underwent screening, of which 780 fulfilled the Rome IV criterion, and 360 consented to participate (180 randomized to PEG and lactulose, respectively). Data from 247 women who completed the study were analyzed. CSBM was achieved in 107/124 (86.3%) versus 102/123 (82.9%) (RR 1.04, 95% CI: 0.93–1.16, P = 0.464) for PEG and lactulose trial arms, respectively. PAC‐SYM mean score improvement was 62/118 (52.5%) in the PEG arm versus 44/118 (37.3%) in the lactulose arm (RR 1.40, 95% CI: 1.05–1.88). Of secondary outcomes, a significant difference was found in favor of PEG, with respect to PAC‐SYM abdominal symptoms subscale, normal stool versus loose stool consistency and side effects of vomiting and diarrhea. After controlling for parity, baseline PAC‐SYM, PAC‐QoL scores, characteristics different at baseline, only diarrhea and loose stools remained significant.Both PEG 4000 and lactulose are effective laxatives in pregnancy with similar performance after adjusted analysis. Diarrhea and loose stools are less frequently reported with PEG. [ABSTRACT FROM AUTHOR]

The discovery that certain cellobiose 2-epimerases (C2E) are capable of synthesizing lactulose and epilactose with high yield and selectivity has renewed the interest in their biological synthesis. In order to provide a valuable tool for the design and optimization of the synthesis of lactulose and epilactose with C2E as biocatalyst, the reaction is modeled here for the first time. Two competing reaction mechanisms, so called extended and reduced mechanisms, were proposed and their corresponding models developed. The extended mechanism was discarded because of the overfitting of the resulting model. The parameters of the reduced model were successfully estimated by no linear regression at 30, 40, 50, 60 and 70 °C, and the temperature dependence of the kinetic parameters was modeled by fitting them to Arrhenius and Vant Hoff-type equations. The reduced model showed a good fit to experimental data within the studied temperature range, well describing the course of reactions. [ABSTRACT FROM AUTHOR]

Nowadays, Functional food products as healthy diets have been considered extensively among consumers. Moreover, the use of particular microorganisms, for instance probiotic bacteria, offers probabilities to progress novel foods with appropriate shelf life. In the current research, in order to produce a functional ultrafiltrated (UF)-cheese, demineralized UF-whey powder (DUWP) at the levels of 0, 1 and 2%, and lactulose powder at the levels of 0 and 1% were used. Furthermore, bifidobacterium bifidum was used as probiotic bacteria. The textural characteristics in terms of hardness, cohesiveness, adhesiveness, springiness, gumminess and chewiness and sensorial propertis of the symbiotic cheese samples including odor, color, texture and taste were evaluated during 60 days of storage period at 4 ◦C. Results showed that addition of DUWP and lactulose powders except for adhesiveness and springiness caused significant decrease in all textural parameters (P<0.001). Besides, except for adhesiveness and cohesiveness, the mean values of textural parameters usually enhanced up to middle of the storage time and thereafter decreased up to end of storage period (p<0.05). Sensory results revealed that although addition of both DUWP and lactulose powders resulted in lower sensory scores, no significant differences were found between control (without DUWP and lactulose) and sample containing 1% of each both mentioned powders (P>0.05). Therefore, based on the obtained results, sample having 1% of DUWP and 1% of lactulose determined as the best symbiotic UF-cheese sample. Since the potential contribution of this product in community health promotion and reduction of diseases risk, the production and consumption of this functional cheese is proposed. [ABSTRACT FROM AUTHOR]

Background & Aims: Lactulose is the first-line drug for both treatment and secondary prophylaxis for overt hepatic encephalopathy (HE). The use of lactulose for the primary prophylaxis of HE in patients with cirrhosis and acute upper gastrointestinal bleeding (AUGIB) has been debated. Hence, we conducted this meta-analysis to assess the role of lactulose in HE prophylaxis in patients with cirrhosis and AUGIB. Methods: A comprehensive search of literature from inception to December 2022 was performed of three databases for randomized studies comparing lactulose and placebo in patients with cirrhosis and AUGIB. Risk ratios (RR) with 95% confidence intervals were calculated for all the dichotomous outcomes. Results: A total of five studies were included in the final analysis, out of which three studies had a low risk of bias, and two had a moderate risk of bias. Lactulose therapy was associated with a significantly lower risk of OHE compared to placebo, with a RR of 0.38 (0.23-0.62) and a number needed to treat of 6. There was no difference in the risk of mortality between the groups, with a RR of 0.71 (0.29-1.76). The pooled incidence rates of overall adverse events (AEs) and diarrhea with the use of lactulose therapy were 53.2% (42.2-64.2) and 34.7% (17.7-51.7), but a majority did not require drug discontinuation. The certainty of the evidence was moderate to low. Conclusions: Prophylactic lactulose reduces the incidence of HE after AUGIB but has no effect on mortality. Diarrhea and abdominal discomfort are common AEs but do not need drug discontinuation. [ABSTRACT FROM AUTHOR]

Prebiotics exert favorable effects on the host through interactions with probiotics, and their beneficial impacts have been extensively validated across various chronic ailments, including diabetes. This study presents findings from a case–control investigation involving 10 individuals with type 2 diabetes mellitus (T2DM) and 10 healthy counterparts. Fresh stool specimens were collected from all participants. Following a 24‐h fermentation period in mediums containing xylitol and mannitol, the observed increase in Lactobacillus abundance within the case group exceeded that of the control group. Similarly, in mediums containing soluble starch, choline, and L‐carnitine, the augmentation of Bifidobacterium within the case group surpassed that of the controls. Notably, a statistically significant divergence in sugar degradation rate emerged between the case and control groups, specifically in the medium harboring lactulose and isomalto‐oligosaccharides. Remarkably, the degradation rate of lactulose exhibited a positive correlation with the expansion of Bifidobacterium (R2 =.147, p =.037). Likewise, the degradation rate of isomalto‐oligosaccharides demonstrated a positive correlation with Bifidobacterium proliferation (R2 =.165, p =.041). In conclusion, prebiotics like xylitol and mannitol exhibit the capacity to enhance intestinal probiotic populations in individuals newly diagnosed with diabetes. The modifications in the intestinal flora homeostasis of diabetic patients may be evidenced by alterations in the degradation rate of specific prebiotic substrates. [ABSTRACT FROM AUTHOR]

Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. We conducted a prospective, randomized controlled clinical trial to study the efficacy of intravenous branched chain amino acids (IV-BCAA) with lactulose versus lactulose alone for improvement in HE at 24 h, day 3, and day 7. The primary outcome was an improvement in encephalopathy by ≥ 1 grade at 72 h. European association for study of liver (EASL) defined ACLF patients with overt HE were assessed and randomized into the experimental arm (IV-BCAA - 500 mL/day for 3 days + Lactulose; n = 39) and the comparator arm (Lactulose alone; n = 37). Six patients developed COVID-19 after randomization and were excluded (4-experimental arm and 2-comparator arm). Of 222 screened patients, 70 (35 in each arm) were included in the analysis. Baseline characteristics, including HE grade (2.9 ± 0.7 vs 2.8 ± 0.7; P = 0.86) and (chronic liver failure) CLIF-C ACLF score (54.2 ± 5.6 vs 54.8 ± 5.7; P = 0.65), were similar. Overall survival was 40% at 28 days (48.5% vs 31.4%; P = 0.14). Improvement in hepatic encephalopathy scoring algorithm (HESA) by ≥ 1 grade at 24 h occurred in 14 patients (40%) in the BCAA arm and 6 patients (17.1%) in the control group (P = 0.03) which translated to a shorter intensive care unit (ICU) stay. The median change in HESA at 24 h was greater in the BCAA arm than the control arm (P = 0.006), which was not sustained at days 3 or 7. Ammonia levels did not correlate with the grade of HE (Spearman's correlation coefficient (ρ) = - 0.0843; P = 0.29). Intravenous BCAA does not lead to a sustained improvement in HE grade in ACLF. NCT04238416 (clinicaltrials.gov). • Hepatic encephalopathy (HE) in acute-on-chronic liver failure (ACLF) is associated with high morbidity and mortality. • Oral branched-chain amino acids (BCAA) are helpful in HE in cirrhosis but role of intravenous BCAA in ACLF is unknown. • We describe the use of intravenous BCAA for HE in ACLF. • IV BCAA given in a short 3-day course helps in early resolution of HE which translated to shorter ICU stay. • The improvement in HE by IV BCAA was not sustained at day 3 or day 7 and there was no 28-day survival benefit. [ABSTRACT FROM AUTHOR]

During last decades, consumer awareness in importance of healthy intake has led their tendency towards the potential health benefits of particular foods and food ingredients. These conditions resulted in development of functional foods. In the current research, the effect of different concentrations of demineralized ultrafiltrated whey powder (DUWP) at levels of 0, 1 and 2% (W/V) and lactulose at levels of 0 and 1% (W/V) on symbiotic ultrafiltrated cheese were evaluated as a functional food. The color values, total acceptability and survival ability of Bifidobacterium bifidium during 60 days of storage at 4 °C were studied. Results showed that as the amount of lactulose and DUWP powders increased, the number of probiotics enhanced meaningfully, while the number of probiotic bacteria deceased with passing the storage time (p<0.001). However, the count of probiotic bacteria in samples containing lactulose and 1 or 2% DUWP at the end of 60 days of storage time were in the standard range of probiotic foods (>107 Log cfu/g). The colorimetric results showed that as the amount of DUWP and the storage time increased, the lightness (L*) decreased significantly (p<0.001); but addition of both powders had no significant effect on a* and b* values. Based on the obtained results, the synbiotic cheese containing 1% DUWP and 1% lactulose powder as compare to control sample had a higher count of probiotic bacteria. Meanwhile, no differences in color quality and total acceptability were found between these two samples. Therefore, this synbiotic ultrafiltrated cheese was determined as the best functional cheese sample. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Hepatic encephalopathy (HE) is prevalent and is associated with increased morbidity and mortality among patients with cirrhosis. On October 1, 2022, a new, specific International Classification of Diseases-10 code for HE, K76.82, was introduced. We aimed to analyze the diagnostic accuracy of K76.82. METHODS: Diagnostic performance of K76.82 for HE (sensitivity, specificity, positive predictive ratio, and negative predictive ratio) was evaluated in 2 large health systems compared with lactulose, rifaximin, and K72.90. RESULTS: A total of 2,483 patients were analyzed. The combination term "lactulose or rifaximin" showed the highest sensitivity of >98% while K76.82 demonstrated a specificity of >87% in all cohorts. DISCUSSION: Although K76.82 is promising, the combination term "lactulose or rifaximin" identified patients with HE more accurately. [ABSTRACT FROM AUTHOR]

The aim of this set of randomised cross‐over studies was to determine the impact of progressive heat exposure and carbohydrate or protein feeding during exertional stress on small intestine permeability using a dual sugar test. In our previous work, and typically in the field, recovery of lactulose and l‐rhamnose is measured cumulatively in urine. This follow‐up study exploits our novel high‐performance anion exchange chromatography with pulsed amperometric detection (HPAEC‐PAD) protocol to accurately quantify the sugars in plasma. Endurance‐trained participants completed experimental trial A (ET‐A; n = 8), consisting of 2 h running at 60% V̇O2max${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ in temperate, warm and hot ambient conditions, and/or experimental trial B (ET‐B; n = 9), consisting of 2 h running at 60% V̇O2max${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{max}}}}$ in the heat while consuming water, carbohydrate or protein. Blood samples were collected and plasma lactulose (L) and l‐rhamnose (R) appearance, after dual sugar solution ingestion at 90 min of exercise, was quantified by HPAEC‐PAD to measure plasma L/R and reveal new information about intestinal permeability immediately post‐exercise and during recovery. In ET‐A, plasma L/R increased immediately post‐exercise in hot compared with temperate and warm conditions, while, in ET‐B, carbohydrate alleviated this, and this information was otherwise missed when measuring urine L/R. Consuming carbohydrate or protein before and during exercise attenuated small intestine permeability throughout recovery from exertional heat stress. We recommend using the dual sugar test with quantification of plasma sugars by HPAEC‐PAD at intervals to maximise intestinal permeability data collection in exercise gastroenterology research, as this gives additional information compared to urinary measurements. Key points: Intestinal permeability is typically assessed using a dual sugar test, by administering a drink containing non‐metabolisable sugars (e.g. lactulose (L) and l‐rhamnose (R)) that can enter the circulation by paracellular translocation when the epithelium is compromised, and are subsequently measured in urine.We demonstrate that our recently developed ion chromatography protocol can be used to accurately quantify the L/R ratio in plasma, and that measuring L/R in plasma collected at intervals during the post‐exercise recovery period reveals novel acute response information compared to measuring 5‐h cumulative urine L/R.We confirm that exercising in hot ambient conditions increases intestinal epithelial permeability immediately after exercise, while consuming carbohydrate or protein immediately before and during exercise attenuates this.We recommend using our dual sugar absorption test protocol to maximise intestinal epithelial permeability data collection in exercise gastroenterology research and beyond. [ABSTRACT FROM AUTHOR]

Background: The rising popularity of eggs as an alternative source of protein to meat has led to significant increase in egg consumption over the past decade. To meet the increasing demand for eggs, poultry farmers have used antibiotics to treat infections and, to some extent, promote growth and egg production in raising layer. However, the emergence and global spread of antibiotic resistant bacteria has now necessitated antibiotic-free poultry farming. As alternatives to antibiotics, prebiotics are feed additives that can be used to improve the growth and laying performance of poultry which positively impacts their performance and general health. In this study we evaluated the effect of lactulose, formulated as Vetelact, on body weight, egg production, egg quality, blood biochemical parameters and expression of genes associated with reproductive performance in laying hens. Results: Vetelact supplementation improved egg weight, egg production as well as egg quality. Following Vetalact supplementation, the levels of total bilirubin, total protein, globulin and phosphorus were increased, while the activities of alkaline phosphatase and lipase enzymes were increased compared to control. Vetelact at 0.10 ml/kg body weight upregulated OCX-36, OVAL, CALB1, OC-116, OCX-32 and IL8 transcripts while downregulating the transcription of Gal-10, PENK and AvBD9. At this optimal inclusion rate of Vetalect, histomorphologic analyses of intestinal tissue showed increased villi length with more goblet cell distribution and obvious mucus covering a surface, increase in the depth of intestinal crypts produce digestive enzymes, as well as more developed muscle layer that promote improved nutrient absorption. Conclusion: Vetelact at a dose of 0.10 ml/ kg body weight was effective in improving productive performance of laying hens. Adding lactulose (0.10 ml/ kg body weight) to layer diet is recommended to promote growth and improve egg laying performance in antibiotics-free poultry production. [ABSTRACT FROM AUTHOR]

The adoption of methods detecting intestinal permeability in poultry has been slow due to the lack of urine availability in avian species. The objective of this study was to examine intestinal permeability assays in broilers using serum. Fluorescein isothiocyanate-dextran (FITC-D) and lactulose/mannitol/sucralose (LMS), indigestible sugars, were used to detect intestinal permeability across two fed states (fed or fasted) and four sugar treatments (Control, FITC-D, LMS, or FITC-D+LMS). Broilers housed in pens were assigned one of eight treatments and sampled on 14, 28, and 42 days of age. Data were analyzed using PROC Glimmix for fed state, sugar treatment, age, and all interactions. Serum lactulose and FITC-D increased in fasted compared to fed birds (p < 0.006), whereas mannitol increased in fed compared to fasted birds (p < 0.001). Serum lactulose and FITC-D decreased on day 28 compared to other timepoints (p < 0.003). Serum FITC-D only had a significant sugar by fed state interaction (p < 0.05) with elevated concentrations in fasted and fed birds that received FITC-D. Serum lactulose was significant for all interactions with elevated concentrations in broilers provided lactulose and fasted (p < 0.001). The ability to detect a three-way interaction with serum lactulose suggests an increased sensitivity; however, additional studies are needed. [ABSTRACT FROM AUTHOR]

The synthetic disaccharide lactulose, consisting of fructose and galactose, after oral administration in an unchanged form reaches the lower part of the gastrointestinal tract, where under the action of normal flora it is broken down into short-chain fatty acids that stimulate colon motility. The effect of lactulose on gastrointestinal tract motility in the conditions of its long-term suppression by omeprazole has not been investigated. We studied the influence of lactulose on spontaneous and carbachol-stimulated gastric and colonic motility in rats treated with omeprazole for 28 days. The animals were divided into 3 groups. The first group of animals served as a control. The animals in the second group were administered omeprazole intraperitoneally at a dose of 14 mg/kg orally once a day for 28 days. The animals in the third group were simultaneously injected intraperitoneally with omeprazole and prebiotic lactulose at a dose of 0.2 g/kg orally once a day for 28 days. On the day after the last injections of drugs, we investigated the spontaneous and carbachol-stimulated contractions in the stomach and colon by the balloon graphic method. It was found that the frequency of spontaneous and stimulated contractions in the stomach and colon did not change significantly after 28 days of omeprazole treatment. The amplitude and index of spontaneous and carbachol-stimulated contractions in the stomach and colon were significantly weaker compared to the control. One day after the 28-day simultaneous administration of omeprazole and lactulose the amplitude and index of spontaneous and stimulated contractions in the stomach and colon increased compared with the group of rats treated with omeprazole alone. We concluded that the positive effect of lactulose on gastric and colon motility is a result of the prebiotic properties of lactulose which leads to the normalization of the microbiocenosis in the gastrointestinal tract and the elimination of the inflammatory process in it. [ABSTRACT FROM AUTHOR]

Ultrafiltrated (UF)-white cheese is almost a new generation of whitecheeses that is produced throughout ultrafiltration process. This cheese has a soft and spreadable texture and is distributed in the market after a short storage period. Lactulose is a prebiotic compound that in addition to its positive effect on the growth of probiotic bacteria, its beneficial health effects on human well-being is proved. In the current research, synbiotic cheese samples were produced with the usage of demineralized ultrafiltrated whey powder (DUWP) at 3 levels of 0, 1 and 2%, lactulose at 2 levels of 0 and 1%, and bifidobacterium bifidum as probiotic bacteria. Experimental samples were analyzed and tested for physicochemical analysis including pH, acidity, moisture, syneresis, fat, protein and soluble nitrogen to total nitrogen ratio (TSN/TN) during 60 days of storage at 4 ◦C. Results revealed that addition of DUWP and lactulose, except for protein, had significant effects on the other tested parameters. In addition, the time of storage period had noticeable impact on all the examined physicochemical properties (P<0.01). Based on the results of this study, it was found that the best UF-white synbiotic cheese could be produced with the usage of 1% of each DUWP and lactulose powders. [ABSTRACT FROM AUTHOR]

This study explores the clinical effect of lactulose combined with acupoint catgut embedding on maintenance hemodialysis (MHD) patients with functional constipation. Patients with MHD complicated with functional constipation in the blood purification centre of Huzhou Central Hospital were enrolled and randomly divided into a control group and an observation group, with 30 cases in each group. The control group was treated with lactulose oral liquid, and the observation group was treated with lactulose oral liquid + acupoint catgut embedding. The scores of constipation symptoms and the average number of weekly spontaneous complete bowel movement (SCBM) were compared between the two groups before and after treatment. Serum brain-gut peptide-related indicators and indoxyl sulfate indicators were used before and after treatment, and the short-term efficacy of the patients was evaluated. Results showed that after treatment, the scores of stool properties, defecation frequency, difficulty, and defecation time in the observation group were significantly lower than those in the control group (P<0.01). The frequency of SCBM in the observation group was significantly more than that in the control group in 2-4 weeks of treatment (P<0.05). Compared with the control group after treatment, the serum 5-hydroxytryptamine four receptors level in the observation group significantly increased (P<0.01), and the serum somatostatin, vasoactive intestinal peptide, and indoxyl sulfate levels significantly decreased (all P<0.01). The results of the curative effect evaluation showed that the total effective rate of the observation group (90.00%) was significantly higher than that of the control group (63.33%, P<0.05). Thus, lactulose combined with acupoint catgut embedding can achieve a good curative effect in the treatment of functional constipation complicated by MHD, relieve the symptoms of constipation, increase the frequency of SCBM, mediate the level of serum brain-gut peptide-related indicators, and promote the recovery of intestinal-kidney function. Thus, this method can alleviate defecation troubles, thereby improving the quality of life of MHD patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE The lactulose-to-mannitol ratio test is a test to assess the disorders associated with gut permeability. The test requires an oral administration of the mixture of lactulose and mannitol and urine collection. The urinary ratio of lactulose to mannitol is an indicator of intestinal permeability. Due to the complexity of urine collection in animal studies, plasma exposure ratios of lactulose to mannitol compared to their urinary concentration ratios were evaluated following an oral administration of the sugar mixture in pigs. ANIMALS 10 pigs were orally dosed with a solution of lactulose and mannitol mixture. PROCEDURES Plasma samples were collected at predose, 10 and 30 minutes and 2, 4, and 6 hours postdosing, and cumulated urinary samples were collected at 6 hours for liquid chromatography-mass spectrometry analysis. The ratios of pharmacokinetic parameters of lactulose to mannitol and the plasma sugar ratios at a single time point or the mean values of several time points were compared to their urinary sugar ratios. RESULTS The results revealed that the lactulose-to-mannitol ratios of AUC0-6h, AUCextrap, and Cmax were correlated to the urinary sugar ratios, and the plasma sugar ratios of a single time point at 2, 4, or 6 hours and the mean values of those time points were also appropriate to replace their urinary ratios in pigs. CLINICAL RELEVANCE Following an oral administration of lactulose and mannitol mixture, blood collection, and assay can be an option for assessing intestinal permeability, especially in animal studies. [ABSTRACT FROM AUTHOR]

Hyperammonaemia is a key pathological feature of liver disease and the primary driver of hepatic encephalopathy (HE). However, the relative roles of increased ammonia production and reduced clearance are poorly understood as is the action of ammonia-targeting drugs for HE. We aimed to quantify whole-body ammonia metabolism in healthy persons and patients with cirrhosis and to validate our method by examining the effects of glycerol phenylbutyrate and lactulose + rifaximin treatment. Ten healthy men and ten male patients with cirrhosis were investigated by 90-minute constant ammonia infusion to achieve steady-state plasma ammonia. Whole-body ammonia clearance was calculated as infusion rate divided by steady-state concentration increase and ammonia production was calculated as clearance multiplied by baseline ammonia concentration. Participants were re-investigated after the ammonia-targeting interventions. In healthy persons, ammonia clearance was 3.5 (3.1–3.9) L/min and ammonia production was 49 (35-63) μmol/min. Phenylbutyrate increased clearance by 11% (4–19%, p = 0.009). In patients with cirrhosis, ammonia clearance was 20% lower at 2.7 (2.1–3.3) L/min (p = 0.02) and production was nearly threefold higher at 131 (102–159) μmol/min (p <0.0001). Lactulose + rifaximin reduced production by 20% (2–37%, p = 0.03). The infusion was generally well-tolerated apart from in one hyperammonaemic patient, with cirrhosis and possible bleeding unrelated to the infusion, who developed clinical HE that reverted when infusion was discontinued. Whole-body ammonia clearance and production may be measured separately using the described technique. This technique identified a lower clearance and a higher production of ammonia in patients with cirrhosis, and showed that phenylbutyrate increases clearance, whereas lactulose + rifaximin reduces production. High blood ammonia plays a key role in cirrhosis-related brain dysfunction. However, the relative roles of reduced ammonia clearance and increased ammonia production are poorly understood as is the action of ammonia-targeting treatments. This study presents a relatively simple test to measure ammonia metabolism. By using this test, it was possible to show that patients with cirrhosis exhibit decreased ammonia clearance and increased ammonia production compared to healthy persons, and to quantify the unique effects of different ammonia-targeting treatments. The test described herein may be used to examine a range of questions related to normal physiology, pathophysiology and the mechanisms of action of ammonia-targeting treatments. ClinicalTrials.gov (1-16-02-297-20). [Display omitted] • The constant ammonia infusion technique quantifies whole-body ammonia metabolism. • The technique measures pathophysiological changes in ammonia metabolism and the effects of ammonia-targeting therapies. • In patients with cirrhosis, ammonia clearance is decreased by 20% and ammonia production is increased three-fold. • Treatment with glycerol phenylbutyrate increases clearance in healthy persons. • Treatment with lactulose + rifaximin decrease production in patients with cirrhosis. [ABSTRACT FROM AUTHOR]

Background: Lactulose as an effective prebiotic protects intestinal mucosal injury. Bacillus coagulans is widely used in feed additives because of its ability to promote intestinal health. Our previous study suggests that the combination of lactulose and Bacillus coagulans may be a good candidate as alternative for antibiotic growth promoters. However, the in vivo effects of lactulose and Bacilluscoagulans on growth and intestinal health under immune challenge in piglets remains unclear. The objective of this study is to explore the protective effects of synbiotic containing lactulose and Bacillus coagulans on the intestinal mucosal injury and barrier dysfunction under immune challenge in weaned piglets. Methods: Twenty four weaned piglets were assigned to 4 groups. Piglets in the CON-saline and LPS-LPS group were fed the basal diet, while others were fed either with chlortetracycline (CTC) or synbiotic mixture of lactulose and Bacillus coagulans for 32 d before injection of saline or lipopolysaccharide (LPS). Piglets were sacrificed 4 h after LPS injection to collect samples to determine intestinal morphology, integrity and barrier functions as well as relative genes and proteins. Results: Our data showed that no differences were observed in the growth performance of the four test groups. LPS injection induced higher serum diamine oxidase activities, D-lactic acid levels, and endotoxin status, lower villus height and ratio of villus height to crypt depth, greater mRNA and lower protein expression related tight junction in both jejunum and ileum. In addition, a higher apoptosis index, and protein expression of Bax and caspase-3 were also observed in the LPS challenge group. Interestingly, dietary synbiotic mixture with lactulose and Bacillus coagulans protected against LPS-induced intestinal damage, barrier dysfunction and higher apoptosis as well as CTC. Conclusions: Our data suggest that dietary supplementation of synbiotic mixture with lactulose and Bacillus coagulans showed resilience to LPS-induced intestinal morphological damage, barrier dysfunction and aggressive apoptosis in piglets as well as the protective effects of CTC. These results indicate that synbiotic mixture of lactulose and Bacillus coagulans showed beneficial effects on performance and resilience to acute immune stress in weaned piglets. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Chronic idiopathic constipation (CIC) is a common disorder associated with significant impairment in quality of life. This clinical practice guideline, jointly developed by the American Gastroenterological Association and the American College of Gastroenterology, aims to inform clinicians and patients by providing evidence-based practice recommendations for the pharmacological treatment of CIC in adults. METHODS: The American Gastroenterological Association and the American College of Gastroenterology formed a multidisciplinary guideline panel that conducted systematic reviews of the following agents: fiber, osmotic laxatives (polyethylene glycol,magnesium oxide,lactulose) stimulantlaxatives (bisacodyl, sodium picosulfate, senna) secretagogues (lubiprostone, linaclotide, plecanatide) and serotonin type 4 agonist (prucalopride). The panel prioritized clinical questions and outcomes and used theGrading ofRecommendations Assessment, Development, and Evaluation framework to assess the certainty of evidence for each intervention. The Evidence to Decision framework was used to develop clinical recommendations based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS: The panel agreed on 10 recommendations for the pharmacological management of CIC in adults. Based on available evidence, the panel made strong recommendations for the use of polyethylene glycol, sodium picosulfate, linaclotide, plecanatide, and prucalopride for CIC in adults. Conditional recommendations were made for the use of fiber, lactulose, senna, magnesium oxide, and lubiprostone. DISCUSSION: This document provides a comprehensive outline of the various over-the-counter and prescription pharmacological agents available for the treatment of CIC. The guidelines are meant to provide a framework for approaching the management of CIC; clinical providers should engage in shared decision making based on patient preferences as well as medication cost and availability. Limitations and gaps in the evidence are highlighted to help guide future research opportunities and enhance the care of patients with chronic constipation. [ABSTRACT FROM AUTHOR]

Background: Hepatic encephalopathy (HE) is a major cause of mortality and morbidity in patients with cirrhosis. Lactulose non-adherence is one of the most frequently reported precipitants of hospital admission for HE. Aims: We aimed to identify which factors contribute most to lactulose non-adherence and propose strategies to promote greater adherence and utilization of lactulose. Methods: Participants in this study consisted of patients with cirrhosis who were taking lactulose for prevention of HE. Subjects were administered the Morisky Adherence Scale 8 (MAS-8) and a customized 16-question survey that assessed barriers to lactulose adherence. Results from the MAS-8 were used to stratify subjects into "adherent" and "non-adherent" groups. Survey responses were compared between groups. Results: We enrolled 129 patients in our study, of whom 45 were categorized as "adherent and 72 were categorized as "non-adherent." Barriers to adherence included large volumes of lactulose, high frequency of dosing, difficulty remembering to take the medication, unpleasant taste, and medication side-effects. Most patients (97%) expressed understanding of the importance of lactulose, and 71% of patients felt that lactulose was working to manage their HE. Hospital admission rates for HE was higher in non-adherent patients, although this difference was not statistically significant. Conclusion: We identified several factors that contribute to lactulose non-adherence among patients treated for HE. Many of these factors are potentially modifiable. Patient and care-giver education are critical to assure adherence. Pharmacists and nurses are an essential but underutilized aspect of education regarding proper medication use. [ABSTRACT FROM AUTHOR]

In this research, the synbiotic effects of the probiotic Lactiplantibacillus plantarum YW11 and lactulose on intestinal morphology, colon function, and immune activity were evaluated in a mouse model of UC induced by dextran sulfate sodium (DSS). The results revealed that L. plantarum YW11 in combination with lactulose decreased the severity of colitis in mice and improved the structure of the damaged colon, as assessed using colon length and disease condition. Moreover, colonic levels of pro-inflammatory cytokines (IL-1β, IL-6, IL-12, TNF-α, and IFN-γ) were significantly lower and anti-inflammatory factors (IL-10) were significantly higher following the synbiotic supplementation. The synbiotic also exerted antioxidant effects by up-regulating SOD and CAT levels and down-regulating MDA levels in colon tissue. It could also reduce the relative expression of iNOS mRNA and increase the relative expression of nNOS and eNOS mRNA. Western blot confirmed the increased expression of c-Kit, IκBα, and SCF and significantly reduced expression of the NF-κB protein. Therefore, the combination of L. plantarum YW11 and lactulose exerted therapeutic effects mainly through the NF-κB anti-inflammatory pathway, which represented a novel synbiotic approach in the prevention of colonic inflammation. [ABSTRACT FROM AUTHOR]

Few studies expressed the β-galactosidase encoding gene from L. plantarum in E. coli so far. In the present study, the recombinant β-galactosidase from L. plantarum FMNP01 was used as a catalyst in transgalactosylation to form tri-GOS and lactosucrose. In the presence of lactose and sucrose, six transfer products were formed in the transgalactosylation reaction with recombinant β-galactosidase L.pFMNP01Gal as a catalyst. Three transfer products were tri-galacto-oligosaccharides (tri-GOS), lactosucrose, and lactulose; the other three transfer products needed to be identified further. Based on a single factor test and response surface methodological approach, the optimal transgalactosylation conditions of the production of tri-GOS and lactosucrose were determined as initial sugar concentration of 50%, lactose: sucrose ratio of 1:2, enzyme concentration of 3 U/mL, and reaction time of 6 h at 50 °C resulting in a maximum tri-GOS concentration of 47.69 ± 1.36 g/L and a maximum lactosucrose concentration of 8.18 ± 0.97 g/L. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Hepatic encephalopathy (HE) is acommon decompensating event in patientswith cirrhosis. Because of the aging population of patients with cirrhosis, differentiating HE from nonhepatic etiologies of cognitive impairment, such as dementia, is increasingly important. METHODS: Veterans with cirrhosis were identified via International Classification of Diseases-10 codes between October 1, 2019, and September 30, 2021, using the VA Corporate Data Warehouse. Baseline characteristics were compared between cohorts based on the presence vs absence of dementia. Factors associated with having a diagnosis of dementia were evaluated using multivariate logistic regression models, adjusting for demographics, comorbid illnesses, cirrhosis etiology, and cirrhosis complications. RESULTS: A total of 71,552 veterans with cirrhosis were identified, of which, 5,647 (7.89%) veterans had a diagnosis of dementia. Veterans with dementia were older, more frequently White, urban located, and diagnosed with alcohol-related cirrhosis, metabolic syndrome, brain trauma, and cerebrovascular disease more frequently. On multivariable analysis, the presence of any decompensating event was associated with dementia. Multivariable analysis of individual decompensating events revealed HE to be associated with a dementia diagnosis, but not ascites, independent of other risk factors analyzed. DISCUSSION: Dementia is commonly diagnosed in patients with cirrhosis and correlates with a diagnosis of HE, independent of alcohol use, brain injury, age, and other metabolic risk factors. Dementia did not correlate with other decompensating events. Increased awareness of the overlap between dementia and HE, as well as reliable diagnostic and treatment strategies, is needed for the aging population of veteranswith cirrhosis. [ABSTRACT FROM AUTHOR]

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) is often used in patients with cirrhosis to manage portal hypertension-related complications. Unfortunately, 35-50% of patients develop overt hepatic encephalopathy (HE) after TIPS. However, data on lactulose and rifaximin to prevent post-TIPS HE is limited. Therefore, we aimed to perform a network meta-analysis to investigate the efficacy of multiple pharmacological regimens in the prevention of post-TIPS HE. Methods: A comprehensive search strategy to identify reports of studies of rifaximin use on post-TIPS hepatic encephalopathy was constructed using truncated keywords, phrases, and subject headings developed in Embase. This strategy was translated to MEDLINE, Cochrane Central Register of Controlled Trials, and the Web of Science Core Collection, with all searches performed on 10 February 2022. No publication date or language limits were used. Results: The initial search identified 72 studies, and 56 studies were screened after removing duplicates. Five studies, two randomized controlled trials (RCTs) and three retrospective studies, met our inclusion criteria and were included in the final analysis. A total of 840 patients were included, with 65% male. Our metaanalysis did not find a statistically significant difference between lactulose vs placebo/no prophylaxis, nor rifaximin vs placebo/no prophylaxis, nor rifaximin plus lactulose vs placebo/no prophylaxis in the reduction of post-TIPS HE. Conclusions: Rifaximin alone, lactulose alone, and rifaximin plus lactulose did not significantly reduce the development of post-TIPS HE. Based on the P-scores of the three treatment groups, the combination of rifaximin plus lactulose showed the most promising trend towards preventing post-TIPS HE. More studies, especially large RCTs, are warranted. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Patients with hepatic encephalopathy (HE) suffer from significant symptoms and impaired quality of life. Improved understanding on the potential benefits of first-line HE therapies may aid patientprovider discussions regarding expected benefits of HE treatments. We aimed to perform a systematic review to assess the effects of lactulose and rifaximin on patient-reported outcomes (PROs). METHODS: We searched MEDLINE, EMBASE, and Cochrane Library databases for randomized trials or prospective cohort studies using lactulose and/or rifaximin for the management of HE and assessing changes inPRO using PRO instruments. Physician reviewers independently reviewed titles, abstracts, and full texts and extracted data independently. We performed random-effects meta-analyses to examine the effects of lactulose and rifaximin on PROs. RESULTS: We identified 16 studies representing 1,376 patients that met inclusion criteria. Most studies assessed treatment of covert HE. In patients with covert HE, lactulose significantly improved overall patientreported health-related quality of lifemeasured by the Sickness Impact Profile with an estimated pooled mean difference of 6.92 (95% confidence interval: 6.66-7.18) and showed improvements in several subscales. Conversely, rifaximin demonstrated a nonstatistically significant mean difference in the total Sickness Impact Profile of 4.76 (95% confidence interval: 24.23 to 13.76), with strong evidence of heterogeneity between these studies. Studies examining otherPROinstruments showed improvements in overall health-related quality of life, social functioning, and sleep from both lactulose and rifaximin. DISCUSSION: Patients with HE treated with lactulose or rifaximin reported improvements in important PROs. These results may inform provider-patient communication and help manage patient expectations regarding the potential benefits of HE therapies. [ABSTRACT FROM AUTHOR]

Lactulose is commonly used in pharmacy for constipation and hepatic encephalopathy treatment. The prebiotic effect of lactulose is also often mentioned. However, its cryoprotective effect in combination with lecithin on the main representatives of probiotics has not been tested yet. The 12 taxa of bifidobacteria and Lactobacillaceae members were used for the purpose. These were mixed in a ratio of 1:1 with lactulose + lecithin (finally 5.0% and 1.25%, respectively; LL). The 25% glycerol (G+) solution and cultures themselves were applied as positive and negative controls, respectively. Bacterial suspensions were stored at a mild freezing temperature (−20°C) until the end of the experiment (210th day). The LL solution had a comparable (insignificant difference at the P -value = 0.05) cryoprotective effect as the positive control in five of six bifidobacteria and in three of six representatives of Lactobacillaceae. The better cryoprotective effect was revealed in other Lactobacillaceae. At the end of the experiment, the generally accepted therapeutic minimum (>107 Colony Forming Units/mL) was determined in LL solution in five bifidobacteria and four Lactobacillaceae strains. The presented results improve knowledge about long-term mild cryopreservation of the most commonly used probiotics and could contribute to developing new forms of (nutri)synbiotics. [ABSTRACT FROM AUTHOR]

Functional chronic constipation (FCC) is a disorder caused by low fiber consumption, lack of fluid intake, lack of mobility, or side effects of medications. The objective of this study was to compare the effects of laser acupuncture and the commonly used osmotic laxative, lactulose (as the control), both combined with behavioral therapy and dietary modification, on children with FCC in a randomized controlled trial (RCT). Forty children were randomly chosen, aged 5–15 years with FCC, and randomized into two equal groups (gender ratio (50% male; 50% female), mean ± SD weight (24.2 ± 6.27 kg and 25.7 ± 7.47 kg for groups A and B, respectively)). Study group (group A): used laser acupuncture (650 nm), 30 mW, 0.15 cm2 spot size, 90 s per acupuncture point (ST25, ST36, ST37, BL25, and LI11). Control group (group B): lactulose syrup (1 to 3 mL/kg/day) orally, in divided doses 3 times weekly for 4 weeks, and behavioral training for both groups. Evaluations were conducted before and after the study to assess the efficacy of the therapy. Median value frequency significantly increased in groups A and B post-treatment (4 (6.75–3) and 3 (3.75–2), respectively) compared to pre-treatment (2 (2–1) and 2 (2–0.25), respectively) (p = 0.0001), in favor of group A (p = 0.01). Significant improvement of stool consistency according to Bristol stool scale (BSS) in groups A and B (p = 0.0001), (p = 0.002) respectively in favor of group A (p = 0.03). T-test, Fisher, and Wilcoxon signed rank tests were conducted to compare groups. Non-invasive, painless laser acupuncture therapy can be considered as an alternative therapy for patients with FCC. [ABSTRACT FROM AUTHOR]

Objectives: The precipitating mechanism(s) from the inactive to the active stage of duodenal ulcer disease (DU) is unclear. It has been shown that hydrogen gas from colonic fermentation provides an important energy source for Helicobacter pylori (Hp) colonization. The lactulose hydrogen breath test (LHBT) is a useful tool to assess the small intestinal and/or colon fermentation. This study examines the association(s) between the status of gastroduodenal disease and the result of a lactulose hydrogen breath test (LHBT). Materials and Methods: We enrolled Hp-positive active duodenal ulcer (aDU) patients, inactive DU (iDU) patients and patients with a positive Hp infection without structural gastroduodenal lesion, i.e., simple gastritis (SG Hp+). The patients with simple gastritis without Hp infection (SG Hp−) served as controls. Histological examinations of the gastric mucosa and lactulose hydrogen breath test (LHBT) were performed. Results: SG Hp+ patients tend to have advanced gastritis (pangastritis or corpus-predominant gastritis) compared with SG Hp− patients (7/29 vs. 0/14, p = 0.08). More iDU patients had advanced gastritis than either the SG Hp+ (7/9 vs. 7/29, p = 0.006) or aDU patients (7/9 vs. 6/24, p = 0.013). In comparison with the aDU patients, the iDU patients were also older (52.1 ± 12.6 vs. 42.2 ± 11.9 years, p = 0.02) and had a lower mean area under the curve value of the LHBT(AUC) (209.1 ± 86.0 vs. 421.9 ± 70.9, p = 0.023). Conclusion: aDU patients with a positive Hp infection have a lower grade of gastric mucosa damage than iDU patients and tend to have a higher level of exhaled hydrogen after LHBT. [ABSTRACT FROM AUTHOR]

This study examined the effect of lactulose, galactooligosaccharide, fructooligosaccharide, inulin, and β-glucan on the probiotic strain Lactobacillus delbrueckii subsp. bulgaricus L14, cultivated in an in vitro gastrointestinal system model. We analyzed the degree of hydrolysis of the studied prebiotic oligosaccharides in condition of simulated gastric fluid. The results showed that lactulose had the highest resistance, galactooligosaccharide underwent hydrolysis, and fructooligosaccharide was the most sensitive. Among the polysaccharides, fructose was released from inulin and glucose from β-glucan. Short-chain oligosaccharides and metabolites derived from studied prebiotic oligosaccharides and polysaccharides, supported the growth of probiotic strain L14, which showed the highest growth with fructooligosaccharides and β-glucan as carbohydrate sources. The profile of the activated enzymes secreted by the probiotic strain L14, indicated their inducible character. Beta-galactosidase was activated in the presence of lactulose and GalOS, inulinase was activated in the presence of inulin and fructooligosaccharides, and β-glucosidase was activated in the presence of β-glucan fragments. Analysis of the produced organic and short-chain fatty acids showed that the typical representative of the homofermentative lactobacilli Lb. delbrueckii subsp. bulgaricus L14 changes its metabolism from a homofermentative to a heterofermentative type, best expressed in the presence of lactulose, galactooligosaccharide, and β-glucan. [ABSTRACT FROM AUTHOR]

The g-C3N4/CF composite carrier was prepared by ultrasound-assisted maceration and high-temperature calcination. The enzyme immobilization using the g-C3N4/CF as the novel carrier to immobilize lactase and glucose isomerase was enhanced for lactulose production. The carbon fiber (CF) was mixed with melamine powder in the mass ratio of 1:8. The g-C3N4/CF composite carrier was obtained by calcination at 550 °C for 3 h. After the analysis of characteristics, the g-C3N4/CF was successfully composited with the carbon nitride and CF, displaying the improvement of co-immobilization efficiency with the positive effects on the stability of the enzyme. The immobilization efficiency of the co-immobilized enzyme was 37% by the novel carrier of g-C3N4/CF, with the enzyme activity of 13.89 U g−1 at 60 °C. The relative activities of co-immobilized enzymes maintained much more steadily at the wider pH and higher temperature than those of the free dual enzymes, respectively. In the multi-batches of lactulose production, the relative conversion rates in enzymes co-immobilized by the composite carrier were higher than that of the free enzymes during the first four batches, as well as maintaining about a 90% relative conversation rate after the sixth batch. This study provides a novel method for the application of g-C3N4/CF in the field of immobilizing enzymes for the production of lactulose. [ABSTRACT FROM AUTHOR]

Background: Hydrogen and methane breath tests (HMBT) are widely used clinical investigations but lack standardization. To address this, the North American Consensus (NAC) group published evidence-based recommendations for HMBT. Aims: To evaluate results obtained using NAC recommendations for HMBT, compared to retrospective data that utilized guidelines previously recommended. Methods: HMBT data from 725 patients referred for small intestinal bacterial overgrowth (SIBO) and/or carbohydrate malabsorption (CM) testing were analyzed. Data were compared regarding dose of substrate for SIBO testing (16 vs. 10 g lactulose, and 50 vs. 75 g glucose) and the effect of post-ingestion sampling period for malabsorption testing. The effect of different recommended cut-off values for SIBO were examined. Results: Substrate dose did not affect methane production. 10 g lactulose significantly reduced positive SIBO results compared to 16 g lactulose (42 vs. 53%, p = 0.04). 75 g glucose significantly increased positive results compared to 50 g glucose (36 vs. 22%, p = 0.04). Provoked symptoms were significantly more prevalent in patients testing positive by both North American Consensus and Ledochowski cut-off values. 34.5% of patients tested positive for CM at 180-min compared to 28% at 120-min (not significant, p = 0.19). Conclusions and Inferences: 10 g lactulose substrate produces fewer positive SIBO results than 16 g lactulose, while 75 g glucose dose produces more positive SIBO results than 50 g. Performing CM breath tests for 180 min increases number of positive results when compared to 120 min. SIBO cut-off timings require further investigation, but our findings broadly support the NAC recommendations for SIBO and CM testing. [ABSTRACT FROM AUTHOR]

Objective. Study on the efficacy and mechanism of trimebutine maleate combined with lactulose in the treatment of constipation-predominant irritable bowel syndrome (IBS-C) in the elderly. Methods. From March 2019 to March 2021, 102 elderly patients with IBS-C were randomly divided into the observation group (51 cases) and the control group (51 cases). The observation group was treated with trimebutine maleate combined with lactulose, while the control group was treated with lactulose. Comparison of the clinical effects of the two groups. Comparison of vasoactive intestinal peptide (VIP) levels, neuropeptide Y (NPY) levels, and quality of life scores before and after treatment between the two groups. Documentation of adverse reactions during treatment. Results. The improvement of clinical symptoms in the observation group was significantly better than that in the control group, and the difference is statistically significant (P < 0.05). The level of VIP after treatment in the observation group was significantly lower than that in the control group and before treatment, and the differences were statistically significant (P < 0.05). The level of NPY after treatment in the observation group was significantly higher than that in the control group and before treatment, and the differences were statistically significant (P < 0.05). The scores of dietary restrictions and health worries in the control group after treatment were significantly higher than those before treatment, and the differences were statistically significant (P < 0.05). The scores of anxious, behavioral conflict, dietary restrictions, health worries, social response, and family relationship in the observation group after treatment were significantly higher than those in the control group and before treatment, and the differences were statistically significant (P < 0.05). There were no serious adverse effects in either group during the treatment period, with some patients experiencing dizziness and dry mouth, which improved after discontinuation of the drug, without special intervention. Conclusion. Trimebutine maleate combined with lactulose can improve clinical symptoms and quality of life in elderly patients with IBS-C, and its mechanism of action may be related to the regulation of the body's VIP and NPY levels. [ABSTRACT FROM AUTHOR]

Résumé: La majorité des patients souffrant d'un syndrome de l'intestin irritable présentent des symptômes digestifs liés à la consommation d'aliments. Ces symptômes ont un impact majeur, notamment sur la qualité de vie. Une alimentation thérapeutique peut être proposée dans leur prise en charge. Cette prise en charge nécessite un encadrement diététique, afin d'éviter des carences nutritionnelles. Il reste encore difficile de savoir comment sélectionner les patients pouvant bénéficier d'une telle prise en prise en charge diététique. Les tests respiratoires sont des examens non invasifs, facilement disponibles qui permettent de mesurer la malabsorption en carbohydrates (lactose et fructose) ainsi que l'intolérance ou la présence de symptômes. Les carbohydrates mal absorbés peuvent être responsables des symptômes digestifs. Ces tests peuvent être proposés après exclusion d'une maladie organique chez des patients chez qui une intolérance semble une cause plausible à leurs symptômes. Il est conseillé de suivre un régime pauvre en lactose (12 g/j) uniquement chez les patients avec malabsorption associée à une intolérance au lactose. La place du test respiratoire au fructose reste encore à définir. Les tests respiratoires au lactulose et au glucose permettent de poser le diagnostic de pullulation bactérienne endoluminale ou Small Intestinal Bacterial Overgrowth (SIBO). Ce test est communément utilisé bien qu'imparfait. En cas de positivité, si et seulement si le tableau clinique est évocateur, un traitement antibiotique séquentiel peut être prescrit afin d'améliorer les symptômes. Les tests respiratoires après la prise d'un repas test sont de plus en plus étudiés en recherche clinique et pourraient faire partis de la prise en charge dans le futur. Most of patients suffering of irritable bowel syndrome (IBS) have gastrointestinal symptoms associated with food intake. These food-related symptoms have a major impact on quality of life. The management of patients with IBS can include diet. Dietary treatments should always involve a dietician in order to avoid nutritional deficiency. Moreover, to select the good patients to a diet remains a challenge. Breath tests are non-invasive and widely available, assessing carbohydrates malabsorption (fructose and lactose), but also intolerance, or the presence of gastrointestinal symptoms. Malabsorbed carbohydrates can lead to gastrointestinal symptoms in IBS. If carbohydrate intolerance is suspected, and after exclusion of an organic disease, breath tests could be proposed. Only patients with lactose malabsorption associated with intolerance should follow a lactose-free diet (12 g/day). The role of fructose breath test need to be defined in the management of patients with IBS. Lactulose and glucose breath tests are useful to diagnose small intestinal bacterial overgrowth (SIBO). This test is imperfect but is commonly used and should be only propose in case of a compatible clinical picture. If positive, antibiotics can improve the symptoms of patients. Meal challenge test associated with breath test might be part of the management in the future, while there are more and more used in clinical research. [ABSTRACT FROM AUTHOR]

Clinical progress in the development of new diagnostic modalities and therapeutic strategies for the management of patients with hepatic encephalopathy has lagged behind the vast knowledge that has been generated from basic studies. In this article, we critically assess matters that should be revisited, such as definition, classification, diagnosis and grading of hepatic encephalopathy, which are difficult to apply reproducibly using the current criteria. Many lines of investigation have confirmed that hepatic encephalopathy is irreversible in many patients and suggest the need for further studies focussing on mechanisms of neuronal injury and death, to guide future drug development for these patients. The clinical evidence behind using lactulose for all severities of hepatic encephalopathy, which is currently considered the standard of care, is poor and placebo-controlled trials for hepatic encephalopathy should be considered ethically sound. This expert opinion identifies current challenges in hepatic encephalopathy and highlights areas which require further debate and investigation in order to help advance the field both scientifically and clinically. [ABSTRACT FROM AUTHOR]

Rifaximin use in combination with lactulose is associated with a decreased risk of overt hepatic encephalopathy (HE). We sought to determine whether race and ethnicity were associated with rifaximin prescriptions. We examined data for a 20% random sample of United States Medicare enrollees with cirrhosis and hepatic encephalopathy treated with outpatient lactulose and Part D prescription coverage from 2011-2019. Beginning at the time of first diagnosis, we evaluated time to first prescription of rifaximin accounting for competing risks (Fine-Gray, yielding subdistribution hazard ratios [sHRs]) and cumulative rifaximin exposure using a gamma hurdle model (yielding exposure length ratios). We aimed to determine the association of race and ethnicity with each outcome, adjusting for demographics, clinical factors, and other features of clinical management. Overall, 29,095 patients were diagnosed with HE and treated with lactulose, of whom 13,272 were prescribed rifaximin. Compared to White patients, Black patients were least likely to receive any prescription for rifaximin (sHR 0.70; 95% CI 0.65-0.76). Asian and Hispanic patients were also less likely to receive rifaximin compared to White patients. Black patients also received fewer doses of rifaximin (exposure length ratio 0.90; 95% CI 0.82-0.98). Hispanic patients also received fewer doses (0.88; 95% CI 0.80-0.98). Out-of-pocket spending on rifaximin per person-year was higher for Black and Hispanic than White patients. Out-of-pocket medication spending was associated with reduced odds of filling a rifaximin prescription. Black and Hispanic patients were least likely to be referred to a gastroenterologist. In a national cohort of patients with HE, we observed stark racial and ethnic disparities in the use of rifaximin, an approved therapy for the improvement of HE-specific outcomes. Access to gastroenterologists and cost controls may reduce disparities. Hepatic encephalopathy is a serious problem that can affect people with cirrhosis. When someone develops hepatic encephalopathy, there are 2 main treatments. The first-line treatment is called lactulose. If episodes of hepatic encephalopathy happen on lactulose, another treatment called rifaximin is recommended. In this study, we found that compared to White patients, Black and Hispanic patients are less likely to be prescribed rifaximin, receive fewer rifaximin refills, spend more on rifaximin, and have less access to subspecialists who are familiar with rifaximin. We conclude that efforts to address the cost of rifaximin and access to gastroenterologists could help improve these disparities. [Display omitted] • Hepatic encephalopathy is associated with frequent hospitalizations and morbidity. • Compared to White patients, Black patients incur a higher burden of hospitalizations. • Rifaximin is a medication approved for secondary prevention of hepatic encephalopathy. • Black and Hispanic patients are less likely to be prescribed or receive rifaximin and have less access to subspecialists. [ABSTRACT FROM AUTHOR]

• Measurement of intestinal permeability and absorptive capacity in the domestic cat. • Quantification of sugars in plasma using liquid chromatography-mass spectrometry. • Simultaneous analysis of lactulose, rhamnose, xylose, and 3-O-methylglucose (3-OMG) • Use of stable isotope labelled 13C standards for each target sugar. A novel method for quantifying the concentration of lactulose, rhamnose, xylose, and 3-O-methylglucose (3-OMG) in cat plasma using liquid chromatography-mass spectrometry (LC-MS) was developed. Domestic male cats (n = 13) were orally dosed with a solution containing the four sugars to test the permeability and absorptive capacity of their intestinal barrier. Plasma samples were taken 3 h later and were prepared with acetonitrile (ACN), dried under N 2, and reconstituted in 90 % ACN with 1 mM ammonium formate. Stable isotope labelled 13C standards for each analyte were used as internal standards. Chromatographic separation was conducted using a Phenomenex Luna NH2 column with a gradient elution system of deionized water and 90 % ACN with 1 mM ammonium formate at 300 µL/min for 13 min total analysis time. Recovery trials were conducted in triplicate over three days with RSD values (%) for each day ranging from 1.2 to 1.4 for lactulose, 5.4 – 6.0 for rhamnose, 3.3 – 5.5 for xylose, and 2.6 – 5.6 for 3-OMG. Inter-day variations for each analyte were not different (p > 0.05). Limit of detection and quantification were 0.2 and 0.7 µg/mL for lactulose, 0.8 and 2.4 µg/mL for rhamnose, 0.6 and 1.8 µg/mL for xylose, and 0.3 and 1.1 µg/mL for 3-OMG, respectively. Plasma sugar concentrations recovered from cats were above the limit of quantification and below the highest calibration standard, validating the use of this method to test intestinal permeability and absorptive capacity in cats. [ABSTRACT FROM AUTHOR]

Bioconversion of lactose to functional lactose derivatives attracts increasing attention. Lactulose is an important high-value lactose derivative, which has been widely used in pharmaceutical, nutraceutical, and food industries. Lactulose can be enzymatically produced from lactose by cellobiose 2-epimerase (CEase). Several studies have already focused on the food-grade expression of CEase, but they are all aimed at the biosynthesis of epilactose. Herein, we reported for the first time the biosynthesis of lactulose using the recombinant food-grade Bacillus subtilis. Lactulose biosynthesis was optimized by varying lactulose-producing CEases and expression vectors. Caldicellulosiruptor saccharolyticus CEase and pP43NMK were determined to be the optimal CEase and expression vector. Fine-tuning of CEase expression was investigated by screening a beneficial N-terminal coding sequence. After fed-batch cultivation, the highest fermentation isomerization activity reached 11.6 U/mL. Lactulose was successfully produced by the broth of the engineered B. subtilis with a yield of 52.1 %. • CEase was effectively expressed in Bacillus subtilis for lactulose production. • N-terminal coding sequence was used to increase the expression level of CEase. • Isomerization activity of the engineered B. subtilis reached 11.6 U/mL. • Lactulose yield of the engineered B. subtilis reached 52.1 %. [ABSTRACT FROM AUTHOR]

Cinnamaldehyde (CA), the main active constituent of cinnamon oil, is reported to have neuroprotective effects. However, the potential benefits of CA for brain protection in hepatic encephalopathy (HE) are still not understood. Thus, the present study investigates the possible ameliorative effect of CA (70 mg/kg/day, I.P.) either alone or in combination with lactulose (Lac) (5.3 g/kg/day, oral) against thioacetamide (TAA)-induced hepatic encephalopathy in rats. For induction of HE, TAA (200 mg/kg) was intraperitoneally administered for 1 week at alternative days. CA, Lac and Lac+CA were administered for 14 days prior to and for further 7 days together with TAA injection. CA, Lac and Lac+CA combination effectively attenuated TAA-induced HE; as indicated by the improvement in behavioral tests, mitigation of pathological abnormalities in both liver and brain, the significant reduction in serum hyperammonemia and amelioration in liver function biomarkers; ALT and AST. This was accompanied with a substantial restoration of redox state in liver and brain; MDA and GSH levels. Moreover, CA, Lac and Lac+CA combination reduced neuroinflammation as demonstrated by the notable attenuation of P2X7R, NLRP3, caspase-1, IL-1β, GFAP and Iba1 brain levels, as well as the amelioration of brain edema as manifested by reduction in AQP4 levels in brain. Our study has demonstrated that CA in combination with Lac possesses a superior neuroprotective effect over Lac alone against TAA-induced HE by attenuation of P2X7R/NLRP3 mediated neuroinflammation and relieving brain edema. [Display omitted] • Cinnamaldehyde (CA)/lactulose (Lac) combination therapy has a neuroprotective activity against acute hepatic encephalopathy. • CA/Lac combination therapy alleviates hyperammonemia-induced cognitive/motor deficits and brain edema. • CA/Lac combination therapy attenuates P2X7R/NLRP3 mediated neuroinflammation. [ABSTRACT FROM AUTHOR]

Background/Aims The effects of probiotics in children vary based on diseases and probiotic strains. We aim to investigate the effectiveness of Saccharomyces boulardii and lactulose for treating childhood functional constipation. Methods This open-label randomized controlled trial was conducted at 10 university hospitals in Korea. Children who were diagnosed with functional constipation were allocated to 3 groups (lactulose monotherapy, combination therapy, and S. boulardii monotherapy). The primary outcome was treatment success rate that was accordingly defined as = 3 bowel movements without incontinence at week 12. The cumulative successful maintenance and drug maintenance rates without drug changes were calculated throughout the study period. We compared stool frequency, incontinence, consistency, and painful defecation at week 2 among the 3 groups. Results Overall, 187 children were assigned to the lactulose monotherapy (n = 69), combination therapy (n = 68), or S. boulardii monotherapy (n = 50) groups. The primary outcome was significantly higher in the lactulose monotherapy group (26.1%) or combination therapy group (41.2%) than in the S. boulardii monotherapy group (8.0%). The S. boulardii monotherapy group showed a significantly lower cumulative successful maintenance and drug maintenance rate than the other 2 groups. There were no significant intergroup differences in the frequency of defecation, incontinence, painful defecation, or stool consistency during the follow-up at week 2. Conclusion S. boulardii monotherapy was not superior to lactulose monotherapy or combination therapy and showed a higher drug change rate, supporting the current recommendation of probiotics in the treatment of childhood functional constipation. [ABSTRACT FROM AUTHOR]

Background: Hepatic supportive diet (HSD), lactulose, and antimicrobials are medical treatments for dogs with congenital extrahepatic portosystemic shunts (cEHPSS). The relative contribution of these treatment components is currently unknown. Objectives: To determine which treatment combinations are most efficacious in pre‐surgical control of clinical signs of cEHPSS in dogs. Animals: Thirty‐six dogs with untreated cEHPSS. Methods: Three‐arm randomized clinical trial. At inclusion (T0), dogs were divided into 3 groups: HSD (n = 12), HSD + lactulose (n = 12), or HSD + metronidazole (n = 12) and received the randomized treatment for 4 weeks (T1) followed by combined treatment of HSD + lactulose + metronidazole for 2 weeks or until cEHPSS attenuation (T2). Clinical score as well as fasting ammonia (FA) and C‐reactive protein (CRP) concentrations were compared among groups and time points. Results: Thirty‐four dogs were evaluated. Thirty‐four dogs reached T1 and 29 dogs T2. At T1, clinical scores decreased in the HSD + lactulose (n = 11; P =.001), but not in the HSD (n = 8; P =.96) and HSD + metronidazole (n = 10; P =.06) groups. Adding metronidazole to HSD + lactulose (n = 11) did not result in further clinical score improvement (T2; P = 1.000). Moderate and weak correlation between clinical score and FA and clinical score and CRP was present (ρ =.35, P <.001; ρ =.27, P =.01, respectively) with FA decreasing over time on medical treatment (P =.001). Conclusions and Clinical Importance: Combined HSD + lactulose seems sufficient for pre‐surgical cEHPSS stabilization unlike sole HSD or HSD + metronidazole. Medical treatment of cEHPSS clinical signs decreases FA. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The intestinal permeability (IP) of sugars and their derivatives has been widely used to assess mucosal damage in gastrointestinal diseases. Ulcerative colitis (UC) is a recurring and relapsing disease that causes inflammation of the gut. IP of sugars can be evaluated and correlated with the flare of UC. MATERIALS AND METHODS: A prospective study was conducted on 91 patients with active UC at the tertiary care center in North India. Mayo grading system assessed disease activity, and IP was assessed by measuring sucrose, lactulose, mannitol, and sucralose in urine samples from UC patients. A high-performance liquid chromatography (HPLC) method to detect all of these sugars simultaneously using a refractive index detector was developed and further validated in patients with UC. RESULTS: The analytical recovery rate of the tested sugars ranged from 95% to 146% in the urine matrix. The limit of detection and limit of quantification were 78.838 mg/L and 262.79 mg/L for sucrose, 84.994 mg/L and 283.31 mg/L for lactulose, 74.789 mg/L and 249.30 mg/L for mannitol, and 50.908 mg/L and 169.69 mg/L for sucralose. CONCLUSION: The standardized HPLC method is sensitive and suitable for the simultaneous detection and determination of different sugar moieties in the urine sample. Patients with UC can be evaluated indirectly for the flare by estimating the recovery rate of sugars through gut permeability. The procedure is noninvasive and thus improves the quality of life of chronically ill patients. [ABSTRACT FROM AUTHOR]

Cirrhosis is associated with substantial morbidity and mortality. Development of complications of cirrhosis, including hepatic encephalopathy (HE), portends poorer outcomes. HE is associated with hospital readmission, impaired patient and caregiver quality of life, risk of falls, and mortality. Guidelines recommend lactulose as first-line therapy for HE and rifaximin in combination with lactulose for reducing the risk of HE recurrence. Improving post-discharge outcomes, including readmissions, is an important aspect in the management of patients with HE. Approaches focused on improving management and prevention of HE, including properly titrating lactulose dosing, overcoming medication-related nonadherence, and incorporating rifaximin as therapy to reduce the risk of recurrence, as well as incorporating supportive care initiatives, may ease the transition from hospital to home. Strategies to decrease readmission rates include using hospital navigators, who can offer patient/caregiver education, post-discharge planning, and medication review; and involving pharmacists in post-discharge planning. Similarly, telemedicine offers providers the opportunity to monitor patients with HE remotely and improves outcomes. Providers offering transitional care management may be reimbursed when establishing contact with patients within 2 days post-discharge and conducting an outpatient visit within 7 days or 14 days. Several approaches have been shown to improve outcomes broadly in patients post-discharge and may also be effective for improving outcomes specifically in patients hospitalized with cirrhosis and HE, thus closing the revolving door on rehospitalizations in this population. [ABSTRACT FROM AUTHOR]