Expert Group Consensus Opinion: Role of Anti-inflammatory Agents in the Management of Type-2 Diabetes (T2D).

Diabetes is a major public health emergency of the 21st century. Results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study have found prevalence of diabetes and prediabetes in India to be as high as 7.3% and 10.3%, respectively with nation-wide projection of 77.2 million people with prediabetes and 69.2 million with diabetes. It is well established that insulin resistance (IR) and islet ß-cell failure are the two major features of T2D Multiple mechanisms including glucotoxicity, lipotoxicity, oxidative stress, endoplasmic reticulum stress, formation of amyloid deposits in the islets, etc. have been hypothesized to participate in the pathology of the disease. In the concluding decade of the last century, numerous studies - prospective and cross-sectional, have confirmed the role of chronic low-grade inflammation as a pathogenetic factor of T2D. It has been shown that increased levels of various inflammatory markers and mediators including fundamental markers like white blood cell count, C-reactive protein (CRP) to the more specific circulating cytokines like, interleukin-6 (IL-6), IL-1ß, plasminogen activator inhibitor-1 (PAI-1), etc. correlate with incident T2D. Based on the robust evidence implying the role of inflammation in T2D pathogenesis, several studies have proven that the proinflammatory cytokines play a central role in the development of microvascular diabetic complications such as nephropathy, retinopathy, and neuropathy. Inflammation in T2D causes accelerated atherosclerosis which predisposes to CVD, the leading cause of mortality in these patients. Recently there is a considerable increase in the interest among the researchers about anti-inflammatory therapies in the setting of chronic disorders such as T2D and CV diseases. In a multi-country study conducted in Asia, approximately 50% of Indian respondents had poor diabetes control. Most patients initially respond to sulfonylurea and/or metformin, and later these agents lose their effectiveness with time. Therapeutic option in patients uncontrolled on two-drug combination therapy is either to add third oral drug or insulin. However, use of insulin is limited due to its high cost and poor compliance. Majority of new treatment options like GLP1 agonists, insulin analogs and SGLT2 inhibitors are costly considering they are still under patent. The thiazolidinedione class of drugs is associated with adverse effects like fluid retention and weight gain that may result in or exacerbate edema and congestive heart failure. Thus there is a need for a safe and inexpensive treatment option for the management of uncontrolled T2D. Considering the role of inflammation in T2D pathogenesis, the drug should not only have antihyperglycemic effects but also reduce inflammatory burden thus reducing the progression and complications of T2D. The current interest is apparently directed towards drugs targeting inflammation acting at different stages of the inflammatory cascade. In the recently published CANTOS study, canakinumab, a selective, high-affinity, fully human monoclonal antibody which inhibits IL-1ß, has no consistent long-term benefits on HbA1c. Other selective inhibitors like anakinra (IL-1 receptor antagonist) and etanercept (TNF inhibitor) too have yielded modest effects on glycemic parameters and insulin sensitivity. However, hydroxychloroquine (HCQ), a broad anti-inflammatory agent has been shown to reduce HbA1c by 0.87%. Hydroxychloroquine (HCQ) is considered as one of the safest disease modifying anti-rheumatic drug, used widely for the treatment of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). The effect of HCQ in preventing development of diabetes in patients with chronic inflammatory diseases was highlighted in a prospective observational study of 4905 adults with rheumatoid arthritis and no diabetes with 21.5 years of follow-up. Patients who took HCQ for more than 4 years had a significant 77% lower risk of diabetes compared with non users of HCQ (RR, 0.23; 95% CI, 0.11-0.50). Taking cue from this study highlighting the anti-diabetic effect of HCQ, pioneering research studies evaluating these effects of HCQ were conducted in India. In 2014, hydroxychloroquine 400 mg got DCGI approval as an adjunct to diet and exercise to improve glycemic control of patients on metformin, sulfonylurea combination in Type 2 diabetes.

An expanding cityscape and its multi-scale effects on lizard distribution.

Urbanization results in complex and variable changes to environmental conditions, which translate to shifts in selection pressures for organisms. Size of a city as well as the intensity and extent of urbanization can synergistically influence how organisms are impacted. However, less is known about how landscape heterogeneity, rate of land-use change, and scale of urbanization affect species persistence. We evaluate the ways in which urbanization changes the environment and examine how some of these environmental factors influence the presence of the lizard Psammophilus dorsalis (Peninsular rock agama), in Bengaluru, India. Variability in environmental factors across the study area was characterised by measures of habitat composition and diversity, habitat connectivity, rate of habitat change, predation pressure, land surface temperature (LST) and artificial light at night (ALAN), that were derived from remotely sensed and citizen science data. Most of these factors showed high variance across two measures of urbanization: distance from city center and proportion of built-up area. Habitat diversity and ALAN were the only two factors that changed predictably and in a non-linear way, with distance from the city center and proportion of built-up area. We then used a multi-scale approach to examine the relative importance of some these environmental factors at the landscape scale, as well as additional factors at the microhabitat-scale, in predicting the presence and relative abundance of P. dorsalis respectively. At the landscape scale, LST, which is positively correlated with proportion of cropland, predicted lizard presence; whereas at the microhabitat scale, P. dorsalis was more likely to be found in sites with higher proportions of rocks. Overall, we demonstrate that urbanization can result in environmental predictors that do not vary linearly across the urbanization gradient. For the iconic rock agama, many of these environmental factors do not seem to be strong selection pressures that influence their distribution in the expanding cityscape. Whether this urban utilizer can continue to persist with increasing anthropogenic development is uncertain. To better understand drivers of species persistence, we emphasize the importance of quantifying urbanization across multiple axes, considering environmental factors that are relevant to species at different spatial and temporal scales.

Cutaneous manifestations of diabetic peripheral neuropathy.

There is a rise in number of people diagnosed with Diabetes Mellitus. The incidence is rising in modern Indian society because of Industrial development and drastically changing lifestyles. Diabetic neuropathies are microvascular disorders that are usually associated with the duration of Diabetes. Among the various forms, the most common is Diabetic Peripheral Neuropathy. The disease if neglected leads to chronic ulcer formation leading to amputations frequently. Hence the aim of this study is to document the early cutaneous changes and create an early awareness in the importance of controlling Diabetes. The study consisted of 205 patients with Type 2 DM. Participant's neuropathy status was determined based on Neuropathy Disability Score and Diabetic Neuropathy Symptom Score. Among the Skin changes documented, the common changes seen were: Peripheral hair loss in 185 (90.2%), Xerosis in 168 (82%), Anhydrosis in 162 (79%), Plantar Fissures in 136 (66.3%), Plantar Ulcer in 80 (39%), common nail changes documented were Onychomycosis in 165 (80.5%) and Onychauxis in 53 (25.8%) patients in relation to the occupation and duration of Diabetes mellitus. In conclusion, it is important to control glycemic levels in the all stages of Diabetes and institute foot care measures to prevent the complications of neuropathy.

Microhyla laterite sp. nov., A New Species of Microhyla Tschudi, 1838 (Amphibia: Anura: Microhylidae) from a Laterite Rock Formation in South West India.

In recent times, several new species of amphibians have been described from India. Many of these discoveries are from biodiversity hotspots or from within protected areas. We undertook amphibian surveys in human dominated landscapes outside of protected areas in south western region of India between years 2013-2015. We encountered a new species of Microhyla which is described here as Microhyla laterite sp. nov. It was delimited using molecular, morphometric and bioacoustics comparisons. Microhyla laterite sp. nov. appears to be restricted to areas of the West coast of India dominated by laterite rock formations. The laterite rock formations date as far back as the Cretaceous-Tertiary boundary and are considered to be wastelands in-spite of their intriguing geological history. We identify knowledge gaps in our understanding of the genus Microhyla from the Indian subcontinent and suggest ways to bridge them.

Architecture of beta-barrel membrane proteins: analysis of trimeric porins.

We have analyzed the known three-dimensional structures of trimeric porins from bacterial outer membranes. The distribution of surface-exposed residues in a direction perpendicular to the membrane is similar to that in helical membrane proteins, with aliphatic residues concentrated in the central 20 A of the bilayer. Outside these residues is a layer of aromatic residues, followed by polar and charged residues. Residues in the trimer interface are more conserved than residues not in the interface. By comparing the interface and noninterface residues, an interface preference scale has been derived that may be used as a basis for predicting interface surfaces in monomer models.

Characterization of substrate UpA binding to RNase A--computer modelling and energetics approach.

In the past two decades RNase A has been the focus of diverse investigations in order to understand the nature of substrate binding and to know the mechanism of enzyme action. Although this system is reasonably well characterized from the view point of some of the binding sites, the details of interactions in the second base binding (B2) site is insufficient. Further, the nature of ligand-protein interaction is elucidated generally by studies on RNase A-substrate analog complexes (mainly with the help of X-ray crystallography). Hence, the details of interactions at atomic level arising due to substrates are inferred indirectly. In the present paper, the dinucleotide substrate UpA is fitted into the active site of RNase A. Several possible substrate conformations are investigated and the binding modes have been selected based on Contact Criteria. Thus identified RNase A-UpA complexes are energy minimized in coordinate space and are analysed in terms of conformations, energetics and interactions. The best possible ligand conformations for binding to RNase A are identified by experimentally known interactions and by the energetics. Upon binding of UpA to RNase A, the changes associated with protein back bone, side chains in general and at the binding sites in particular are described. Further, the detailed interactions between UpA and RNase A are characterized in terms of hydrogen bonds and energetics. An extensive study has helped in interpreting the diverse results obtained from a number of experiments and also in evaluating the extent of changes the protein and the substrate undergo in order to maximize their interactions.

Molecular dynamics studies on nucleoside 2',3'-cyclic phosphates.

2',3'-cyclic nucleotides are intermediates and substrates of Ribonuclease (RNase)-catalysed reactions. The characterization of the equilibrium conformation as well as the flexibility inherent in these molecules helps in understanding the enzymatic action of RNases. The present study explores parameters like phase angle, glycosydic torsion angle and hydrogen bond to find possible interrelationship between them through Molecular Dynamics (MD) simulations on 3'-GMP,3'-UMP, A greater than p, G greater than p, U greater than p, C greater than p, GpA greater than p and UpA greater than p. Interesting results of the effect of cyclisation and other constraints such as hydrogen bond between certain groups on the equilibrium ribose conformation have emerged from this study.

Computer modelling studies of ribonuclease A-pyrimidine nucleotide complexes.

Different modes of binding of pyrimidine monophosphates 2'-UMP, 3'-UMP, 2'-CMP and 3'-CMP to ribonuclease (RNase) A are studied by energy minimization in torsion angle and subsequently in Cartesian coordinate space. The results are analysed in the light of primary binding sites. The hydrogen bonding pattern brings out roles for amino acids such as Asn44 and Ser123 apart from the well known active site residues viz., His12,Lys41,Thr45 and His119. Amino acid segments 43-45 and 119-121 seem to be guiding the ligand binding by forming a pocket. Many of the active site charged residues display considerable movement upon nucleotide binding.

Successful outcome with methimazole and lithium combination therapy for propylthiouracil-induced hepatotoxicity.

OBJECTIVE: To assess the efficacy and safety of combination therapy with methimazole and lithium carbonate in management of severe thyrotoxicosis and propylthiouracil-induced hepatotoxicity. METHODS: We present a case report of a patient with severe thyrotoxicosis and worsening liver dysfunction after propylthiouracil therapy, and we review the pertinent literature. RESULTS: In a 49-year-old man with severe thyrotoxicosis and propylthiouracil-induced hepatotoxicity, indices of liver function continued to increase despite discontinuation of propylthiouracil treatment. Adjunctive therapy with methimazole and lithium resulted in prompt remission of clinical manifestations and normalization of thyroid hormone indices, as well as a gradual reversal of liver dysfunction. CONCLUSION: Adjunctive therapy with methimazole and lithium is synergistic in promptly achieving a euthyroid state. Therefore, this combination therapy provides a safe and effective alternative option in patients with thyrotoxicosis associated with propylthiouracil-induced hepatotoxicity.

Investigations of V(2)O(5)-based LPG sensors.

Sensor characteristics of V(2)O(5) dispersed on oxide supports such as Al(2)O(3), TiO(2) and ZrO(2) with respect to various gases and vapours including liquefied petroleum gas (LPG) have been investigated. Of all the systems studied, 20 mol% V(2)O(5) dispersed on ZrO(2) shows the highest sensitivity for LPG, the log sensitivity-log concentration (in ppm) plots being linear up to 1000 ppm or more. The sensitivity is not affected by humidity or recycling. Addition of P(2)O(5) to V(2)O(5) however destroys the sensitivity. Considering all aspects, 20 mol% V(2)O(5)/ZrO(2) is suggested for use as a practical LPG sensor. ESR spectroscopy indicates the formation of V(4+) species on exposure of V(2)O(5)/ZrO(2) or TiO(2) to LPG. In-situ high-temperature x-ray diffraction measurements show the formation of an unusual monoclinic form of VO(2) on exposure to LPG at 625 K which gets oxidized back to V(2)O(5) on exposure to air.

Thyrotoxicosis.

Thyrotoxicosis is a clinical syndrome caused by circulation of excess thyroid hormones. Classic hyperkinetic thyrotoxicosis is readily recognizable. Atypical presentations, however, can lead to diagnostic dilemmas. The sensitive thyroid-stimulating hormone assay has become an invaluable tool in the diagnosis of thyrotoxicosis. Causes of thyrotoxicosis include Graves' disease, toxic multinodular goiter, toxic adenoma, thyroiditis, inappropriate secretion of thyroid-stimulating hormone, trophoblastic tumor, exposure to iodine, and use of drugs. Increased uptake of radioidine by the thyroid gland differentiates true hyperthyroidism from other causes of thyrotoxicosis. Graves' disease is the most common cause of hyperthyroidism. It is caused by antibodies to the thyroid-stimulating hormone receptor that are stimulatory in nature. Extrathyroidal manifestations of Graves' disease include orbitopathy, dermopathy, and acropachy. Therapy includes thionamides, radioactive iodine, surgical intervention, and other adjunctive modalities. Thyroid storm is a medical emergency that necessitates prompt and aggressive therapy.

Two interesting cases highlighting an oblivious specialty of psychoneuroendocrinology.

Psychoneuroendocrinology deals with the overlap disorders pertaining to three different specialties. Awareness about the somatic manifestations of psychiatric diseases and vice versa is a must for all the clinicians. The knowledge of this interlinked specialty is essential because of the obscure presentation of certain disorders. Our first case was treated as depressive disorder, whereas the diagnosis was hypogonadism with empty sella. Our second patient was managed as schizophrenia and the evaluation revealed bilateral basal ganglia calcification and a diagnosis of Fahr's disease. We report these cases for their unusual presentation and to highlight the importance of this emerging specialty.

Gliptins: a new class of oral antidiabetic agents.

India has the largest population of patients with type 2 diabetes mellitus. The conventional agents used to treat type 2 diabetes frequently exhibit reduced efficacy over time leading to inadequate glycaemic control and are also associated with adverse effects. Hence, there is a need for alternative therapies that can overcome the limitations associated with conventional antidiabetic agents. This review focuses on Gliptins, which have become a research area of intense focus and present an alternative therapeutic strategy for patients with type 2 diabetes. Gliptins show significant improvements in glycaemic control and are well tolerated, particularly with regard to weight change and hypoglycemia. Hence, gliptins are considered as useful agents for the treatment of type 2 diabetes mellitus.