Do we need to change the Patient Indications for Trimetazidine after ATPCI?

The results of the ATPCI (efficAcy and safety of Trimetazidine in patients with angina pectoris treated by Percutaneous Coronary Intervention) study showed no significant difference in the incidence of primary endpoint events between trimetazidine and the placebo group in angina patients who recently underwent percutaneous coronary intervention. The study had limitations specific to the design and selection of the target patient population. However, safety outcomes for trimetazidine were reconfirmed in this study. In this article, we discuss the limitations of study design, patient inclusion criteria and their implications in routine practice. We have also dissected the evidence to tweeze out patient groups who are likely to benefit from trimetazidine treatment.

Characterization and bioremediation potential of native heavy-metal tolerant bacteria isolated from rat-hole coal mine environment

Identification and characterization of endogenous and stress adapted bacterial species, from rat-hole coal mines in Meghalaya, amplify the ambit of bioremediation for eco-restoration. 52 native bacterial isolates, drawn from soil and water samples of these mines, were analysed for bioremediation potential, based on growth and metal tolerance parameters. 12 of these isolates were metal tolerant with Bacillus spp. being the most promising taxon. Three isolates, namely, Serratia marcescens KH-CC, Bacillus altitudinis KH-16F and Bacillus siamensis KH-12A, exhibited high Maximum Tolerable Concentration (MTC) against Fe (500 ppm), Mn (830 ppm) and Pb (1400 ppm). B. siamensis showed highest Fe remediation with 48.34% removal capacity, while maximum removal for Mn and Pb was exhibited by Serratia marcescens at 72.5 and 83%, respectively. The growth profile of the isolates indicated their ability to survive under pH, temperature and salt stress conditions. In vitro growth kinetics studies of the isolates revealed their ability to decrease the acidity of growth media and improve alkalinity from an initial of pH 4.8-5.2 to an alkaline level of pH 8.5-9. These native bacteria, extracted from the stressed coal mine habitat, are potential germane applicants for rehabilitation and eco-restoration of ecologically degraded mine sites.

New and Unique Clusters of Type 2 Diabetes Identified in Indians

Type 2 diabetes (T2D), the most common form of diabetes, is recognized as being a heterogenous disorder, and presents a universal threat to health. In T2D, the pathophysiology and phenotype differ significantly by ethnicity, particularly among Asian Indians, who are known to have the 'Asian Indian phenotype', which makes them more susceptible to develop T2D than white Caucasians. The recent subclassification of T2D into different subtypes or clusters, which behave differently with respect to clinical presentation and risk of developing complications is a remarkable development. Five unique "clusters" of individuals with diabetes were described in the Scandinavian population [Severe Autoimmune Diabetes (SAID), Severe Insulin Deficient Diabetes (SIDD), Severe Insulin Resistant Diabetes (SIRD), Mild Obesity-related Diabetes (MOD) and Mild Age-Related Diabetes (MARD)]. For the first time in India, identification of clusters of diabetes was done on 19,084 individuals with T2D, using 8 clinically relevant variables (age at diagnosis, BMI, waist circumference, HbA1c, triglycerides, HDL cholesterol and fasting and stimulated C-peptide). Four replicable clusters were identified [SIDD, MARD, IROD (Insulin Resistant Obese Diabetes) and CIRDD (Combined Insulin Resistant and Deficient Diabetes)], two of which were unique to the Indian population (IROD and CIRDD). Clustering of T2D helps i) to accurately subclassify diabetes into different subtypes, ii) plan therapies based on the pathophysiology, iii) predict prognosis and prevent diabetic complications and iv) helps in our approach to precision diabetes. Further studies would help us to refine the usefulness of these clusters of T2D particularly in the Indian population, with respect to selection of appropriate therapies and hopefully in the prevention of complications of diabetes.

COVID-19 Care in India: Evolving Paradigms from Public Health to Critical Care

Covid-19 pandemic in India has rapidly grown though we have a low case fatality rate, high recovery rate and large population is asymptomatic or presymptomatic. Public health measures to close the tap across the country need hypervigilance and follow simple dictum of aggressive testing, tracing and isolation. The covid cases need an early diagnosis with treat and care model. Most can be managed with home isolation under telemedicine supervision with oxygen saturation screening by a simple six minute walk test. Hospitalised cases have emerging evidence in different therapies from antivirals, steroids, immunologic to heparins but high flow oxygen, prone position and supportive care remains the cornerstone in critical care with nursing and nutrition. Vaccine research is ongoing but currently only social vaccine can mitigate the pandemic. Covid appropriate behaviour of Masking, sanitisation and physical distancing with immune modulating behaviour like adequate sleep, digital detox for two hour and clean well ventilated environment is the key with breathing exercises including yoga and positive mental health and avoidance of crowds the only vaccine to live with covid -19 today.

Risk Benefit Analysis in Reference to use of LMWH in COVID-19

Venous thromboembolism (VTE) and disseminated intravascular coagulation (DIC) are frequent cardiovascular and/or respiratory complications among hospitalized patients of COVID-19 infection. A relatively high mortality of severe coronavirus disease 2019 (COVID-19) is worrying, and the application of heparin in COVID-19 has been assessed and recommended with some expert consensus because of the risk of DIC and venous thromboembolism. However, "Risk Benefit Analysis" on the aspect of safety in using low molecular weight heparin (LMWH) in COVID-19 patients for thrombosis prophylaxis has been explained below with a few case studies and detailed information from various clinical evidence. COVID-19 infection has been associated with inflammation and a prothrombotic state, with increase in fibrin, fibrin degradation products, fibrinogen, and D-dimers. Heparin treatment including unfractionated and low molecular weight heparin appears to be associated with better prognosis in severe COVID-19 patients with coagulopathy. Major studies since the onset of this pandemic, found better prognosis in severe COVID-19 patients meeting SIC criteria or with markedly elevated D-dimer, by approaching thrombosis prophylaxis with LMWH.

Prognostic Factors for Adverse Outcomes in COVID-19 Infection

Whilst COVID-19 infection generally run a mild course in up to 80% of those affected, a number of pre-existing co-morbidities determine the severity of infection and the outcome in an individual patient. The most important of these co-morbidities that have consistently emerged in studies from across the globe, are the patients age and sex. Other important co-morbidities that adversely affect outcomes include pre-existing diabetes, obesity, hypertension, chronic lung disease and malignancy. This comprehensive review discusses the impact of these co-morbidities and the role of laboratory predictors of poor patient outcomes.

Remogliflozin Etabonate in the Treatment of Type 2 Diabetes: Design, Development, and Place in Therapy

Type 2 diabetes mellitus (T2DM) is an emerging epidemic in Asian countries, especially in India. With the advent of the SGLT2 inhibitor class of drugs demonstrating benefits beyond glycemic control, viz. weight loss, blood pressure reduction, and cardiovascular and renal protection, the management of T2DM has taken a quantum leap. Remogliflozin etabonate (RE) is the latest addition to the SGLT2 inhibitor class of drugs that have been recently approved in India for the management of T2DM. RE is a potent and selective inhibitor of SGLT2 with the unique distinction of being administered as a prodrug, existence of active metabolites, and short half-life necessitating twice-daily dosing. The Phase III study of RE demonstrated it to be an efficacious and safe agent and non-inferior to the currently available SGLT2 inhibitors. This paper reviews not only the pharmacokinetics, pharmacodynamics, clinical efficacy, and safety profile of RE but also its molecular and clinical development program. This review has taken into consideration all available published as well as unpublished literature on RE and discusses the individual studies performed during its development for characterization of pharmacological profile.

Association of vitamin D with fatty acids in pregnancy

Preeclampsia is a pregnancy complication, associated with an increased risk of maternal and neonatal morbidity and mortality. The etiology of preeclampsia is not yet fully understood, although the current literature indicates an up regulation of inflammatory mediators. Vitamin D is known to have anti-inflammatory properties and influence vascular function. Fatty acids are also known to regulate inflammation in pregnancy. This study was carried out to explore the association of maternal vitamin D and fatty acids in pregnancy. The present study includes 69 normotensive control (NC) and 50 women with preeclampsia (PE). Maternal and cord serum 25-hydroxyvitamin D [25(OH)D] levels were lower (p<0.01for both) in women with PE compared to NC women. Maternal plasma total polyunsaturated fatty acids (PUFA) levels were lower (p<0.05) while levels of total saturated fatty acids (SFA) and total monounsaturated fatty acids (MUFA) were higher (p<0.05 for both) in women with PE. Cord erythrocyte PUFA levels were higher (p<0.01) in PE women. Maternal 25(OH)D levels were negatively associated with maternal systolic and diastolic BP (p<0.01 for both). Maternal 25(OH)D levels were positively associated with maternal total PUFA (p<0.01) and negatively associated with maternal total SFA (p<0.05), total MUFA (p<0.01). This study for the first time demonstrates an association of maternal vitamin D with fatty acid levels in pregnancy. Our results suggest that vitamin D and fatty acids may work in concert to regulate fetal growth.

Hydroxychloroquine for COVID-19: What is our Current State of Knowledge?

Chloroquine and Hydroxychloroquine are drugs which have been widely used in malaria and rheumatoid arthritis respectively for over 50 years. There was anecdotal evidence of their efficacy in the earlier SARS outbreak in 2003. This prompted physicians from across the world to use them in the present SARS-CoV- 2 pandemic that is currently sweeping the globe, with 5 million people already infected to date. These drugs are already in widespread use for the treatment of COVID-19 in India, mainly because they are cheap and easily available, and because of the absence of any readily available alternative therapy. This timely review discusses the pre-clinical evidence, and data from the eight available clinical trials. We emphasise that careful monitoring for cardiac toxicity is required when these drugs are used. Finally, we conclude that current data does not allow us to recommend for or against the use of these drugs. Results of two large RCTs, one from the NIH and the other from WHO (Solidarity) are eagerly awaited before the role of these drugs in COVID-19 can be definitively established.

COVID 19: Diabetes and Obesity API-ICP Recommendations

Diabetes and Obesity are major risk factors which confer vulnerability to Covid 19 . Diabetes has immune defects which makes the individual susceptible to infections and covid 19 is no exception . Also covid 19 can cause pancreatic damage as well as stress hyperglycaemia in hospitals which may need Insulin . Among diabetes male gender,elderly,hypertension ,heart disease and chronic renal disease are more vulbwdvale to covid 19 and need strict supervision . Diabetes management in hospitalised situation merits early diabetes specific nutrition with Insulin. Adherence to lifestyle with self monitoring of blood glucose and adequate supply of Insulin and Oral antidiabetic agents is encouraged.

Physician Burnout: Cause and Prevention Strategies

Ongoing evolution in healthcare places physicians under an ever-increasing pressure to consistently perform at a higher level, leading to a significant number of physicians including those in training feeling "burnt-out". Burnout is a result of interplay between personal charateristics and environmental factors. Unadressed physician burnout negatively affects the individual, work environment and most importantly patient care. Individual and environmenal changes are needed to assess and effectively manage burnout. Stigma and fear of professional consequences, especially among regional doctors appears to be an important barrier to access services and address burnout. There is an ever increasing need to expand the Triple Aim (enhancing patient experience, improving population health, and reducing costs) to a Quadruple Aim that goal of improving the work life of health care providers, including clinicians and staff.

Distribution of carbapenem resistant Acinetobacter baumannii with blaADC-30 and induction of ADC-30 in response to beta-lactam antibiotics

A wide range of intrinsic Acinetobacter-derived cephalosporinases (ADC) along with other carbapenemases has now been detected in Acinetobacter baumannii leaving clinicians with few treatment options. The present study reports the spread of ADC-30 co-producing KPC-2 along with other β-lactamases among carbapenem resistant A. baumannii strains obtained from ICU patients in two Indian hospitals. Primer extension analysis revealed higher transcript level of the ADC gene when induced with cefoxitin at 8 μg/ml (170 fold), ceftriaxone at 8 μg/ml (136 fold), ceftazidime at 4 μg/ml (65 fold), cefepime at 8 μg/ml (77 fold) and aztreonam at 8 μg/ml (21 fold) when compared with the basal level without antibiotic pressure. Slight increase in expression of bla_ADC-30 when induced with imipenem and meropenem at 0.25 μg/ml (3 and 6 fold) was observed and may help in conferring resistance to carbapenem. MLST analysis revealed the circulation of A. baumannii sequence types ST188, ST386, ST583 and ST390 in these hospitals.

Bioprospection of anti-inflammatory phytochemicals suggests rutaecarpine and quinine as promising 15-lipoxygenase inhibitors

15-Lipoxygenase (15-LOX) belongs to the family of nonheme iron containing enzymes that catalyzes the peroxidation of polyunsaturated fatty acids (PUFAs) to generate eicosanoids that play an important role in signaling pathways. The role of 15-LOX has been demonstrated in atherosclerosis as well as other inflammatory diseases. In the present study, drug-like compounds were first screened from a set of anti-inflammatory phytochemicals based on Lipinski's rule of five (ROF) and in silico toxicity filters. Two lead compounds-quinine (QUIN) and rutaecarpine (RUT) were shortlisted by analyzing molecular interactions and binding energies of the filtered compounds with the target using molecular docking. Molecular dynamics simulation studies indicate stable trajectories of apo_15-LOX and docked complexes (15-LOX_QUIN and 15-LOX_RUT). In vitro 15-LOX inhibition studies shows that both QUIN and RUT have lower inhibitory concentration (IC₅₀ ) value than the control (quercetin). Both QUIN and RUT exhibit moderate antioxidant activities. The cell viability study of these compounds suggests no significant toxicity in HEK-293 cell lines. Further, QUIN and RUT both did not show any inhibition against selected Gram-positive and Gram-negative bacterial species. Thus, based on our present findings, rutaecarpine and quinine may be suggested as promising 15-LOX inhibitor for the prevention of the atherosclerosis development.

Interlining Cr(VI) remediation mechanism by a novel bacterium Pseudomonas brenneri isolated from coalmine wastewater

A bioremedial approach was investigated on the removal of Cr(VI) from aqueous solution using a novel chromium reducing bacteria isolated from coalmine wastewater. Cr(VI) removal efficacy of the bacterium was determined in a series of batch studies under the influence of various parameters viz., pH (1-7), temperature (20-40 °C), initial metal concentration (1-150 mg/L), agitation speed (80-150 rpm) and substrate concentration (1-5 mg/L). Oxygen involvement in the removal process was determined by different incubation conditions. Substrate consumption and its resultant biomass generation were considered for determining the viability of the microbe under varied metal concentration. The microbial isolate survived in Cr(VI) tainted solution with initial concentration of 1-140 mg/L, among which maximum remediation was found in 60 mg/L Cr(VI) loaded solution. The bacterial species also survived in other metal solution viz., Fe(II), As(V), Cu(II), Pb(II), Zn(II), Mg(II), Mn(II) apart from Cr(VI). Multiple approaches were tested to facilitate understanding of the bacterial Cr(VI) removal mechanism. The bacteria accumulated metal ions in the exponential growth phase both on and within the cell. Underlying latent factors which governed the bacterial growth and its removal activity was determined with the classical Monod equation. The isolated bacterium also survived in the bimetallic solutions with significant removal of Cr(VI). The microbial species isolated from mining area was identified as Pseudomonas brenneri by 16s rRNA molecular characterization. Hence, the isolated novel bacterium illustrated promising involvement towards bio-treatment of Cr(VI) laden wastewater.

Vitamin D deficiency influences fatty acid metabolism

Reports indicate that maternal vitamin D deficiency may be associated with increased inflammation. Long chain polyunsaturated fatty acids (LCPUFAs); omega-3 and omega-6 fatty acids are known to have anti-inflammatory and pro-inflammatory properties respectively. The present study examines the effect of vitamin D deficiency on fatty acid composition and metabolism in a rat model. Female Wistar rats were randomly divided into two groups (n = 8/group) as follows; control and vitamin D deficient (VDD). Diets (control: 1000 IU D3/kg diet; VDD: 0 IU D3/kg diet) were given from weaning and continued throughout pregnancy. Pregnant female rats were dissected on gestational day 20 to collect blood, liver and placenta. The VDD diet reduced maternal serum 25-hydroxyviatmin D3 levels (p < 0.001) as compared to control. Maternal vitamin D deficiency resulted in lower total weight gain and placental weight (p < 0.05 for both) during pregnancy. Animals from VDD group demonstrated higher arachidonic acid (AA) levels in both the liver and plasma (p < 0.05 for both) as compared to control. Liver, plasma and placental monounsaturated fatty acid levels (MUFA) were lower (p < 0.01 for all) while plasma total saturated fatty acids (SFA) (p = 0.05) were higher in the VDD group. Animals from the VDD group demonstrated lower ∆9-desaturase activity index (p < 0.01 for all) in the liver, plasma and placenta. The plasma ∆5-desaturase activity index (p < 0.05) was higher although no change was observed in the ∆6-desaturase activity index. However, the mRNA levels of liver ∆6-desaturase was lower (p < 0.05) in the VDD group. Our findings indicate that maternal vitamin D deficiency influences fatty acid desaturase activity and expression and therefore alters maternal fatty acid metabolism.

Efficacy of SGLT2 Inhibitors as the Fifth Drug in the Management of Type 2 Diabetes Mellitus in Asian Indians not Controlled with at least 4 Oral Antidiabetic Drugs

AIM

To evaluate the efficacy of SGLT2 inhibitors as an add-on therapy along with stricter lifestyle modification in Asian Indian type 2 diabetes mellitus (T2DM) patients with inadequate glycemic control despite receiving an optimum dose of at least 4 oral antidiabetic drugs (OADs).

METHODOLOGY

A retrospective analysis of data of 808 T2DM patients being treated with an SGLT2 inhibitor (Dapagliflozin, Empagliflozin or Canagliflozin) as an add-on drug in patients with inadequate glycemic control despite receiving optimum doses of at least any four OADs(metformin, sulphonylureas, pioglitazone, DPP4 Inhibitors, alpha-Glucosidase Inhibitors) and who preferred not to initiate insulin.

RESULTS

The average age of the patients included was 51.63 years (SD ± 9.88). 57.7% were males. Average weight was 81.95±16.08 kg. Mean duration of diabetes was 34.08±39.04 months. The mean baseline fasting plasma glucose was 198.21 ± 38.21 mg/dl and mean post prandial plasma glucose was 264.22 ± 45.22 mg/ dl. The baseline HbA1c was 8.92 ± 1.47 %. Total 87.4 % of the cases responded to addition of SGLT2 inhibitors during a mean follow-up period of 6 months. The fasting plasma glucose (FBS) was reduced by -63.65 ± 19.93 mg/dl to a mean FBS of 134.57 ± 33.65 mg/dl (P=0.001). The post prandial plasma glucose (PPBS) was reduced by -79.28 ± 23.57 mg/dl to a mean PPBS of 184.94 ± 38.34 mg/dl (P=0.001). The mean HbA1c reduced significantly by -1.63 ± 0.99 % (P= 0.001). The mean weight reduction at 6 months of therapy was -3.03± 01.84 kg that is 3.8 % decrease from baseline (p=0.001).The response in age group < 55 years was 90.9 %, whereas in ≥55 years, it was 82.2% (p=0.001). The males responded more (91.0%) compared to females (82.5%) (p=0.001). Those with BMI < 23.5 kg/ m2 had marginally higher but insignificant response of 93.0% as compared to 87.1% in patients with high a BMI (≥23.5 kg/m2) (p=0.253). Patients with < 5years duration of diabetes responded better (91.8%) as compared to patients with a ≥ 5 years of diabetes (85.4%).

CONCLUSION

SGLT2 inhibitors are effective in achieving desired glycemic goals even when used as a fifth add-on drug along with strict lifestyle modification in patients with inadequate glycemic control despite receiving an optimum dose of at least 4 oral antidiabetic drugs (OADs). SGLT2 inhibitors can be effectively used at any stage of diabetes.

Co-occurrence of antimicrobial resistance and virulence determinants in enterococci isolated from traditionally fermented fish products

OBJECTIVES

Fermented foods frequently consumed in Northeast India can act as a reservoir for disseminating pathogenic organisms. Enterococci are often responsible for contamination of food products. This study investigated the antimicrobial resistance and co-existing virulence determinants of enterococci found in traditionally processed foods in India.

METHODS

A total of 38 enterococci isolates identified as Enterococcus faecalis isolated from fermented fish samples from retail markets of Northeast India were selected for screening of pathogenic traits.

RESULTS

Of the 38 isolates, 8 (21%) were able to hydrolyse gelatin and 13 (34%) showed protease activity. Screening for haemolytic activity of the isolates showed no positive test on sheep blood. The presence of virulence genes (gelE, agg, esp, cpd, efaAfs and cylA) was investigated by PCR. gelE, agg and esp were present in 17, 13 and 4 isolates, respectively. cpd and efaAfs were found in all isolates, whereas cylA was not detected. High resistance percentages to various antibiotics included kanamycin (63%), vancomycin and gentamicin (58%), tetracycline (53%) and rifampicin (50%). The vanA genotype was confirmed in 15 multidrug- and vancomycin-resistant strains.

CONCLUSION

The simultaneous occurrence of virulence determinants and antimicrobial resistance in enterococci prevalent in the fermented fish products studied poses a potential threat of transmission to humans through the food chain. This study highlights the importance of E. faecalis as a reservoir of antimicrobial resistance and virulence factors and their potential transfer to humans. The findings reopen the issue of food safety regarding enterococci prevalent in traditionally processed fish products in the region.

Therapeutic Role of Yoga in Type 2 Diabetes

Yoga originated in India more than 5,000 years ago and is a means of balancing and harmonizing the body, mind, and emotions. Yoga practice is useful in the management of various lifestyle diseases, including type 2 diabetes. Psycho-neuro-endocrine and immune mechanisms are involved in the beneficial effects of yoga on diabetes. Incorporation of yoga practice in daily life helps to attain glycaemic control and reduces the risk of complications in people with diabetes. In this review, we briefly describe the role of various yoga practices in the management of diabetes based on evidence from various clinical studies.

Thyro-weight: Unlocking the Link between Thyroid Disorders and Weight

Thyroid hormone is an important determinant of energy expenditure and contributes to appetite regulation, while hormones and cytokines from the adipose tissue act on the CNS to inform on the quantity of energy stores. A continuous interaction between the thyroid hormone and regulatory mechanisms localized in adipose tissue and brain is important for human body weight control and maintenance of optimal energy balance. Direct effects on ATP utilization are a result of thyroid hormone's actions on metabolic cycles and increased cell membrane ion permeability. However, the majority of thyroid hormone induced energy expenditure is thought to be a result of indirect effects, which, in turn, increase capacity for energy expenditure. This review discusses the direct actions of thyroid hormone on energy expenditure, and places special emphasis on the indirect actions of thyroid hormone, which include mitochondrial biogenesis and reduced metabolic efficiency through mitochondrial uncoupling mechanisms.

Diabetes Care in India

BACKGROUND

Diabetes has become a major health care problem in India with an estimated 66.8 million people suffering from the condition, representing the largest number of any country in the world.

OBJECTIVE

The rising burden of diabetes has greatly affected the health care sector and economy in India. The goal of health care experts in India is to transform India into a diabetes care capital in the world.

METHODS

An expert detailed review of the medical literature with an Asian Indian context was performed.

FINDINGS

Recent epidemiologic studies from India point to a great burden from diabetes. Diabetes control in India is far from ideal with a mean hemoglobin A1c of 9.0%-at least 2.0% higher than suggested by international bodies. Nearly half of people with diabetes remain undetected, accounting for complications at the time of diagnosis. Screening can differentiate an asymptomatic individual at high risk from one at low risk for diabetes. Despite the large number of people with diabetes in India, awareness is low and needs to be addressed. Other challenges include balancing the need for glycemic control with risk reduction due to overly tight control, especially in high-risk groups and taking into account health care professional expertise, attitudes, and perceptions. Pharmacologic care should be individualized with early consideration of combination therapy. Regular exercise, yoga, mindful eating, and stress management form a cornerstone in the management of diabetes.

CONCLUSIONS

Considering the high cost incurred at various steps of screening, diagnosis, monitoring, and management, it is important to realize the cost-effective measures of diabetes care that are necessary to implement. Result-oriented organized programs involving patient education, as well as updating the medical fraternity on various developments in the management of diabetes, are required to combat the current diabetes epidemic in India.