Use of High Dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

Introduction

In acute respiratory distress syndrome (ARDS) patients with irreversible lung damage, lung transplantation from a ventilator and/or extracorporeal membrane oxygenation support (ECMO) is feasible. Recently, selection criteria for lung transplant candidates with a COVID-19 associated ARDS have been published. Here, we report the efficacy of high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation.

Case Report

A 50-year-old female with a medical history of Multiple Sclerosis (relapsing-remitting type under treatment with anti-alpha4 -integrin therapy), was tested positive for COVID-19. She deteriorated and was admitted to the hospital. High flow oxygen and dexamethasone (six milligram daily), were started but unfortunately, she developed a severe ARDS with need for mechanical ventilation and ECMO support. Corticosteroids according to the Meduri scheme and ciprofloxacin were started. Weaning trials were initiated but failed and CT-thorax showed consolidation and presumed fibrosis. After 37 days on ECMO, she was evaluated and listed for bilateral lung transplantation. A corticosteroid pulse therapy of 1000 mg of methylprednisolone IV for three days during antibiotic coverage with piperacillin/tazobactam was started and within three days the clinical condition of the patient improved and she could be weaned from ECMO (51 days of ECMO) and delisted from the lung transplantation waiting list. Nowadays, patient does not require oxygen, is at home and revalidating.

Summary

Here, we report the efficacy of a regimen with high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. Corticosteroids are beneficial for immunomodulation and may reduce hyperinflammation. Our trial with administration of high dose corticosteroids pulse therapy in COVID-19 ARDS patients refractory to corticosteroids according to “classical schemes” has been successful and is informative. Further studies, will hopefully further elucidate responders and non-responders to high dose corticosteroid pulse therapy and preferably answer the question if prophylactic use of antibiotics and antifungals (in view of possible complications such as pulmonary aspergillosis and mucormycosis) is prudent in this vulnerable group.

Tongue lesions as an oral diagnostic challenge for a primary care physician- A clinical case series

Tongue acts as a mirror of our body. Diagnosis of tongue lesions is challenging to primary physicians as they might be the first sign or may be a part of underlying systemic diseases. Knowledge on the lesions of tongue is necessary for oral and overall health planning and education. Hence, this article illustrates a clinical case series of tongue lesions among a rural population in south Chennai, thus imparting a higher awareness of the specific tongue pathology-related etiology and management to increase the awareness on thorough oral screening including detailed assessment of tongue and provide a holistic care to patients to improve the Oral health related and Overall quality of life of patients (OHRQOL/QOL).

Curcumin on Camphor-Induced Chemical Burn on the Palate: Report of a Peculiar Self-Inflicted Case

Intraoral soft tissue injuries occur due to physical, chemical, or thermal agents, which may present as ulcerations, burns, desquamation, and gingival recession. Camphor is one such substance easily available in many Indian households and is not a very well-recognized potentially fatal toxic compound. Here, we report the first case of an intraoral soft-tissue burn in a geriatric female, as a result of direct injury to tissues due to the application of crushed camphor powder to manage tooth pain at home, which was successfully treated with 2% Curcuma longa. Health care professionals must be aware of the presentation and extent of injury that can be caused by camphor when placed on intraoral soft tissues. Awareness among the public and professionals must be created in order to avoid any potential mortality. The diagnostician must consider the possibility of a chemical agent, such as camphor, as a potential source of the oral mucosal injury.

Complex Regional Pain Syndrome Post COVID-19 Vaccine Shot: An Autobiographical Case Report

Complex regional pain syndrome (CRPS) is a pathological exaggeration caused by trauma from injections and vaccine administration characterized by severe pain (often burning), hyperesthesia, allodynia, edema, vasomotor changes, decreased range of motion, hyperhidrosis, and trophic changes. It occurs at all ages with female predominance, and the incidence increases until late middle age. Hand and foot involvement is well recognized, and this may spread proximally. Treatment usually requires a multimodal approach, including medications and physical and cognitive therapy. Reports of CRPS after vaccination are rare. The incidence of CRPS post coronavirus disease 2019 (COVID-19) vaccination is not yet reported. This case report describes my experience with deltoid hematoma, tennis elbow, and living with CRPS post COVID-19 vaccine shot, including the psychosocial adaptations I made in my day-to-day life.

Communication, Counseling and Compassionate Care: The least explored and challenging Palliative Care approaches among Primary Care Physicians - Clinical Case series of Oral Potentially malignant disorders in Tamil Nadu

Background:

Globally, the sixth most common malignancy is oral cancer, which is predominantly due to consumption of potent, proven carcinogens which includes smoking and smokeless form of tobacco and areca nut. Habits associated oral malignancies are mostly preceded by clinically asymptomatic oral lesions collectively referred under the umbrella term as oral potentially malignant disorders (OPMDs). There is a delayed presentation of oral pre cancer and oral cancer in India, as approximately 50% of patients are diagnosed at last stage since the asymptomatic pre cancer lesions are missed by oral physicians/dentists either due to lack of timely communication and habit counseling, lack of knowledge, or inappropriate attitude, putting all in a nut shell --- sheer lack of empathy and commitment towards patient care and society. Early diagnosis greatly increases patient's chances of survival. Patient awareness is much spoken in literature; however, the flip side of the coin lies within the attitude of the primary care physician. They play a pivotal role in effective communication and timely counseling of patients with OPMDs and should prevent malignant transformation to improve quality of life of patients. Poor compliance to attend for oral cancer screening links to the attitude and ignorance of the primary care physician. Palliative care concepts should be integrated to dentistry especially to oral medicine speciality.

Clinical Significance:

The author believes that the three most important, least explored and challenging palliative care approaches namely, “Communication,” “Counseling,” and “Compassionate care,” should be effectively practiced by a primary care physician, to improve their level of commitment to society and attitude towards patient care which can help in early diagnosis of OPMDs and decreased incidence of oral cancer, thus improving quality of life of patients.

Tobacco Awareness with Socioeconomic Status and Pictorial Warning in Tobacco Cessation: An Exploratory Institutional Survey in a Semi-urban Population

AIM

To explore the impact of socioeconomic status (SES) and/on the awareness of ill effects of tobacco on oral and general health and to evaluate the effectiveness of pictorial warning on tobacco cessation in a semi-urban population of South Chennai.

MATERIALS AND METHODS

This cross-sectional survey for 1 week was conducted using a two-stage sampling design, with a sample size of 300. New op patients constitute the first sampling design, and patients with history of any form of tobacco constituted second sampling design for the second part of the study. Following an informed consent in patient's own language, and as per inclusion criteria's, new op patient was interviewed with questionnaire 1, which comprised 27 closed-ended questions to assess subject's general awareness on tobacco, awareness of ill effects of tobacco on oral and general health, and their SES. Sociodemographic information such as age, sex, marital status, occupation, address, educational level, and family income per month was also recorded. Response categories for each of the questions were "yes", "no", and "don't know". The Questionnaire-2 comprised 8 closed-ended questions that assessed the subject's willingness to quit and to evaluate the effectiveness of pictorial warning on tobacco cessation, which was subjected only to those patients who had a history of tobacco usage which was recorded after completing the Questionnaire-1. This group formed the secondary sampling unit. Questionnaire-2 also included an individual suggestion for the preference of type of warning sign on the tobacco packet/sachet in the end. Statistically, Cronbach's α coefficient, one-way analysis of variance, Tukey HSD post hoc tests, and Chi-square test were used.

RESULTS

On the whole, this study reported good awareness about harmful effects of tobacco. In all, 33.2% of respondents could not change after noticing the warning ads, 90.3% of our respondents are not aware that a professional help is available to motivate quitting. Smokers were more aware than smokeless tobacco users, and tobacco users recommended a greater area to be covered for pictorial warnings and to increase the frequency to change the pictorial warning signs.

CONCLUSION

Alarmingly high statistics and delayed presentation of oral and health hazards at the time of primary diagnosis underscores the need for an extensive awareness campaign on the issues related to ill effects of tobacco more focused on tobacco user's perspective and feedback.

CLINICAL SIGNIFICANCE

Health awareness programs related to awareness of ill effects of tobacco should be tailor-made to the targeted population and should be more focused on the control of specific risk factors. Health warnings on tobacco packages that combine text and pictures, along with the frequent role of impact of mass media and campaigns on mouth self-examination and improvement in quality of life can effectively increase the general public awareness of the serious and deleterious health risks of tobacco use and to reduce its consumption.

Topical Curcumin and Triamcinolone Acetonide in Recurrent Minor Aphthous Ulcers: A Pilot Trial

AIM

To evaluate the efficacy of topical curcumin and topical triamcinolone acetonide in a professional population with minor aphthous ulcers by assessing six clinical variables: site, size, pain, healing period, frequency of recurrence and number of ulcers.

MATERIALS AND METHODS

This randomized, parallel designed pilot trial was performed on 60 symptomatic individuals with minor aphthous ulcer. Willing participants were allocated randomly into group I and group II. Participants in group I were treated with topical curcumin and group II were treated with topical triamcinolone acetonide for a period of 6 months. All participants were blinded to the drug they received. Participants were assessed on day 1, day 3, day 5, day 7, and after healing for symptomatic reduction in pain, size, healing period, frequency of recurrence, and in the number of ulcers. Statistically, independent sample t test, Chi-square test, and Log rank Kaplan-Meier survival analysis were performed.

RESULTS

Lower labial mucosa was found to be the predominant site of minor aphthous ulcer in both the groups. A gradual reduction in pain and size was noted in both the groups with statistical significance of p value <0.001. All the ulcers in both the groups healed completely without scarring within 2 weeks with statistical significance. In both the treatment groups, new ulcers occurred throughout the follow-up period of 6 months. The mean number of the ulcers are statistically not significant with p value >0.05.

CONCLUSION

Our study showed clinically beneficial effects with topical curcumin with regard to ulcer size, pain, healing, and recurrence rate. Also topical curcumin gel was well tolerated and performed ot par with topical triamcinolone acetonide oral paste with a borderline favorable result with triamcinolone.

CLINICAL RELEVANCE

Curcumin can be safely recommended on a long-term basis as a more appealing therapeutic agent and is a better alternative choice for aphthous ulcers in children, pregnant woman, lactating mother, and in immunocompromised individuals.

The Kuala Pilah cluster cataract study: Accessible eye care reduces cataract blindness

OBJECTIVE

The Ministry of Health introduced the cluster hospital project in Kuala Pilah district in 2016 to allow sharing of resources between the hospitals in the same vicinity. The aim of this study is to compare the demographic profile, prevalence of cataract blindness and low vision among patients who presented for cataract surgery before and after the programme.

METHODOLOGY

This is a retrospective cohort study of patients who underwent cataract surgery in Kuala Pilah Cluster Hospitals between 2010 and 2017. A total of 2539 records of patients were reviewed. Patients were assigned into two groups: Group 1 (2010-2012)- before the programme (2010-2012) and Group 2 (2015-2017) after the introduction of the programme.

RESULTS

There was a significant increase in number of cataract cases in the district hospital after the cluster initiative. The mean age of patients undergoing cataract surgery was similar in both groups. The common comorbidities were hypertension (Group 1=57.3%; Group 2=70.8%) and diabetes mellitus (Group 1=40.6%; Group 2=51.1%). In 2010-2012, most of the patients were one eye blind (34.4%), whereas in 2015-2017 majority of patients presented with vision better than 6/18 (43.5%). The proportion of patients with cataract blindness reduced from 6% in 2010-2012 to 4.3% in 2015-2017 (p<0.01).

CONCLUSION

There is a significant decrease in percentage of patients with cataract blindness and low vision after the introduction of Kuala Pilah Cluster Hospital Program. We believe that that cluster hospital system is effective in improving accessibility to eye care and therefore increases the cataract detection rate.

Dentist's Delay or Dexterity to Diagnose the Deadly: A Clinico-radiological Series of Oral Malignancies Exhibiting Varied Presentations in the Tamil Nadu Rural Belt

Oral cancer is the sixth most common malignancy globally with a wide geographic variation. India is the second largest consumer and third largest producer of tobacco in the world. One-third of the global burden of oral cancer is predominantly attributed to high prevalence of tobacco consumption. The highest incidence and prevalence of oral squamous cell carcinoma is found in the Indian subcontinent particularly in the lower socioeconomic strata, due to an increase in the deleterious habits of potent, proven carcinogens like smoking, chewing tobacco, betel quid and areca-nut. Also, there is a delayed presentation of oral cancer in India, as approximately 50% of patients are diagnosed at stage III or IV. In this article, we report five varied presentations of well differentiated oral squamous cell carcinoma from rural belt of Tamil Nadu. All the cases were reported late to diagnose. Clinical and radiological staging plays a pivotal role to stage an oral malignant patient which aids in guiding him to a proper treatment plan. Early diagnosis along with patient counselling is of vital importance for the prognosis of the patients with oral malignancies. Also, it is an utmost important duty of the health care professionals to create awareness on oral cancer especially in rural areas. For this reason, dentists play a very significant role in the early detection and prevention of oral malignancies.

Tooth and Advanced Oral Submucous Fibrosis Obscuring Buccal Squamous Cell Carcinoma: A Case Report and Literature Review

Oral squamous cell carcinoma is a leading cause of mortality due to late diagnosis in India and most other developing countries. Buccal squamous cell carcinoma is almost always preceded by premalignant conditions that include leukoplakia, erythroplakia, oral lichen planus, and submucous fibrosis of the oral cavity. Hence, these patients warrant regular screening by oral health care professionals and proper monitoring for any dysplastic changes. Implementing social awareness about early signs and symptoms, as well as education on self-oral screening methods so as to avoid the risk of late presentation of oral squamous cell carcinoma, should be made mandatory for such individuals to prevent further complications.

Thrombospondin-4 mediates TGF-β-induced angiogenesis

TGF-β is a multifunctional cytokine affecting many cell types and implicated in tissue remodeling processes. Due to its many functions and cell-specific effects, the consequences of TGF-β signaling are process-and stage-dependent, and it is not uncommon that TGF-β exerts distinct and sometimes opposing effects on a disease progression depending on the stage and on the pathological changes associated with the stage. The mechanisms underlying cell- and process-specific effects of TGF-β are poorly understood.

We are describing a novel pathway that mediates induction of angiogenesis in response to TGF-β1. We found that in endothelial cells (EC) TSP-4, a secreted extracellular matrix (ECM) protein is upregulated in response to TGF-β1 and mediates the effects of TGF-β1 on angiogenesis.

Upregulation of TSP-4 does not require the synthesis of new protein, is not caused by decreased secretion of TSP-4, and is mediated by activation of SMAD3. Using Thbs4^−/− mice and TSP-4 shRNA, we found that TSP-4 mediated pro-angiogenic functions on cultured EC and angiogenesis in vivo in response to TGF-β1. We observed ~ 3-fold increases in tumor mass and levels of angiogenesis markers in animals injected with TGF-β1, and these effects did not occur in Thbs4^−/− animals. Injections of an inhibitor of TGF-β1 signaling SB431542 also decreased the weights of tumors and cancer angiogenesis.

Our results from in vivo angiogenesis models and cultured EC document that TSP-4 mediates upregulation of angiogenesis by TGF-β1. Upregulation of pro-angiogenic TSP-4 and selective effects of TSP-4 on EC may contribute to stimulation of tumor growth by TGF-β despite the inhibition of cancer cell proliferation.

In situ measurement of low-Z material coating thickness on high Z substrate for tokamaks

Rutherford backscattering of energetic particles can be used to determine the thickness of a coating of a low-Z material over a heavier substrate. Simulations indicate that 5 MeV alpha particles from an (241)Am source can be used to measure the thickness of a Li coating on Mo tiles between 0.5 and 15 μm thick. Using a 0.1 mCi source, a thickness measurement can be accomplished in 2 h of counting. This technique could be used to measure any thin, low-Z material coating (up to 1 mg/cm(2) thick) on a high-Z substrate, such as Be on W, B on Mo, or Li on Mo. By inserting a source and detector on a moveable probe, this technique could be used to provide an in situ measurement of the thickness of Li coating on NSTX-U Mo tiles. A test stand with an alpha source and an annular solid-state detector was used to investigate the measurable range of low-Z material thicknesses on Mo tiles.

Simultaneous occurrence of toxic epidermal necrolysis and neuroleptic malignant syndrome

Toxic epidermal necrolysis (TEN) is an acute life-threatening blistering disease characterized by involvement of the skin, multiple mucous membranes and internal organs. It is most commonly precipitated by the administration of medications like anticonvulsants. Neuroleptic malignant syndrome (NMS) is a rare complication of neuroleptic therapy characterized by catatonic behavior, generalized muscular rigidity, hyperthermia and autonomic dysfunction. An 18-year-old girl presenting with simultaneous appearance of TEN and NMS following anti-psychotic drugs given for bipolar mood disorder, is reported for the rare association and her complete recovery.

The Membrane Protein Data Bank

The Membrane Protein Data Bank (MPDB) is an online, searchable, relational database of structural and functional information on integral, anchored and peripheral membrane proteins and peptides. Data originates from the Protein Data Bank and other databases, and from the literature. Structures are based on X-ray and electron diffraction, nuclear magnetic resonance and cryoelectron microscopy. The MPDB is searchable online by protein characteristic, structure determination method, crystallization technique, detergent, temperature, pH, author, etc. Record entries are hyperlinked to the PDB and Pfam for viewing sequence, three-dimensional structure and domain architecture, and for downloading coordinates. Links to PubMed are also provided. The MPDB is updated weekly in parallel with the Protein Data Bank. Statistical analysis of MPDB records can be performed and viewed online. A summary of the statistics as applied to entries in the MPDB is presented. The data suggest conditions appropriate for crystallization trials with novel membrane proteins.

Managing equipment for emergency obstetric care in rural hospitals

In resource-poor countries, substantial sums of money from governments and international donors are used to purchase equipment for health facilities. WHO estimates that 50-80% of such equipment remains non-functional. This article is based on experience from various projects in developing countries in Asia and Africa. The key issues in the purchase, distribution, installation, management and maintenance of equipment for emergency obstetric care (EmOC) services are identified and discussed. Some positive examples are described to show how common equipment management problems are solved.

Role of glucose and insulin in thiazolidinedione-induced alterations in hepatic gluconeogenesis

Previous studies from our laboratory as well as from others have suggested that the thiazolidinediones have the capacity to act as insulinomimetic agents, especially in the liver. In order to further characterize this insulinomimetic action, we evaluated the effect of troglitazone, a representative thiazolidinedione, on lactate- and glucagon-stimulated gluconeogenesis, in the presence or absence of insulin (10 nM) in isolated rat hepatocytes. The antigluconeogenic effect of troglitazone under basal (lactate-stimulated) conditions was found to be due to an elevation in the fructose 2,6-bisphosphate content, which was, however, not mediated by an activation of 6-phosphofructo 2-kinase. Troglitazone (125 and 250 microM) in the absence of insulin, produced a dose-dependent reduction in glucagon-stimulated gluconeogenesis, thereby suggesting an insulinomimetic effect. In addition, troglitazone (125 and 250 microM), in combination with insulin, produced an additive inhibition of gluconeogenesis during glucagon-stimulated conditions. However, unlike insulin, the metabolic mechanism responsible for these effects (in the presence or absence of insulin) does not involve fructose 2,6-bisphosphate.

Titanium(IV)-mediated tandem deprotection-cyclodehydration of protected cysteine N-amides: biomimetic syntheses of thiazoline- and thiazole-containing heterocycles

The scope and limitations of TiCl(4)-mediated Delta(2)-thiazoline synthesis via tandem deprotection-dehydrocyclization of trityl-protected cysteine N-amides is presented. While chemical yields are acceptable (53-96%), the stereochemical outcomes vary on the basis of structural considerations and reaction conditions (22-99% ee). Racemization at the C(2)-exomethine position limits the utility of this method for the formation of a thiazoline within a peptide. Treatment of a tritylated Cys-Cys dipeptide with TiCl(4) afforded the corresponding thiazole-thiazoline heterocycle 12 (38% yield, 97% ee).

Rational design of potent human transthyretin amyloid disease inhibitors

The human amyloid disorders, familial amyloid polyneuropathy, familial amyloid cardiomyopathy and senile systemic amyloidosis, are caused by insoluble transthyretin (TTR) fibrils, which deposit in the peripheral nerves and heart tissue. Several nonsteroidal anti-inflammatory drugs and structurally similar compounds have been found to strongly inhibit the formation of TTR amyloid fibrils in vitro. These include flufenamic acid, diclofenac, flurbiprofen, and resveratrol. Crystal structures of the protein-drug complexes have been determined to allow detailed analyses of the protein-drug interactions that stabilize the native tetrameric conformation of TTR and inhibit the formation of amyloidogenic TTR. Using a structure-based drug design approach ortho-trifluormethylphenyl anthranilic acid and N-(meta-trifluoromethylphenyl) phenoxazine 4, 6-dicarboxylic acid have been discovered to be very potent and specific TTR fibril formation inhibitors. This research provides a rationale for a chemotherapeutic approach for the treatment of TTR-associated amyloid diseases.

Comparative effects of englitazone and glyburide on gluconeogenesis and glycolysis in the isolated perfused rat liver

Englitazone (CP 68,722, Pfizer) is a member of a family of drugs known as thiazolidinediones. One member of this family, troglitazone (Rezulin), is currently utilized in the treatment of Type 2 diabetes. Previous studies have focused on the ability of englitazone to increase insulin sensitivity in various tissues. However, little information is available regarding the direct effect of englitazone on hepatic glucose metabolism in the absence of insulin. Therefore, the following studies were conducted to comparatively evaluate the effect of englitazone and glyburide (a representative sulfonylurea) on gluconeogenesis and glycolysis from various substrates in the isolated perfused rat liver (IPRL). In isolated perfused rat livers of 24-hr fasted rats infused with lactate (2 mM), englitazone (6.25 to 50 microM) produced a concentration-dependent decrease (32-93%) in hepatic gluconeogenesis. When dihydroxyacetone (1 mM) and fructose (1 mM) were used as metabolic substrates, englitazone inhibited gluconeogenesis by 31 and 15%, respectively, while increasing glycolysis by 42 and 50%. Similar effects on gluconeogenesis and glycolysis were observed with glyburide, even though the effects with glyburide were more acutely evident, reversible, and of a greater magnitude. Such data suggest alterations in hepatic glucose production may contribute to the decrease in plasma glucose concentrations observed in individuals treated with englitazone and glyburide. These alterations may include effects on several regulatory enzymes (e.g. fructose-1,6-bisphosphatase, pyruvate kinase, and phosphoenolpyruvate carboxykinase), which warrant further investigation.

Effect of troglitazone (Rezulin) on fructose 2,6-bisphosphate concentration and glucose metabolism in isolated rat hepatocytes

The effect of troglitazone, an orally effective thiazolidinedione, on lactate- and glucagon-stimulated gluconeogenesis (in the absence of insulin) was examined in hepatocytes isolated from rats under different nutritional states. Hepatocytes obtained from fed or 20-24 hr fasted male Sprague-Dawley rats were incubated in Krebs-Henseleit Bicarbonate buffer (KHBC) (in presence or absence of 10.0 mM glucose) containing 2.0 mM [U-14C]lactate (0.1-0.25 microCi) with or without 10.0 nM glucagon and troglitazone (30.0 microM) or the appropriate vehicle. Aliquots were removed at specified endpoints and assayed for glucose and fructose 2,6-bisphosphate (F-2,6-P2) concentrations. In 20-24 hour starved hepatocytes, troglitazone produced a 26.1% inhibition of lactate-stimulated gluconeogenesis. This inhibitory effect of troglitazone on hepatic gluconeogenesis was further potentiated by incubation of the cells with glucose in vitro. In hepatocytes obtained from fasted rats (and incubated with 10 mM glucose in vitro) troglitazone reduced lactate-and glucagon-stimulated gluconeogenesis by 53% and 56%, respectively. This reduction in hepatic glucose production was associated with 1.06 and 1.04 fold increase in the hepatocyte F-2,6-P2 content. In isolated hepatocytes from fed animals and incubated with 10 mM glucose in vitro, troglitazone (15 and 30 microM) did not have any effect on either lactate- or glucagon-stimulated gluconeogenesis. However, 30 microM troglitazone significantly enhanced (36%) F-2,6-P2 concentrations during lactate-stimulated gluconeogenesis. These findings demonstrate that troglitazone decreases hepatic glucose production through alterations in the activity of one or more gluconeogenic/glycolytic enzymes, depending upon the nutritional state of the animal and the presence or absence of hormonal modulation. All of the effects of troglitazone in the present study were observed in the absence of insulin, suggesting an "insulinomimetic" effect. However, this does not exclude the possibility that troglitazone may also function as an "insulin sensitizer" in hepatic and certain other tissues.