Surface-Initiated Reversible Addition-Fragmentation Chain Transfer Polymerization (SI-RAFT) to Produce Molecularly Imprinted Polymers on Graphene Oxide for Electrochemical Sensing of Methylparathion.

A nonenzymatic redox-responsive sensor was put forward for the detection of methylparathion (MP) by designing globular nanostructures of molecularly imprinted polymers on graphene oxide (GO@MIPs) via surface-initiated reversible addition-fragmentation chain transfer polymerization (SI-RAFT). Fourier transform infrared (FTIR) spectroscopy, field emission scanning electron microscopy (FESEM), and small-angle X-ray scattering (SAXS) studies have confirmed the successful formation of receptor layers of MIPs on RAFT agent-functionalized GO sheets. The electrochemical signal with an amplified current response was attained because of the enhanced diffusion rate of ions at the interface provided by widening the pore size of the MIP film. The analytical response of GO@MIPs, validated by recording square-wave anodic stripping voltammetry (SWASV) at varying MP concentrations, followed the linear response between 0.2 and 200 ng/mL. Under optimized conditions, the sensor exhibited a limit of detection of 4.25 ng/mL with high selectivity over other interfering ions or molecules. The anti-interfering ability and good recovery (%) in food samples directed the use of the proposed sensor toward real-time monitoring and also toward future mimicking of surfaces.

X-ray Induced Cycling of Rare-Earth Elements between Bulk and Interfacial Liquid.

Reversible cycling of rare-earth elements between an aqueous electrolyte solution and its free surface is achieved by X-ray exposure. This exposure alters the competitive equilibrium between lanthanide ions bound to a chelating ligand, diethylenetriamine pentaacetic acid (DTPA), in the bulk solution and to insoluble monolayers of extractant di-hexadecyl phosphoric acid (DHDP) at its surface. Evidence for the exposure-induced temporal variations in the lanthanide surface density is provided by X-ray fluorescence near total reflection measurements. Comparison of results when X-rays are confined to the aqueous surface region to results when X-rays transmit into the bulk solution suggests the importance of aqueous radiolysis in the adsorption cycle. Amine binding sites in DTPA are identified as a likely target of radiolysis products. The molecules DTPA and DHDP are like those used in the separation of lanthanides from ores and in the reprocessing of nuclear fuel. These results suggest that an external source of X-rays can be used to drive rare-earth element separations. More generally, use of X-rays to controllably dose a liquid interface with lanthanides could trigger a range of interfacial processes, including enhanced metal ion extraction, catalysis, and materials synthesis.

Altitude-related features and prognosis in patients with reversible splenial lesion syndrome.

INTRODUCTION: RESLES (Reversible splenial lesion syndrome) can be observed secondary to various diseases, and intramyelinic edema may play a crucial role in the pathogenesis of SCC (Splenium of the corpus callosum). Some studies have suggested that hypoxic-ischaemic encephalopathy may constitute a risk factor for SCC lesions. However, the potential impact of high-altitude environments on SCC, especially during chronic exposure, remain obscure. METHODS: Our study included 19 patients who satisfied the diagnostic criteria of RESLES at high altitudes. Ten low-altitude patients with RESLES were included as controls. All participants received MRI (Magnetic resonance imaging) scans twice. Routine blood tests, liver, kidney and thyroid function, coagulation function, electrolytes and vitamins were detected during hospitalization and before discharge. In addition, the patients were followed up in May 2023. RESULTS: Hypoxic environments at high altitudes may increase the risk of RESLES. The two groups showed different clinical symptoms. High-altitude patients had significantly higher CRP levels than low-altitude patients. The lesion size in high-altitude patients showed a positive correlation with SaO2 levels. However, the patients at low altitudes had positive correlation trends between lesion size and several inflammatory markers (WBC, NEU and CRP). All patients had a benign prognosis that may not be affected by the use of prednisone acetate. CONCLUSIONS: Hypoxic environments at high altitudes may play a role in the aetiology of RESLES. Additionally, RESLES is a reversible disease and the administration of glucocorticoids may be dispensable for its treatment.

Injection Depot Medroxyprogesterone Acetate as an Early Postpartum Contraceptive Measure: Evaluation of Its Acceptability, Efficacy, and Impact on Lactation.

Introduction Through its National Family Planning Programme, India has been relentlessly working to decrease society's unmet contraception needs. The postpartum period is of paramount importance for addressing these contraceptive needs owing to alterations in fertility and coital behavior associated with childbirth. Depot medroxyprogesterone acetate (DMPA), a long-acting reversible contraceptive, is one of the safe options available in the early postpartum period. In this study, we aimed to evaluate its efficacy and acceptability among postpartum women delivering in Guru Gobind Singh Medical College and Hospital. Methodology We recruited 206 early postpartum women for the study. After thorough counseling and ensuring establishment of lactation, we administered DMPA 150mg by injection intramuscularly and repeated it at intervals of three months in willing patients. We then evaluated them for their symptoms, side effects, and lactation status using a predesigned proforma either during their follow-up visits or telephonically. Results We found DMPA to be 100% efficacious as an early postpartum contraceptive measure. The main reasons for acceptance were its ease of use, long-term effects of a single dose, and noninterference with lactation. However, the continuation rate for the second dose was only 18% in our study, highlighting the need for better counseling and improving awareness among our patients. Ninety-nine percent of our patients were satisfied with their lactation. Conclusion We found injectable DMPA used as a contraceptive in the immediate postpartum period to be a safe and effective alternate method with no deleterious effect on lactation and an acceptable side effect profile. However, more awareness programs are necessary to encourage women, especially those in low-resource areas, to continue using DMPA.

Magnetic resonance imaging patterns and perfusion changes of posterior reversible encephalopathy syndrome in children with clinical outcome correlation.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) in children has a propensity towards atypical features on magnetic resonance (MR) imaging, with limited literature on perfusion changes and clinicoradiological correlation. OBJECTIVE: We aimed to comprehensively study MR imaging patterns of pediatric PRES, including cerebral blood flow variations on arterial spin labeling, and looked for any MR biomarkers of poor clinical outcome. MATERIALS AND METHODS: In this retrospective observational study conducted in a tertiary hospital setting, MR records over a 4-year period (May 2019 to May 2023) were systematically searched along with their clinical details. Patients with an age less than 18 years and a clinicoradiological constellation consistent with PRES were included. MR scans were analyzed by two neuroradiologists with 8 years' and 10 years' experience. Association was sought with poor clinical outcome (defined as modified Rankin Scale score at discharge of > 2). RESULTS: A total of 45 patients (29 boys) were included in the study, with a mean age (± standard deviation) of 11.19 (± 4.53) years. On MR imaging, 95.6% of patients (n = 43) showed atypical features and/or atypical areas of involvement. The superior frontal sulcus (n = 18) was the most predominant MR pattern, and cerebellar involvement was not uncommon (n = 15). Unilateral involvement (n = 3), isolated central pattern (n = 1), and spinal cord involvement (PRES-SCI: n = 1) were also encountered. Brainstem involvement (n = 4) showed a characteristic "V-sign" of anterior medullary hyperintensity. Patchy restricted diffusion (46.6%), punctate hemorrhages (37.7%), and leptomeningeal contrast enhancement (36%) were not uncommon. Arterial spin labeling sequence (available in 24 patients) showed increased cerebral blood flow in the involved areas in 79.2% of patients. Univariate analysis showed a significant association of the presence of hemorrhage (P = 0.003), involvement of brainstem (P = 0.007), deep white matter (P = 0.008), and thalamus (P = 0.026) with poor clinical outcome. Multivariate regression analysis found that hemorrhage on MRI (P = 0.011, odds ratio 8) was an independent factor associated with poor clinical outcome. CONCLUSIONS: The conventionally described atypical features in PRES are common in children and therefore may no longer be considered exceptions. Raised perfusion on arterial spin labeling sequence was seen in the majority of cases. Hemorrhage on MRI was an independent predictor of poor clinical outcome in pediatric PRES.

A novel mertansine conjugate for acid-reversible targeted drug delivery validated through the Avidin-Nucleic-Acid-NanoASsembly platform.

In targeted cancer therapy, antibody-drug-conjugates using mertansine (DM1)-based cytotoxic compounds rely on covalent bonds for drug conjugation. Consequently, the cytotoxic DM1 derivative released upon their proteolytic digestion is up to 1000-fold less potent than DM1 and lacks a bystander effect. To overcome these limitations, we developed a DM1 derivative (keto-DM1) suitable for bioconjugation through an acid-reversible hydrazone bond. Its acid-reversible hydrazone conjugate with biotin (B-Hz-DM1) was generated and tested for efficacy using the cetuximab-targeted Avidin-Nucleic-Acid-NanoASsembly (ANANAS) nanoparticle (NP) platform. NP-tethered B-Hz-DM1 is stable at neutral pH and releases its active moiety only in endosome/lysosome mimicking acidic pH. In vitro, the NP/Cetux/B-Hz-DM1 assembly showed high potency on MDA-MB231 breast cancer cells. In vivo both B-Hz-DM1 and NP/Cetux/B-Hz-DM1 reduced tumor growth. A significantly major effect was exerted by the nanoformulation, associated with an increased in situ tumor cell death. Keto-DM1 is a promising acid-reversible mertansine derivative for targeted delivery in cancer therapy.

Case Report: AMSAN variant of GBS complicating immediate postpartum period with severe dysautonomia leading to Posterior Reversible Encephalopathy Syndrome.

A 20's primiparous woman, following spontaneous expulsion of intrauterine death of the fetus at 30 weeks of gestation, presented on post-partum day 8 with acute onset flaccid quadriparesis and breathing difficulty, which had rapidly progressed to involve the legs on day 3 up to her upper limbs on post-partum day 5. Following examination, Guillain Barre Syndrome (GBS) with ascending diaphragmatic involvement was diagnosed, and plasma exchange was initiated. She developed raised blood pressure, headache, sudden onset visual loss with 2 episodes of generalized seizures on post-partum day 14. Brain MRI and clinical suspicion helped diagnose Posterior Reversible Encephalopathy Syndrome (PRES). The patient was treated with anticonvulsants and antihypertensive agents. She regained her vision over the next two days, completed the treatment for GBS, and made a good recovery with independence for advanced activities of daily living on follow-up.

Association of Sjögren's syndrome with immune-mediated thrombotic thrombocytopenic purpura and posterior reversible encephalopathy syndrome: A case report.

Background: A patient with Sjögren's syndrome (SS), immune-mediated thrombotic thrombocytopenic purpura (ITTP), and posterior reversible encephalopathy syndrome (PRES) was reported, and all published cases with thrombotic thrombocytopenic purpura (TTP), PRES, and SS were retrieved and analysed. The patient's clinical data and treatment procedure have been discussed. Case summary: A 45-year-old Chinese female was hospitalized with headache and low platelet count. She had previously presented to a local hospital with a 7-month history of epigastric discomfort and anorexia, and was diagnosed with SS and ITTP. Laboratory investigations after admission showed platelet (PLT) of 13*10^9/L, red blood cell (RBC) fragments of 6 %, ADAMTS13 Activity＜0.2 %, anti-ADAMTS13 IgG of 88.3U/mL. Brain magnetic resonance imaging (MRI) showed gyriform restricted diffusion along with increased T2-FLAIR signal in the left frontal cortex and bilateral parietal temporal cortex. She was diagnosed with SS, ITTP and PRES, and received the treatment of methylprednisolone, cyclosporine, plasma exchange, IVIG, and rituximab. This patient did not experience the recurrence during the 8-month follow-up period. Conclusion: ITTP and PRES are rare manifestations of SS. After a suspected or confirmed diagnosis of ITTP, plasma exchange and immunosuppressive therapy should be immediately administered. We suggest that rituximab could have additional therapeutic value for SS combined with ITTP and PRES.

Multifunctional Interface Layer Constructed by Trace Zwitterions for Highly Reversible Zinc Anodes.

The inhomogeneous plating/stripping of Zn anode, attributed to dendrite growth and parasitic reactions at the electrode/electrolyte interface, severely restricts its cycling life-span. Here, trace zwitterions (trifluoroacetate pyridine, TFAPD) are introduced into the aqueous electrolyte to construct a multifunctional interface that enhances the reversibility of Zn anode. The TFA- anions with strong specific adsorption adhere onto the Zn surface to reconstruct the inner Helmholtz plane (IHP), preventing the hydrogen evolution and corrosion side reactions caused by free H2O. The Py+ cations accumulate on the outer Helmholtz plane (OHP) of Zn anode with the force of electric field during Zn2+ plating, forming a shielding layer to uniformize the deposition of Zn2+. Besides, the adsorbed TFA- and Py+ promote the desolvation process of Zn2+ resulting in fast reaction kinetics. Thus, the Zn||Zn cells present an outstanding cycling performance of more than 10000 hours. And even at 85% utilization rate of Zn, it can stably cycle for over 200 hours at 10 mA cm-2 and 10 mAh cm-2. The Zn||I2 full cell exhibits a capacity retention of over 95% even after 30000 cycles. Remarkably, the Zn||I2 pouch cells (95 mAh) deliver a high-capacity retention of 99% after 750 cycles.

Entropy-Driven Reversible Melting and Recrystallization of Layered Hybrid Perovskites.

Typical layered 2D A2PbX4 (A: organic ammonium cation, X: Br, I) perovskites undergo irreversible decomposition at high temperatures. Can they be designed to melt at lower temperatures without decomposition? Which thermodynamic parameter drive the melting of layered perovskites? These questions are addressed by considering the melt of A2PbX4 as a mixture of ions (like ionic liquids), and hypothesized that the increase in the structural entropy of fusion (ΔSfus) will be the driving force to decrease their melting temperature. Then to increase structural ΔSfus, A-site cations are designed that are rigid in the solid crystal, and become flexible in the molten state. Different tail groups in the A-site cations form hydrogen-, halogen- and even covalent bonding-interactions, making the cation-layer rigid in the solid form. Additionally, the rotation of ─NH3 + head group is suppressed by replacing ─H with ─CH3, further enhancing the rigidity. Six A2PbX4 crystals with high ΔSfus and low melting temperatures are prepared using this approach. For example, [I-(CH2)3-NH2(CH3)]2PbI4 reversibly melts at 388 K (decomposition temperature 500 K), and then recrystallizes back upon cooling. Consequently, melt-pressed films are grown demonstrating the solvent- and vacuum-free perovskite films for future optoelectronic devices.

Modulation of Electron Push-Pull by Redox Non-Innocent Additives for Long Cycle Life Zinc Anode.

Application of an aqueous Zn-ion battery is plagued by a water-induced hydrogen evolution reaction (HER), resulting in local pH variations and an unstable electrode-electrolyte interface (EEI) with uncontrolled Zn plating and side reactions. Here, 4-methyl pyridine N-oxide (PNO) is introduced as a redox non-innocent additive that comprises a hydrophilic bipolar N+-O- ion pair as a coordinating ligand for Zn and a hydrophobic ─CH3 group at the para position of the pyridine ring that reduces water activity at the EEI, thereby enhancing stability. The N+-O- moiety of PNO possesses the unique functionality of an efficient push electron donor and pull electron acceptor, thus maintaining the desired pH during charging/discharging. Intriguingly, replacing ─CH3 (electron pushing +I effect) by ─CF3 group (electron pulling ─I effect), however, does not improve the reversibility; instead, it degrades the cell performance. The electrolyte with 2 m ZnSO4 + 15 mm PNO enables symmetric cell Zn plating/stripping for a remarkable > 10 000 h at 0.5 mA cm-2 and exhibits coulombic efficiency (CE) ≈99.61% at 0.8 mA cm-2 in Zn/Cu asymmetric cell. This work showcases the immense interplay of the electron push-pull of the additives on the cycling.

Posterior Reversible Encephalopathy Syndrome (PRES) following blood transfusion in a polytrauma victim, an atypical occurrence.

Posterior reversible encephalopathy syndrome (PRES) is a neuroradiological syndrome, clinically present by impaired consciousness, headache, visual disturbances, and seizures, and radiologically brain edema. Cases of PRES induced by blood transfusion are rarely documented. We report this case to increase the awareness of treating physicians for the possible complications of rapid blood transfusion. A 29-year-old man presented with polytrauma and was in hemorrhagic shock. He was transfused with multiple transfusions. Later, he was found to have quadriplegia with minimal movement of fingers in the left hand. His computed tomography showed cerebral edema in multiple cerebral regions. We propose that the etiology in this case is that rapid blood transfusion induced acute rise in hemoglobin which led to PRES. The influences of blood transfusion on blood flow, blood viscosity, and endothelial dysfunction lead to blood-brain barrier dysfunction, which can result in PRES.

Posterior Reversible Encephalopathy Syndrome, not so Uncommon in Pediatric Patients with Renal Involvement: A Case Series.

Introduction: Posterior reversible encephalopathy syndrome (PRES) primarily shows neurological symptoms and is more frequent in males, often occurring in oncological patients. It can also be associated with renal conditions like post-streptococcal glomerulonephritis, a common cause of pediatric hypertension. Management involves blood pressure and seizure treatment. In some cases, it may lead to irreversible and severe complications. Early treatment is essential for prevention. Presentation of case series: In the past six months, we have documented the cases of two patients, aged 15 and 10, both of whom presented with PRES and renal disease. These patients were admitted because of general malaise, headaches, nausea, vomiting, visual disturbances, and elevated blood pressure. Subsequently, both patients experienced epileptic episodes. Only the first patient required transfer to the Pediatric Intensive Care Unit (PICU). Cerebral magnetic resonance imaging (MRI) scans revealed distinct PRES lesions in both cases. Following comprehensive investigations, both cases were diagnosed with PRES in the context of acute post-streptococcal glomerulonephritis. Conclusions: The patients showed improvement following the administration of antihypertensive and anticonvulsant medications, along with treatment for the underlying renal condition.

Adrenaline in pulp capping treatment of reversible pulpitis.

BACKGROUND: The role of epinephrine in the treatment of pulp capping in patients with reversible pulpitis is not clear. AIM: To explore the role of epinephrine in the treatment of pulp capping in patients with reversible pulpitis. METHODS: A total of 100 patients with reversible pulpitis who were treated in Anhui Jieshou People's Hospital from January 2020 to December 2021 were included in the study. They were categorized into an observation group (n = 50; treatment with adrenaline) and a control group (n = 50; treatment with zinc oxide eugenol paste). The 24-h postoperative pain, regression time of gingival congestion and redness, clinical efficacy, and incidence of adverse reactions were compared between the groups. Patients were further categorized into the ineffective and effective treatment groups based on clinical efficacy. Logistic multiple regression analysis explored factors affecting the efficacy of pulp capping treatment. RESULTS: A significant difference in 24-h postoperative pain was observed between the groups (P < 0.05), with a higher proportion of grade I pain noted in the observation group than in the control group (P < 0.01). The regression time of gingival congestion and swelling was lower in the observation group (2.61 ± 1.44 d and 2.73 ± 1.36 d, respectively) than in the control group (3.85 ± 1.47 d and 4.28 ± 1.61 d, respectively) (P < 0.05). The 2-wk postoperative total effective rate was lower in the control group (80.00%) than in the observation group (94.00%) (P < 0.05). The incidence of adverse reactions was not significantly different between the control (14.00%) and observation (12.00%) groups (P > 0.05). The proportion of adrenaline usage was lower (P < 0.05) and that of anaerobic digestion by Streptococcus and Fusobacterium nucleatum was higher in the ineffective treatment group than in the effective treatment group (P < 0.05). Logistic multiple regression analysis revealed adrenaline as a protective factor (P < 0.05) and anaerobic digestion by Streptococcus and F. nucleatum as risk factors for pulp capping in reversible pulpitis (P < 0.05). CONCLUSION: Adrenaline demonstrated therapeutic efficacy in pulp capping treatment for reversible pulpitis, reducing pain and improving clinical symptoms safely. It is a protective factor for pulp capping, whereas Streptococcus and F. nucleatum are risk factors. Targeted measures can be implemented to improve clinical efficacy.

A case report on posterior reversible encephalopathy syndrome (PRES) in an elderly female.

Introduction and importance: Posterior reversible encephalopathy syndrome (PRES) is a medical condition characterized by symptoms such as headache, altered consciousness, visual abnormalities, seizures, and associated radiological vasogenic edema. The condition, as its name suggests, is generally reversible. PRES typically affects individuals around the age of 45 and is rarely seen in the elderly population. Case presentation: In this report, the authors present the case of an 83-year-old woman who presented to the emergency department with a history of seizures and visual disturbances. Upon examination, her Glasgow Coma Scale (GCS) was 14, and she had bilateral round,reactive, regular pupils. A plain computed tomography (CT) head was performed, which revealed multiple hemorrhagic areas in the occipital region associated with vasogenic edema. magnetic resonance imaging was done which was suggestive of PRES. The individual underwent conservative management in the authors' institute and gradually recovered. Clinical discussion: PRES typically presents in middle-aged individuals, with infrequent occurrences in the elderly population. Early radiological and clinical assessments are crucial for the prompt diagnosis of this condition. Additionally, it is essential to identify predisposing factors such as hypertension, eclampsia, electrolyte imbalances, renal failure, autoimmune diseases, and the use of cytotoxic drugs for optimum management of the patient. Conclusion: PRES is generally reversible, as its name implies. Maintaining a high level of suspicion based on radiological and clinical correlations, coupled with the effective management of underlying conditions, can contribute to its potential reversibility.

Reversible cerebral vasoconstriction syndrome due to teprotumumab: two case reports.

BACKGROUND: Reversible Cerebral Vasoconstriction Syndrome (RCVS) involves cerebral vasculature constriction and dilation. While the exact pathophysiology of RCVS is still not fully understood, there are multiple etiological factors suggested to be implicated in triggering RCVS. We report two RCVS cases potentially linked to teprotumumab. Case 1: A 59-year-old female with Graves' eye disease (GED) developed leg weakness and headache after initiating teprotumumab, and neuroimaging studies revealed multifocal cerebral vasospasm (CVS). Verapamil mitigated vasospasm and the patient overall improved. Case 2: A 71-year-old female with GED developed thunderclap headache two months after starting teprotumumab, with subarachnoid hemorrhage (SAH) and CVS revealed on neuroimaging studies. The patient improved on verapamil and was discharged without deficits. CONCLUSIONS: The temporal correlation between teprotumumab initiation and RCVS's symptom onset raises concern for the potential involvement of teprotumumab in triggering RCVS via disrupting cerebrovascular modulation. Further research is needed to investigate this proposed association.

Digital training for self-injectable contraceptives: a feasibility and acceptability pilot study.

BACKGROUND: Self-injectable contraceptives, namely subcutaneous depot medroxyprogesterone acetate 104 mg micronised formulation delivered via uniject system, reduce the need to travel to a facility for contraceptive access, but the initial, in-person, training may be a barrier to starting this method. This article reports on a small, exploratory pilot in Kenya to test the feasibility and acceptability of digital self-injection training. METHODS: Participants (n=11) who were currently using injectable contraceptives, intramuscular depot medroxyprogesterone acetate 150 mg injected by a healthcare worker, received digital self-injection training from a trained clinician via a WhatsApp video call. Participants administered a simulated self-injection on a model and an actual self-injection (under supervision) on themselves. The participants' self-injection proficiency, a measure of the feasibility of remote training, was documented using a checklist, and participants were administered a questionnaire about their training experience. The training was observed, and content analysis was used to understand the functionality of training. RESULTS: All participants were proficient when performing the self-injection on themselves after receiving the remote training and reported that the training was acceptable. A barrier to training via a video call was lack of access to quality digital devices. Eight training 'lessons learnt' emerged from the training observations. CONCLUSIONS: Training participants to administer self-injectable contraceptives via WhatsApp video call was feasible and acceptable. Training lessons learnt offer pragmatic adaptations for communicating about a practical skill via a digital channel. Further research is needed to ascertain the efficacy of digital training for self-injection and feasibility and acceptability for wider groups.

Evaluation of pulsed field ablation lesion characteristics using an in vitro vegetable model.

BACKGROUND: In vitro models to evaluate cardiac pulsed field ablation (PFA) have not been well established. We sought to create a standardized vegetable model and staining protocol for assessing unipolar PFA using a surface electrode. METHODS: We exposed potato slabs to unipolar PFA in a saline bath using a 3.5 mm electrode catheter and grounding pad connected to a custom-built high-voltage generator. Lesions were clearly visualized after staining with 2,3,5-triphenyltetrazolium chloride (TTC) using a timed protocol to reveal a necrotic center and a periphery of electroporated cells with intact mitochondria. RESULTS: Lesion volume increased linearly with increasing voltage and logarithmically with repetitive PFA applications. CONCLUSION: The findings observed in this vegetable model using a TTC staining protocol are consistent with findings observed with cardiomyocytes.

A Review of Concordance and Quality in Clinical Guidelines for Hormonal Contraceptives to Mitigate Drug-Drug Interactions in Women With Epilepsy.

PURPOSE: Concomitant use of hormonal contraceptive agents (HCAs) and enzyme-inducting antiepileptic drugs (EIAEDs) may lead to contraceptive failure and unintended pregnancy. This review identified and evaluated concordance and quality of clinical treatment guidelines related to the use of HCAs in women with epilepsy (WWE) receiving EIAEDs. METHODS: Relevant clinical guidelines were identified across four databases and were independently evaluated for quality utilizing the AGREE-II protocol instrument. Quality in this context is defined as the rigor and transparency of the methodologies used to develop the guideline. Guidelines were further assessed in terms of concordance and discordance with the latest body of knowledge concerning the use of hormonal contraception in the presence of EIAEDs. RESULTS: A total of n = 5 guidelines were retrieved and evaluated. Overall guideline scores ranged from 17% to 92%, while individual domain scores ranged from 0% to 100%. Contraceptive guidelines consistently recommended the use of intrauterine systems and long-acting injectables in the presence of EIAEDs, recommended against the use of oral, transdermal, and vaginal ring contraceptives, and differed regarding recommendations related to implants. Guidelines agreed regarding recommendations that women treated with EIAEDs should receive intrauterine systems and long-acting injectables; however, the suggested frequency of administration of injectable contraceptives differed. The use of intrauterine systems in this population is supported by evidence, but there is uncertainty surrounding the use of long-acting injectables and contraceptive implants. CONCLUSIONS: To mitigate the risk of unintended pregnancy and its consequences, recommendations related to implants and long-acting injectable contraceptives should be evidence-based.

Atypical posterior reversible encephalopathy syndrome: A lentiform fork sign following transplantation.

Key Clinical Message: Posterior Reversible Encephalopathy Syndrome, typically characterized by parieto-occipital vasogenic edema, can present atypically, as a bilateral symmetrical vasogenic edema in the basal ganglia, featuring the called "lentiform fork sign." Prompt recognition of such variations is crucial for accurate diagnosis and tailored management, highlighting the complexity of this syndrome's manifestations. Abstract: Posterior Reversible Encephalopathy Syndrome (PRES) manifests as transient neurological symptoms and cerebral edema, commonly associated with immunosuppressive drugs (ISDs) in transplant recipients. ISDs can lead to endothelial dysfunction and compromise the blood-brain barrier. Typically, PRES exhibits identifiable MRI patterns, often demonstrating vasogenic edema in the bilateral parieto-occipital white matter. Identifying unique presentations, such as the recently observed "lentiform fork sign," commonly seen in uremic encephalopathy, emphasizes this syndrome's broad spectrum manifestations. A 19-year-old male, who underwent bilateral lung and liver transplantation, experienced a bilateral tonic-clonic seizure of unknown onset 47 days post-surgery. MRI findings revealed an unconventional PRES pattern, featuring the "lentiform fork sign" as bilateral symmetrical vasogenic edema in the basal ganglia, surrounded by a hyperintense rim outlining the lentiform nucleus bilaterally. Subsequent management, including ISD modification and magnesium supplementation, resulted in clinical and neuroimaging resolution. An almost complete clinical and radiological resolution was achieved after 14 days. The occurrence of PRES in transplant recipients highlights the intricate interplay among ISDs, physiological factors, and cerebrovascular dynamics, potentially involving direct neurovascular endothelial toxicity and disruption of the blood-brain barrier. Neuroimaging plays a pivotal role in diagnosis. The distinctive "lentiform fork sign" was observed in this patient despite the absence of typical metabolic disturbances. Management strategies usually involve reducing hypertension, discontinuing ISDs, correcting electrolyte imbalances, and initiating antiseizure drugs if necessary. Identifying the presence of the "lentiform fork sign" alongside typical PRES edema in a patient lacking renal failure emphasizes that this manifestation is not solely indicative of uremic encephalopathy. Instead, it might represent the final common pathway resulting from alterations in the blood-brain barrier integrity within the deep white matter. Understanding such atypical imaging manifestations could significantly aid earlier and more precise diagnosis, influencing appropriate management decisions.