Toxicological profile and potential health concerns through metals and trace elements exposure in brick kiln workers from Lahore, Pakistan.

This study examined levels of lead (Pb), cadmium (Cd), chromium (Cr), copper (Cu), mercury (Hg), and arsenic (As) in blood, hair, and nails of 18 brick kiln workers from three brick kiln units located around a metropolitan city, Lahore, Pakistan. All the trace elements except Hg and As were detected in the studied matrices of Brick kiln workers. In general, brick kiln workers reflect the highest concentration of Pb, followed by Cd, Cr, and Cu. Of the pollutants analyzed, Pb has the highest mean (min-max) concentrations at 0.35 (0.09-0.65) in blood (µg/mL), 0.34 (0.14-0.71) in hairs (µg/g), and 0.44 (0.32-0.59) in nails (µg/g) of brick kiln workers. Following Pb, the trend was Cd 0.17 (0.10-0.24), Cu 0.11(0.03-0.27), and Cr 0.07 (0.04-0.08) in blood (µg/mL), followed by Cr 0.11(0.05-0.20), Cd 0.09 (0.03-0.13), and Cu 0.08 (0.04-0.16) in hairs (µg/g) and Cu 0.16 (0.05-0.36), Cd 0.13 (0.11-0.17), and Cr 0.10 (0.05-0.14) in nails (µg/g) respectively. Relatively higher concentrations of metals and other trace elements in blood depicts recent dietary exposure. The difference of trace elements except Pb was non-significant (P > 0.05) among studied matrices of workers as well as between Zigzag and traditional exhaust-based brick kilns. The concentrations of Pb, Cd and Cr in blood of brick kilns workers are higher than the values reported to cause health problems in human populations. It is concluded that chronic exposure to metals and other trace elements may pose some serious health risks to brick kiln workers which needs to be addressed immediately to avoid future worst-case scenarios.

Comparison of modified extended right lobe graft versus modified right lobe graft in adult living donor liver transplantation: Experience from Pakistan.

Objectives: To compare the outcomes of modified extended right lobe graft (MERLG) and modified right lobe graft (MRLG) in living-donor liver transplantation (LDLT). Methods: This retrospective study was performed at the Liver transplant department of the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences Hospital, Gambat, Pakistan, from March 2019 to September 2020. The outcomes of 20 MERLG donors and recipients were compared to those of 74 MRLG donors and recipients. Demographics, operative parameters, complications, hospital stay, and one-year survival were compared between the two groups. Results: The mean graft volume of the MERLG group was more (637.10 ± 71.35 g) than in the MRLG group (562.27 ± 57.77 g), (p= 0.001). Donor blood loss was higher in the MERLG group (680.10±170.60 ml) compared to the MRLG group (650.23±190.65 ml), p=0.527. In addition, the operative time was longer in the MERLG group (345.80±76.90 min) than in the MRLG group (318.12±100.80 min) (p= 0.257). The MERLG recipients were sicker (mean MELD score of 22.54±3.67) than the MRLG (18.86±4.37) (p=0.001). The drain output was higher in the MRLG group (1340 ± 470.32 ml) than in the MERLG group (1110 ± 450.60 ml) (P =0.045). No significant difference was found when comparing postoperative laboratory results and complications between the donor and recipient groups (p >0.05). Kaplan-Meier analysis showed a 95% one-year survival in MERLG group compared to 90.7% in the MRLG group (p=0.549). Conclusion: With appropriate technical expertise, MERLGs are technically safe and feasible in LDLT donors without any added risks. MERLGs also yielded better outcomes in sick recipients.

Micro-dispenser-based optical packaging scheme for grating couplers.

Due to their sub-millimeter spatial resolution, ink-based additive manufacturing tools are typically considered less attractive than nanophotonics. Among these tools, precision micro-dispensers with sub-nanoliter volumetric control offer the finest spatial resolution: down to 50 µm. Within a sub-second, a flawless, surface-tension-driven spherical shape of the dielectric dot is formed as a self-assembled µlens. When combined with dispersive nanophotonic structures defined on a silicon-on-insulator substrate, we show that the dispensed dielectric µlenses [numerical aperture (NA) = 0.36] engineer the angular field distribution of vertically coupled nanostructures. The µlenses improve the angular tolerance for the input and reduces the angular spread of the output beam in the far field. The micro-dispenser is fast, scalable, and back-end-of-line compatible, allowing geometric-offset-caused efficiency reductions and center wavelength drift to be easily fixed. The design concept is experimentally verified by comparing several exemplary grating couplers with and without a µlens on top. A difference of less than 1 dB between incident angles of 7° and 14° is observed in the index-matched µlens, while the reference grating coupler shows around 5 dB contrast.

DRCNNTLe: A deep recurrent convolutional neural network with transfer learning through pre-trained embeddings for automated ICD coding.

The International Classification of Diseases (ICD), which is endorsed by the World Health Organization, is a diagnostic classification standard. ICD codes store, retrieve, and analyze health information to make clinical decisions. Currently, ICD coding has been adopted by more than 137 countries. However, in Pakistan, very few hospitals have implemented ICD coding and conducted different epidemiological studies. Moreover, none of them have reported the spectrum of liver disease burden based on ICD coding, nor implemented automated ICD coding. In this study, we annotated ICD codes for the database of the liver transplant unit of the Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences. We named this database Medical Information Mart for Liver Transplantation (MIMLT). The results revealed that the database contains 34 ICD codes, of which V70.8 is the most frequent code. Furthermore, we determined the spectrum of liver disease burden in liver recipients based on ICD coding. We found that chronic hepatitis C (070.54) is the most frequent indication for liver transplantation. Additionally, we implemented automated ICD coding utilizing the MIMLT database and proposed a novel Deep Recurrent Convolutional Neural Network with Transfer Learning through pre-trained Embeddings (DRCNNTLe) model, which is an extended version of our DRCNN-HP model. DRCNNTLe extracts robust text representations from its pre-trained embedding layer, which is trained on a large domain-specific MIMIC III database corpus. The results indicate that utilizing pre-trained word embeddings, which are trained on large domain-specific corpora can significantly improve the performance of the DRCNNTLe model and provide state-of-the-art results when the target database is small.

Splenic artery transposition for hepatic arterial supply in living donor liver transplantation.

Objective: To determine the safety and outcome of splenic artery(SA) transposition in extra-anatomic hepatic arterial reconstruction (HAR) in living donor liver transplantation(LDLT). Methods: We retrospectively compared the outcome of the ten liver recipients who underwent HAR with the transposed splenic artery (SA group) with a matched cohort of 40 recipients who underwent HAR with the standard hepatic artery (HA group) between March, 2019 and December, 2020 at liver transplantation department, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Pakistan. The comparison of recipients' and donor demographics, operative and graft characteristics, post-operative labs, Doppler ultrasound(USG) findings, and complications, along with 30-day mortality, and 1-year survival were reported for both groups. Results: The mean age of patients in the SA group was 42.80±7.510 and in the HA group was 43.73±8.171 years. The common indication of LDLT was viral hepatitis in both groups. The operative duration was longer in the SA group (597.50±41.3156 min) than in the HA group (530.75±66.502 min) with a significant p-value= 0.004. Similarly, blood loss was also more in the SA group (1635±226.139 ml) than in the HA group (1477.50±270.316 ml) (p-value= 0.096). The incidence of biliary and vascular complications, early allograft dysfunction, acute cellular rejection, 30-day mortality, and 1-year survival were comparable in both groups. Post-operatively splenectomy was not needed in any SA group recipients. Conclusion: The SA is easily approachable, suitable, and safe for HAR in the difficult situation of hepatic arterial flow inadequacy during LDLT due to its appropriate length, and good blood flow.

Safety of glucose-6 phosphate dehydrogenase deficient donors in living right lobe liver donation.

BACKGROUND: The literature lacks data on World Health Organization (WHO) class II and III deficient liver donors who underwent right hepatectomy during living donor liver transplantation (LDLT). METHODS: In this prospective cohort study, we compared the perioperative outcomes of 15 glucose-6 phosphate dehydrogenase (G6PD) deficient living liver donors with a matched cohort of 39 nondeficient living liver donors undergoing right lobe donation. RESULTS: Out of 15 G6PD deficient donors, four (26.67%) donors had class II, and 11 (73.34%) had class III G6PD deficiency. The mean postoperative trough hemoglobin level was significantly lower in the deficient group than the nondeficient group (9.38 ± 1.59 g/dL vs. 10.27 ± .91 g/dL, p = .046). The mean peak indirect bilirubin level was significantly higher in the deficient group than the nondeficient group (2.22 ± 1.38 mg/dL vs. 1.40 ± .89 mg/dL, p = .047), and a similar trend was observed in total serum bilirubin (3.99 ± 2.57 mg/dL vs. 2.99 ± 1.46 mg/dL, p = .038). Biochemical evidence of hemolysis was found only in three (20%) deficient donors, but none of them needed a blood transfusion. No mortality was observed in either group. All other parameters, including demographics, operative parameters, graft characteristics, and hospital stay were comparable between both groups (p > .05). CONCLUSION: G6PD deficiency with WHO class II and above should not be considered a contraindication for right lobe donation.

Biosynthesis of Polyhydroxyalkanoates (PHAs) by the Valorization of Biomass and Synthetic Waste.

Synthetic pollutants are a looming threat to the entire ecosystem, including wildlife, the environment, and human health. Polyhydroxyalkanoates (PHAs) are natural biodegradable microbial polymers with a promising potential to replace synthetic plastics. This research is focused on devising a sustainable approach to produce PHAs by a new microbial strain using untreated synthetic plastics and lignocellulosic biomass. For experiments, 47 soil samples and 18 effluent samples were collected from various areas of Punjab, Pakistan. The samples were primarily screened for PHA detection on agar medium containing Nile blue A stain. The PHA positive bacterial isolates showed prominent orange-yellow fluorescence on irradiation with UV light. They were further screened for PHA estimation by submerged fermentation in the culture broth. Bacterial isolate 16a produced maximum PHA and was identified by 16S rRNA sequencing. It was identified as Stenotrophomonas maltophilia HA-16 (MN240936), reported first time for PHA production. Basic fermentation parameters, such as incubation time, temperature, and pH were optimized for PHA production. Wood chips, cardboard cutouts, plastic bottle cutouts, shredded polystyrene cups, and plastic bags were optimized as alternative sustainable carbon sources for the production of PHAs. A vital finding of this study was the yield obtained by using plastic bags, i.e., 68.24 ± 0.27%. The effective use of plastic and lignocellulosic waste in the cultivation medium for the microbial production of PHA by a novel bacterial strain is discussed in the current study.

Engineering the optical properties of dielectric nanospheres by resonant modes.

Recent progress in nanoscale optical physics is associated with the development of a new branch of nanophotonics exploring strong Mie resonances in dielectric nanoparticles with high refractive index (HRI). The high-index resonant dielectric nanostructures form building blocks for novel photonic meta-devices with low losses and advanced functionalities. In this work, we investigate the size effect of an HRI cuprous oxide (Cu2O) nanosphere on the optical properties of the structure, such as, scattering and absorption spectrum. We also experimentally demonstrate that the scattering field can be significantly engineered by tuning the radius of Cu2O. It is found that the resonant eigenmodes supported by the nanospheres play the dominant role in the absorption and scattering characteristic of the structure. From the perspective of eigenmodes, we can immediately find the right structure parameters to realize strong absorption (scattering) at either single wavelength or broadband wavelength. Furthermore, the multipole expansion method has been applied to explore the physical nature (i.e. electric mode or magnetic mode) of the eigenmode as well as contributions from different modes.

Total Avulsed Ear Management With Radial Forearm Free Flap.

Avulsive injuries to the ear are extremely challenging to treat. The literature documents numerous ways to manage such injuries. This report describes a case of total auricular cartilaginous avulsion that occurred during a motor vehicle accident. The avulsed segment had an ischemia time longer than 8 hours by the time of presentation at the authors' tertiary care facility. The avulsed segment was de-epithelialized and embedded into the volar forearm. After a healing period of 6 months, a radial forearm free flap was harvested and the ear was reconstructed. After ensuring good flap uptake and adequate primary healing, the flap was debulked and reshaped at 4 months after inset.

Lethal toxic Dose (i.p LD50), total protein contents and comparative hemolytic potential of (99mTc labeled & non-labeled) Naja naja karachiensis venom.

Recent recognition about snake bite envenomation on June, 2017 as neglected tropical disease under category-A by World Health Organization advocated again its undeniable importance. Present circumstances reasoned to work on a neglected subspecies of Naja naja, i.e., Naja naja karachiensis (N. n. karachensis) has been documented for frequent deaths in Pakistan. In this study median lethal toxic dose (LD50) was determined intraperitoneally in Swiss albino mice and was found to be 2.0µg/g (2.0mg/kg) equal in potency to Naja pallida (red spitting African cobra). Total protein contents (188±0.011µg / 200µg of dry weight) were high enough (94%) to represent an arsenal of proteins. Furthermore, 99mTc was labeled 99.9% with venom and didn't find to alter hemolytic activity of venom in dose dependent manner at 125µg/ml (p>0.5), 250 µg/ml (p>0.1) and 500 µg/ml (p>0.1) when compared with its crude form. Present work will pave the way for proteomics study in effective production of antidote against specific species of snakes as dare demand of it has been felt since long period of time in Pakistan.

Light scattering by subwavelength Cu2O particles.

Novel metamaterials with new capabilities to manipulate light may be used by considering basic building blocks with new optical properties. This is the case with resonant magneto-dielectric particles. In this work, the resonant response of a high-dielectric Cu2O subwavelength particle is analyzed, both analytically and experimentally. The emergence of electric and magnetic resonances and their interferential effects, producing directional behaviors, can be used in a new generation of metamaterials, as well as new integrated optical devices.

FORMULATION, EVALUATION AND IN VITRO DISSOLUTION PERFORMANCE OF ENALAPRIL MALEATE SUSTAINED RELEASE MATRICES: EFFECT OF POLYMER COMPOSITION AND VISCOSITY GRADE.

The present study aimed at developing the sustained release matrix tablets of enalapril maleate and evaluating the effect of polymer concentration and viscosity grade on drug release. The sustained release enalapril maleate tablets were successfully formulated by direct compression method using nonionic cellulose ethers HPMC K15, HPMC K100 and HPC polymers either alone or in combination. In-vitio drug release study was carried out in phosphate buffer (pH 6.8) for a period of 24 h following USP dissolution apparatus II i.e., paddle apparatus. Model dependent approaches like zero-order, first order, Higuchi's model and Korsmeyer-Peppas model were used to assess drug release from various formulations. All the three polymers alone or in combination sustained the drug release. The drug release characteristics from HPMC and HPC polymer followed zero order release kinetics except for 45% concentration of all polymers alone or in combination where by the drug release followed Higuchi's model. In all cases, the drug release mechanism was both diffusion as well as erosion.

A newly discovered neurotoxin ADTIQ associated with hyperglycemia and Parkinson's disease.

BACKGROUND: Diabetes is associated with an increased risk of Parkinson's disease (PD). Number of studies have suggested that methylglyoxal (MGO) induced by diabetes is related to PD. However, very little is known about its molecular mechanism. On other hand, 1-acetyl-6, 7- dihydroxyl-1, 2, 3, 4- Tetrahydroisoquinoline(ADTIQ) is a dopamine (DA)-derived tetrahydroisoquinoline (TIQ), a novel endogenous neurotoxins, which was first discovered in frozen Parkinson's disease human brain tissue. While ADTIQ precursor methylglyoxal was also found in diabetic patients related to the glucose metabolism and diabetic patients. METHODS: LC-MS/MS, 1H NMR and infrared spectroscopy identified the structure of ADTIQ. The Annexin V-FITC/PI, MTT and western blot analysis were used to measure the neurotoxicity of ADTIQ. The levels of ADTIQ and methylglyoxal were detected by LC-MS/MS. RESULTS: Here we report the chemical synthesis of ADTIQ, demonstrate its biosynthesis in SH-SY5Y neuroblastoma cell line and investigate its role in the pathogenesis of PD. In addition, a significant increase in the level of ADTIQ was detected in the brains of transgenic mice expressing mutant forms (A53T or A30P) of α-synuclein. ADTIQ also reduced the cell viability and induced mitochondrial apoptosis in dopaminergic cells, suggesting that ADTIQ acts as an endogenous neurotoxin and potentially involved in the pathogenesis of PD. Methylglyoxal, a major byproduct of glucose metabolism and abnormalities in glucose metabolism could influence the levels of ADTIQ. Consistent with the hypothesis, increased levels of ADTIQ and methylglyoxal were detected in the striatum of diabetic rats and SH-SY5Y cells cultured in the presence of high glucose concentrations. CONCLUSIONS: Increased levels of ADTIQ could be related with Hyperglycemia and death of dopaminergic neurons. GENERAL SIGNIFICANCE: The increased levels of ADTIQ could be a reason of dopamine neuron dysfunction in diabetes. Therefore, ADTIQ may play a key role in increasing the risk for PD in patients with diabetes.

Distortion of homeostatic signaling proteins by simulated microgravity in rat hypothalamus: A(16) O/(18) O-labeled comparative integrated proteomic approach.

Microgravity generates oxidative stress in central nervous system, causing distortion of various vital signaling cascades involved in many homeostatic functions. Here, we performed comparative (16) O/(18) O labeled integrated proteomic strategy to observe the differential expression of signaling proteins involved in homeostasis. In this study, rat-tail suspension model is employed to induce simulated microgravity in CNS. By wide proteomic analysis, total of 35 and 97 significantly differentially expressed proteins were found by HPLC/ESI-TOF and HPLC-Q-TOF analysis, respectively. Among the total of 132 proteins quantified, 25 proteins were found related to various signaling cascades. Protein Thy-1, 14-3-3 gamma, 14-3-3 epsilon, 14-3-3 theta, 14-3-3 eta, and 14-3-3 beta/alpha proteins, calmodulin and calcium/calmodulin-dependent protein kinase type-II subunit beta were found upregulated under the influence of simulated microgravity. These proteins are found involved in disrupting homeostatic pathways like sleep/wake cycle, drinking behavior, hypothalamic-pituitary-adrenocortical regulation and fight and/or flee actions under stress. Furthermore, MS results for protein Thy-1 were verified by Western blot analysis showing the quantification accuracy of MS instruments. Results presented here will serve as means to understand the mechanism of action of microgravity and further reference for future detailed study of consequences of microgravity on astronauts and their possible countermeasures.

LX loaded nanoliposomes synthesis, characterization and cellular uptake studies in H2O2 stressed SH-SY5Y cells.

In this study, we report the cellular uptake studies of novel LX loaded nanoliposomes in H2O2 stress SH-SY5Y Cells synthesized by thin film evaporation method. We have isolated the smallest size nanoliposomes after 90 min ultrasonification, keeping Polydisperse Index as 0.259. The morphology, size, zepta potential and drug efficiency of prepared nanoliposomes are characterized by using Transmission Electron Microscope (TEM), particle size analyzer and High Pressure Liquid Chromatography (HPLC). The particle size analyzer have confirmed the particle size of nanoluposomes measured in range of 100-250 nm, whereas the shape of these nanoliposomes is almost spherical. The zeta potential of small size nanoliposomes was measured as -49.62 and encapsulation efficiency of the LX loaded nanoliposomes was 87%. The oxidative stress response in SH-SY5Y Cells for various doses of drug with and without nanoliposomes has affectively improved the cell-stress response up to 20% after 24 h of incubation at 37 degrees C. The results indicated that LX loaded nanoliposomes were taken by the cells effectively which ultimately improved the cell-stress response. Thus, this study confirmed that synthesized nanoliposomes are not only effective drug carriers but could be potentially used for delivery of genes, antibodies, and proteins in future.

Methylglyoxal increases dopamine level and leads to oxidative stress in SH-SY5Y cells.

More and more studies have suggested that methylglyoxal (MGO) induced by type-2 diabetes is related to Parkinson's disease (PD). However, little is known about the molecular mechanism. In this study, we explored the MGO toxicity in neuroblastoma SH-SY5Y cells. Neurotoxicity of MGO was measured by mitochondrial membrane potential, malondialdehyde, and methylthiazoletetrazolium assays. The levels of dopamine, 3,4-dihydroxyphenylacetic acid (DOPAC), and 1-methyl-4-phenyl-1,2,3,4-tetrahydroisoquinoline (salsolinol) were detected by liquid chromatography-mass spectrometry/mass spectrometry. The expressions of tyrosine hydroxylase (TH) and dopamine transporter (DAT) were detected by reverse transcriptase polymerase chain reaction and western blot analysis. The results showed that MGO induced an increase in TH and DAT expressions in SH-SY5Y neuroblastoma cells, while the levels of dopamine, DOPAC, and endogenous neurotoxin salsolinol also increased. Aminoguanidine (AG) is an inhibitor of MGO. It was found that AG could decrease the reactive oxygen species (ROS) level induced by MGO, but could not inhibit an increase of TH, DAT and dopamine. The increase of dopamine, DOPAC and salsolinol levels could lead to high ROS and mitochondrial damage. This study suggests that ROS caused by dopamine could contribute to the damage of dopaminergic neurons when MGO is increased during the course of diabetes.

Heavy-metal levels in feathers of cattle egret and their surrounding environment: a case of the Punjab Province, Pakistan.

Levels of 10 heavy metals in cattle egret chick feathers, prey, and surrounding soils from three heronries in Punjab Province, Pakistan, were assessed by atomic absorption spectrophotometry. Mean levels of cadmium (Cd), iron (Fe), chromium (Cr), and lithium (Li) in feathers, manganese (Mn), cobalt (Co), and nickel (Ni) in prey, and lead (Pb), iron (Fe), chromium (Cr), zinc (Zn), cobalt (Co), and lithium (Li) in soils were significantly different among Trimun Headworks, Shorkot, and Mailsi heroneries. Mean levels of Pb (43.10 µg/g), Cr (35.77 µg/g), Co (18.34 µg/g), Cu (0.20 µg/g), and Ni (0.22 µg/g) in feathers were significantly greater at Mailsi, and Mn (3.07 µg/g), Zn (18.83 µg/g), and Li (1.5 µg/g) levels were significantly greater at Shorkot. Multivariate analysis identified that some metals, such as Fe, Zn, and Li, in feathers were either associated with natural sources or with human-related activities, whereas Ni, Cr, Pb, Cd, Cu, Co, and Mn were correlated mainly with anthropogenic processes. Alarming levels were recorded for Cr, Pb, and Cd in feathers that were above threshold levels that may affect cattle egret flighting capacity and reproduction, thus leading to their population decline in Punjab Province. The results of this study provide evidence for the potential of feathers of cattle egret to be used as a biomonitor for the local heavy-metal contamination.

Exploring the correlation between rising temperature and household electricity consumption: An empirical analysis in China.

This study investigates the nexus between rising temperatures and household energy consumption using data from respondents' electricity bills in the "China Residential Energy Consumption Survey." Our analysis reveals a significant correlation, with an 8.9 % increase in yearly energy consumption observed when the average temperature exceeds 32 °C. Additionally, we explore potential shifts in power usage due to global warming by integrating baseline estimates with daily temperature forecasts from eight contemporary climate models. Our findings project alarming trends: without interventions to curb greenhouse gas emissions, home electricity consumption could surge by 9.59-30.09 % in the medium term and by 9.77-47.70 % in the long run. By shedding light on these critical connections, our research underscores the urgent need for policy actions to mitigate the adverse impacts of climate change on energy consumption patterns.

Acute Viral Hepatitis E Infection Complicating Postliving Liver Donor Hepatectomy Recovery.

This study presents a case of a living liver donor who developed a hepatitis E virus (HEV) infection postdonation, complicating his recovery. The donor was a 28-year-old male with no prior health issues who underwent a right lobe hepatectomy. Initially, his postoperative course was uneventful, but on the third postoperative day, he became lethargic and icteric. Laboratory tests showed elevated liver function markers, with peak levels on the 5th day. The HEV infection was confirmed through serological and polymerase chain reaction (PCR) testing. The donor was managed supportively and recovered, with normal liver function at discharge. Unfortunately, the recipient of the liver graft died on the 5th postoperative day due to sepsis, and the impact of HEV infection on the recipient could not be fully assessed due to the complicating factors. This case highlights the importance of considering HEV infection in donors with abnormal postoperative liver functions, especially in regions with high HEV prevalence, and suggests the potential benefit of HEV vaccination for liver donors. Further research is needed to better understand and manage HEV infection in the context of liver donation.

Early onset of posterior reversible encephalopathy syndrome (PRES) following postpartum eclampsia-A case report.

Early screening and management of postpartum posterior reversible encephalopathy syndrome (PRES) can reduce hospital stay and complications. Obstetricians, gynecologists, ophthalmologists, and even general physicians should be aware of PRES since its presentation is variable.