UGT polymorphisms and epileptic seizure control in pregnant women treated with Lamotrigine

OBJECTIVE

We investigated whether polymorphisms of selected uridine-diphospho-glucuronosyl-tranferases (UGT) involved in Lamotrigine (LTG) metabolism are associated with seizure control during pregnancy and post-partum in women with epilepsy treated with LTG.

METHODS

Single nucleotide polymorphisms for UGT1A4 * 2 (P24T, c.70 C>A), UGT1A4 * 3 (L48V c.142 T > G) and UGT2B7 * 2 (H268Y, c.802 C>T), were determined in 47 pregnancies in 40 non-smoking women with LTG-treated epilepsy. Retrospectively collected data included seizure type and frequency, LTG dosage and LTG plasma level changes during pregnancy and PP. We evaluated the effect of UGT genotype on seizure control throughout pregnancy and post-partum (T1-PP).

RESULTS

In 47 pregnancies, seizure control was achieved in 60 % in T1-PP. Occurrence of seizures T1-PP was not directly associated with UGT genotype, but with having pre-pregnant seizures within the past 6 months (OR 8.33 (95 % CI 1.53-45.41, p = 0.01) and 12 months (OR 5.25, 95 % CI 1.47-18.77, p = 0.02) preceding pregnancy.

CONCLUSION

We did not observe any proximate effect of UGT genotypes on seizure control during pregnancy and post-partum in women treated with LTG, but seizures within the year preceding pregnancy had a significant impact.

Inflammatory disorders that affect the cerebral small vessels

ABSTRACT

This comprehensive review synthesizes the latest advancements in understanding inflammatory disorders affecting cerebral small vessels, a distinct yet understudied category within cerebral small vessel diseases (SVD). Unlike classical SVD, these inflammatory conditions exhibit unique clinical presentations, imaging patterns, and pathophysiological mechanisms, posing significant diagnostic and therapeutic challenges. Highlighting their heterogeneity, this review spans primary angiitis of the central nervous system, cerebral amyloid angiopathy-related inflammation, systemic vasculitis, secondary vasculitis, and vasculitis in autoinflammatory diseases. Key discussions focus on emerging insights into immune-mediated processes, neuroimaging characteristics, and histopathological distinctions. Furthermore, this review underscores the importance of standardized diagnostic frameworks, individualized immunomodulation approaches, and novel targeted therapies to address unmet clinical demands.

A culturally-specific education strategy to improve stroke health literacy in Vietnamese communities in South Western Sydney

Background

South-Western Sydney (SWS) is home to a large Vietnamese community, who are at higher risk of stroke and adverse health outcomes than Australian-born individuals. There is limited research on the effect of educational interventions on stroke literacy in Vietnamese communities. This study aimed to characterise recognition of stroke symptoms, risk/protective factors, and stroke response in Vietnamese communities living in SWS and investigate whether culturally tailored education sessions could improve stroke literacy.

Methods

A prospective interventional study evaluated a single 1.5-h stroke education workshop. Data included pre/post-education surveys, participant demographics and stroke literacy. Change in literacy and contributing factors were analysed.

Results

There were 195 participants in three sessions. Stroke symptoms were recognised by the majority [Face:(56.4 %), Arms:(66.7 %), Speech:(61.5 %)], with 52.8 % identifying all three whilst 29.2 % recognised none. Most participants were confident calling an ambulance (60.0 %), aware of diabetes as a risk factor (73.9 %) and recognised healthy diet/exercise (82.5 %) as protective factors. Post-education, 24.6 % recognised more symptoms, with 73.4 % identifying all three and only 16.6 % recognising none. 33.1 % were more confident calling an ambulance, 32.4 % more aware of diabetes mellitus, and 29.8 % more aware of diet/exercise. Smaller group size [OR = 2.83, 95 %CI = 1.15-6.96 (p = 0.024), lower age [OR = 0.93, 95 %CI = 0.87-1.00 (p = 0.037)] and lower baseline literacy [OR = 6.38, 95 %CI = 2.48-16.41 (p < 0.001)] were significantly associated with improved stroke literacy post-education.

Conclusion

Stroke literacy in the SWS Vietnamese community improved with a single culturally tailored education session. This study underscores the importance of tailored educational interventions and highlights the need for strategies addressing low baseline literacy and age-related barriers.

Emerging Imaging Technologies in Forensic Medicine: A Systematic Review of Innovations, Ethical Challenges, and Future Directions

Forensic medicine has increasingly integrated advanced imaging technologies to improve the accuracy and efficiency of investigations. Techniques such as virtual autopsy, multi-detector computed tomography (MDCT), and artificial intelligence (AI)-driven imaging have revolutionized the identification of injuries and causes of death. Despite these advancements, the field faces operational, ethical, and legal challenges that hinder widespread adoption. Objectives: This systematic review aimed to explore the role of emerging imaging technologies in forensic medicine, identify key challenges in their implementation, and provide insights into optimizing their use in forensic practice, with particular attention to cultural, ethical, and interdisciplinary aspects. Methods: A systematic review was conducted following PRISMA guidelines. Literature searches were performed across six databases, including PubMed, Scopus, Web of Science, and others, focusing on studies discussing imaging technologies in forensic contexts. A total of 10 studies were included after applying eligibility criteria. The data were synthesized using narrative synthesis and thematic analysis. Results: Four key themes emerged: (1) advancements in AI and imaging technologies, (2) operational and financial barriers, (3) ethical and legal considerations, and (4) interdisciplinary collaboration and training. Emerging imaging modalities enhance diagnostic precision and facilitate non-invasive examinations, offering culturally sensitive alternatives to traditional autopsies. However, high costs, algorithmic biases, data security risks, and the lack of standardized forensic imaging protocols present significant challenges. The potential for cross-cultural and international forensic collaborations through AI-enabled imaging was also identified as a promising future direction. Conclusions: Advanced imaging technologies hold transformative potential in forensic medicine. Addressing financial, ethical, and operational challenges through interdisciplinary collaboration, standardized guidelines, and culturally sensitive practices is crucial for maximizing their utility and global acceptance.

Prescription pattern of driving-impairing psychotropic medications in Tabriz in 2022

OBJECTIVES

Some psychotropic medications could impair drivers' cognitive skills, concentration and reaction by affecting the central nervous system (CNS), thereby increasing the risk of traffic accidents. However, there is limited evidence regarding the prescription pattern of these medications in Iran. The present study aims to investigate the prescription pattern of psychotropic medications impairing driving in Tabriz, Iran.

METHODS

In this descriptive-analytical cross-sectional study, psychotropic medications prescribed by physicians in Tabriz from March, 2021, to March, 2022, were reviewed. The data were obtained from Iranian Social Security Organization (SSO), which included 1,167,460 eligible prescriptions. Psychotropic medications were classified into six main categories based on reliable scientific sources, and their level of effect on driving was determined using driving-impairing medication classification system. The data were analyzed using Stata 17.0 and Chi-square test. The significance level was considered to be less than 0.05.

RESULTS

The results showed out of 1,167,460 prescribed psychotropic medications, 65.32% were for women, and the rest were for men. The most frequently prescribed medications were antidepressants (38.07%), followed by anxiolytics (18.60%) and antipsychotics (15.48%), respectively. More than half of the medications (57.10%) was categorized to have moderate effect, 23.73% was categorized to have mild effect and 18.87% was categorized to have severe effect on driving. Gabapentin, sertraline, nortriptyline, fluoxetine and trifluoperazine were the most frequently prescribed medications, respectively. A significant correlation was observed between the impairment category of prescribed medications and patients' gender and age (P <0.001). Additionally, general practitioners prescribed the highest number of medications with severe adverse effects, while neurosurgeons, general surgeons, neurologists and psychiatrists prescribed the highest number of medications with moderate adverse effects on driving.

CONCLUSIONS

More than half of the prescribed psychotropic medications in Tabriz was categorized to have moderate effects on driving, and about one-fifth was categorized to have severe effects. Antidepressants, anxiolytics and antipsychotics are considered to have the most relevant impairing effects on driving according to the categorization system, with gabapentin, sertraline, nortriptyline, fluoxetine and trifluoperazine being the most frequently prescribed medications. The findings highlighted the importance of raising awareness among physicians and patients about the effects of psychotropic medications on driving.

Scientometric analysis and historical review of diabetic encephalopathy research: Trends and hotspots (2004-2023)

BACKGROUND

Diabetic encephalopathy (DE) is a common and serious complication of diabetes that can cause death in many patients and significantly affects the lives of individuals and society. Multiple studies investigating the pathogenesis of DE have been reported. However, few studies have focused on scientometric analysis of DE.

AIM

To analyze literature on DE using scientometrics to provide a comprehensive picture of research directions and progress in this field.

METHODS

We reviewed studies on DE or cognitive impairment published between 2004 and 2023. The latter were used to identify the most frequent keywords in the keyword analysis and explore the hotspots and trends of DE.

RESULTS

Scientometric analysis revealed 1308 research papers on DE, a number that increased annually over the past 20 years, and that the primary topics explored were domain distribution, knowledge structure, evolution, and emergence of research topics related to DE. The inducing factors, comorbidities, pathogenesis, treatment, and animal models of DE help clarify its occurrence, development, and treatment. An increasing number of studies on DE may be a result of the recent increase in patients with diabetes, unhealthy lifestyles, and unhealthy eating habits, which have aggravated the incidence of this disease.

CONCLUSION

We identified the main inducing factors and comorbidities of DE, though other complex factors undoubtedly increase social and economic burdens. These findings provide vital references for future studies.

Seizure control and pregnancy outcomes in Chinese women with epilepsy: A prospective multicenter cohort study

OBJECTIVE

Data on seizure and pregnancy outcomes in Asian women with epilepsy are limited. We used a Chinese pregnancy registry to assess the impact of seizures and antiseizure medications (ASMs) on pregnant women with epilepsy and their children.

METHODS

This is an ongoing prospective multicenter study of pregnant women with epilepsy that has been running since 2012. Eligible participants were consecutively enrolled and had multiple follow-ups up to one year after delivery. We assessed ASM use and seizure frequency during pregnancy to establish potential effects on the mothers and infants and to identify relevant correlations. Descriptive analysis was used to estimate proportions. Logistic regression was used to identify the relevant risk factors and correlations.

RESULTS

Of 1907 potentially eligible pregnancies, we included 1763 in 1483 women with known outcomes from January 2012 to February 2022. There were 1278 completed pregnancies, resulting in 1270 live births. Tonic-clonic seizures occurred in fewer than one-third of pregnancies in each trimester. Compared with baseline, seizure frequency remained relatively stable throughout approximately two-thirds of the pregnancies. The majority were on ASM, with levetiracetam (39%), oxcarbazepine (19%), and lamotrigine (17.5%) being the most commonly used. In contrast, only 14.2% of pregnancies were exposed to valproate (VPA). There was a declining trend in treatment adjustments over the course of the pregnancy, with most changes occurring in the first trimester. The incidence of major congenital malformation (MCM) was 4.4%, with cardiogenic and orofacial anomalies being the most common. VPA use (p < .001), lack of folic acid use (p = .009), positive family history of MCM (p = .006), and topiramate (TPM) use (p = .04) were the most important predictors of MCM.

SIGNIFICANCE

Seizure control remained stable for the majority of women with epilepsy throughout pregnancy. Family history of MCM, VPA use, TPM use, and not taking folic acid were strong predictors of MCM in infants born to women with epilepsy.

Left ventricular rigor mortis interferes with postmortem aortic root geometry

Aortic regurgitation is a common valve disease and can be caused by delineated findings such as fenestrations or hardly discernible alterations of the aortic root geometry. Therefore, aortic regurgitation can be a challenging diagnosis during an autopsy. Cardiac surgeons, however, are confronted with comparable problems during surgery and have developed a refined knowledge of the anatomy of the aortic root including its geometry. Transferring this knowledge from the operating room to the dissection would further complement the panel of postmortem diagnostic tools. To foster translation of the clinical anatomy, the present study assessed the impact of postmortem peculiarities (i.e. myocardial rigor mortis, putrefaction) that might influence aortic root geometry. The aortic root geometry was described by aortic perimeters (basal, sinus, sino-tubular junction, and ascending aorta), effective height (distance from the cusp's free margin to its nadir), geometric height (cusp height), commissural height (distance from the base of an interleaflet triangle to the end of a commissure), and length of the ascending aorta. Data from 140 cases were analyzed (linear regression, comparative testing). Myocardial rigor mortis was associated with smaller basal rings. Weak positive correlations between the duration of the postmortem interval and aortic root dimensions were observed. In summary, postmortem peculiarities, especially the myocardial cadaveric rigidity, influence postmortem aortic root geometry. Despite these circumstances, the current study demonstrates that aortic root geometric assessment, including effective height, is feasible in a postmortem setting. Further studies are needed to elaborate on aortic root geometry as a diagnostic tool in a necropsy setting.

Associations of prenatal glyphosate exposure with child neurodevelopment in a Canadian pregnancy cohort study

OBJECTIVE

Glyphosate is the most widely used pesticide worldwide. Few epidemiologic studies have examined the potential for neurotoxicity by glyphosate or its degradate, Aminomethylphosphonic Acid (AMPA). We examined associations of maternal urinary glyphosate and AMPA concentrations with child cognitive, social, and behavioural functioning in participants enrolled in the Maternal-Infant Research on Environmental Chemicals (MIREC) study.

METHODS

Maternal urinary glyphosate and AMPA concentrations were measured in first trimester spot urine samples. We assessed children's cognition (IQ) at 3-4 years of age (n = 572) using the Wechsler Preschool and Primary Scale of Intelligence-III. Social (n = 566) and behavioural (n = 840) functioning were assessed using parent-report versions of the Social Responsiveness Scale-2 and Behavioral Assessment System for Children-2. We quantified associations between maternal urinary glyphosate and AMPA concentrations and child neurodevelopmental outcomes using multivariable linear regression models and assessed effect modification by child sex, maternal folic acid, and plasma folate.

RESULTS

Median (IQR) urinary glyphosate and AMPA concentrations were 0.31 (0.33) μg/L and 0.25 (0.25) μg/L. Maternal urinary glyphosate and AMPA concentrations were not significantly associated with children's cognitive, social or behavioural functioning, and there was no evidence of effect modification. We found a non-significant inverse trend between maternal urinary AMPA concentrations and Performance IQ (B = -0.85; 95 %CI: -1.71,0.01).

CONCLUSION

In this primarily urban cohort of Canadian mother-child pairs, prenatal glyphosate and AMPA exposure were not significantly associated with child neurodevelopment. Further evaluation of glyphosate as a potential developmental neurotoxicant in a study with multiple urine samples per participant and at higher exposure levels is warranted.

Navigating the landscape of legal medicine: a 4-year analysis of forensic consultations in an Italian hospital

Introduction

This study explores a comprehensive 4-year retrospective analysis of 511 forensic consultations conducted at "Policlinico" hospital in Bari, Italy. It highlights the expanding role of legal medicine within healthcare settings, an area that has traditionally been limited to expert testimony and forensic pathology. Over time, legal medicine in Italy has evolved to address a variety of clinical areas, including informed consent, disability assessment, personal injuries, and sexual violence. This research aims to examine these diverse applications and their impact on patient care.

Methods

Data were systematically categorized and analyzed using a multivariate multinomial regression model. The study focused on key variables, such as patient demographics and timing of shifts, to identify significant determinants that influence the types of forensic consultations conducted. The dataset consisted of 511 consultations, covering a range of clinical and legal issues.

Results

The analysis revealed that informed consent issues were the most prominent, with 58.7% of consultations addressing concerns related to patient autonomy and the capacity for consent, particularly in neuropsychiatric conditions. Personal injury consultations accounted for 24.3% of the total, and sexual assault cases made up 10%. These results underscore the intersection of medical practice and forensic evaluation, highlighting societal issues such as interpersonal violence and the importance of legal medicine in healthcare.

Discussion

The findings highlight significant gaps in the literature regarding the broader applications of legal medicine, especially in terms of integrating advanced methodologies like artificial intelligence. Such technologies could enhance patient profiling and predictive care, ultimately improving patient safety, risk management, and the protection of patient rights. The study advocates for structured forensic consultation services to be incorporated into clinical practice, emphasizing the role of legal medicine in improving patient-centered care and promoting justice. These insights are crucial for healthcare professionals, administrators, and policymakers aiming to optimize healthcare systems.

Global insights on diversity, equity, and inclusion-perspectives and experiences from musculoskeletal radiologists of the International Skeletal Society DEI Committee

Diversity, equity, and inclusion (DEI) is important for delivering high-quality, culturally competent care and ensuring equal access to resources and opportunities in healthcare. However, the implementation of DEI has been met with unique challenges and successes across the globe. The International Skeletal Society (ISS), a multidisciplinary musculoskeletal society, made a conscious effort to promote DEI. This article discusses advantages and controversies of DEI approaches, DEI initiatives implemented by the ISS, and experiences of the ISS DEI committee members from their respective continents. The ISS DEI committee implemented educational webinars with expert panel discussions, revising membership criteria and policies for enhancing inclusiveness, advising on programing and speakers for the annual meeting, and fostering mentorship. From a global perspective, in North America, DEI has improved health outcomes and patient care, but anti-DEI legislation has posed significant challenges. Europe relies on international recruitment but faces challenges in staff retention. South America's cultural diversity necessitates culturally sensitive approaches, but discussions about DEI are scarce, and gender inequalities persist in leadership. In Africa, DEI principles are underdeveloped, with limited engagement among stakeholders. In Asia, DEI is emerging, with more women being appointed to faculty positions and leadership roles in academic societies. The implementation of meaningful DEI initiatives requires long-term institutional buy-in and the global participation and commitment of employees and institutional leaders at all levels.

Bridging the Gap Between Research and Clinical Practice in Treatment Strategies and Mechanisms of Acute Ischemic Stroke

Acute ischemic stroke (AIS) remains a formidable global health challenge, with approximately 11 [...].

Evaluating the effectiveness of two video-based educational interventions to enhance knowledge about epilepsy in preschool children

OBJECTIVES

Current research affirms that sufficiently high knowledge about epilepsy is crucial for reducing stigmatization and improving the quality of life for people with epilepsy. While educational interventions targeting older children, adolescents, and adults are relatively common, there is a notable lack of approaches suitable for preschool children. Building on our previous research, which focused on educational interventions using a game and a story, this study aims to evaluate the effectiveness of two video-based interventions, Campi the Seahorse and Adventure While Fishing, in children aged 5-6 years with no prior knowledge about epilepsy.

METHODS

A total of 199 children participated in two intervention studies. Knowledge about epilepsy was assessed through interviews using an 11-item test that had been successfully employed in our previous intervention studies, demonstrating satisfactory internal consistency and construct validity. The level of knowledge was evaluated immediately after each intervention and one month later. Additionally, satisfaction with the intervention and its potential impact on epilepsy-related stigma were measured using a smiley-face scale.

RESULTS

The Adventure While Fishing intervention demonstrated notable effectiveness compared to our previously developed intervention using an educational story. Its impact was also significant when compared to the level of knowledge observed in children aged 9-11 years with no prior exposure to epilepsy-related interventions. In contrast, the outcomes of the Campi the Seahorse intervention were significantly poorer across all comparisons, likely due to its insufficient coverage of key aspects of the topic.

CONCLUSIONS

The results indicated that the Adventure While Fishing intervention was an effective approach to establishing basic knowledge about epilepsy within the targeted age group. In contrast, the Campi the Seahorse intervention would require further extension and/or modification to achieve sufficient effectiveness for this purpose.

More severe cerebral small vessel disease associated with poor leptomeningeal collaterals in symptomatic intracranial atherosclerotic stenosis

We investigated the association between cerebral small vessel disease (CSVD) and ipsilateral leptomeningeal collateral (LMC) status in patients with symptomatic intracranial atherosclerotic stenosis (sICAS). In 108 patients with 50-99% symptomatic intracranial internal carotid artery or M1 middle cerebral artery stenosis, 4 CSVD imaging markers (lacunes, cerebral microbleeds, enlarged perivascular spaces [EPVSs], and white matter hyperintensities [WMHs]) were assessed in MRI. Score of 0 or 1 was assigned to each marker and added up as a summary CSVD score (ranging 0-4) to reflect an overall CSVD burden. Ipsilateral LMC status was assessed by determining the laterality of distal vessels in anterior and posterior cerebral artery territories on CT angiography. Moderate-to-severe EPVSs (adjusted odds ratio [aOR] = 4.15; p = 0.031) and WMHs (aOR = 5.90; p = 0.010), and higher summary CSVD score (aOR = 1.66; p = 0.030) were independently associated with poor LMCs. There was significant interaction between stenosis percentage in sICAS and summary CSVD score on poor LMCs (p = 0.022 for interaction), when higher CSVD score was significantly associated with poor LMCs in patients with severe sICAS (aOR = 2.84; p = 0.011) but not in those with moderate sICAS. The findings indicated possibly adverse effect of CSVD on the recruitment or development of LMCs in sICAS patients, especially in patients with severe sICAS.

Cardiovascular Effects of Antiseizure Medications for Epilepsy

Antiseizure medications (ASMs) are the primary treatment for epilepsy. However, adverse cardiac effects of ASMs can occur, related to their effects on lipid metabolism, raising ischemic heart disease risk; or specific actions on cardiac ion channels, increasing cardiac arrhythmia risk. Select ASMs, particularly enzyme inducers used at higher doses or for longer durations, can adversely affect lipids or cause metabolic changes, and thereby increase the risk for ischemic heart disease. These metabolic and potentially proarrhythmic actions may contribute to the increased cardiovascular morbidity and mortality that occur in epilepsy. Many ASMs block sodium channels or affect the QT interval, which can lead to proarrhythmia, particularly when used in combination with other medications or given to vulnerable populations. While ASMs are rarely reported to cause cardiac arrhythmias directly, population data raise concerns that cardiac arrhythmias and sudden cardiac death may be more common in epilepsy, and that sodium channel blocking ASMs in particular, might contribute. It is also possible that some cases of sudden cardiac death could be misclassified as sudden unexpected death in epilepsy (SUDEP), leading to an underestimation of the cardiovascular risk in this population. Cardiovascular risk factors, such as smoking and a sedentary lifestyle, are also associated with epilepsy, and should also be addressed. This summary is a narrative review of the literature, clarifies which ASMs tend to have more cardiovascular effects, and provides practical suggestions for medication management and monitoring from neurology and cardiology perspectives.

Clinical Practice Evidence of Treatment Satisfaction with Moderate and High-Efficacy Drugs in Multiple Sclerosis

Introduction

Generally, the choice of disease-modifying treatment (DMT) for people with multiple sclerosis (PwMS) is based on aspects of efficacy and safety. However, due to the diversity of drugs and the different routes of administration, it is essential to know the experience and satisfaction of PwMS. Patient- reported outcomes (PROs) help us to optimize and improve adherence.

Methods

Our objective with this cross-sectional, non-interventional study is to analyze satisfaction outcomes using the treatment satisfaction questionnaire for medication (TSQM) according to moderate or high efficacy of DMTs and the relationship with demographic, clinical and quality of life (QoL) aspects.

Results

PwMS receiving high-efficacy DMTs show greater overall satisfaction, but not in the other TSQM subscales. The route of administration did not show differences in treatment satisfaction. The best QoL scores were observed in patients treated with oral DMTs compared to injectables or infusions.

Discussion

The efficacy of DMT is a significant predictor of overall satisfaction. Quality of life has a minimal impact on overall satisfaction. EDSS, treatment duration and fatigue (MFIS) were not significant predictors of satisfaction outcomes. The knowledge provided by the PROs allows healthcare professionals to better understand the preferences and needs of PwMS, adjusting therapeutic strategies, improving patient experience and treatment effectiveness.

Seizure first aid in the community: current situation, suggestions, and the role of the general practitioner in seizure management

The unpredictability of seizures underscores the importance of timely recognition and intervention for optimal prognosis. Seizure first aid (SFA) is an essential skill for community members. We reviewed the literature to assess the challenges and explore potential solutions for effective SFA implementation in community settings. The findings reveal that the knowledge of SFA varies significantly among different groups and countries. There are common misunderstandings, such as point therapy, unnecessary ambulance calls, putting objects into the mouth, inappropriate administration of anti-seizure medications, and performing cardiopulmonary resuscitation. Effective SFA training content includes ensuring the safety of patients, avoiding restraint, using lateral position, clearing the respiratory tract, avoiding placing objects into the mouth, recording details, and seeking for professional help. Training methods range from hospital-based courses to community center workshops and online platforms. General practitioners play a pivotal role in epilepsy management and should be actively involved in SFA training initiatives. Therefore, the development of targeted, diverse, and comprehensive training and evaluation strategies, along with collaborative efforts from the whole society, is essential to improve the level and effectiveness of community SFA.

Epilepsy and employment: A qualitative interview study with heads of human resources and occupational physicians in Austria - A call for legislative optimization according to the WHO Intersectoral Global Action Plan

OBJECTIVE

People with epilepsy (PWEs) often face difficulties in obtaining or keeping employment. To determine the views on this topic of the heads of human resources (HHRs) and occupational physicians (OCPs).

METHOD

Twelve HHRs and five OCPs underwent a telephone interview concerning the opportunities and limitations of job applications for PWEs. The interviews were performed in May 2020, in the federal state of Salzburg, Austria, and they were analyzed using the qualitative method of content analysis (Kuckartz). The legal situation was investigated according to Global target 5.2 of the Intersectoral Global Action Plan (IGAP) on epilepsy and other neurological disorders 2022-2031 by WHO.

RESULTS

Employers were confident that employees with epilepsy could be managed well in a positive company culture and with first responders in place. The Austrian law predisposes to uncertainty among both employers and employees. In particular, it allows only retrospective juridical clarification of health-related questions in the job interview. The authors developed a classification system of workplaces, with "D0" (D-zero) meaning no health or financial danger, for example, office workers and "D1" posing still no health hazard but includes regular work with cash, for example, salespersons. "D2" means potential medical implications for the person with epilepsy or any other person at the workplace, for example, industrial worker. Measures taken to abandon the risk in D2 workplaces, for example, a total sheath for a machine, leads to reclassification as "D2-0." With D2, OCPs evaluate the applicant's medical fitness for the job without disclosing medical details to the employer. The "compartment model of medical information in the job application process" guarantees that OCPs are the only persons who learn about the applicant's medical details.

SIGNIFICANCE

The practical and simple classification of workplaces according to the D-system, and the concept of making medical information accessible only to OCPs may diminish stigma and discrimination in the working world for PWEs.

Serious adverse events associated with conservative physical procedures directed towards the cervical spine: A systematic review

BACKGROUND

Previous reviews on serious adverse events (SAEs) following physical interventions involving the neck have focused on vascular SAEs or those related to cervical manipulation.

OBJECTIVE

To review the evidence for all serious adverse events associated with any physical cervical procedures and describe SAE characteristics.

METHODS

Searches were conducted in PubMed, EMBASE, CINAHL, Scopus, Cochrane, Web of Science and Index to Chiropractic Literature from inception to May 2023 for studies reporting characteristics of SAE following any neck intervention and patient demographics.

RESULTS

Two hundred and thirty-three studies describing 334 SAE cases were identified. Forty-one were reported in the last 5 years. The results confirmed findings of past reviews with most events being vascular (58%) and mainly arterial dissection or vertebral artery related and the majority involving manipulation (75%). However lesser-known SAES ie neurological (25%), combined vascular/neurological (12%) and others (5%) which included cases such as cerebrospinal fluid leaks, phrenic nerve palsies and retinal detachments were identified. Further, some followed procedures such as vestibular testing, gentle mobilization, exercises, acupuncture or even massage. Initial symptoms included sharp increases in headache/neck pain, nausea, vomiting, dizziness and altered sensation, during treatment or within 48 h, often preceding neurological signs. Most recovered favourably (62%), 16% with disability, 6% died, the rest were unspecified.

CONCLUSION

Most SAEs were vascular and associated with manipulation but awareness of potential neurological and orthopaedic injuries and other procedures should be raised. Monitoring for early signs of SAEs for up to 48 h post-intervention is advisable if a SAE is suspected.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease part II. Neuroimaging of selected etiologies : Part II. Neuroimaging of selected etiologies

INTRODUCTION

As detailed in the first part of this review, post-infectious vasculitides are a wide and complex category, including several clinical, microbiological and neuroradiological patterns. In order to raise the suspicion for diagnosis, the knowledge of two different neuroradiological issues is needed, i.e. the knowledge of neuroimaging pattern of infections and the one of neuroimaging pattern of vasculitis.

AIMS

The main aim of this second part is to summarize the neuroradiological features of post-infectious vasculitides focusing on imaging of vessels and consequences of vessel involvement, continuing the discussion proposed in the first part about neuroimaging of infections. In some cases, the two neuroradiological issues are both simultaneously present in the same patient, but in other cases only the second one can be depicted due to the latency between infection and vasculitis.

FINDINGS

Beyond general features of cerebral vascular involvement in post-infectious vasculitides, some well-studied and homogenous diseases, as treponemal vasculitis, Varicella Zoster Virus (VZV) arteriopathy, neuroborreliosis, SARS-CoV2-related endotheliopathy are described in detail, being not rare and sometimes underdiagnosed. The main clinical and neuroradiological features of these conditions are deeply addressed, providing diagnostic clues and pictorial examples.

CONCLUSIONS

Although some general features are common in clinical presentation and neuroimaging of post-infectious vasculitides, there are few neuroimaging clues pointing out a specific microbial agent as causative. The main step is to raise the diagnostic suspicion in order to start the dedicated investigation pathway and treatment.

Experiences of people with epilepsy in their professional development and daily working life: An exploratory study

PURPOSE

The primary objective of this exploratory study was to examine the current situation of people with epilepsy (PWE) in the German labor market and how epilepsy affects their daily working life.

METHODS

From June 2023 to March 2024, we conducted an exploratory online survey in adult PWE in Germany.

RESULTS

The online survey was completed by 193 PWE (median age: 40.5 years; Q25/75: 27/53; 62 % female). The participants reported the following effects of their diagnosis on their professional lives: Experiencing reduced work performance due to perceived adverse drug reactions (102/193; 53 %), worrying often about the professional future (93/193; 48 %), and perceiving every-day work or school life to be more challenging because of the diagnosis (90/193; 47 %). Of the 81 participants who were diagnosed before finishing school, 26/81 (32 %) could not pursue their initial career aspirations after receiving their diagnosis. Of the PWE who were diagnosed during their vocational or academic training, 3/35 (9 %) had to specialize differently in their field of training, and 10/35 (29 %) were forced to stop their training. 10/77 (13 %) PWE who were diagnosed during their professional life could not keep their job following the diagnosis.

CONCLUSION

According to self-reports, one of the main challenges faced by adult PWE is the deterioration of work performance due to perceived adverse drug reactions. They also perceived a major mental strain regarding their professional future because of the diagnosis. Moreover, they felt considerably limited in their career choices, especially if they were diagnosed early in life.

Drugs used in psychiatry causing an increase in body weight in children-a review

Body weight gain is a prevalent adverse effect observed in psychiatric medication therapy. With the notable increase in mental health diagnoses among children and adolescents over the last decade, exacerbated by the COVID-19 pandemic, the use of medications associated with weight gain poses an additional risk for obesity development. This study aimed to identify psychiatric drugs that may induce weight gain in children as a side effect. Twenty-nine publications were included in this systematic review, investigating the effects of nineteen different drugs on children's weight. The majority of these drugs belonged to atypical antipsychotics and anticonvulsants. Nearly all included articles reported that the examined substances resulted in weight gain in children. As childhood obesity has become a significant problem with various metabolic, psychological and social consequences, it is crucial to carefully consider therapy options. In addition to evaluating effectiveness, it is important to also assess the potential for weight gain. Clinicians and nutrition specialists should individually evaluate patients' nutritional needs, evaluate obesity risk, and provide appropriate dietary guidance to minimalize the risk of weight gain.

Determination of Intrinsic Clearance and Fraction Unbound in Human Liver Microsomes and In Vitro-In Vivo Extrapolation of Human Hepatic Clearance for Marketed Central Nervous System Drugs

OBJECTIVE

The objective of this study was to determine the apparent intrinsic clearance (Clint, app) and fraction unbound in human liver microsomes (fu, mic) of 86 marketed central nervous system (CNS) drugs and to predict the in vivo hepatic blood clearance (CLh, b).

METHODS

Clint, app in human liver microsomes (HLM) was determined by substrate depletion, and fu, mic was determined by equilibrium dialysis. The relationship between lipophilicity (logP) and unbound intrinsic clearance (Clint, u) was explored using the Biopharmaceutical Drug Disposition Classification System (BDDCS) and Extended Clearance Classification System (ECCS). The predicted hepatic blood clearance by direct scaling, conventional method and Poulin method using well-stirred (WS) and parallel-tube (PT) models were compared with observed values.

RESULTS

The Clint, app in HLM ranged from < 5.8 to 477 µl/min/mg. The fu, mic in HLM ranged from 0.02 to 1.0. The scaled Clint values ranged from < 5 to 4496 ml/min/kg. The metabolic rate increased with an increase in logP (logP ≥ 2.5) of the CNS compounds. The direct scaling and Poulin methods showed comparable results based on the percentage of clearance predictions within a two-fold error. The conventional method resulted in under-predictions of Clint, in vivo or CLh, b using the WS or PT models. The Poulin method is favored over the other methods based on the statistical parameters.

CONCLUSIONS

Experimental Clint, app and fu, mic for 86 CNS compounds were successfully determined, and the scaled clearance was used to predict the hepatic blood clearance of 34 drugs. The success of prospective clearance predictions using HLM is expected to be high for most of the lipophilic BDDCS class 1 and class 2 and ECCS class 2 CNS compounds. The Poulin method resulted in more accurate predictions falling within a two-fold error of the observed values using the WS or PT models.

Central Venous Pressure as a Predictor of Acute Kidney Injury in Cardiac Surgery: A Systematic Review of Observational Studies

Background/Objectives: Acute kidney injury (AKI) is a syndrome characterized by impaired kidney function, which is associated with reduced survival and increased morbidity. Central venous pressure (CVP) is a widely used hemodynamic parameter for assessing the volume status of patients and evaluating their response to fluid resuscitation. This systematic review aims to analyze various prospective and retrospective observational and controlled trials to determine the association between CVP and the risk of developing AKI in patients undergoing cardiac surgery. Additionally, it examines whether elevated CVP serves as an accurate predictor of AKI in this patient population. Methods: A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using PubMed as the primary database. The search focused on studies published after 2014 that included adult patients undergoing cardiac surgery with reported measurements of CVP and kidney function assessment. Studies conducted on animals, pediatric populations, those published before 2014, or in languages other than English were excluded from the review. Results: Through the analysis of 21 studies, a clear association between higher CVP and increased AKI risk emerged. The most critical CVP thresholds identified were 10 mmHg, 12 mmHg, 14 mmHg, and 20 mmHg, with risk increasing progressively beyond these values. CVP ≥ 10 mmHg was the most commonly reported cutoff for elevated AKI risk, showing 1.42 to 4.53 times increased odds. CVP ≥ 12 mmHg further amplified the risk, while CVP ≥ 14 mmHg was consistently associated with severe AKI and the need for RRT. The highest threshold (CVP ≥ 20 mmHg) showed the greatest risk escalation, linked to fluid overload, right heart failure, and mortality. Studies also suggest an optimal CVP range of 6-8 mmHg to minimize AKI incidence. Conclusions: Elevated CVP is an independent risk factor for the development of AKI in patients undergoing cardiac surgery. These findings suggest that CVP monitoring can play a significant role in predicting AKI and guiding perioperative management strategies.

Spinal Cord Infarction: Clinical and Neuroradiological Clues of a Rare Stroke Subtype

Spinal cord infarction (SCI) of arterial origin is a rare vascular event, and its incidence is probably underestimated. There are no strong epidemiological data, and the diagnostic pathway is complex and sometimes incomplete. Furthermore, many cases may be misdiagnosed as other forms of acute and subacute myelopathies. The focus of this review is the clinical and neuroradiological issues in diagnosing SCI and their respective reliability in a clinical setting. The new proposed diagnostic criteria of SCI, although not covering all aspects, highlight the need for a comprehensive approach, including even atypical cases, as the lack of cord compression on Magnetic Resonance Imaging (MRI) is the only mandatory feature for diagnosis. Some MRI features are supportive of the diagnosis, particularly when the anterior spinal artery territory is involved and diffusion-weighted imaging (DWI) is used. Several etiologies can be considered, considering traditional vascular risk factors and diseases affecting the aorta and its main branches, yet a significant proportion of cases remain without a definite etiology. The strongest predictor of SCI diagnosis is a clinical variable, i.e., a time to nadir of severe deficits < 12 h.

Association of late-life variability in hemoglobin A1C with postmortem neuropathologies

INTRODUCTION

To study the relationship of late-life hemoglobin A1C (A1C) with postmortem neuropathology in older adults with and without diabetes mellitus (DM).

METHODS

A total of 990 participants from five cohort studies of aging and dementia with at least two annually-collected A1C measures, who had autopsy. Neuropathologic evaluations documented cerebrovascular disease, Alzheimer's disease (AD), and other pathologies. To evaluate the association of A1C mean and variability (standard deviation [SD]) with neuropathology, we used a series of adjusted regression models.

RESULTS

Participants (mean age at death = 90.8 years; education = 15.8 years; 76% women) had six A1C measurements on average. Mean A1C was associated with greater odds of macroinfarcts (estimate = 0.14; p = 0.04) and subcortical infarcts (estimate = 0.16; p = 0.02). A1C variability was not associated with cerebrovascular pathology. A1C mean and variability were inversely associated with AD pathology.

DISCUSSION

The A1C average over time was associated with infarcts, and the A1C average and variability were inversely associated with AD pathology. Future studies should explore the underlying mechanisms linking A1C to dementia-related neuropathologies.

HIGHLIGHTS

Hemoglobin A1C (A1C), a measure of peripheral insulin resistance, is used to assess glycemic control. Higher A1C mean was associated with greater odds of macroscopic subcortical infarcts. A1C variability was not associated with cerebrovascular pathology. Both A1C mean and variability had inverse associations with AD pathology. None of the associations varied by diabetes mellitus status.

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

BACKGROUND

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

METHODS

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

RESULTS

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

CONCLUSION

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Impact of problem-based learning on stigma toward epilepsy among medical students: An intervention verification study

INTRODUCTION

Stigma toward epilepsy is widespread not only among the general population but also among healthcare professionals. Therefore, the necessity of providing educational opportunities for epilepsy from an early stage in student education has been emphasized. Recently, problem-based learning (PBL) has gained importance in higher education, with reports indicating that it not only enhances knowledge but also reduces stigma.

OBJECTIVE

This study aimed to evaluate the effects of an epilepsy-related problem-based learning (E-PBL) program on medical students' stigma toward epilepsy. Additionally, we assessed whether the E-PBL program improved medical students' knowledge of epilepsy.

MATERIALS AND METHODS

Participants were fourth-year medical students. The E-PBL program was conducted over 5 days, from July 3, 2023 to July 7, 2023. The outcomes included the Japanese version of the Public Attitudes Toward Epilepsy (PATE-J) scale, which was used to assess stigma toward epilepsy before and after the E-PBL program. We also administered a short, structured questionnaire to assess participants' knowledge of epilepsy.

RESULTS

In total, 112 students were examined. The total PATE-J score was significantly lower after E-PBL (median: 18; interquartile range [IQR]: 14-20) than before PBL (median: 19; IQR: 16-23) (p = 0.013). Additionally, the number of correct responses to the short, structured questionnaire after the E-PBL program was significantly higher than before the program (p < 0.001).

CONCLUSIONS

E-PBL programs have the potential to decrease stigma toward epilepsy while enhancing knowledge about epilepsy among medical students. E-PBL represents a novel educational approach for medical students in the context of epilepsy education.

Strategies to promote contraception use by female volunteers in Alzheimer's Prevention Initiative Autosomal-Dominant Alzheimer's Disease (API ADAD) Colombia trial

BACKGROUND/AIMS

Including women of childbearing age in a clinical trial makes it necessary to consider two factors from a bioethical perspective: first, the lack of knowledge about the potential teratogenic effects of an investigational product, and also, the principle of justice not to exclude any population from the benefits of research. The most common way to address this issue is by requiring volunteers to use contraceptives before, during, and a few weeks after the clinical trial. This work presents all the strategies used to promote contraception use and prevent pregnancy during the Alzheimer's Prevention Initiative Autosomal-Dominant Alzheimer's Disease (API ADAD) Colombia clinical trial. Two characteristics of this trial make it of special interest for closely monitoring contraception use. One is that the trial lasted more than 7 years, and the other is that participants could be carriers of the E280A PSEN1 mutation, leading to a mild cognitive impairment as early as their late 30s.

METHODS

An individual medical evaluation to select the contraception method that best fits the volunteer was carried out during the screening visit, remitting to the gynecologist when necessary. All non-surgical contraception methods were supplied by the sponsor. Staff were trained on contraception counseling, correctly dispensing contraceptive drugs to volunteers, and identifying, reporting, and following up on pregnancies. Two comprehensive educational campaigns on contraception use were performed, and the intervention included all volunteers. In addition, volunteers were asked on an annual survey to evaluate the dispensing procedure. Finally, the effectiveness of these strategies was retrospectively evaluated, comparing by extrapolation the number of pregnancies presented throughout the trial with the General Fertility Rate in Colombia.

RESULTS

A total of 159 female volunteers were recruited. All strategies were implemented as planned, even during the COVID-19 contingency. Ten pregnancies occurred during the evaluation period (2015-2021). Two were planned; the rest were associated with a potential therapeutic failure or incorrect use of contraceptive methods for a contraceptive failure of 0.49% per year. Sixty percent of pregnancies led to an abortion, either miscarriage or therapeutic abortion. However, there was not enough data to associate the pregnancy outcome with the administration of the investigational product. Finally, we observed a lower fertility rate in women participating in the trial compared to the Colombian population.

CONCLUSION

The lower rates of contraceptive failure and the decrease in the incidence of pregnancies in women participating in the trial compared to the Colombian population across the 7 years of evaluation suggest that the strategies used in API ADAD Colombia were adequate and effective in addressing contraception use.

Development of individualized risk assessment models for predicting post-traumatic epilepsy 1 and 2 years after moderate-to-severe traumatic brain injury: A traumatic brain injury model system study

OBJECTIVE

Although traumatic brain injury (TBI) and post-traumatic epilepsy (PTE) are common, there are no prospective models quantifying individual epilepsy risk after moderate-to-severe TBI (msTBI). We generated parsimonious prediction models to quantify individual epilepsy risk between acute inpatient rehabilitation for individuals 2 years after msTBI.

METHODS

We used data from 6089 prospectively enrolled participants (≥16 years) in the TBI Model Systems National Database. Of these, 4126 individuals had complete seizure data collected over a 2-year period post-injury. We performed a case-complete analysis to generate multiple prediction models using least absolute shrinkage and selection operator logistic regression. Baseline predictors were used to assess 2-year seizure risk (Model 1). Then a 2-year seizure risk was assessed excluding the acute care variables (Model 2). In addition, we generated prognostic models predicting new/recurrent seizures during Year 2 post-msTBI (Model 3) and predicting new seizures only during Year 2 (Model 4). We assessed model sensitivity when keeping specificity ≥.60, area under the receiver-operating characteristic curve (AUROC), and AUROC model performance through 5-fold cross-validation (CV).

RESULTS

Model 1 (73.8% men, 44.1 ± 19.7 years, 76.1% moderate TBI) had a model sensitivity = 76.00% and average AUROC = .73 ± .02 in 5-fold CV. Model 2 had a model sensitivity = 72.16% and average AUROC = .70 ± .02 in 5-fold CV. Model 3 had a sensitivity = 86.63% and average AUROC = .84 ± .03 in 5-fold CV. Model 4 had a sensitivity = 73.68% and average AUROC = .67 ± .03 in 5-fold CV. Cranial surgeries, acute care seizures, intracranial fragments, and traumatic hemorrhages were consistent predictors across all models. Demographic and mental health variables contributed to some models. Simulated, clinical examples model individual PTE predictions.

SIGNIFICANCE

Using information available, acute-care, and year-1 post-injury data, parsimonious quantitative epilepsy prediction models following msTBI may facilitate timely evidence-based PTE prognostication within a 2-year period. We developed interactive web-based tools for testing prediction model external validity among independent cohorts. Individualized PTE risk may inform clinical trial development/design and clinical decision support tools for this population.

A high-performance aptasensing interface based on pseudo-AuNBs@Ti3C2Tx MXene nanocomposite for non-invasive measurement of carbamazepine in human biofluids

For the first time, a novel aptasensing interface based on smart integration of pseudo-gold nanobons (AuNBs) and Ti3C2Tx MXene is introduced for high selective detection of carbamazepine (CBZ). The large specific surface area achieved from the proposed nanocomposite increases the targeted immobilization of the Apt sequence on the surface via AuNBs as the linkage. It embeds a high-performance grafting platform for trapping CBZ with high sensitivity and accuracy in human biofluids and pharmaceutical formulations. The molecular dynamic (MD) simulation method that exhibits how the Apt binds to CBZ in a conformation-switching assay format from a molecular view is a valid certification for the interaction of CBZ on the developed aptasensing interface. The aptasensor measured CBZ from 1 fM to 100 nM with a superior detection limit (LOD) value of 330 aM compared with other reported CBZ sensors. Due to using biocompatible and non-toxic compounds, consuming low energy and chemicals the greenness of the proposed strategy has been certified by the international scoring system.

LncRNA-MEG3 Mediated Diabetic Cerebral Ischemia-Reperfusion Injury-Induced Apoptosis via Modulating Interaction Between Annexin A2 and Akt in Mitochondria

BACKGROUND

In clinical domains, encompassing neurosurgery and macrovascular cardiac procedures, certain interventions result in cerebral ischemia- reperfusion injury (CIRI). Diabetes mellitus (DM) increases the risk of CIRI and worsens the severity of neurological impairment. It was documented that lncRNA-MEG3 contributed to the pathogenesis of CIRI. However, the pivotal significance of lncRNA-MEG3 in diabetic CIRI has never been studied.

AIMS

This study's aims were two-fold, to (1) figure out the influence of lncRNA-MEG3 on neurological dysfunction subsequent to diabetic cerebral ischemic injury, (2) elucidate its potential role in mitochondria-related apoptosis via modulating the Anxa2 signaling pathway.

MATERIALS AND METHODS

We mainly collected plasma from clinical patients to measure the expression of lncRNA-MEG3, and explored the molecular mechanism of lncRNA-MEG3 in CIRI combined with DM by immunofluorescence, western blot, co-ip and other molecular biology experiments in rat MACO+DM model and cellular OGD/R+HG model.

RESULTS

LncRNA-MEG3 expression in DM+AIS cases was remarkably higher than that in cases with AIS and healthy controls. Moreover, lncRNA-MEG3 expression was strongly linked to the National Institutes of Health Stroke Scale (NIHSS) score. Additionally, the findings unveiled that lncRNA-MEG3 depletion alleviated neurological impairments following CIRI in diabetic rats, and cellular death resulted from Oxygen-glucose deprivation (OGD) plus hyperglycemic reperfusion in rat brain microvascular endothelial cells (RBMVECs) that was concomitant with the increased phosphorylation of Annexin A2 (Anxa2) at Tyr23. Meanwhile, over expression of Anxa2, identified as a lncRNA-MEG3-associated mitochondrial protein, remarkably suppressed mitochondria-derived apoptosis. Importantly, lncRNA-MEG3 knockdown enhanced the mitochondrial translocation of Anxa2 via promoting its phosphorylation at Tyr23 in OGD+HG-treated RBMVECs. Furthermore, Anxa2 enhanced Akt phosphorylation at Ser473 and bound to Akt in mitochondria, which was involved in lncRNA-MEG3 depletion-induced neuroprotection. However, lncRNA-MEG3 mobilized to mitochondria in a Plectin-dependent manner and subsequently impeded the interaction between p-Anxa2 and p-Akt.

DISCUSSION AND CONCLUSION

The outcomes provided clinical evidence that lncRNA-MEG3 appeared as an unfavorable prognostic factor for diabetic CIRI and revealed that lncRNA-MEG3 knockdown could be protective against diabetic CIRI-induced mitochondria-related apoptosis through modulating Anxa2 binding to Akt in mitochondria.

Calcium signaling hypothesis: A non-negligible pathogenesis in Alzheimer's disease

BACKGROUND

Alzheimer's disease (AD) presents a significant challenge to global healthcare systems, with an exacerbation by an aging population. Although the plethora of hypotheses are proposed to elucidate the underlying mechanisms of AD, from amyloid-beta (Aβ) accumulation and Tau protein aggregation to neuroinflammation, a comprehensive understanding of its pathogenesis remains elusive. Recent research has highlighted the critical role of calcium (Ca2+) signaling pathway in the progression of AD, indicating a complex interplay between Ca2+ dysregulation and various pathological processes.

AIM OF REVIEW

This review aims to consolidate the current understanding of the role of Ca2+ signaling dysregulation in AD, thus emphasizing its central role amidst various pathological hypotheses. We aim to evaluate the potential of the Ca2+ signaling hypothesis to unify existing theories of AD pathogenesis and explore its implications for developing innovative therapeutic strategies through targeting Ca2+ dysregulation.

KEY SCIENTIFIC CONCEPTS OF REVIEW

The review focuses on three principal concepts. First, the indispensable role of Ca2+ homeostasis in neuronal function and its disruption in AD. Second, the interaction between Ca2+ signaling dysfunction and established AD hypotheses posited that Ca2+ dysregulation is a unifying pathway. Third, the dual role of Ca2+ in neurodegeneration and neuroprotection, highlighting the nuanced effects of Ca2+ levels on AD pathology.

Effect of patients in-use and accelerated stability conditions on quality attributes and pharmacokinetic profile of four FDA approved extended-release anti-epileptic-drug products

Divalproex (DVS) is a popular drug widely used in various neurological and psychiatric disorders. Commercially, it is a multisource-drug available in different generic equivalents. Incidents of (class II)-recalls have been repeated over the last years due to failure to consistently meet dissolution specifications. Class II recalls are known to be associated with temporary or medically reversible adverse health consequences. This study aimed to evaluate the dissolution profiles, among other quality attributes, of select FDA-approved extended-release DVS products before and after exposure to conditions usually seen as short-lived and insignificant on product stability, such as pharmacy dispensing and patients' in-use conditions to assess their possible role in the failures observed. Products were stored for 6 weeks in pharmacy vials at 30 °C/75 % RH to simulate patient in-use conditions, for 12 weeks in unsealed HPDE bottles at 25 °C/65 % RH to simulate the pharmacy storage conditions, and for 3 days in open containers at 40 °C/75 % RH for accelerated stability studies. Physicochemical changes were detected by near infrared imaging, Fourier transformed infrared, X-ray powder diffraction and differential scanning calorimetry. All samples were analyzed for in vitro dissolution. Two products were further selected for in vivo study on Beagle dogs before and after storage. The physicochemical characterization tests revealed changes in tablets' composition and drug crystallinity over time. An improved discriminatory dissolution test was developed and used in this study. The in vitro release testing revealed that short-lived environmental changes at 30 or 25 °C could fail some unit doses and significantly lower the drug release (average reduction among all products was 12.97 ± 11.3 % and 27.48 ± 10.26 %, respectively). Some extended-release products showed a significant increase in the amount of drug dissolved in the first 6 h (early burst) owing to changes in tablet surface morphology and enhanced drug dissolution. In vivo studies showed a decrease in the AUC0-t by overall average of 21.1 % using the non-transformed data, a decrease that mirrored the dissolution results. The study shows that significant changes can occur during routine drug dispensing and patients' use that might variably impact the stability and quality of commercial bioequivalent unit doses. It is possible that these changes may also contribute to the adverse effects reported on DVS or upon drug switches that were previously attributed to the intersubject variability. The study findings are encouraging to further investigate the effect of such minor excursions on the drug effectiveness during products' shelf lives especially for narrow therapeutic index drugs.

MicroRNA-33 regulates the synaptic plasticity-related gene ARC in temporal lobe epilepsy

This study aimed to elucidate the expression patterns of miR-33 and ARC in both a rat model of temporal lobe epilepsy (TLE) and human TLE patients, to explore the role of miR-33 in epilepsy onset through its regulation of ARC expression in the hippocampus. Our findings, supported by a Dual-Luciferase reporter assay, suggest that miR-33 can bind to the 3' UTR region of ARC. We observed that miR-33 levels were reduced at 1 hour and 60 days post-seizure, while ARC expression notably increased at these time points. In the hippocampal CA1 and CA3 regions of post-seizure rats, ARC expression significantly exceeded that of control groups. Following the transfection of HEK cells with a miR-33 mimic, there was a decrease in both ARC mRNA and protein levels, whereas the group treated with a miR-33 inhibitor displayed the opposite effect. RNA sequencing in TLE patients revealed a similar miR-33 and ARC interaction. The regulation of Arc expression by miR-33 suggests that Arc may be a target gene of miR-33 in the context of epilepsy. Our findings indicate that miR-33 downregulation could contribute to the dysregulation of Arc expression observed in TLE, potentially influencing the disease process. Further studies are required to establish the exact role of miR-33-mediated Arc regulation in the development of epilepsy.

Efficacy and safety of tirofiban in acute ischemic stroke patients with ideal reperfusion: A cohort study of LAA and CE subgroups

BACKGROUND AND OBJECTIVES

Despite achieving ideal reperfusion (eTICI = 3) through endovascular treatment (EVT), some acute ischemic stroke (AIS) patients still experience poor outcomes. This study aims to evaluate the efficacy and safety of tirofiban in AIS patients with ideal reperfusion, focusing on its effects in large artery atherosclerosis (LAA) and cardioembolic (CE) stroke.

METHODS

A total of 474 AIS patients from the RESCUE-BT database were included. Patients were assigned to either the tirofiban or placebo group based on the treatment received. The primary outcome was favorable functional recovery at 90 days (mRS ≤2), and safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. Multivariable logistic regression was used to adjust for confounders, and subgroup and interaction analyses assessed tirofiban's efficacy in LAA and CE populations.

RESULTS

In the overall population that achieved ideal reperfusion, Tirofiban did not improve clinical outcomes and did not increase the risk of mortality or incidence of sICH (p > 0.05). However, subgroup analysis indicated potential clinical benefits for patients with higher NIHSS scores in the LAA group, especially in the subgroup with NIHSS scores >13 (adjusted OR 4.671, 95% CI [1.545, 14.122]). No significant differences were found in the CE group.

CONCLUSIONS

Tirofiban showed potential benefits for LAA patients with ideal reperfusion, especially those with NIHSS scores above 13. Careful patient selection is recommended.

Epilepsy-pregnancy registries: An update

This report is the first comprehensive update on the activities of existing epilepsy-pregnancy registries since 2010. The primary aim of these registries, which were initiated by independent international research groups some 25 years ago, has been to assess the risk of major congenital malformations (MCMs) in offspring exposed in utero to different antiseizure medications (ASMs). Progress reports are provided here from the five original registries (the International Registry of Antiepileptic Drugs and Pregnancy EURAP, the North American Antiepileptic Drug Pregnancy Registry, the UK and Ireland Epilepsy and Pregnancy Register, the Kerala Registry of Epilepsy and Pregnancy, and the Raoul Wallenberg Australian Pregnancy Register of Antiepileptic Drugs) plus the more recently initiated West China Registry. Since their inception, the registries have published a wealth of data revealing important differences in risks across the most frequently used ASM treatments, thereby facilitating rational management of women with epilepsy who are of childbearing potential. Although the number of pregnancies enrolled in the different registries has more than doubled since the 2010 report, many questions remain. These include outcomes following prenatal exposure to most of the newer ASMs or different ASM combinations, as well as associations with specific MCMs rather than MCMs as a collective. All the registries, therefore, remain active and continue to enroll pregnancies. Administrative health care databases have been utilized more recently for the assessment of MCM risks and other adverse pregnancy outcomes associated with in utero exposure to ASMs. Although these can provide population-based complementary information, they cannot replace the specific epilepsy-pregnancy registries with their more detailed validated individual information. Given the multiple newer ASMs that are increasingly used and the continuing multiple knowledge gaps for the older ASMs, epilepsy-pregnancy registries will continue to play an important role in the future.

Identification of potentially causative drugs associated with hypotension: A scoping review

Drug-induced hypotension can be harmful and may lead to hospital admissions. The occurrence of hypotension during drug therapy is preventable through increased awareness. This scoping review aimed to provide a comprehensive overview of antihypertensive and nonantihypertensive drugs associated with hypotension in adults. A systematic literature search was conducted using MEDLINE, Embase and Cochrane Library, focusing on studies from January 2013 to May 2023. Search terms were developed to capture key concepts related to hypotension and adverse drug events in adults while excluding terms related to allergic reactions, phytotherapy and studies involving paediatric, pregnant or animal populations. The eligibility criteria included a wide range of study types evaluating hypotension as an adverse drug event across all healthcare settings. Relevant information was extracted from the included studies, while identified drugs associated with hypotension were categorised into drug classes. The review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist. In 97 eligible studies, we identified 26 antihypertensive drugs grouped into nine different antihypertensive classes and 158 other drugs grouped into 22 other drug classes. Common antihypertensive classes were angiotensin-converting enzyme inhibitors, beta blockers and diuretics. Frequently reported nonantihypertensive classes were neuroleptics, alpha-1 blockers for benign prostatic hyperplasia, benzodiazepines, opioids and antidepressants. The results highlight the importance of healthcare professionals being aware of nonantihypertensive drugs that can cause hypotension. This review provides a basis for future systematic reviews to explore dose-dependence, drug-drug interactions and confounding factors.

Proteinuria's Influence on Clinical Outcomes and Prognostic Accuracy in Acute Ischaemic Stroke Patients Undergoing Reperfusion Therapy: A Comprehensive Meta-Analysis

AIM

Proteinuria commonly accompanies acute ischaemic stroke (AIS) patients undergoing reperfusion therapies such as intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). Understanding its influence on outcomes is crucial for prognosis and optimising management strategies. This study aims to elucidate proteinuria's role in mediating outcomes among reperfusion-treated patients.

METHODS

Through a random-effects meta-analysis, we analysed data to assess the association of proteinuria with functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. A total of 33 140 patients were included in the meta-analysis.

RESULTS

Proteinuria demonstrated a pooled prognostic sensitivity of 58% (95% CI: [48%; 67%]; p < 0.001) for poor functional outcomes at 90 days. It was linked with increased odds of unfavourable functional outcome at 90 days in both IVT (OR 2.27; 95% CI: [1.95; 2.66]; p < 0.001) and EVT (OR 2.57; 95% CI: [2.16; 3.05]; p < 0.001) groups. Furthermore, it was associated with increased odds of 90-day mortality in IVT-treated patients (OR 2.31; 95% CI: [1.76; 3.02]; p < 0.001), while EVT-treated patients exhibited increased odds of in-hospital mortality (OR 2.71; 95% CI: [1.22; 6.04]; p < 0.05).

CONCLUSIONS

The clinical significance of proteinuria is underscored by its impact on outcomes for AIS patients receiving reperfusion treatments. This awareness may guide individualised treatment by considering the intricate interplay between kidney function and its correlation with stroke. Consequently, this has the potential to improve prognosis and overall outcomes in AIS therapy.

Development and internal validation of a prognostic model for predicting tonic-clonic seizures during pregnancy in women with epilepsy

BACKGROUND

We aim to develop a model to predict the probability of tonic-clonic seizures in women with epilepsy (WWE) at any point during pregnancy until six weeks postpartum.

METHODS

We conducted a screening of patients diagnosed with epilepsy and who were pregnant, at a tertiary hospital in China, during the period of 1 January 2010 to 31 December 2020. We then followed up with these patients for at least one year postpartum. A total of 271 eligible patients were included in the cohort. The outcome was the occurrence of a tonic-clonic seizure during pregnancy or within six weeks postpartum. Predictors were screened through univariate analysis, and models were fitted through multivariate logistic regression analysis. Further, we compared the WMU model with the AntiEpileptic drug Monitoring in PREgnancy (EMPiRE) model in terms of discrimination (the area under receiver operating characteristic curve [AUC]), accuracy (GiViTI calibration belt), decision curve analysis (DCA), net reclassification index (NRI), and integrated discrimination improvement (IDI). Finally, we plotted a nomogram of the WMU model.

RESULTS

Of the 271 pregnant WWE, 62 patients (22.9%) had the outcome. The WMU model included three predictors: age at the time of pregnancy, admission to hospital for seizures in previous pregnancy, and seizures in the 12 months before pregnancy. Compared to the EMPiRE model, the AUC value of the WMU model was higher (0.76 vs. 0.639, P < 0.05). GiViTI calibration belt showed that the predicted risks of the WMU model were mostly consistent with the observed risks. In terms of DCA, the WMU model revealed the highest net proportional benefit for predicted probability thresholds between 10% and 90%. Additionally, our model exhibited better reclassification performance than the EMPiRE model (NRI: 0.331, P < 0.01 and IDI: 0.129, P < 0.01).

CONCLUSION

We attempted to develop a prognostic model for predicting the risk of tonic-clonic seizures in pregnant WWE. The WMU model showed good performance, but without external validation, it is unclear whether WMU model could be generalized.

Differential impact of TyG and TyG-BMI indices on short- and long-term mortality in critically ill ischemic stroke patients

BACKGROUND

Ischemic stroke is a major contributor to global morbidity and mortality, particularly in critically ill patients in intensive care units (ICUs). While advances in stroke management have improved outcomes, predicting mortality remains challenging due to the involvement of complex metabolic and cardiovascular factors. The triglyceride-glucose (TyG) index, a marker for insulin resistance, has gained attention for its potential to predict adverse outcomes in stroke patients. Furthermore, the TyG-BMI index, which combines TyG with body mass index (BMI), may offer a more comprehensive measure by accounting for obesity-related metabolic burden. However, the comparative impact of these indices on short- and long-term mortality among critically ill ischemic stroke patients remains unclear.

METHODS

This retrospective cohort study analyzed data from the Medical Information Mart for Intensive Care IV (MIMIC-IV 3.0) database, including 1,334 critically ill ischemic stroke patients. The patients were divided into four groups based on TyG and TyG-BMI quartiles, respectively. Cox proportional hazards models were employed to assess the association of these indices with 30-day, 90-day, 180-day, and 1-year all-cause mortality (ACM). Kaplan-Meier survival analysis was used to compare survival rates across different index levels. We utilized restricted cubic splines (RCS) to examine the association between the TyG, TyG-BMI index and the specified outcomes. Furthermore, TyG and TyG-BMI index were utilized to establish logistic regression models for mortality across different time periods, and corresponding Receiver Operating Characteristic (ROC) curves were generated.

RESULTS

Kaplan-Meier survival analysis show that Higher TyG levels were associated with significantly increased mortality risk at all time points, with patients in the highest TyG quartile exhibiting the greatest risk. Conversely, patients having a lower TyG-BMI level faced a heightened risk of long-term ACM. The RCS analysis results demonstrated that the TyG index did not exhibit a statistically significant nonlinear relationship with mortality across all time points. However, a significant nonlinear relationship was observed between the TyG index and long-term mortality. From the ROC curve, it can be observed that TyG performs better in predicting short-term mortality. Conversely, TyG-BMI demonstrates superior performance in predicting long-term mortality. The analysis revealed that while the TyG index alone is a strong predictor of mortality, the TyG-BMI index enhances the ability to predict long-term outcomes.

CONCLUSION

This finding suggests both the TyG and TyG-BMI indices serve as valuable predictors of mortality in critically ill ischemic stroke patients. However, significant differences were observed across the various follow-up periods. Based on the distinct characteristics of these two indicators, future research should focus on the selective integration of TyG and TyG-BMI indices into clinical risk assessment models, tailored to the metabolic profiles of ischemic stroke patients in the ICU. This approach could enhance the precision of mortality risk stratification and optimize patient management strategies.

Subchronic Treatment with CBZ Transiently Attenuates Its Anticonvulsant Activity in the Maximal Electroshock-Induced Seizure Test in Mice

The objective of this study is to evaluate the anticonvulsant efficacy of carbamazepine (CBZ) following acute and chronic administration across four treatment protocols in a murine model of maximal electroshock-induced seizures. A single dose of the drug was utilized as a control. The neurotoxic effects were evaluated in the chimney test and the passive avoidance task. Furthermore, plasma and brain concentrations of CBZ were quantified across all treatment protocols. The subchronic administration of CBZ (7 × 2 protocol) resulted in an attenuation of its antielectroshock effect. In the three remaining treatment regimens (7 × 1, 14 × 1, and 14 × 2) the median effective doses of CBZ were comparable to the control. Neither acute nor chronic treatment with CBZ resulted in a discernible impact on motor coordination or long-term memory. The plasma and brain concentrations of CBZ were significantly lower in most chronic protocols when compared to a single-dose application. This may explain the transient attenuation of CBZ effectiveness in the 7 × 2 protocol, but not the return to the previous level. The anticonvulsant and neurotoxic profiles of CBZ did not differ after single and chronic administration. Therefore, experimental chronic studies with CBZ are not prerequisites for concluding and possibly translating results to clinical conditions.

New Onset Absence Status Epilepticus in Pregnancy: A Case Report

Absence status epilepticus may occur in persons diagnosed with idiopathic/genetic epilepsy as well as de novo in adult and elderly patients. Despite being a rare phenomenon, pregnant women with no previous history of epileptic seizures may be presented with new onset status epilepticus. In this report, we describe the case of a 22-year-old pregnant female with no prior history of seizures. The patient was admitted to our center with reduced spontaneous speech and perplexity. Electroencephalography showed continuous, generalized synchronous paroxysms of 3 Hz spike-wave complexes. The patient's clinical condition improved following the administration of diazepam and levetiracetam. To the best of our knowledge, we describe the first case of new onset absence status epilepticus during pregnancy.

Evolucollateral dynamics in stroke: Evolutionary pathophysiology, remodelling and emerging therapeutic strategies

Leptomeningeal collaterals (LMCs) are crucial in mitigating the impact of acute ischemic stroke (AIS) by providing alternate blood flow routes when primary arteries are obstructed. This article explores the evolutionary pathophysiology of LMCs, highlighting their critical function in stroke and the genetic and molecular mechanisms governing their development and remodelling. We address the translational challenges of applying animal model findings to human clinical scenarios, emphasizing the need for further research to validate emerging therapies-such as pharmacological agents, gene therapy and mechanical interventions-in clinical settings, aimed at enhancing collateral perfusion. Computational modelling emerges as a promising method for integrating experimental data, which requires precise parameterization and empirical validation. We introduce the 'Evolucollateral Dynamics' hypothesis, proposing a novel framework that incorporates evolutionary biology principles into therapeutic strategies, offering new perspectives on enhancing collateral circulation. This hypothesis emphasizes the role of genetic predispositions and environmental influences on collateral circulation, which may impact therapeutic strategies and optimize treatment outcomes. Future research must incorporate human clinical data to create robust treatment protocols, thereby maximizing the therapeutic potential of LMCs and improving outcomes for stroke patients.

Characterization of the Epileptogenic Phenotype and Response to Antiseizure Medications in Lissencephaly Patients

BACKGROUND

Patients with lissencephaly typically present with severe psychomotor retardation and drug-resistant seizures. The aim of this study was to characterize the epileptic phenotype in a genotypically and radiologically well-defined patient cohort and to evaluate the response to antiseizure medication (ASM). Therefore, we retrospectively evaluated 47 patients of five genetic forms (LIS1/PAFAH1B1, DCX, DYNC1H1, TUBA1A, TUBG1) using family questionnaires, standardized neuropediatric assessments, and patients' medical reports.

RESULTS

All but two patients were diagnosed with epilepsy. Median age at seizure onset was 6 months (range: 2.1-42.0), starting with epileptic spasms in 70%. Standard treatment protocols with hormonal therapy (ACTH or corticosteroids) and/or vigabatrin were the most effective approach for epileptic spasms, leading to seizure control in 47%. Seizures later in the disease course were most effectively treated with valproic acid and lamotrigine, followed by vigabatrin and phenobarbital, resulting in seizure freedom in 20%. Regarding psychomotor development, lissencephaly patients presenting without epileptic spasms were significantly more likely to reach various developmental milestones compared to patients with spasms.

CONCLUSION

Classic lissencephaly is highly associated with drug-resistant epilepsy starting with epileptic spasms in most patients. The standard treatment protocols for infantile epileptic spasms syndrome lead to freedom from seizures in around half of the patients. Due to the association of epileptic spasms with an unfavorable course of psychomotor development, early and reliable diagnosis and treatment of spasms should be pursued. For epilepsies occurring later in childhood, ASM with valproic acid and lamotrigine, followed by vigabatrin and phenobarbital, appears to be most effective.

Neurological care and outcomes in a cohort of Canadian pregnant patients with epilepsy

PURPOSE

To characterize anti-seizure medication (ASM) use over time, therapeutic drug monitoring, ASM dose adjustments and gestational seizure frequency among Canadian people with epilepsy of childbearing potential seen in an urban tertiary care center.

METHODS

Participants were retrospectively identified from the medical records of pregnant patients with epilepsy seen at the University Health Network Comprehensive Epilepsy Program between 2014 and 2021. A descriptive analysis of outcomes, a logistic regression analysis of the odds of patients being on three ASMs associated with higher rates of teratogenicity (i.e., valproate, carbamazepine, and topiramate) over time, and a second logistic regression for predictors of seizure freedom during pregnancy were performed.

RESULTS

195 pregnancies were included: 52 % had a maternal diagnosis of generalized epilepsy and 92 % were prescribed at least one ASM, with 75 % on monotherapy. The majority underwent therapeutic drug monitoring (77 %) with approximately two-thirds requiring dose adjustments (69 %), typically dosage increases (82 %). The proportion of patients on either valproate, topiramate, or carbamazepine decreased over time (OR=0.80; p<0.01). Fifty-seven percent of pregnancies maintained seizure freedom, with seizure-freedom for ≥1 year prior to conception being the strongest predictor of this outcome (OR of gestational seizure recurrence=0.04; p < 0.01).

CONCLUSION

The proportion of patients on three ASMs associated with higher rates of teratogenicity has decreased over the duration of this study. Seizure-freedom prior to conception was associated with a decreased risk of gestational seizure recurrence.

Rasmussen Encephalitis: Clinical Features, Pathophysiology, and Management Strategies-A Comprehensive Literature Review

Rasmussen encephalitis (RE) is a rare and progressive form of chronic encephalitis that typically affects one hemisphere of the brain and primarily occurs in pediatric individuals. The current study aims to narratively review the literature about RE, including historical information, pathophysiology, and management of this condition. RE often occurs in individuals with normal development, and it is estimated that only a few new cases are identified each year in epilepsy centers. Approximately 10% of cases also occur in adolescents and adults. The hallmark feature of RE is drug-resistant focal seizures that can manifest as epilepsia partialis continua. Also, patients with RE usually develop motor and cognitive impairment throughout the years. Neuroimaging studies show progressive damage to the affected hemisphere, while histopathological examination reveals T-cell-dominated encephalitis with activated microglial cells and reactive astrogliosis. The current therapy guidelines suggest cerebral hemispherotomy is the most recommended treatment for seizures in RE, although significant neurological dysfunction can occur. Another option is pharmacological management with antiseizure medications and immunomodulatory agents. No significant progress has been made in understanding the pathophysiology of this condition in the last decades, especially regarding genetics. Notably, RE diagnosis still depends on the criteria established by Bien et al., and the accuracy can be limited and include genetically different individuals, leading to unexpected responses to management.

Case report: Combined transcutaneous spinal cord stimulation and physical therapy on recovery of neurological function after spinal cord infarction

The case of a 37-year-old woman who suffered from spinal cord infarction (SI), resulting in a complete spinal cord injury (AIS A, neurological level T10), and autonomic dysfunction is presented. This study aimed to assess the effect of transcutaneous Spinal Cord Electrical Stimulation (tSCS) on improving motor, sensory, and autonomic function after SI. During the first 8 months, tSCS was applied alone, then, physical therapy (PT) was included in the sessions (tSCS+PT), until completion of 20 months. Compared to baseline, at 20 months, an increase in ISNCSCI motor (50 vs. 57) and sensory scores (light touch, 72 vs. 82; pinprick, 71 vs. 92) were observed. Neurogenic Bladder Symptoms Score (NBSS) changed from 27 at baseline to 17 at 20 months. ISAFSCI scores in sacral autonomic function improved from 0 pts (absent function) to 1 pt. (altered function) indicating better sphincter control. EMG recordings during volitional movements, including overground stepping with 80% of body weight support showed activity in gluteus medialis, tensor fascia latae, sartorius, rectus femoris, biceps femoris, tibialis anterior, and gastrocnemius medialis, indicating a partial reversion of paralysis. RMS analysis indicated higher activity during "tSCS on" compared to "tSCS off" during overground stepping in bilateral rectus femoris (p < 0.001) and gastrocnemius medialis (p < 0.01); and unilateral biceps femoris, and tibialis anterior (p < 0.001). As this is the first report on the use of tSCS in the case of SI, future studies in a case series are warranted.

The impacts of venous outflow profiles on outcomes among large vessel occlusion patients receiving endovascular treatment in the late window

OBJECTIVES

To investigate the association between venous outflow (VO) profiles and outcomes among acute ischemic stroke caused by anterior circulation large vessel occlusion (AIS-LVO) patients who had undergone endovascular treatment (EVT) in the late window of 6-24 h from stroke onset.

METHODS

This was a post-hoc analysis of our preceding RESCUE-BT trial, with findings validated in an external cohort. Baseline computed tomographic angiography (CTA) was performed to assess VO using the Cortical Vein Opacification Score (COVES). The primary clinical outcome was functional independence at 90 days (modified Rankin Scale score of 0-2). The adjusted odd ratio (aOR) and confidence interval (CI) were obtained from multivariable logistic regressions.

RESULTS

A total of 440 patients were included in the present study. After identifying the cutoff of COVES by marginal effects approach, enrolled patients were divided into the favorable VO group (COVES 4-6) and the poor VO (COVES 0-3) group. Multivariable logistic regression analysis showed that favorable VO (aOR 2.25; 95% CI 1.31-3.86; p = 0.003) was associated with functional independence. Similar results were detected in the external validation cohort. Among those with poor arterial collateralization, favorable VO was still an independent predictor of functional independence (aOR 2.09; 95% CI 1.06-4.10; p = 0.032).

CONCLUSION

The robust VO profile indicated by COVES 4-6 could promote the frequency of functional independence among AIS-LVO patients receiving EVT in the late window, and the prognostic value of VO was independent of the arterial collateral status.

CLINICAL RELEVANCE STATEMENT

The robust venous outflow profile was a valid predictor for functional independence among AIS-LVO patients receiving EVT in the late window (6-24 h) and the predictive role of venous outflow did not rely on the status of arterial collateral circulation.