Risk Management and Patient Safety in the Artificial Intelligence Era: A Systematic Review.

BACKGROUND: Healthcare systems represent complex organizations within which multiple factors (physical environment, human factor, technological devices, quality of care) interconnect to form a dense network whose imbalance is potentially able to compromise patient safety. In this scenario, the need for hospitals to expand reactive and proactive clinical risk management programs is easily understood, and artificial intelligence fits well in this context. This systematic review aims to investigate the state of the art regarding the impact of AI on clinical risk management processes. To simplify the analysis of the review outcomes and to motivate future standardized comparisons with any subsequent studies, the findings of the present review will be grouped according to the possibility of applying AI in the prevention of the different incident type groups as defined by the ICPS. MATERIALS AND METHODS: On 3 November 2023, a systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was carried out using the SCOPUS and Medline (via PubMed) databases. A total of 297 articles were identified. After the selection process, 36 articles were included in the present systematic review. RESULTS AND DISCUSSION: The studies included in this review allowed for the identification of three main "incident type" domains: clinical process, healthcare-associated infection, and medication. Another relevant application of AI in clinical risk management concerns the topic of incident reporting. CONCLUSIONS: This review highlighted that AI can be applied transversely in various clinical contexts to enhance patient safety and facilitate the identification of errors. It appears to be a promising tool to improve clinical risk management, although its use requires human supervision and cannot completely replace human skills. To facilitate the analysis of the present review outcome and to enable comparison with future systematic reviews, it was deemed useful to refer to a pre-existing taxonomy for the identification of adverse events. However, the results of the present study highlighted the usefulness of AI not only for risk prevention in clinical practice, but also in improving the use of an essential risk identification tool, which is incident reporting. For this reason, the taxonomy of the areas of application of AI to clinical risk processes should include an additional class relating to risk identification and analysis tools. For this purpose, it was considered convenient to use ICPS classification.

Oxidative Stress in Sepsis: A Focus on Cardiac Pathology.

This study aims to analyze post-mortem human cardiac specimens, to verify and evaluate the existence or extent of oxidative stress in subjects whose cause of death has been traced to sepsis, through immunohistological oxidative/nitrosative stress markers. Indeed, in the present study, i-NOS, NOX2, and nitrotyrosine markers were higher expressed in the septic death group when compared to the control group, associated with also a significant increase in 8-OHdG, highlighting the pivotal role of oxidative stress in septic etiopathogenesis. In particular, 70% of cardiomyocyte nuclei from septic death specimens showed positivity for 8-OHdG. Furthermore, intense and massive NOX2-positive myocyte immunoreaction was noticed in the septic group, as nitrotyrosine immunostaining intense reaction was found in the cardiac cells. These results demonstrated a correlation between oxidative and nitrosative stress imbalance and the pathophysiology of cardiac dysfunction documented in cases of sepsis. Therefore, subsequent studies will focus on the expression of oxidative stress markers in other organs and tissues, as well as on the involvement of the intracellular pattern of apoptosis, to better clarify the complex pathogenesis of multi-organ failure, leading to support the rationale for including therapies targeting redox abnormalities in the management of septic patients.

Focus on Prevention: Peripheral Arterial Disease and the Central Role of the Cardiologist.

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerotic disease. PAD patients have a poor prognosis with an increased risk of cardiovascular (CV) events, including myocardial infarction (MI), stroke, limb ischemia and CV death; therefore, it is important to detect and treat PAD early. PAD and coronary artery disease (CAD) share a common pathogenesis and risk factors for development; therefore, cardiologists are in a unique position to screen, diagnosis and treat PAD. Moreover, PAD and CAD also share some treatment goals, including an aggressive modification of risk factors to reduce the risk of CV events. However, PAD remains an underdiagnosed and undertreated disease with medico-legal implications. As the role of cardiologists is expanding, the purpose of this review was to awaken the clinicians to the significance of PAD.

The international reference system for beta-particle emitting radionuclides: Validation through the pilot study CCRI(II)-P1.Co-60.

The Bureau International des Poids et Mesures (BIPM) is developing a new transfer instrument to extend its centralized services for assessing the international equivalence of radioactive standards to new radionuclides. A liquid scintillation counter using the triple/double coincidence ratio method is being studied and tested in the CCRI(II)-P1.Co-60 pilot study. The pilot study, involving 13 participating laboratories with primary calibration capabilities, validated the approach against the original international reference system based on ionization chambers, which has been in operation since 1976. The results are in agreement and an accuracy suitable for purpose, below 5×10-4, is achieved. The pilot study also reveals an issue when impurities emitting low-energy electrons are present in the standard solution, which have a different impact on liquid scintillation counting compared to other primary measurement methods.

'Compressed Baby Head': A New 'Abusive Head Trauma' Entity?

BACKGROUND: Child abuse represents an important issue in the medico-legal and social context. In the last few decades, various aspects and mechanisms have been identified in child abuse case studies; however, constant research is needed in the field. With this paper, the authors will present a case of a new entity of Abusive Head Trauma that has come to the attention of medico-legal experts. DISCUSSION: The trauma analysis performed on the cranio-encephalic district of the baby revealed quite peculiar lesions that led the authors to exclude that the injuries had been solely caused by violent shaking of the baby's head, as suggested by Shaken Baby Syndrome. Instead, the authors hypothesised that another lesion mechanism had been added to this one, namely latero-lateral cranial compression. The comprehensive and exhaustive analysis of the case led the authors to present a new possible entity in child abuse trauma, namely 'Compressed Baby Head'. CONCLUSIONS: To the best of our knowledge, in the current literature, no similar clinical cases have ever been described. Thus, the case's uniqueness deserves to be brought to the attention of experts and the entire scientific community, as well as medical personnel, paediatricians, and reanimators. These professional figures are the first individuals who may encounter complex clinical cases such as the one presented in this paper; thus, they need to know how to properly manage the case and ensure protection for the abused infants and children.

Dipeptidyl Amino-Peptidase 3 (DPP3) as an Early Marker of Severity in a Patient Population with Cardiogenic Shock.

Dipeptidyl amino-peptidase 3 (DPP3) is an aminopeptidase that is released into circulation upon cell death. DPP3 is involved in the degradation of angiotensins, enkephalines, and endomorphines. It has been shown that circulating DPP3 (cDPP3) plasma concentration increases in cardiogenic shock (CS) patients and correlates with high mortality risk. Cardiogenic shock is a life-threatening syndrome associated with organ hypoperfusion. One of the common causes of CS is acute myocardial infarction (AMI). This study aimed to investigate if cDPP3 levels are associated with CS severity and the need for ventilation in patients suffering from CS. Fifteen patients with CS were included in this study. Six patients were invasively ventilated. The values of cDPP3 were higher in ventilated patients than in non-ventilated patients at admission, 3 h, and 24 h after admission in the intensive care unit. Patients with pulmonary hypertension at admission also showed high cDPP3 values at all time points. Furthermore, high cDPP3 levels were associated with reduced stroke volume. Our results suggest that cDPP3 could predict CS progression and guide therapy escalation.

Learning from the Past to Improve the Future-Vaccine Hesitancy Determinants in the Italian Population: A Systematic Review.

WHO identifies vaccine hesitancy (VH) as one of the ten threats to global health. The authors bring to the international scientific community an Italian episode that offers the opportunity to renew the discussion on the extent of the VH matter. The purpose of this systematic review is to analyze the factors determining vaccine hesitancy in the Italian population, to understand its roots, and suggest potential strategies to mitigate it. A systematic review of the literature according to the PRISMA guidelines was carried out using the SCOPUS and Medline (via PubMed) databases, using the following strategy: (COVID-19 vaccines) AND (vaccination hesitancy) AND (Italy). After the selection process, 36 articles were included in this systematic review. The most frequently detected factors associated with VH in the Italian population can be grouped as vaccine-related factors, socio-cultural factors, and demographic factors. Currently, we are facing a gap between the population and science, governments, and institutions. To heal this breach, it is necessary to strengthen the trust of the population through the implementation of health communication and public education strategies, while scientific literacy must continue to support families and individuals in discerning evidence from opinions to recognize the real risks and balance them with the benefits.

Irisin Role in Chondrocyte 3D Culture Differentiation and Its Possible Applications.

Irisin is a recently discovered cytokine, better known as an exercise-induced myokine, produced primarily in skeletal muscle tissue as a response to exercise. Although the skeleton was initially identified as the main target of Irisin, its action is also proving effective in many other tissues. Physical activity determines a series of beneficial effects on health, including the possibility of counteracting the damage that is caused by arthritis to the cartilage of people suffering from osteoarthritis. Nevertheless, up to now, the studies that have taken into consideration the possible involvement of Irisin on the well-being of cartilage tissue are particularly limited. In this study, we postulated that the protective effect of physical activity on cartilage tissue may depend on the paracrine action of Irisin secreted during exercise; therefore, we analyzed the effects of Irisin, in vitro, on chondrogenic differentiation. To achieve this goal, three-dimensional cultures of commercially available human articular chondrocytes (HACs) were treated with the molecule under study. Our results revealed new crosstalk mechanisms between muscle and cartilage tissue. Furthermore, the confirmation of Irisin ability to induce chondrogenic differentiation could favor the development of exercise-mimetic drugs, with application relevance for patients who cannot perform physical activity.

"Freedom and Dignity Are Worth More than Life": The Dramatic Suicide of an Anti-Vax Man.

Since the beginning of the COVID-19 public health emergency, we have witnessed an increase in psychiatric problems and pathologies, such as depression, anxiety, isolation, posttraumatic stress disorder, substance abuse, and burnout. The world's collective sentiment finally turned toward optimism after authorization was granted for the COVID-19 vaccines' emergency use by the FDA in December 2020. With the increase in vaccine coverage in Western countries, case counts and deaths gradually plummeted while activity restrictions were progressively lifted. At the same time, however, a new COVID-19-related public health issue has arisen, as a substantial number of eligible individuals refused vaccination. Behaviors assumed by the so-called anti-vax people in manifesting their own opposition towards COVID-19 vaccination are various, and sometimes assume the forms of dramatic gestures with symbolic value, such as suicide. Here, we present the case of a healthy, convinced anti-vax, 58-year-old man, who allowed himself to be run over by a moving train in the presence of eyewitnesses, bringing with him a demonstrative note of his reasons. The present article aims to raise awareness against the social and psychological impact of COVID-19 vaccination refusal and to point out the need of a specific support net to avoid the spread of psychological impairment, social isolation and suicidal behaviors among the "anti-vax community".

14 MeV Neutrons for 99Mo/99mTc Production: Experiments, Simulations and Perspectives.

BACKGROUND: the gamma-emitting radionuclide Technetium-99m (99mTc) is still the workhorse of Single Photon Emission Computed Tomography (SPECT) as it is used worldwide for the diagnosis of a variety of phatological conditions. 99mTc is obtained from 99Mo/99mTc generators as pertechnetate ion, which is the ubiquitous starting material for the preparation of 99mTc radiopharmaceuticals. 99Mo in such generators is currently produced in nuclear fission reactors as a by-product of 235U fission. Here we investigated an alternative route for the production of 99Mo by irradiating a natural metallic molybdenum powder using a 14-MeV accelerator-driven neutron source. METHODS: after irradiation, an efficient isolation and purification of the final 99mTc-pertechnetate was carried out by means of solvent extraction. Monte Carlo simulations allowed reliable predictions of 99Mo production rates for a newly designed 14-MeV neutron source (New Sorgentina Fusion Source). RESULTS: in traceable metrological conditions, a level of radionuclidic purity consistent with accepted pharmaceutical quality standards, was achieved. CONCLUSIONS: we showed that this source, featuring a nominal neutron emission rate of about 1015 s-1, may potentially supply an appreciable fraction of the current 99Mo global demand. This study highlights that a robust and viable solution, alternative to nuclear fission reactors, can be accomplished to secure the long-term supply of 99Mo.

InSiCal - A tool for calculating calibration factors and activity concentrations in in situ gamma spectrometry.

In situ gamma spectrometry is a widely applied analysis technique for the determination of radioactivity levels in soil. Compared to traditional laboratory analysis of soil samples, in situ techniques offer a quick and low-cost way of obtaining accurate results from on-site measurements. However, although the technique is well-known, the dependence of in situ gamma spectrometry on complex and time-consuming calibration procedures as well as in-depth knowledge of the geometric distribution of the source in the ground deters many potential users from employing it in their routine work. Aiming to alleviate this issue, a software tool named InSiCal (In Situ gamma spectrometry Calculator) has been developed to make in situ gamma spectrometry more accessible to both experts and non-experts in the field. This is done by simplifying and streamlining both calibration and activity calculation through a simple and intuitive graphical user interface. Testing in real field conditions show that InSiCal is capable of yielding results which are in very good agreement with soil sample analyses, and that the results may be obtained using different detector types (HPGe, NaI, LaBr and CZT). Overall, InSiCal, provides results which are comparable in accuracy to laboratory measurements, indicating that it fulfills its purpose successfully.

(60)Co in cast steel matrix: A European interlaboratory comparison for the characterisation of new activity standards for calibration of gamma-ray spectrometers in metallurgy.

Two series of activity standards of (60)Co in cast steel matrix, developed for the calibration of gamma-ray spectrometry systems in the metallurgical sector, were characterised using a European interlaboratory comparison among twelve National Metrology Institutes and one international organisation. The first standard, consisting of 14 disc shaped samples, was cast from steel contaminated during production ("originally"), and the second, consisting of 15 similar discs, from artificially-contaminated ("spiked") steel. The reference activity concentrations of (60)Co in the cast steel standards were (1.077±0.019) Bqg(-1) on 1 January 2013 12h00 UT and (1.483±0.022) Bqg(-1) on 1 June 2013 12h00 UT, respectively.

(18)F primary standard at ENEA-INMRI by three absolute techniques and calibration of a well-type IG11 ionization chamber.

A new (18)F primary standardization carried out at ENEA-INMRI by three different absolute techniques, i.e. 4πγNaI(Tl)γ high-efficiency counting, TDCR and 4πß(LS)-γ[NaI(Tl)] coincidence counting method, allowed the calibration of a fixed well-reentrant IG11 ionization chamber (IC), with an uncertainty lower than 1%, and to check the calibration factor of a portable well-type IC NPL-CRC model, previously calibrated. By the new standard the ENEA-INMRI was linked to the BIPM International Reference System (SIR) through the BIPM SIR Transfer Instrument (SIRTI).

Comparison of methods to determine accurate dose calibrator activity measurements.

BACKGROUND: In nuclear medicine, liquid radiopharmaceuticals for diagnostic or therapeutic purposes are administered to patients by using various types of syringes with different volumes. The activity of each "dose" must be carefully measured and documented prior to administration using an activity calibrator. METHODS: Calibrator response is a function of the measurement geometry and, in particular, it depends on the syringe type and filling volume. To minimize the uncertainty associated with the measured activity of the syringe, it is necessary to calculate a calibration curve depending on filling volume for each syringe type. This curve can be obtained by fitting experimentally determined volume correction factors. RESULTS: A theoretical evaluation of volume correction factors for syringes is reported for three different experimental methods. The aim is to determine the most accurate experimental method among those considered, by examining the expression of uncertainty for the correction factor. This theoretical analysis was then tested experimentally. CONCLUSION: The agreement between the experimental data obtained in the constant activity method and gravimetric method at constant specific activity and the small associated uncertainties show the accuracy of these two procedures; while the volumetric method at constant specific activity could lead to a wrong evaluation of the correction factors.

Experimental determination of the radionuclide calibrator setting for Technesium-99m, by using a primary standardisation method.

BACKGROUND: A new 99mTc national standard has been developed at the Italian National Metrology Institute for Ionizing Radiation quantities of ENEA (ENEA-INMRI). METHODS: The stock radioactive solution was prepared at the Ospedale Pediatrico Bambino Gesù (OPBG) and standardized at the ENEA-INMRI by using the 4pigamma absolute measurement method. The new standard was used to calibrate the dose calibrator of the OPBG Nuclear Medicine Unit (NMU) and the ENEA-INMRI portable ionization chamber which was employed as the secondary standard measurement system to calibrate the dose calibrator of another Italian nuclear medicine unit. RESULTS AND CONCLUSION: Remarkable improvement of measurement accuracy was achieved. The importance of traceable calibrations is underlined. Specific comments are made about quality control performance and measurement accuracy for the instrumentation used in nuclear medicine units of paediatric hospitals.

A singular case of murder-suicide committed with a homemade firearm.

The authors illustrate a peculiar case of murder-suicide committed with a homemade firearm loaded with 12-gauge cartridges (buckshot). The structure and function of this handcrafted firearm were simple but effective: an iron tube did duty as a barrel in this primitive firearm. The cartridges (modified by winding sticky tape around the external surface of the base) were inserted down one end of the tube (serving as the breech). A second iron tube with a larger diameter (so as to be able to run over each of the preloaded barrels) and with a jutting, cone-shaped metal wedge soldered to the base, was used as a rudimental firing pin. After loading the "barrel" with the modified cartridge, the gunman would ram the "firing pin" tube violently down to fire the shot. Autopsy of the woman's body showed the presence of 3 gunshot wounds caused by buckshot, while the man had a single buckshot wound in the head. Subsequent ballistic investigations enabled reconstruction of the event (typical of murder-suicide) and the functioning of the firearm, demonstrating its lethal nature, remarkably easy handling, and simplicity of production.

A national campaign for coincidence-summing correction in gamma-ray spectrometry.

A national campaign was carried out in Italy for the application of coincidence-summing correction in gamma-ray spectrometry. Twelve laboratories, belonging to the National Environmental Radioactivity Surveillance Network, took part in the campaign. They are equipped with gamma-ray spectrometry systems based on p- and n-type HPGe detectors with different relative efficiencies. A simplified procedure was used for coincidence-summing correction. This procedure requires a single-photon, single-nuclide source to measure the peak-to-total efficiency ratio at just one photon energy value. All the laboratories were given a 137Cs standard source for total efficiency determination, and a 134Cs source in the same geometry whose activity they had to determine. The results show the usefulness of the procedure. The average deviation of all the laboratory results from the ENEA-INMRI reference value was reduced from -12% before correction to +1% after correction. The paper gives a description of the different organisational aspects of the campaign, reports the results obtained and draws conclusions in which the gain in measurement accuracy is evaluated in the light of the effort required for each participant to perform the correction.