14th Day Research Articles

Comparison of live birth rates following the transfer of day-6 blastocysts on the 6th versus 7th day of progesterone exposure in hormone replacement treatment–frozen embryo transfer cycles

Objective: The duration of progesterone exposure is critical for establishing and maintaining a pregnancy in hormone replacement treatment (HRT)–frozen embryo transfer (FET) cycles. This study compared the live birth rates (LBRs) of patients undergoing day-6 warmed blastocyst transfer on either the 6th or 7th day of progesterone administration in HRT-FET cycles.Methods: A retrospective cohort study was conducted using data from the central registry of Indira IVF Hospital Private Limited. In total, 2,633 patients who underwent day-6 blastocyst transfer cycles with HRT-FET were identified. The cycles were categorized based on the timing of the day-6 blastocysts transfer: P+6 vs. P+7 (initiation date: P+1). Propensity scores were calculated. The primary outcome measure was the LBR.Results: Following propensity score matching, a total of 1,401 patients were included in the final analysis (P+6: n=1,212; P+7: n=189). The number of previous attempts was significantly higher in the P+6 group, whereas the rate of preimplantation genetic testing for aneuploidy was significantly higher in the P+7 group. The LBRs were 59.2% and 54.5% in the P+6 and P+7 groups, respectively (p=0.21). Multivariate regression analysis revealed that the number of previous in vitro fertilization attempts (odds ratio [OR], 3.246; 95% confidence interval [CI], 2.429 to 4.337; p<0.001), the number of blastocysts transferred (OR, 2.011; 95% CI, 1.461 to 2.768; p<0.01), and endometrial thickness on the day of progesterone initiation (OR, 1.143; 95% CI, 1.022 to 1.28; p=0.02) were independent predictors of live birth.Conclusions: The LBRs were comparable in patients who underwent day-6 warmed blastocyst transfer on day 6 or 7 post-progesterone initiation in HRT-FET cycles.

Isolation of Orientia tsutsugamushi in Culture from Vellore, South India.

Background: Orientia tsutsugamushi, causative agent of scrub typhus is an obligate intracellular parasite. We present information on isolation of this pathogen at a tertiary care centre in Vellore, Southern India. Materials & Methods: PBMCs (peripheral blood mononuclear cells) collected from suspected scrub typhus patients were inoculated into Vero and L929 cell lines and incubated at 37°C with 5% CO2 for 30 days. They were examined for presence of Orientia tsutsugamushi on 10, 15, 20 days post-inoculation and everyday thereafter for a maximum of 30 days post inoculation. The scrapings were subjected to Giemsa staining, IFA, 47kDa qPCR and transmission electron microscopy (TEM). The isolates were passaged 3-4 times to ensure viability and then stored in DMEM with 10% FBS (-80). Genotyping of the isolates was performed by amplifying a 650 bp segment of the TSA 56 (type specific antigen 56) gene. Results: Amongst the 50 samples inoculated, three were culture positive as confirmed by 47 kDa qPCR on 24th day post inoculation. This was further confirmed by Giemsa, IFA staining and TEM. The 650bp amplicons showed 99.5 to 100% homology with Orientia tsutsugamushi MW604716, MH003839, MW604718, MW604717, MH922787 and MH003838 strains. Phylogenetic analysis revealed that 2 isolates belong to TA763 genotype and one belongs to Gilliam genotype. Conclusion: Orientia tsutsugamushi has been isolated for the first time at Vellore, South India from PBMCs. Complete genomic analysis will give more information.

Fertility and teratogenic study of the aqueous extract of Hibiscus sabdariffa L. in female Sprague Dawley rats

Hibiscus sabdariffa (roselle) has long been gaining attention in phytotherapy research due to its medicinal properties. Despite its benefits, there is very scarce information available on the reproductive toxicity of this plant. The aqueous extract of H. sabdariffa (AEHS) was tested in the present study to investigate its potential effects on fertility and teratogenicity in 40 female Sprague Dawley rats. AESH treatment was administered orally by gavage at four different dosages: 250, 500 and 1000 mg/kg/day or distilled water (control). Treatment began from pre-mating and continued through mating up to the 19th day of pregnancy periods. Throughout this study, the reproductive parameters were evaluated until the day of sacrifice (day 20th of pregnancy). Results obtained revealed no significant differences in general physical health, behaviours and maternal body weights throughout the treatment period. Furthermore, the mean length of the oestrous cycle was not statistically affected, even though a few rats displayed irregular cycles. In addition, there was no statistical significance in the mating and pregnancy indices, number of corpora lutea and implantation sites, percentages of pre-implantation loss and postimplantation death and reproductive organ weights. Foetal parameters such as the number of live foetuses, sex ratio and body weight were also not statistically affected by AESH. Ultimately, there were no signs of teratogenicity observed since none of the foetuses exhibited congenital malformations. In conclusion, these findings imply that the oral administration of AEHS up to 1000 mg/kg/day did not pose any significant toxicity on the fertility and teratogenicity but slightly affected the oestrous cycle in rats.

Identification and expression profiling of neuropeptides and neuropeptide receptor genes in a natural enemy, Coccinella septempunctata.

Neuropeptides and their receptors constitute diverse and abundant signal molecules in insects, primarily synthesized and released primarily from neurosecretory cells within the central nervous system Neuropeptides act as neurohormones and euromodulators, regulating insect behavior, lifecycle, and physiology by binding to receptors on cell surface. As a typical natural predator of agricultural pests, the lady beetle, Coccinella septempunctata, has been commercially mass-cultured and widely employed in pest management. Insect diapause is a physiological and ecological adaptative strategy acquired in adverse environments. In biological control programs, knowledge about diapause regulation in natural enemy insects provides important insight for improving long-term storage, transportation, and field adoption of these biological control agents. However, little is known about the function of neuropeptides and their receptors in controlling reproductive diapause of C. septempunctata. It is unclear which neuropeptides affect diapause of C. septempunctata. In this study, RNA-seq technology and bioinformatics were utilized to investigate genes encoding neuropeptides and their receptors in female adults of C. septempunctata. Quantitative real-time PCR (qRT-PCR) analysis was employed to examine gene expression across different development/diapause stages. A total of 17 neuropeptide precursor genes and 9 neuropeptide receptor genes were identified, implicated in regulating various behaviors such as feeding, reproduction, and diapause. Prediction of partial mature neuropeptides from precursor sequences was also performed using available information about these peptides from other species, conserved domains and motifs. During diapause induction, the mRNA abundance of AKH was notably higher on the 10th day compared to non-diapause females, but decreased by the 20th day. In contrast, GPHA showed lower expression levels on the 5th day of diapause induction compared to non-diapause females, but increased significantly by the 15th and 20th days. NPF was higher expressed in head and midgut while DH showed higher expression in the fat body and midgut. Additionally, NPF expression remained consistently lower throughout all stages of diapause induction compared to non-diapause conditions in females. This study represents the first sequencing, identification, and expression analysis of neuropeptides and neuropeptide receptor genes in C. septempunctata. Our results could provide a foundational framework for further investigations into the presence, functions, and potential targets of neuropeptides and their receptors, particularly in devising novel strategies for diapause regulation in C. septempunctata.

Induction of cytochrome P450 via upregulation of CAR and PXR: a potential mechanism for altered florfenicol metabolism by macranthoidin B in vivo.

Macranthoidin B (MB) is a primary active component of Flos Lonicerae. In Chinese veterinary clinics, Flos Lonicerae is frequently used in combination with florfenicol to prevent and treat infections in livestock and poultry. However, potential interactions between Flos Lonicerae and florfenicol remain unclear. To systematically study these interactions, it is crucial to investigate the individual phytochemicals within Flos Lonicerae. Therefore, MB was selected for this study to assess its effect on the pharmacokinetics of florfenicol in vivo and to explore the underlying mechanisms involved. Male Sprague-Dawley rats were administered MB (60 mg/kg BW) or sterile water orally for 7 consecutive days. On the 8th day, a single oral dose of florfenicol (25 mg/kg BW) was given. Florfenicol pharmacokinetics were analyzed using ultra-high performance liquid chromatography. The hepatic expression levels of cytochrome P450 (CYP1A2, CYP2C11, CYP3A1), UDP-glucuronosyltransferase (UGT1A1), P-glycoprotein (P-gp), and nuclear receptors, including constitutive androstane receptor (CAR), pregnane X receptor (PXR), and retinoid X receptor alpha (RXRα), were quantified via reverse transcription-quantitative polymerase chain reaction and Western blotting (WB). Hepatic CYP1A2 and CYP2C11 activities were measured using a cocktail method. Additionally, the subcellular expression and localization of CAR, PXR, and RXRαin hepatocytes was assessed using WB and immunofluorescence staining. MB significantly reduces the AUC(0-∞) and MRT(0-∞) of florfenicol. MB also markedly upregulates the mRNA and protein expression of hepatic CYP1A2 and CYP2C11, along with their catalytic activities. Substantial upregulation of CAR and PXR proteins occurs in the hepatocyte nucleus, along with significant nuclear colocalization of the transcriptionally active CAR/RXRα and PXR/RXRαheterodimers, indicating MB-induced nuclear translocation of both CAR and PXR. These findings suggest that MB-induced alterations in florfenicol pharmacokinetics, particularly its accelerated elimination, may be due to increased expression and activities of CYP1A2 and CYP2C11, with CAR and PXR potentially involved in these regulatory effects. Further investigation is yet needed to fully elucidate the clinical implications of these interactions concerning the efficacy of florfenicol in veterinary medicine.

An incomplete form of Kawasaki disease in a 2-month-old girl. How the diagnostic algorithm works in practice

BACKGROUND. Kawasaki disease is a rare, self-limiting inflammatory disease primarily affecting children under 5 years old. In 25 % of cases, it can lead to coronary artery aneurysms if not treated promptly with intravenous human immunoglobulin. A significant portion of Kawasaki disease patients present with an incomplete form, complicating diagnosis, while the risk of coronary artery aneurysms remains unchanged. Particularly vulnerable are infants under 6 months old, who may exhibit even more limited clinical symptoms, making them especially susceptible to severe cardiac complications. OBJECTIVE. To analyze a clinical case of an incomplete form of Kawasaki disease in a 2-month-old girl, raise awareness of Kawasaki disease, including its incomplete form, among healthcare workers in Ukraine, emphasize the critical importance of proper diagnostic evaluation of coronary arteries, and underscore the necessity of early administration of immunoglobulin when Kawasaki disease is suspected, even in the absence of pathological changes in the heart. MATERIALS AND METHODS. The study involved collecting medical history, physical examination data, laboratory and instrumental studies, and their analysis. The diagnosis of Kawasaki disease, including its incomplete form, was based on the 2017 recommendations of the American Heart Association. CLINICAL CASE. A 2-month-old girl presented with symptoms initially resembling a urinary tract infection, with no therapeutic response to multiple courses of antibacterial therapy. During the second week of illness, she developed swelling in her hands and feet, which, along with persistent fever, significant inflammatory response, and lack of improvement with antibiotics, led to the suspicion and diagnosis of Kawasaki disease based on the algorithm for incomplete Kawasaki disease. After administration of an immunomodulatory dose of intravenous human immunoglobulin at 2 g/kg on the 11th day of illness, there was a rapid regression of symptoms, normalization of inflammation markers, and overall improvement in the child's condition. By the second week of illness, small aneurysms of the right and left coronary arteries had formed but regressed within a few weeks from the onset of the disease. CONCLUSIONS. Kawasaki disease requires prompt therapeutic intervention and should be suspected in any child, especially those under one year of age, with a high fever lasting at least 5 days, unexplained by a preliminary diagnosis, and no response to antibiotic treatment in the presence of “bacterial” blood tests. Serial echocardiograms assessing coronary arteries, absolute dimensions, and Z-scores are mandatory.

Clean label extraction of bioactive compounds from Chenopodium album and their role in the characterization and stability of ostrich meat

The demand for clean-label products continues to rise, as consumers increasingly prioritize natural and transparent ingredient lists. Natural substances are generally deemed safe for consumption by consumers. This study was focused on the development of clean-label ostrich meat patties with Chenopodium album extract and their storage stability. To prepare C. album extract, microwave-assisted extraction (MAE) and ultrasound-assisted extraction (UAE) were employed. Ostrich meat patties were prepared using diverse combinations of extract, including 1% UAE, 2% UAE, 1% MAE, 2% MAE, 0.5% UAE+0.5% MAE, and 1% UAE + 1% MAE. The highest pH was observed for MAE in T3 on the 14th day (6.19 ± 0.03). The L* value was observed between 39.12 ± 1.09 and 44.00 ± 1.1. As storage intervals passed, the a* and b* values of ostrich meat patties decreased. After the 14th day of storage, the best results were obtained from 2% UAE (T2), with the lowest TBRAS, Peroxide value (POV), and Total of volatile basic nitrogen (TVBN) readings recorded for T2 (0.74 ± 0.02 MDA/kg, 0.56 ± 0.01 meq peroxide/kg, and 6.28 ± 0.40 mg/100 mL, respectively). At the end of the storage study, the lowest Total Microbial Count (TMC) and coliform count were recorded for T2 (8.08 ± 0.03 and 4.97 ± 0.05 cfu/mL, respectively). At the end of the storage study, T2 exhibited the highest values for total phenolic content (TPC), diphenyl-1-picrylhydrazyl (DPPH), Ferric reducing antioxidant power (FRAP), and azino-bis-3-ethylbenzothiazoline-6-sulfonic acid (ABTS) assay, namely of T2 122 ± 0.28 mg GAE/100 g, 73 ± 0.27%, 5.9 ± 0.01 mmol FSE/100 g, and 83 ± 0.08 mmol/L, respectively. The current study concludes that the UAE extract of C. album incorporated into ostrich meat patties manifests improved safety, quality, and storage stability. The implementation of clean label strategies can facilitate food manufacturers to align with consumer preferences for product transparency and sustainability while ensuring product safety and quality.

Systemic iodine levels increase with povidone-iodine irrigation, but does this affect thyroid functions? A case-control study.

Intraoperative irrigation with diluted povidone iodine (PI) can be used to reduce the incidence of infection-related complications in arthroplasty surgeries. Since PI is associated with many interventions, especially skin antisepsis, its systemic effects are being studied. The aim of our study is to evaluate the systemic effects of PI, which we use as an irrigation solution, by means of urine iodine and thyroid function tests. In this case-control study, 96 patients who underwent knee or hip arthroplasty were included and divided into two groups according to the irrigation solution. In the first group, PI was added to the standard irrigation. The second group was considered as the control group and only standard irrigation was applied. Urine iodine, thyroid stimulating hormone, free T3 and free T4 values were compared in the preoperative and postoperative periods of these two groups. In this way, the effect of absorbed iodine on thyroid functions was investigated. In the diluted PI group, urinary iodine levels were measured at maximum levels (450µg/L) in the early postoperative period in most of the patients. The statistically significant difference in urinary iodine levels between the PI group and the control group, which started in the early postoperative period, continued until the last follow-up on the 14th postoperative day. In terms of thyroid functions, the observed differences were not statistically significant. Studies to reduce periprosthetic infection show that PI can be preferred for irrigation before the closure of the joint area in total joint arthroplasty. Although the success of this treatment in periprosthetic infection has been investigated, its systemic examination has not been demonstrated. It was determined that PI treatment, which was seen to decrease in the systemic circulation within 14 days, did not show a statistically significant change in terms of thyroid functions when used at the determined concentration and duration. These results should be evaluated with larger and longer-term studies. Clinical trials ID no. NCT05599841.

PENGARUH FREKUENSI PEMBERIAN VITAMIN E TERHADAP POST PARTUS ESTRUS DAN POST PARTUS MATING SAPI PERANAKAN FRIESIEN HOLSTEIN

This study aimed to determine the effect of the frequency of vitamin E application on the reproductive performance of postpartum FH crossbreed cows, which Include Post Partus Estrous (first estrus after calving) and Post Partus Mating (first mating after calving). The study used treatment giving vitamin E to cows after calving with treatment 0 (P0)/control, treatment 1 (P1) was injected on the 7th and 14th days after calving and treatment 2 (P2) was injected on the 7th day, the 14th day after calving and 17th day after calving. Post Partus Estrous (PPE) and Post Partus Mating (PPM) were the treatment variables observed. Giving vitamin E on the 7th, 14th, and 17th days after calving (P2) showed a very significant effect (P<0.01) on Post Partum Estrous (PPE). The results of ANOVA analysis of treatment 2 (P2) days 7, 14, and 17 after calving showed a very significant effect (P<0.01) on Post Partus Mating (PPM). This study shows that the P2 treatment with vitamin E injection on days 7, 14, and 17 after calving obtained the best reproductive performance by producing the shortest Post-Partus Estrus (PPE) of 51 days and the shortest Post-Partus Mating (PPM) of 71.83 days.

Possibilities of using innovative non-drug technologies in the rehabilitation of patients with early post-stroke cognitive impairment

BACKGROUND: One of the leading factors complicating social adaptation after ischemic stroke is cognitive and motor impairment. AIM: This study aimed to evaluate the effect of rehabilitation using virtual reality technologies and the influence of the main clinical and functional parameters on virtual reality (VR) therapy in patients with different degrees of cognitive decline in the acute period of ischemic stroke. MATERIALS AND METHODS: This study examined 170 patients diagnosed with ischemic stroke with cognitive decline according to the Montreal Cognitive Assessment. Depending on the volume of therapy, the patients were divided into two groups: group 1 included 120 patients who received additional therapy using VR technologies (62 patients with moderate cognitive impairment, 58 patients with dementia), and group 2 consisted of 50 patients who received only basic therapy and standard methods of early rehabilitation. In group 1, on days 4–5 following basic therapy, rehabilitation using VR was performed. The Barthel Index (BI) scale, Rankin Scale (mRS), and National Institute of Health Stroke Scale (NIHSS) were used to examine cognitive and functional status, and tests were performed to assess cognitive functions, as well as neuroimaging scales ASPECTS, STRIVE, and MTA. The effectiveness of rehabilitation (ΔRE) was measured by the indicator of changes in the parameters of the VR system before and after treatment. RESULTS: A more significant improvement of the patient’s independence and regression of perceptual and executive functions was demonstrated in group 1 than in the control group. In patients with MCI, significant improvement was observed in all cognitive and functional parameters except semantic information processing, attention, and constructive praxis. In patients with dementia, improvement was noted in NIHSS, speech and amnestic disorders. In group 1, ΔRE was found to be associated with the parameters of perception, attention, semantic information processing, IQCODE, and NIHSS and the presence of hypertension and repeated stroke. In patients with MCI, ΔRE was correlated with lesion size, attention level, BI, mRS, and NIHSS and with age, sex, degree of IQCODE and STRIVE, semantic aphasia, and perceptual impairment in patients with dementia. CONCLUSION: The present study revealed a polymorphism of factors influencing the effectiveness of VR therapy in patients with varying degrees of cognitive decline. Modern approaches to VR rehabilitation of patients with post-stroke cognitive impairment require the development of individual methods of rehabilitation using immersion environment focused on the structure, etiology, and severity of cognitive deficit considering the degree of the patient’s functional state.

Evaluation of three inert materials in controlling Cowpea weevil (<em>Callasobruchus maculatus</em> F.) on stored cowpea (<em>Vigna unguiculate</em> L.)

Eco-friendly inert materials can be achieved minimizing insect damages, this study was conducted to explore the efficacy of the three inert materials at 20% (w/w) paddy husk ash (PHA), fine dry sea salt and tiny bricks against the cowpea weevil C. maculatus on stored cowpea (V. unguiculata) on the basis of adulticidal effects and asses the influence against germination losses of the seeds. The result exhibited a significant difference (p≤ 0.0001) in their level of weevil attack during the storage. Maximum 100% adult mortality was recorded in the cowpea seeds incorporated with PHA after 96 hours of the treatment followed by dry salt it was observed 94% at the 5th day whereas, tiny bricks killed only 20% weevils as untreated control until 5th day after the treatment. Further, PHA treated seeds much reduced the capable of the egg laying capacity of weevil (9.8± 0.58eggs/ female) as well as minimized the production of new progenies (13.6 ± 0.37) and also there were recorded 0.03% weight loss and zero percent germination losses proving it to be best protectant on stored cowpea. However, significantly (p≤ 0.0001) any adverse effects that, egg laying capacity and new progeny production did not visible in dry salt up to 90 days after the treatments except minimize the germination loss. Among the inert materials used, tiny bricks were found ineffective to cause adult mortality, fecundity and adult emergency in F1 generation (119.8± 1.78), it was further increased production of new weevils obtained following the next F2 generation (1301 ± 0.65) and play down the losses of weight and germination of the seeds. Considering it was noticed tiny bricks treated seeds significantly equivalence with the level of damage by the weevil C. maculatus in untreated control on stored cowpea.

MICROBIOME: The trials and errors of developing an experimental model to study the impact of maternal gut microbiome disruption on perinatal asphyxia.

Maternal gut microbiome impairment has garnered attention for its potential role in influencing neurodevelopmental outcomes in offspring, especially in situations that increase brain vulnerability such as perinatal asphyxia (PA). Maternal microbiome and fetal brain interplay emerge as a critical link between maternal health and offspring neurodevelopment. This study aims to generate a model to assess the impact of maternal dysbiosis triggered by gestational antibiotic administration and PA on offspring neurodevelopment. Wistar rats were subjected to antibiotics in drinking water from the 11th gestational day until birth. On the 6th postnatal day, pups were subjected to PA/normoxia, resulting in four experimental groups: control-normoxia, antibiotics-normoxia, control-asphyxia, and antibiotics-asphyxia. Early-life behavioral tests were conducted between postnatal days 7 and 9. The initial antimicrobial cocktail (ampicillin, vancomycin, neomycin, clindamycin, amphotericin-B) led to an increased number of miscarriages, poor weight gain during pregnancy, reduced offspring weight, and changes in the maternal gut microbiome compared to control. Offspring presented impaired neurodevelopmental reflexes in both PA and antibiotic groups and increased hippocampal neuroinflammation. Due to these detrimental effects, a more pregnancy-safe antibiotic cocktail was used for a second experiment (ampicillin, vancomycin, neomycin, meropenem). This resulted in no miscarriages or pregnancy-weight loss but was still linked to gut microbiome disruption. PA impaired neurodevelopmental reflexes and increased neuroinflammation, effects amplified by antibiotic administration. These preliminary findings reveal the cumulative potential of maternal dysbiosis and PA on neurodevelopment impairment, emphasizing caution in gestational antimicrobial use. Further investigations should include offspring long-term follow-up and maternal behavior and integrate probiotics to counteract antibiotic effects. This study investigates the impact of maternal gut microbiome disruptions caused by gestational antibiotic treatment and low oxygen exposure shortly after birth on the development of the rats' babies. We found that both antibiotic exposure and reduced oxygen levels led to changes in early behavior and increased inflammation of the nervous tissue in the baby rats. Although using a different, potentially safer antibiotic combination reduced pregnancy complications, it still changed the bacteria in the mother's gut and worsened early behavior. These findings show that antibiotics during pregnancy can affect the developing brain of baby rats and careful consideration should be used before prescribing them. Future research will explore longer-term effects and potential medicines.

Awake prone positioning in an infant following living donor liver transplantation

BackgroundProne position has been proven to improve ventilation and oxygenation in infants. Currently, there are few reports of early prone position ventilation after pediatric liver transplantation. Here, we present our experience with prone position in an infant following living donor liver transplantation, in an attempt to improve oxygenation.Case presentationAn 8-month-old boy, 7.5 kg, experienced two failed extubations that presented with Type II respiratory failure due to dyspnea, potentially caused by consolidation and airway secretions. To prevent the third failure of extubation, prone position ventilation was implemented after the third extubation on the 11th postoperative day. Oxygenation increased after each prone position session with no signs of transplant liver ischemia or other adverse outcomes. Following two days of continuous prone position, airway secretions decreased, and the infant was discharged from the ICU. The third extubation procedure was successful.ConclusionsProne position ventilation may be effective in this infant without adverse events, indicating that early prone position is not absolutely contraindicated after pediatric liver transplantation. Therefore, more reasonable prone position strategies should be sought in infants undergoing liver transplantation.

Guava leaf extract - Phytochemical therapy for periodontitis patients

Introduction: Periodontitis is one of the most prevailing diseases associated with the oral cavity. It is important to treat the disease effectively as it results in tooth loss and also affects the host extensively. Treatment of periodontitis includes various surgical and non-surgical modalities. Non-Surgical modalities include Scaling and Root Planing (SRP), Local Drug Delivery (LDD), laser and HMT therapy. In the present study, the effect of guava leaf extract gel as a local drug delivery agent for the treatment of chronic periodontitis is evaluated. Aim: The aim of this study is to analyze the efficacy of guava gel extract as a local drug delivery agent in patients with periodontitis following scaling and root planing (SRP). Materials and method: A randomized, controlled study was conducted in 21 systemically healthy patients suffering from moderate periodontitis with isolated pockets (pocket depths 45mm). Clinical parameters GI, PI and PPD were recorded at baseline and subsequently after 7th, 14th and 21st day. The study design consisted of three groups, each group having 7 subjects, allocated in these groups randomly. Group A - Guava leaf extract gel (7), Group B – Chlorhexidine group (7), Group C - Control group (7). Results: Both the groups, Group A and Group B showed similar reduction in Gingival Index, Plaque Index and Probing Pocket Depth values when compared at baseline and on 21st day but the differences failed to reach the level of significance. Conclusions: The results suggest that Guava leaf extract gel as a local drug delivery is highly effective and comparable to gold standard.

5175 A Rare Case of Type B Insulin Resistance Syndrome

Abstract Disclosure: S. Fatima: None. A. Champion: None. S. Ward: None. Q. Aziz: None. K.E. Izuora: None. Introduction: Severe insulin resistance may be defined as a severely diminished response to insulin’s biological effects and is characterized by substantial hyperinsulinemia and impaired glucose response to endogenous and exogenous insulin. We hereby present a rare case of Type B Insulin Resistance Syndrome (TBIRS). Case:40-years old female with history of systemic lupus erythematosus (SLE), diabetes mellitus was admitted with multiple rheumatologic complaints, including arthralgias, oral ulcers, skin rash, and hair loss secondary to SLE flare. Endocrinology was consulted for diabetes management. Her HbA1c had increased from 7.3% to 11.6% in 3 months despite taking Glargine 45 units daily, Lispro 15 units pre-meals and metformin. She noticed 80 lbs weight loss for past 6 months. Her BMI was 26 and exam showed acanthosis of neck, armpits, groin, hair loss on scalp, multiple genital ulcers, and facial rash. She was noted to have refractory hyperglycemia despite high insulin doses. By 14th day of hospitalization, she was on 287 units of insulin (3.4units/kg) daily. We suspected TBIRS in the setting of SLE. Metformin and pioglitazone were started. Further testing showed insulin level 152mIU/ml (2.6-14.9mIU/ml), C-peptide 1.7 ng/ml (1.1-4.4 ng/ml), islet-cell antibody negative, GAD-65 antibody <5 u/ml, insulin antibody 6.5 uU/ml, IGF-1 14 (79-259 ng/ml), adiponectin 13.3 (2.4-17.9 ug/ml), testosterone 7 (8-60 ng/dl), free testosterone <0.2 (0-4.2 pg/ml), total cholesterol 200 mg/dl (<200 mg/dl), triglycerides 85 mg/dl (<150 mg/dl), LDL 154 mg/dl (<100 mg/dl), HDL 29 mg/dl (>60 mg/dl). She was transferred to National Institute of Health for further care. She was confirmed to have TBIRS by insulin receptor antibody testing, started on regular insulin U500 initially, and then switched to IV insulin drip requiring up to 1700 units of insulin per hour. She received methylprednisolone, cyclophosphamide (2 doses), rituximab (2 doses), hydroxychloroquine and IV immunoglobulin. Her stay was complicated by hemophagocytic lymphohistiocytosis. She was discharged on U-500 Regular insulin, 1000 units with breakfast and 500 units with lunch, Prednisone 60 mg daily and Hydroxychloroquine. Two months later she was found unresponsive at home secondary to hypoglycemic seizures. She required dextrose drip and was discharged on Glargine 16 units and Lispro 6 units with meals. Conclusion: TBIRS is caused by a highly specific polyclonal autoantibody against the cell surface insulin receptor that decreases the cellular insulin response and causes refractory hyperglycemia. About 100 cases have been reported in literature. 60% of the cases are associated with SLE. The goal of therapy is to reverse the hypercatabolic state with high doses of insulin and to eliminate the autoantibodies with immunosuppressive therapy. The most common cause of mortality is hypoglycemia. Presentation: 6/3/2024

12615 Extremely High-dose Insulin Requirement In A Child With Covid-19 Infection

Abstract Disclosure: R. Pratibha: None. T.R. Langner: None. Background: COVID-19 infection has been associated with new diagnosis of diabetes, worsening of hyperglycemia, and increased frequency and severity of diabetic ketoacidosis (DKA) in type 1 diabetes (DM) patients. Stress- related and steroid induced hyperglycemia are also well described during COVID infection with poor glycemic control being linked to more severe SARS-CoV-2 infection outcomes. While insulin needs increase during infection, extremely high insulin requirement is uncommon and not described in the pediatric population. We present here a case of mild COVID infection with transient markedly high insulin requirements. Clinical Case A 16-year-old-African-American- female with history of fairly well controlled type 2 diabetes mellitus on closed loop system insulin pump (Omnipod) with continuous glucose monitor (CGM), was admitted with COVID-19, aspiration pneumonia and hyperglycemia. She had been diagnosed 10 months prior with Hemoglobin A1c (HbA1c) of 11.4% and mild diabetic ketoacidosis (DKA). Diabetes antibodies were negative. Four months prior to admission her HbA1c was 7.8%. Upon this hospitalization she had no hypoxemia or respiratory failure and did not need steroids. Procalcitonin level 0.09 ng/mL was normal. Developmental delay, non-ambulatory and non-verbal status, an underlying mitochondrial neurological disease with G tube and ventilator dependence added to the medical complexity. HbA1c (8.1%) and Fructosamine 316 (n 200-285 mcmol/L) were not indicative of poor control. While her pneumonia resolved promptly, blood sugar (BG) elevation prolonged her hospitalization. She was not in DKA. Despite increasing her basal rate by 50% and an additional 20% higher temporary basal rate via her insulin pump there was little response. She was switched to Insulin drip by the 7th day. Her Insulin rate had increased to 26 units per hour (at 0.64 Units/Kg/hour) by day 8. This high insulin-dose need lasted for around 36 hours, before gradually reducing over a week. She has a history of recurrent pancreatitis. Lipase 335 U/L was elevated initially but started reducing within 2 days and had normalized by day 13. She was transitioned back to her pump although at higher basal rate than the previous home regimen, by 14th day. Conclusion While a constellation of factors such as stress, steroids, underlying poor glycemic control may cause hyperglycemia in COVID-19, these do not explain the high insulin demand in our patient. COVID infection with impaired insulin secretion, mild pancreatitis may have contributed to the brief remarkably high-dose insulin requirement, but it appears to be increased insulin resistance which could possibly explain the transient derangement. To our knowledge this has previously not been described in a pediatric diabetic patient. Presentation: 6/3/2024

8355 Pheochromocytoma In The Elderly: A Mini Case Series

Abstract Disclosure: S. Nabi: None. A. Golash: None. P. Panwar: None. G. Powner: None. C. Schiteanu: None. C. George: None. M. Vallabhaneni: None. B.G. Issa: None. A. Clark: None. D. Bailey: None. J. Waldron: None. F.W. Hanna: None. Diagnosis and management of pheochromocytoma in the older population is challenging due to the co-morbidities and general age-related frailty. We present a mini case series of four patients aged 72 to 86 years who presented to our tertiary referral center at the University Hospitals of North Midlands UK, between 2019 and 2022.The case series documents the challenges of managing pheochromocytoma in this population, emphasizing how close monitoring, regular follow ups and collaboration between different members of the multidisciplinary team helped to achieve the desirable outcomes in these cases. Case 1: Adrenal incidentaloma in 84-year-old female. Background of hypertension and diabetes mellitus. History of occasional palpitations. Investigations showed raised plasma and urinary metanephrines. MIBG scan confirmed pheochromocytoma and after adequate alpha and beta blockade underwent successful laparoscopic surgery. No intra or post operative complications and showed good recovery. Discharged on the 5th day post operative. Case 2: 82-year female under cardiology with non-ST elevation myocardial infarction. Background of hypertension, chronic kidney disease and gastroesophageal reflux disease. Initial presentation with shortness of breath, sweating and swelling lower limbs. Normal coronary arteries on angiography, so investigated for possible excess catecholamine production. Had significantly raised 24-hour urinary normetadrenaline. Paraaortic paraganglioma confirmed on MIBG SPECT scan. Initially opted for medical treatment however quality of life worsened over the next year and eventually underwent robot assisted excision. Procedure was uneventful with good post-operative recovery. Was able to go home 2 days after the procedure. Case 3: 72-year-old female referred with right adrenal incidentaloma. Background of hypertension, diabetes mellitus, hypothyroidism, asthma, arthritis and Ca breast treated 10 years ago. Results showed raised plasma metanephrines, subsequently, MIBG scan revealed a 3 cm right adrenal nodule with increased uptake. Full alpha and beta blockade achieved before she underwent surgical treatment with no complications. Discharged on the 3rd day post op. Case 4: An 80-year-old male was referred with left adrenal incidentaloma. History of diabetes, chronic kidney disease, ischemic heart disease and heart failure, recent myocardial infarction and atrial fibrillation. Biochemical and radiological investigations confirmed pheochromocytoma. He was started on alpha blockade that proved difficult to achieve due to underlying co-morbidities. The patient needed close monitoring by the endocrine team and was finally established on adequate alpha and beta blockade. Due to significant risks associated with the procedure, the patient decided not to proceed with the surgery and opted for medical management. Remains under active follow up. Presentation: 6/2/2024

12344 Four-Month Delay In Denosumab Induced Severe Hypocalcemia And Hypophosphatemia. Case Report

Abstract Disclosure: M.M. Eid: None. S. Reutrakul: None. Introduction: Denosumab is a fully human monoclonal antibody that binds to the receptor activator of nuclear factor kappa Β ligand, blocks osteoclast function and reduces bone resorption. Case: A 91 year old male with history of osteoporosis, type 2 diabetes, chronic kidney disease (CKD) and prostate cancer. Presented with fatigue and cold intolerance. Denied confusion, muscle cramp, perioral numbness/tingling, bowel habit change. Medications included empagliflozin 12.5 mg/day, leuprorelin 45 mg every 6 months since 2021 and cholecalciferol 1000IU/day. On examination, he was alert and oriented x 3 with stable vital signs. No thyromegaly. Chvostek's sign was negative. Labs: serum calcium (Ca) 6.5 mg/dl, corrected Ca (Co Ca) 6.7mg/dl(N 8.7-10.4), ionized Ca 0.7mMol/l (N 1.13-1.32), TSH 131uIU/ml (N 0.55-4.78), free T4 0.72ng/dl (N 0.89-1.76), creatinine 1.55mg/dl, GFR 42ml/min/1.73m2, HbA1C 6.1%. EKG with corrected QT interval of 499 msec. Hypocalcemia work up : parathyroid hormone (PTH) 762 pg/ml (N 18.4-80.1), 25 OH vitamin D (Vit D) 37ng/ml (N 30-100), 1,25 OH Vit D 77pg/ml (N 18-72), phosphorus (Phos) 1mg/dl (N 2.4-5.1), magnesium (Mag) 1.7mg/dl (N 1.6-2.6),ALP 59U/L(N 45-117). Clinical impressions were a new diagnosis of primary hypothyroidism and non PTH mediated hypocalcemia with secondary hyperparathyroidism. A thorough review of medication revealed that he received the first dose of denosumab 60 mg 4 months prior to this presentation. Baseline labs 1 month prior to denosumab: Ca/Co Ca 9.1/9.2mg/dl, Phos 4.5mg/dl, PTH 199.6pg/ml, Mag 2.1mg/dl,TSH 2.72 uIU/ml. 2 months after denosumab administration, serum Ca/Co Ca 8.8/8.6mg/dl. He was admitted and received Ca gluconate 2gm IV pushes, calcitriol 0.5 mcg/day and levothyroxine 50 mcg/day and kept on cardiac monitoring. He remained asymptomatic. On the 5th day, serum Ca/Co Ca 8.4/8.6mg/dl, Phos 3mg/dl, Mag 2mg/dl. He was discharged on oral Ca Carbonate, calcitriol and levothyroxine. The second denosumab dose was cancelled. Conclusion: Denosumab is an effective anti-osteoporotic medication but can cause hypocalcemia. The risks for denosumab induced hypocalcemia include renal impairment, Vit D deficiency and lack of Ca/Vit D supplementation. Hypocalcemia usually occurs 1 - 2 weeks after denosumab, corresponding to its peak of action. Checking serum Ca and Vit D with correction of deficiencies before starting denosumab is recommended. In high risk patients with CKD, daily Ca and Vit D supplements are recommended (1). Our case has CKD and developed severe hypocalcemia and hypophosphatemia 4 months after receiving denosumab without other apparent causes for hypocalcemia. Hypothyroidism is likely an incidental diagnosis and not contributing to hypocalcemia in the absence of rhabdomyolysis. Reference: 1.Jalleh R, Basu G, Leu RL, Jesudason S: Denosumab induced severe hypocalcemia in chronic kidney disease. Case Rep Nephrol.2018 Presentation: 6/2/2024

12616 Pembrolizumab-induced Autoimmune Adrenal Insufficiency: A Case Report And Literature Review

Abstract Disclosure: A. Calderon: None. E. Calderon-Martinez: None. J. Shakil, MD: None. A. Kansara: None. Immunechekpoint inhibitors (ICI)-related Primary Adrenal Insufficiency (PAI) is an uncommon entity. Compared to other endocrine-related adverse effects (irAES), antibody detection is less consistent. TPO and GAD65 antibodies are usually present in about 40-80% of the cases with hypothyroidism, hyperthyroidism, and diabetes. On the contrary, case reports and series for PAI seldom report the presence or absence of 21OH antibodies. We present a case and perform a literature review of PAI, in a patient who received pembrolizumab and developed PAI with 21 hydroxylase antibodies. A 62-year-old man with history HIV on ART (last CD4 count 590 cells/mm3) and locally advanced urothelial cancer on Pembrolizumab, presented with nausea, vomiting, abdominal pain, and decreased urine output. He was noted to be confused, and in hypoactive delirium. On admission, his chemistry panel he was noticed to have normal sodium and potassium levels. The CT scan of the abdomen revealed regional enteritis and was started on IV fluid therapy. His adrenal glands were described as normal on imaging. On the 16th day of hospitalization, the patient became unresponsive and hypotensive. He was transferred to the ICU. His sodium level was 132 mEq/L and potassium level was 6.1 mEq/L, bicarbonate level was 18 mEq/L, calcium of 10.3 mg/dl, and eosinophils of 15%. Random cortisol levels measured before administration of steroids were undetectable twice, 9 hours apart, with an ACTH level of 94. He underwent an ACTH stimulation test with cosyntropin 250 mcg IV with resulting undetectable cortisol levels after 30 and 60 minutes. CT and MRI of the brain showed no signs of hypophysitis. He was started on high-dose hydrocortisone with improvements in his mental status, hypotension, and gastrointestinal symptoms. He was discharged on hydrocortisone. His 21-Hydroxylase antibody was later found out to be positive. After combination immunotherapy regimens, CTLA-4 inhibitors are the most common to cause any irAE, however endocrine irAE particularly are mostly associated with PD-1 inhibitors. Among these, thyroid and pituitary disorders are the most common ones. Reports show that about 10% of patients receiving immunotherapy will develop endocrinopathy. ICI-induced PAI has been reported to occur in 7.6% of patients receiving combination therapy, and 2% of patients receiving Pembrolizumab. It has been reported that only 15% of patients will recover adrenal function. A meta-analysis that gathered 15 cases of ICI-induced PAI, found that only 2 cases had positive 21-hydroxylase antibodies. In our presented case, we have robust biochemical confirmation of PAI, with positive 21 hydroxylase antibody, after being on pembrolizumab for 9 months. Further information is needed to establish the pathophysiology, presentation, and prognosis of ICI-related PAI when anti adrenal antibodies are positive. Presentation: 6/1/2024

A rare occurrence of Vancomycin-induced gastrointestinal hemorrhage without thrombocytopenia: a case report and literature review

BackgroundVancomycin-induced bleeding has been reported, attributed to the mechanism of immune thrombocytopenia. A rare case of vancomycin-induced gastrointestinal hemorrhage in a young patient with no underlying disease, receiving intravenous vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) infection, is presented. This occurrence occurred without thrombocytopenia. Relevant cases reported in the literature were also reviewed.Case presentationA 34-year-old male patient presented with maxillofacial multiple spaces infection accompanying left temporal abscess, bilateral lung abscesses. Culture results from both blood and secretion indicated that the infection was caused by MRSA. The patient received standard-dose vancomycin (1 g q12h intravenously guttae) for treatment. On the 5th day of therapy, he presented with bright red blood in his stool; however, vancomycin treatment was continued. By the 9th day, a decrease in hemoglobin level to 76 g/L and a platelet (PLT) count of 424 × 109/L raised concerns about gastrointestinal hemorrhage. The hemoglobin level decreased to 62 g/L on day 12. Due to the high tissue concentration of linezolid, administration of linezolid at a dose of 600 mg q12h intravenously guttae commenced on the 13th day as an alternative to vancomycin(D13-D17). Subsequently, on the 17th day, there was an improvement in hemoglobin level to 78 g/L. However, despite treatment with linezolid, the patient’s fever showed no significant improvement, prompting a switch back to vancomycin at a dosage of 1 g q12h intravenously guttae(D18-D22). On the 21st day, there was a recurrence of gastrointestinal hemorrhage, accompanied by a hemoglobin level of 42 g/L and a PLT count of 224 × 109/L. Gastroscopy revealed the presence of a gastroduodenal ulcer. The patient had no prior history of hemorrhoids, gastrointestinal ulcers, liver cirrhosis, or purpura. Prior to admission, he had not been administered non-steroidal anti-inflammatory drugs (NSAIDs) or steroids. During hospitalization, the only medications given were vancomycin, ambroxol and lidocaine. Additional tests ruled out immunological disorders as the cause of gastrointestinal ulcers, and a positive vancomycin rechallenge test indicated an association between vancomycin and bleeding. After discontinuation of vancomycin, no further bleeding occurred. This case highlights a rare occurrence of vancomycin-induced bleeding without thrombocytopenia, classified as “Certain” according to the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) scale for standardized case causality assessment.ConclusionThis case represents the first documented instance of vancomycin-induced bleeding without thrombocytopenia, as confirmed by a positive rechallenge test. This discovery will aid in the early detection of this rare adverse reaction in future cases.