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Chen Q, Pan Y, Hu Y, Chen G, Chen X, Xie Y, Wang M, Li Z, Huang J, Shi Y, Huang H, Zhang T, Wang M, Zeng P, Wang S, Chen R, Zheng Y, Zhong L, Yang H, Liang D. An L-type calcium channel blocker nimodipine exerts anti-fibrotic effects by attenuating TGF-β1 induced calcium response in an in vitro model of thyroid eye disease. EYE AND VISION (LONDON, ENGLAND) 2024; 11:37. [PMID: 39237996 PMCID: PMC11378575 DOI: 10.1186/s40662-024-00401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 08/02/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND Thyroid eye disease (TED) is a vision-threatening autoimmune disorder. Orbital tissue fibrosis leading to intractable complications remains a troublesome issue in TED management. Exploration of novel therapeutic targets and agents to ameliorate tissue fibrosis is crucial for TED. Recent work suggests that Ca2+ signaling participates in tissue fibrosis. However, whether an alteration of Ca2+ signaling has a role in fibrogenesis during TED remains unclear. In this study, we aimed to investigate the role of Ca2+ signaling in the fibrogenesis process during TED and the potential therapeutic effects of a highly selective inhibitor of the L-type calcium channel (LTCC), nimodipine, through a TGF-β1 induced in vitro TED model. METHODS Primary culture of orbital fibroblasts (OFs) were established from orbital adipose connective tissues of patients with TED and healthy control donors. Real-time quantitative polymerase chain reaction (RT-qPCR) and RNA sequencing were used to assess the genes expression associated with LTCC in OFs. Flow cytometry, RT-qPCR, 5-ethynyl-2'-deoxyuridine (EdU) proliferation assay, wound healing assay and Western blot (WB) were used to assess the intracellular Ca2+ response on TGF-β1 stimulation, and to evaluate the potential therapeutic effects of nimodipine in the TGF-β1 induced in vitro TED model. The roles of Ca2+/calmodulin-dependent protein kinase II (CaMKII) and signal transducer and activator of transcription 1 (STAT1) in fibrogenesis during TED were determined by immunohistochemistry, WB, flow cytometry and co-immunoprecipitation assay. Selective inhibitors were used to explore the downstream signaling pathways. RESULTS LTCC inhibitor nimodipine blocked the TGF-β1 induced intracellular Ca2+ response and further reduced the expression of alpha-smooth muscle actin (α-SMA), collagen type I alpha 1 (Col1A1) and collagen type I alpha 2 (Col1A2) in OFs. Besides, nimodipine inhibited cell proliferation and migration of OFs. Moreover, our results provided evidence that activation of the CaMKII/STAT1 signaling pathway was involved in fibrogenesis during TED, and nimodipine inhibited the pro-fibrotic functions of OFs by down-regulating the CaMKII/STAT1 signaling pathway. CONCLUSIONS TGF-β1 induces an LTCC-mediated Ca2+ response, followed by activation of CaMKII/STAT1 signaling pathway, which promotes the pro-fibrotic functions of OFs and participates in fibrogenesis during TED. Nimodipine exerts potent anti-fibrotic benefits in vitro by suppressing the CaMKII/STAT1 signaling pathway. Our work deepens our understanding of the fibrogenesis process during TED and provides potential therapeutic targets and alternative candidate for TED.
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Affiliation(s)
- Qian Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
- Department of Ophthalmology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510630, China
| | - Yuan Pan
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Yunwei Hu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
- Ophthalmic Center, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Guanyu Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Xiaoqing Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Yanyan Xie
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Minzhen Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Zhuang Li
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Jun Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
- Ophthalmic Center, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yuxun Shi
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Haixiang Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Te Zhang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Mei Wang
- Department of Ophthalmology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Peng Zeng
- Department of Ophthalmology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, China
| | - Sha Wang
- Eye Center of Xiangya Hospital, Central South University, Hunan Key Laboratory of Ophthalmology, Changsha, 410008, China
| | - Rongxin Chen
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Yongxin Zheng
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Liuxueying Zhong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Huasheng Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China
| | - Dan Liang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology Visual Science, Guangzhou, 510060, China.
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Koponen K, Kambur O, Joseph B, Ruuskanen MO, Jousilahti P, Salido R, Brennan C, Jain M, Meric G, Inouye M, Lahti L, Niiranen T, Havulinna AS, Knight R, Salomaa V. Role of Gut Microbiota in Statin-Associated New-Onset Diabetes-A Cross-Sectional and Prospective Analysis of the FINRISK 2002 Cohort. Arterioscler Thromb Vasc Biol 2024; 44:477-487. [PMID: 37970720 PMCID: PMC10805357 DOI: 10.1161/atvbaha.123.319458] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/31/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Dyslipidemia is treated effectively with statins, but treatment has the potential to induce new-onset type-2 diabetes. Gut microbiota may contribute to this outcome variability. We assessed the associations of gut microbiota diversity and composition with statins. Bacterial associations with statin-associated new-onset type-2 diabetes (T2D) risk were also prospectively evaluated. METHODS We examined shallow-shotgun-sequenced fecal samples from 5755 individuals in the FINRISK-2002 population cohort with a 17+-year-long register-based follow-up. Alpha-diversity was quantified using Shannon index and beta-diversity with Aitchison distance. Species-specific differential abundances were analyzed using general multivariate regression. Prospective associations were assessed with Cox regression. Applicable results were validated using gradient boosting. RESULTS Statin use associated with differing taxonomic composition (R2, 0.02%; q=0.02) and 13 differentially abundant species in fully adjusted models (MaAsLin; q<0.05). The strongest positive association was with Clostridium sartagoforme (β=0.37; SE=0.13; q=0.02) and the strongest negative association with Bacteroides cellulosilyticus (β=-0.31; SE=0.11; q=0.02). Twenty-five microbial features had significant associations with incident T2D in statin users, of which only Bacteroides vulgatus (HR, 1.286 [1.136-1.457]; q=0.03) was consistent regardless of model adjustment. Finally, higher statin-associated T2D risk was seen with [Ruminococcus] torques (ΔHRstatins, +0.11; q=0.03), Blautia obeum (ΔHRstatins, +0.06; q=0.01), Blautia sp. KLE 1732 (ΔHRstatins, +0.05; q=0.01), and beta-diversity principal component 1 (ΔHRstatin, +0.07; q=0.03) but only when adjusting for demographic covariates. CONCLUSIONS Statin users have compositionally differing microbiotas from nonusers. The human gut microbiota is associated with incident T2D risk in statin users and possibly has additive effects on statin-associated new-onset T2D risk.
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Affiliation(s)
- Kari Koponen
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
| | - Oleg Kambur
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
| | - Bijoy Joseph
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
| | | | - Pekka Jousilahti
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
| | - Rodolfo Salido
- Department of Pediatrics (R.S., C.B., R.K.), University of California San Diego, La Jolla
- Department of Bioengineering (R.S., R.K.), University of California San Diego, La Jolla
| | - Caitriona Brennan
- Department of Pediatrics (R.S., C.B., R.K.), University of California San Diego, La Jolla
| | - Mohit Jain
- Department of Medicine and Pharmacology (M.J.), University of California San Diego, La Jolla
| | - Guillaume Meric
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Melbourne, Australia (G.M., M.I.)
- Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia (G.M.)
| | - Michael Inouye
- Cambridge Baker Systems Genomics Initiative, Baker Heart and Diabetes Institute, Melbourne, Australia (G.M., M.I.)
- Cambridge Baker Systems Genomics Initiative, Department of Public Health and Primary Care, University of Cambridge, United Kingdom (M.I.)
| | - Leo Lahti
- Department of Computing, University of Turku, Finland (M.O.R., L.L.)
| | - Teemu Niiranen
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
- Department of Medicine, Turku University Hospital and University of Turku, Finland (T.N.)
| | - Aki S. Havulinna
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
- Institute for Molecular Medicine Finland, FiMM-HiLIFE, Helsinki, Finland (A.S.H.)
| | - Rob Knight
- Department of Pediatrics (R.S., C.B., R.K.), University of California San Diego, La Jolla
- Department of Bioengineering (R.S., R.K.), University of California San Diego, La Jolla
- Department of Computer Science and Engineering (R.K.), University of California San Diego, La Jolla
- Center for Microbiome Innovation (R.K.), University of California San Diego, La Jolla
| | - Veikko Salomaa
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland (K.K., O.K., B.J., P.J., T.N., A.S.H., V.S.)
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Xiao X, Luo Y, Peng D. Updated Understanding of the Crosstalk Between Glucose/Insulin and Cholesterol Metabolism. Front Cardiovasc Med 2022; 9:879355. [PMID: 35571202 PMCID: PMC9098828 DOI: 10.3389/fcvm.2022.879355] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/07/2022] [Indexed: 12/19/2022] Open
Abstract
Glucose and cholesterol engage in almost all human physiological activities. As the primary energy substance, glucose can be assimilated and converted into diverse essential substances, including cholesterol. Cholesterol is mainly derived from de novo biosynthesis and the intestinal absorption of diets. It is evidenced that glucose/insulin promotes cholesterol biosynthesis and uptake, which have been targeted by several drugs for lipid-lowering, e.g., bempedoic acid, statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Inversely, these lipid-lowering drugs may also interfere with glucose metabolism. This review would briefly summarize the mechanisms of glucose/insulin-stimulated cholesterol biosynthesis and uptake, and discuss the effect and mechanisms of lipid-lowering drugs and genetic mutations on glucose homeostasis, aiming to help better understand the intricate relationship between glucose and cholesterol metabolism.
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Al-Kuraishy HM, Al-Gareeb AI, Naji MT. Statin therapy associated with decreased neuronal injury measured by serum S100β levels in patients with acute ischemic stroke. Int J Crit Illn Inj Sci 2021; 11:246-252. [PMID: 35070915 PMCID: PMC8725813 DOI: 10.4103/ijciis.ijciis_7_20] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023] Open
Abstract
Background Acute ischemic strokes (AIS) are a common cause of morbidity, mortality, and disability. The serum biomarker S100β correlates with poor neurological outcomes in the setting of AIS. This study describes the impact of statin treatment on S100β levels following AIS. Methods This was a prospective case-control study of AIS patients compared to healthy controls. Patients were stratified into three groups: (1) AIS patients on statin therapy, (2) AIS patients not on statin therapy, and (3) healthy controls. Demographics, clinical parameters, stroke risk scores (SRS), and S100β levels were recorded for all patients. Results Blood pressure, lipids, and SRS scores were higher in stroke versus control patients (all P < 0.05), and lower in Group I versus II (all P < 0.05). S100β levels were higher in stroke versus nonstroke patients (P = 0.001), and lower in Group I versus II (P = 0.001). Furthermore, patients on atorvastatin showed greater S100β reductions than those on rosuvastatin therapy (P = 0.01). Conclusion In acute stroke patients, statins therapy correlated with reductions in the neuronal injury biomarker S100β, with greater reductions observed for atorvastatin than rosuvastatin therapy.
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Affiliation(s)
- Hayder M Al-Kuraishy
- Department of Pharmacology, Toxicology and Medicine, College of Medicine Almustansiriya University, Baghdad, Iraq
| | - Ali I Al-Gareeb
- Department of Pharmacology, Toxicology and Medicine, College of Medicine Almustansiriya University, Baghdad, Iraq
| | - Marwa Thaier Naji
- Department of Pharmacology, Toxicology and Medicine, College of Medicine Almustansiriya University, Baghdad, Iraq
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Moschetti A, Dagda RK, Ryan RO. Coenzyme Q nanodisks counteract the effect of statins on C2C12 myotubes. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2021; 37:102439. [PMID: 34256063 DOI: 10.1016/j.nano.2021.102439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 04/23/2021] [Accepted: 05/23/2021] [Indexed: 11/16/2022]
Abstract
Depletion of coenzyme Q (CoQ) is associated with disease, ranging from myopathy to heart failure. To induce a CoQ deficit, C2C12 myotubes were incubated with high dose simvastatin. This resulted in a concentration-dependent inhibition of cell viability. Simvastatin-induced effects were prevented by co-incubation with mevalonic acid. When myotubes were incubated with 60 μM simvastatin, mitochondrial CoQ content decreased while co-incubation with CoQ nanodisks (ND) increased mitochondrial CoQ levels and improved cell viability. Incubation of myotubes with simvastatin also led to a reduction in oxygen consumption rate (OCR). When myotubes were co-incubated with simvastatin and CoQ ND, the decline in OCR was ameliorated. The data indicate that CoQ ND represent a water soluble vehicle capable of delivering CoQ to cultured myotubes. Thus, these biocompatible nanoparticles have the potential to bypass poor CoQ oral bioavailability as a treatment option for individuals with severe CoQ deficiency syndromes and/or aging-related CoQ depletion.
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Affiliation(s)
- Anthony Moschetti
- Department of Biochemistry and Molecular Biology, University of Nevada, Reno, NV
| | - Ruben K Dagda
- Department of Pharmacology, University of Nevada, Reno, NV
| | - Robert O Ryan
- Department of Pharmacology, University of Nevada, Reno, NV.
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Statin Treatment-Induced Development of Type 2 Diabetes: From Clinical Evidence to Mechanistic Insights. Int J Mol Sci 2020; 21:ijms21134725. [PMID: 32630698 PMCID: PMC7369709 DOI: 10.3390/ijms21134725] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022] Open
Abstract
Statins are the gold-standard treatment for the prevention of primary and secondary cardiovascular disease, which is the leading cause of mortality worldwide. Despite the safety and relative tolerability of statins, observational studies, clinical trials and meta-analyses indicate an increased risk of developing new-onset type 2 diabetes mellitus (T2DM) after long-term statin treatment. It has been shown that statins can impair insulin sensitivity and secretion by pancreatic β-cells and increase insulin resistance in peripheral tissues. The mechanisms involved in these processes include, among others, impaired Ca2+ signaling in pancreatic β-cells, down-regulation of GLUT-4 in adipocytes and compromised insulin signaling. In addition, it has also been described that statins’ impact on epigenetics may also contribute to statin-induced T2DM via differential expression of microRNAs. This review focuses on the evidence and mechanisms by which statin therapy is associated with the development of T2DM. This review describes the multifactorial combination of effects that most likely contributes to the diabetogenic effects of statins. Clinically, these findings should encourage clinicians to consider diabetes monitoring in patients receiving statin therapy in order to ensure early diagnosis and appropriate management.
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Ghadge GA, Gourishetti K, Chamallamudi MR, Nampurath GK, Nandakumar K, Kumar N. Sesamol protects MIN6 pancreatic beta cells against simvastatin-induced toxicity by restoring mitochondrial membrane potentials. 3 Biotech 2020; 10:149. [PMID: 32181111 DOI: 10.1007/s13205-020-2146-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 02/16/2020] [Indexed: 11/28/2022] Open
Abstract
Statins, the drugs for the treatment of dyslipidemia, have been suggested to impact insulin sensitivity, resulting in pancreatic β-cell dysfunction, and consequently, lead to new onset of diabetes. Taking this as a clue, the present study was designed to evaluate the protective effect of sesamol (a known antioxidant, antidiabetic and antidyslipidemic agent) against the diabetogenic potential of simvastatin. The toxic effects of simvastatin and sesamol on MIN6 insulinoma (Mouse pancreatic β cells) cells were evaluated separately by MTT assay. The protective effect of sesamol was evaluated at the IC50 value of simvastatin at doses ranging from 7.8 to 62.5 micromolar (µM). Further, the reversal of the impact of simvastatin on cell cycle and mitochondrial membrane potential by sesamol pretreatment was studied. The IC50 for simvastatin and sesamol were found to be 70.05 ± 2.34 μM and 2134 ± 8.41 μM, respectively, after 48 h and 72 h of incubation. Sesamol pretreatment protected the MIN6 cells from simvastatin toxicity (70 µM) in a dose-dependent manner from 7.8 to 31.25 µM. Simvastatin induced cell cycle arrest in G0/G1 phase. However, when cells were preincubated with sesamol for 24 h, a reversal in the cell cycle arrest was observed in simvastatin-treated cells (G0/G1). Pretreatment with sesamol also reduced the mitochondrial membrane potential loss compared to simvastatin treatment alone. These in vitro findings indicate that sesamol has a protective effect against simvastatin-induced toxicity on the pancreatic beta cells.
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Affiliation(s)
- Girish A Ghadge
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Karthik Gourishetti
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Mallikarjuna Rao Chamallamudi
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Gopalan Kutty Nampurath
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Krishnadas Nandakumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - Nitesh Kumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
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