Neurosyphilis: Old Disease, New Implications for Emergency Physicians

Recent epidemiologic data demonstrate increasing rates of neurosyphilis, particularly among those in the community of men who have sex with men and those coinfected with the human immunodeficiency virus (HIV). Here we discuss a case of early neurosyphilis and new HIV diagnosis in a 27-year-old previously-healthy trans woman presenting for the second time with progressive, ascending weakness and cranial nerve VI palsy. Emergency physicians should consider this rare but highly morbid diagnosis, given the rising prevalence of neurosyphilis among at-risk patients and those with new neurologic deficits

Neural Summarization of Electronic Health Records

Hospital discharge documentation is among the most essential, yet time-consuming documents written by medical practitioners. The objective of this study was to automatically generate hospital discharge summaries using neural network summarization models. We studied various data preparation and neural network training techniques that generate discharge summaries. Using nursing notes and discharge summaries from the MIMIC-III dataset, we studied the viability of the automatic generation of various sections of a discharge summary using four state-of-the-art neural network summarization models (BART, T5, Longformer and FLAN-T5). Our experiments indicated that training environments including nursing notes as the source, and discrete sections of the discharge summary as the target output (e.g. "History of Present Illness") improve language model efficiency and text quality. According to our findings, the fine-tuned BART model improved its ROUGE F1 score by 43.6% against its standard off-the-shelf version. We also found that fine-tuning the baseline BART model with other setups caused different degrees of improvement (up to 80% relative improvement). We also observed that a fine-tuned T5 generally achieves higher ROUGE F1 scores than other fine-tuned models and a fine-tuned FLAN-T5 achieves the highest ROUGE score overall, i.e., 45.6. For majority of the fine-tuned language models, summarizing discharge summary report sections separately outperformed the summarization the entire report quantitatively. On the other hand, fine-tuning language models that were previously instruction fine-tuned showed better performance in summarizing entire reports. This study concludes that a focused dataset designed for the automatic generation of discharge summaries by a language model can produce coherent Discharge Summary sections

Noble Metal Nanoparticles Networks Stabilized by Rod‐Like Organometallic Bifunctional Thiols

od-like organometallic dithiol containing square-planar Pt(II) centers, i. e., trans,trans- [(H3COCS)Pt(PBu3)2(C�C C6H4 C6H4 C�C)(PBu3)2Pt(SCOCH3)] was used as bifunctional stabilizing agent for the synthesis of Pd-, Au-, and AgNPs (MNPs). All the MNPs showed diameters of about 4 nm, which can be controlled by carefully modulating the synthesis parameters. Covalent MNPs stabilization occurred through a single S bridge between Pt(II) and the noble metal nanocluster surfaces, leading to a network of regularly spaced NPs with the formation of dyads, as supported by SR-XPS data and by TEM imaging analysis. The chemical nature of NPs systems was also confirmed by EDS and NMR. Comparison between SR-XPS data of MNPs and self-assembled monolayers and multilayers of pristine rod-like dithiols deposited onto polycrystalline gold surfaces revealed an electronic interaction between Pt(II) centers and biphenyl moieties of adjacent ligands, stabilizing the organic structure of the network. The possibility to obtain networks of regularly spaced MNPs opens outstanding perspectives in optoelectronics

Echocardiographically defined haemodynamic categorization predicts prognosis in ambulatory heart failure patients treated with sacubitril/valsartan

Aim: Echo-derived haemodynamic classification, based on forward-flow and left ventricular (LV) filling pressure (LVFP) correlates, has been proposed to phenotype patients with heart failure and reduced ejection fraction (HFrEF). To assess the prognostic relevance of baseline echocardiographically defined haemodynamic profile in ambulatory HFrEF patients before starting sacubitril/valsartan. Methods and results: In our multicentre, open-label study, HFrEF outpatients were classified into 4 groups according to the combination of forward flow (cardiac index; CI:< or ≥2.0 L/min/m2 ) and early transmitral Doppler velocity/early diastolic annular velocity ratio (E/e': ≥ or <15): Profile-A: normal-flow, normal-pressure; Profile-B: low-flow, normal-pressure; Profile-C: normal-flow, high-pressure; Profile-D: low-flow, high-pressure. Patients were started on sacubitril/valsartan and followed-up for 12.3 months (median). Rates of the composite of death/HF-hospitalization were assessed by multivariable Cox proportional-hazards models. Twelve sites enrolled 727 patients (64 ± 12 year old; LVEF: 29.8 ± 6.2%). Profile-D had more comorbidities and worse renal and LV function. Target dose of sacubitril/valsartan (97/103 mg BID) was more likely reached in Profile-A (34%) than other profiles (B: 32%, C: 24%, D: 28%, P < 0.001). Event-rate (per 100 patients per year) progressively increased from Profile-A to Profile-D (12.0%, 16.4%, 22.9%, and 35.2%, respectively, P < 0.0001). By covariate-adjusted Cox model, profiles with low forward-flow (B and D) remained associated with poor outcome (P < 0.01). Adding this categorization to MAGGIC-score and natriuretic peptides, provided significant continuous net reclassification improvement (0.329; P < 0.001). Intermediate and high-dose sacubitril/valsartan reduced the event's risk independently of haemodynamic profile. Conclusions: Echocardiographically-derived haemodynamic classification identifies ambulatory HFrEF patients with different risk profiles. In real-world HFrEF outpatients, sacubitril/valsartan is effective in improving outcome across different haemodynamic profiles

The production of ionizing photons in UV-faint z~3-7 galaxies

The demographics of the production and escape of ionizing photons from UV-faint early galaxies is a key unknown in discovering the primary drivers of reionization. With the advent of JWST it is finally possible to observe the rest-frame optical nebular emission from individual sub-L$^*$ z>3 galaxies to measure the production of ionizing photons, $\xi_\mathrm{ion}$. Here we study a sample of 380 z~3-7 galaxies spanning -23 <M$_\mathrm{UV}$ < -15.5 (median M$_\mathrm{UV}\approx$ -18) with deep multi-band HST and JWST/NIRCam photometry covering the rest-UV to optical from the GLASS and UNCOVER JWST surveys. Our sample includes 109 galaxies with Lyman-alpha emission detected in MUSE spectroscopy. We use H-alpha fluxes inferred from NIRCam photometry to estimate the production rate of ionizing photons which do not escape these galaxies $\xi_\mathrm{ion}(1-f_\mathrm{esc})$. We find median $\log_{10}\xi_\mathrm{ion}(1-f_\mathrm{esc})=25.33\pm 0.47$, with a broad intrinsic scatter 0.42 dex, implying a broad range of galaxy properties and ages in our UV-faint sample. Galaxies detected with Lyman-alpha have ~0.1 dex higher $\xi_\mathrm{ion}(1-f_\mathrm{esc})$, which is explained by their higher H-alpha EW distribution, implying younger ages, higher sSFR and thus more O/B stars. We find significant trends of increasing $\xi_\mathrm{ion}(1-f_\mathrm{esc})$ with increasing H-alpha EW, decreasing UV luminosity, and decreasing UV slope, implying the production of ionizing photons is enhanced in young, low metallicity galaxies. We find no significant evidence for sources with very high ionizing escape fraction ($f_\mathrm{esc}$>0.5) in our sample, based on their photometric properties, even amongst the Lyman-alpha selected galaxies. This work demonstrates that considering the full distribution of $\xi_\mathrm{ion}$ across galaxy properties is important for assessing the primary drivers of reionization.Comment: 10 pages, 7 figures, submitted to A&

Early results from GLASS-JWST. III: Galaxy candidates at z∼\sim9-15

We present the results of a first search for galaxy candidates at z$\sim$9--15 on deep seven-bands NIRCam imaging acquired as part of the GLASS-JWST Early Release Science Program on a flanking field of the Frontier Fields cluster A2744. Candidates are selected via two different renditions of the Lyman-break technique, isolating objects at z$\sim$9-11, and z$\sim$9-15, respectively, supplemented by photometric redshifts obtained with two independent codes. We find six color-selected candidates at z$>$9, plus one additional candidate with photometric redshift z$_{phot}\geq$9. In particular, we identify two bright candidates at $m_{F150W}\simeq 26$ that are unambiguously placed at $z\simeq 10.6$ and $z\simeq 12.3$, respectively. The total number of galaxies discovered at $z>9$ is in line with the predictions of a non-evolving LF. The two bright ones at $z>10$ are unexpected given the survey volume, although cosmic variance and small number statistics limits general conclusions. This first search demonstrates the unique power of JWST to discover galaxies at the high redshift frontier. The candidates are ideal targets for spectroscopic follow-up in cycle$-2$.Comment: Submitted to ApJL, 9 pages, 4 figure

Distinct patterns of brain atrophy in Genetic Frontotemporal Dementia Initiative (GENFI) cohort revealed by visual rating scales.

BACKGROUND: In patients with frontotemporal dementia, it has been shown that brain atrophy occurs earliest in the anterior cingulate, insula and frontal lobes. We used visual rating scales to investigate whether identifying atrophy in these areas may be helpful in distinguishing symptomatic patients carrying different causal mutations in the microtubule-associated protein tau (MAPT), progranulin (GRN) and chromosome 9 open reading frame (C9ORF72) genes. We also analysed asymptomatic carriers to see whether it was possible to visually identify brain atrophy before the appearance of symptoms. METHODS: Magnetic resonance imaging of 343 subjects (63 symptomatic mutation carriers, 132 presymptomatic mutation carriers and 148 control subjects) from the Genetic Frontotemporal Dementia Initiative study were analysed by two trained raters using a protocol of six visual rating scales that identified atrophy in key regions of the brain (orbitofrontal, anterior cingulate, frontoinsula, anterior and medial temporal lobes and posterior cortical areas). RESULTS: Intra- and interrater agreement were greater than 0.73 for all the scales. Voxel-based morphometric analysis demonstrated a strong correlation between the visual rating scale scores and grey matter atrophy in the same region for each of the scales. Typical patterns of atrophy were identified: symmetric anterior and medial temporal lobe involvement for MAPT, asymmetric frontal and parietal loss for GRN, and a more widespread pattern for C9ORF72. Presymptomatic MAPT carriers showed greater atrophy in the medial temporal region than control subjects, but the visual rating scales could not identify presymptomatic atrophy in GRN or C9ORF72 carriers. CONCLUSIONS: These simple-to-use and reproducible scales may be useful tools in the clinical setting for the discrimination of different mutations of frontotemporal dementia, and they may even help to identify atrophy prior to onset in those with MAPT mutations

Ethical Criteria for the Admission and Management of Patients in the ICU Under Conditions of Limited Medical Resources: A Shared International Proposal in View of the COVID-19 Pandemic

Introduction The present pandemic has exposed us to unprecedented challenges that need to be addressed not just for the current state, but also for possible future similar occurrences. It is worth pointing out that discussions on the allocation of medical resources may not necessarily refer to an exception, but, unfortunately, to a regular condition for a large part of humanity (1). The criteria for admission to an Intensive Care Unit (ICU) setting generally take into account multiple factors. There must be a diagnostic and prognostic basis for the decisions made, considering both biological factors and patient values and wishes. Furthermore, the decision-making process should, whenever possible, respect the patient's advance directives as well as the relationship with the patient's family or attorney. Therapeutic neglect should be avoided. Having applied standard clinical evaluation criteria for the appropriate treatment of patients with COVID-19, including consideration of prognosis, if a hospital then finds itself unable to provide optimal treatment (e.g., due to a disproportion between the number of patients and the availability of beds, healthcare providers, ventilators, and drugs in the ICU), it becomes necessary to evaluate, case by case, how to achieve justice and the best possible good for the greatest number of patients. It is therefore mandatory to explore alternative solutions; these include increasing available beds and healthcare providers, implementing alternative, though suboptimal, approaches (where appropriate), transferring patients to other clinical units, etc. Making these decisions properly also involves the recovery of the political role of medicine and science (2). If the imbalance between needs and resources reaches a critical level, an emergency triage protocol, following the operational and ethical indications of “disaster medicine,” should be activated. These have been deployed in major and serious natural (earthquakes or tsunamis for example) and technological (factory explosions, public transport accidents for example) disasters, as well as following terrorist attacks (3, 4). The question of the feasibility of developing a clinical evaluation algorithm to support the decision-making of the triage team remains open, though many such protocols have been written. According to the above, we propose the following five ethical criteria for the triage of patients in conditions of limited resources, such as the COVID pandemic. They are the result of an interdisciplinary and intercultural dialogue between specialists from different disciplines. Several of the authors are working in the main epicenters of the crisis and currently are playing a central role in the bioethical, clinical, social and legal aspects of the management of the COVID-19 pandemic

Early Results from GLASS-JWST. XIX: A High Density of Bright Galaxies at z≈10z\approx10 in the Abell 2744 Region

We report the detection of a high density of redshift $z\approx 10$ galaxies behind the foreground cluster Abell 2744, selected from imaging data obtained recently with NIRCam onboard {\it JWST} by three programs -- GLASS-JWST, UNCOVER, and DDT\#2756. To ensure robust estimates of the lensing magnification $\mu$, we use an improved version of our model that exploits the first epoch of NIRCam images and newly obtained MUSE spectra, and avoids regions with $\mu>5$ where the uncertainty may be higher. We detect seven bright $z\approx 10$ galaxies with demagnified rest-frame $-22 \lesssim M_{\rm UV}\lesssim -19$ mag, over an area of $\sim37$ sq. arcmin. Taking into account photometric incompleteness and the effects of lensing on luminosity and cosmological volume, we find that the density of $z\approx 10$ galaxies in the field is about $10\times$ ($3\times$) larger than the average at $M_{UV}\approx -21~ (-20)$ mag reported so far. The density is even higher when considering only the GLASS-JWST data, which are the deepest and the least affected by magnification and incompleteness. The GLASS-JWST field contains 5 out of 7 galaxies, distributed along an apparent filamentary structure of 2 Mpc in projected length, and includes a close pair of candidates with $M_{\rm UV}< -20$ mag having a projected separation of only 16 kpc. These findings suggest the presence of a $z\approx 10$ overdensity in the field. In addition to providing excellent targets for efficient spectroscopic follow-up observations, our study confirms the high density of bright galaxies observed in early {\it JWST} observations, but calls for multiple surveys along independent lines of sight to achieve an unbiased estimate of their average density and a first estimate of their clustering.Comment: Accepted for publication in ApJL, 13 pages, 4 figure