Medicolegal and insurance issues regarding BRCA1 and BRCA2 gene tests in high income countries

Hereditary breast and ovarian cancer syndrome is an autosomal dominant cancer susceptibility syndrome mainly due to variants in BRCA1 or BRCA2 genes. Patients presenting with BRCA1 or BRCA2 gene mutations have a lifetime risk of developing breast or ovarian cancer (80% and 40%, respectively). Genetic testing to explore the predisposition to develop cancer represents a pivotal factor in such cases, and this review wants to explore the main implications in terms of medicolegal liability and insurance issues. Medicolegal issues related to these diagnostic processes include: (a) failure to recommend the test; (b) failure to properly interpret the test; (c) failure to correctly translate results into clinical practice; (d) lack of informed consent; and (e) failure to refer patients to specialized genetic counseling. Such errors may lead to compensation since the legal burden inherent in the efficacy of prophylactic interventions is a proof that requires the so-called 'preponderance of the evidence'. Concerning insurance issues, the carriers of such alleles without cancer are healthy because the genetic predisposition is not a disease per se but represents a (relevant) health risk. However, disclosure of these conditions can be impelled by insurers. It can lead to so-called 'genetic discrimination' because insurance companies might use genetic information to limit insurance options or increase their costs. Many private and public healthcare funders do not cover risk reducing surgeries, even when recommended as part of a risk reduction management plan for BRCA gene mutation carriers. Here, positions on these matters from different high income countries are discussed, stressing the importance of a common supranational or international regulatory framework to reach a trade-off between the economic interests of insurers and the rights of carriers not to disclose extremely sensitive information.

Postmortem diagnosis of Takotsubo syndrome on autoptic findings: is it reliable? A systematic review

Takotsubo syndrome (TTS) is a cardiac syndrome characterized by transient left ventricular systolic dysfunction in the absence of significant obstructive coronary artery disease. At the autopsy, its diagnosis is often challenging, since it is generally thought that it relates to no characteristic macroscopic or microscopic findings. In order to verify this last statement, we performed a systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA) criteria. To the best of our knowledge, it is the first systematic review addressing this issue. We identified recurring but not pathognomonic (microscopic) features of TTS: contraction band necrosis and non-specific inflammatory changes (e.g., interstitial infiltrates of mononuclear lymphocytes and macrophages) typically in the absence of microscopic findings typical of acute myocardial infarction. In cases of TTS-related sudden death, careful evaluation of anamnesis, autopsy data and post-mortem genetic results (to exclude other causes) should be considered to overcome the complexity of these cases.

Potentiality of algorithms and artificial intelligence adoption to improve medication management in primary care: a systematic review

OBJECTIVES

The aim of this study is to investigate the effect of artificial intelligence (AI) and/or algorithms on drug management in primary care settings comparing AI and/or algorithms with standard clinical practice. Second, we evaluated what is the most frequently reported type of medication error and the most used AI machine type.

METHODS

A systematic review of literature was conducted querying PubMed, Cochrane and ISI Web of Science until November 2021. The search strategy and the study selection were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Population, Intervention, Comparator, Outcome framework. Specifically, the Population chosen was general population of all ages (ie, including paediatric patients) in primary care settings (ie, home setting, ambulatory and nursery homes); the Intervention considered was the analysis AI and/or algorithms (ie, intelligent programs or software) application in primary care for reducing medications errors, the Comparator was the general practice and, lastly, the Outcome was the reduction of preventable medication errors (eg, overprescribing, inappropriate medication, drug interaction, risk of injury, dosing errors or in an increase in adherence to therapy). The methodological quality of included studies was appraised adopting the Quality Assessment of Controlled Intervention Studies of the National Institute of Health for randomised controlled trials.

RESULTS

Studies reported in different ways the effective reduction of medication error. Ten out of 14 included studies, corresponding to 71% of articles, reported a reduction of medication errors, supporting the hypothesis that AI is an important tool for patient safety.

CONCLUSION

This study highlights how a proper application of AI in primary care is possible, since it provides an important tool to support the physician with drug management in non-hospital environments.

What can autopsy say about COVID-19? A case series of 60 autopsies

INTRODUCTION

Autopsies in SARS-CoV-2 infected cadavers are mainly performed to distinguish patients who died with SARS-CoV-2 infection from those who died of COVID-19. The aim of the current study is to assess the most frequent autopsy findings in patients who died of COVID-19 and to establish an association with clinical records.

MATERIALS AND METHODS

60 patients died between April 2020 and March 2021 after SARS-CoV-2 infection underwent a full autopsy performed at Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Rome). Ante-mortem diagnosis of SARS-CoV-2 infection was microbiologically confirmed.

RESULTS

55 (92%) of cases had at least a comorbidity. At microscopic examination, 40 (67%) of the patients presented pulmonary intravascular coagulation with an inflammatory pattern. Pulmonary microangiopathy was a rare finding (n = 8; 13%). Myocardiosclerosis was the main heart finding (n = 44; 73%). Liver involvement with congestion and hypotrophy was found in 33 (55%) of cadavers. Renal tubular epithelial exfoliation (n = 12; 20%) and intravascular coagulation (n = 4; 7%) were frequent observations. During hospitalization 31% of patients (n = 19) developed acute kidney injury (AKI).

CONCLUSIONS

Lungs and kidneys have been shown to play a pivotal role in COVID-19. The gradual worsening of renal function and AKI might be the result of the progressive collapse of cardiopulmonary system.

Virtual autopsy in SARS-CoV-2 breakthrough infection: a case report

It is well documented that COVID-19 vaccines are effective tools for limiting the pandemic. Unfortunately, as is true for all vaccines, SARS-CoV-2 infection in vaccinated individuals is still possible.

We present an autopsy case of SARS-CoV-2 infection after vaccination (“breakthrough infection”) in an elderly man with several comorbidities where post-mortem CT scan was performed. The death was histologically attributed to cardio-respiratory arrest due to ischemic heart failure related to superinfected COVID-19 pneumonia and pre-existing comorbidities. For the first time in the literature, PMCT imaging related to a fatal, autopsy case of breakthrough SARS-CoV-2 infection is reported. PMCT of the lungs, in accordance with histopathological results, showed few signs of COVID-19 pneumonia, large area of consolidation in the right lower lobe, interpreted as bronco-pneumonic focus, and hypostasis.

These findings were well-correlated with the previously reported literature about both PMCT and clinical CT imaging of the lungs in non-vaccinated individuals with early COVID-19 pneumonia and about pulmonary clinical CT imaging in COVID-19 pneumonia in breakthrough SARS-COV-2 infections.

Further studies are needed to cover the whole spectrum of PMCT lung imaging in fatal breakthrough SARS-CoV-2 infection, however, this case represent a first step for exploring this difficult challenge during SARS-CoV-2 pandemic using virtual autopsy.

Ethical and medico-legal issues of TOETVA procedure and simulation on cadavers: a scoping review

Conventional open thyroidectomy is still considered the gold standard for thyroid surgery. Transoral endoscopic thyroidectomy vestibular approach (also known as TOETVA) is often considered to be more advantageous than the other approaches, such as minimally invasive video assisted thyroidectomy, thyroidectomy via breast/axillary/retroauricular access, bilateral axillo-breast approach and axillo-bilateral breast approach. In this scoping review, we discuss the risks and the benefits of this surgical approach and its medico-legal and ethical implications, particularly focusing on the importance of practice on cadavers. Currently, there is little scientific evidence supporting TOETVA, since there are few papers on the comparison with the traditional open thyroidectomy that have been published and thus little data on the long-term outcomes of TOETVA are available. Since the better cosmetic outcome currently represents the main indication for this surgical technique, substantial medico-legal and ethical issues arise. Moreover, practice on cadavers can help surgeons to develop the technical and non-technical skills required to perform efficiently and safely this new surgical procedure.

Assessing the potentiality of algorithms and artificial intelligence adoption to disrupt patient primary care with a safer and faster medication management: a systematic review protocol

INTRODUCTION

In primary care, almost 75% of outpatient visits by family doctors and general practitioners involve continuation or initiation of drug therapy. Due to the enormous amount of drugs used by outpatients in unmonitored situations, the potential risk of adverse events due to an error in the use or prescription of drugs is much higher than in a hospital setting. Artificial intelligence (AI) application can help healthcare professionals to take charge of patient safety by improving error detection, patient stratification and drug management. The aim is to investigate the impact of AI algorithms on drug management in primary care settings and to compare AI or algorithms with standard clinical practice to define the medication fields where a technological support could lead to better results.

METHODS AND ANALYSIS

A systematic review and meta-analysis of literature will be conducted querying PubMed, Cochrane and ISI Web of Science from the inception to December 2021. The primary outcome will be the reduction of medication errors obtained by AI application. The search strategy and the study selection will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the population, intervention, comparator and outcome framework. Quality of included studies will be appraised adopting the quality assessment tool for observational cohort and cross-sectional studies for non-randomised controlled trials as well as the quality assessment of controlled intervention studies of National Institute of Health for randomised controlled trials.

ETHICS AND DISSEMINATION

Formal ethical approval is not required since no human beings are involved. The results will be disseminated widely through peer-reviewed publications.

Microbiological screening tests for SARS-CoV-2 in the first hour since the hospital admission: A reliable tool for enhancing the safety of pediatric care

INTRODUCTION/PURPOSE

Since a significant proportion of SARS-CoV-2 infections occur within healthcare facilities, a multidisciplinary approach is required for careful and timely assessment of the risk of infection in asymptomatic patients or those whose COVID-19 diagnosis has not yet been made. The aim of this study was to investigate whether an adaptative model based on microbiological testing can represent a valid risk management strategy.

MATERIAL AND METHODS

We collected data from the risk management unit database of a 1,550-bed tertiary hospital (Fondazione Policlinico Gemelli IRCCS, Rome, Italy) concerning pediatric admissions to the Emergency Department (ED) from 1 March 2020 to 31 December 2021. The study period was subdivided in period A and period B according to the technique used for the microbiological screening, respectively reverse-transcription polymerase chain reaction (RT-PCR) and antigen-detection test.

RESULTS

In Period A, 426 children (mean age: 6 years) underwent microbiological screening at the ED. The total number of molecular tests performed was 463. 459/463 tested negative at the molecular test. In Period B, 887 children (mean age: 6 years) underwent microbiological screening in the ED. The total number of molecular tests performed was 1,154. 1,117/1,154 tested negative at the molecular test. Neither in Period A nor in Period B hospital-acquired SARS-CoV-2 infections were reported.

DISCUSSION AND CONCLUSION

Despite high volumes, no cases of hospital-acquired SARS-CoV-2 infection have been reported. SARS-CoV-2 antigen-based tests can be used as a first-line option as they provide rapid results compared to RT-PCR, reducing the risk of infection in ED waiting rooms.

Trend in 167 cases of minors witnessing violence: The role played by COVID-19 pandemic

BACKGROUND

There currently is no evidence that COVID-19 has had an impact on the rates of psychological abuses occurring when a minor witnesses interpersonal violence.

AIM

Our aim was to describe the accesses of the last four years to the Emergency Department of a tertiary hospital (Careggi University Hospital-Florence, Italy) due to this issue and then to evaluate whether the COVID-19 has had an impact on this trend.

METHODS

We collected data regarding cases of abuse in which at least a minor had reportedly witnessed the event. Medical records stored between January 1, 2018 to January 1, 2022 were analyzed, extracting sex, age and nationality of the victim; sex of the perpetrator and relationship with the victim; known previous episodes of abuse in the medical history of the victim; setting of the abuse (domestic vs. non-domestic); type of abuse (physical, psychological, sexual); whether the perpetrator was under the influence of alcohol/drugs; whether the victim was hospitalized; prognosis of the victim; number, relation with the victim and involvement in the abuse (as co-victim) of the minor(s) who witnessed the abuse.

RESULTS

A total of 167 eligible cases were registered. 69% of victims had previous episodes of abuse. The perpetrators were all known and mainly males (96%).The abuses were mainly domestic (79%). In 74% of the cases only a type of violence was perpetrated. In 12% of the cases, the minors were also victims of physical abuse. No statistically significant relationships were found between the start of the COVID-19 pandemic and the changes in the number of cases of domestic abuse (p = 0.07), physical abuse (p = 0.62), psychological abuse (p = 0.83) or sexual abuse (p = 0.88). However, during the institutional lockdown in Italy (March-May 2022) only two cases occurred - a number that did not allow period-specific statistical inference.

CONCLUSIONS

Empowering the hospital policies specifically aimed at identifying and protecting the victims of violence/witnessed violence remains a critical goal from both a public health and medico-legal point of view.

Update on the Diagnostic Pitfalls of Autopsy and Post-Mortem Genetic Testing in Cardiomyopathies

Inherited cardiomyopathies are frequent causes of sudden cardiac death (SCD), especially in young patients. Despite at the autopsy they usually have distinctive microscopic and/or macroscopic diagnostic features, their phenotypes may be mild or ambiguous, possibly leading to misdiagnoses or missed diagnoses. In this review, the main differential diagnoses of hypertrophic cardiomyopathy (e.g., athlete's heart, idiopathic left ventricular hypertrophy), arrhythmogenic cardiomyopathy (e.g., adipositas cordis, myocarditis) and dilated cardiomyopathy (e.g., acquired forms of dilated cardiomyopathy, left ventricular noncompaction) are discussed. Moreover, the diagnostic issues in SCD victims affected by phenotype-negative hypertrophic cardiomyopathy and the relationship between myocardial bridging and hypertrophic cardiomyopathy are analyzed. Finally, the applications/limits of virtopsy and post-mortem genetic testing in this field are discussed, with particular attention to the issues related to the assessment of the significance of the genetic variants.

Respecting nasal mucosa during turbinate surgery: end of the dogma?

BACKGROUND

Chronic rhinitis with inferior turbinate hypertrophy is the most common cause of chronic nasal obstruction. Pharmacological treatment, mainly consisting of corticosteroids, is largely inadequate and, therefore, in the last few years several surgical techniques have been proposed (emptying, radiofrequency, cryotherapy, etc...). The aim of our work is to demonstrate that surgical removal of the inferior turbinate mucosa with the microdebrider, along with the submucosal chorion, results in a full restoration of mucosal physiological structure and function.

METHODOLOGY

Thirteen symptomatic adult patients were subjected to bilateral inferior partial turbinoplasty with the microdebrider. All patients underwent endoscopic examination, functional nasal tests and nasal mucosa biopsy before and after surgery.

RESULTS

The sensitivity in open airspaces improved after nasal surgery, and the results of functional tests returned to within a normal range. SEM examination confirmed that complete mucosal regeneration was within 4 months.

CONCLUSION

Total removal of the inferior turbinate mucosa with the microdebrider in patients suffering from hypertrophic chronic rhinitis allows the perfect regeneration of physiological respiratory tissue and doesn`t have a negative impact on healing time and offsets any adverse postoperative event.

[Is intermittent peritoneal dialysis with icodextrin a valid option in the long-term treatment of refractory congestive heart failure?]

Refractory congestive heart failure (CHF) is affected by a very high morbidity and mortality. We report our experience in the long-term treatment of refractory CHF (NYHA class IV) by means of intermittent peritoneal dialysis (PD) with icodextrin (ICO) solutions in 4 male patients with a mean age of 71.5 + or - 5.6 (standard deviation) years and with a variable degree of chronic renal failure: 1 nocturnal exchange with ICO in 3 patients and 2 exchanges (ICO + isotonic dextrose solution) in 1 patient. The mean PD follow-up period was 24.3 + 15.6 months. After stabilization on PD, all patients had a statistically significant increase in daily diuresis (from 587.5 + or - 165.2 to 1700.0 + or - 141.4 mL, p < 0.003), a statistically significant decrease in body weight (11.3 + or - 3.4 kg, p < 0.007), and a statistically significant improvement in NYHA class (from 4.0 + or - 0.0 to 2.5 + or - 2.6, p < 0.01). Three patients had no hospitalizations due to cardiac illness in the PD follow-up period. No episodes of peritonitis occurred. Three patients died after 11, 13 and 43 months of PD treatment: 2 because of sudden death and 1 because of neoplastic cachexia. No death could be attributed to any complication related to PD treatment. Intermittent PD with ICO solutions can be proposed as a long-term treatment modality for refractory CHF. It allows an improvement in quality - if not quantity - of life. Randomized controlled trials are needed to confirm the evidence derived from case reports.