Note that 2-PAM has an affinity for the acetylcholine anionic binding site on cholinesterase (right middle panel), which could explain the oxime related worsening of cholinergic side effects when 2-PAM is administered prior to the onset of action of atropine in the setting of organophosphate poisoning, by transiently preventing nerve-agent free cholinesterase from interacting with acetylcholine
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Finally, long-standing diabetes patients require an exogenous insulin injection to sustain high-insulin concentration, which is the so-called exogenous hyperinsulinemia. Moreover, a unique portal structure enables insulin secreted from the pancreatic islet to perfuse the exocrine pancreas first, significantly increasing the regional insulin concentration in PDA tissue