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The limited availability of specialized image databases (particularly in hospitals, where tools vary between providers) makes it difficult to train deep learning models. This paper presents a few-shot learning methodology that uses a pre-trained ResNet integrated with an encoder as a backbone to encode conditional shape information for the classification of neonatal resuscitation equipment from less than 100 natural images. The model is also strengthened by incorporating a reliability score, which enriches the prediction with an estimation of classification reliability. The model, whose performance is cross-validated, reached a median accuracy performance of over 99% (and a lower limit of 73.4% for the least accurate model/fold) using only 87 meta-training images. During the test phase on complex natural images, performance was slightly degraded due to a sub-optimal segmentation strategy (FastSAM) required to maintain the real-time inference phase (median accuracy 87.25%). This methodology proves to be excellent for applying complex classification models to contexts (such as neonatal resuscitation) that are not available in public databases. Improvements to the automatic segmentation strategy prior to the extraction of conditional information will allow a natural application in simulation and hospital settings.

Background: Despite increased awareness of eosinophilic esophagitis (EoE), the diagnostic delay has remained stable over the past 3 decades. There is a need to improve the diagnostic performance and optimize resources allocation in the setting of EoE., Objective: We developed and validated 2 point-of-care machine learning (ML) tools to predict a diagnosis of EoE before histology results during office visits., Methods: We conducted a multicenter study in 3 European tertiary referral centers for EoE. We built predictive ML models using retrospectively extracted clinical and esophagogastroduodenoscopy (EGDS) data collected from 273 EoE and 55 non-EoE dysphagia patients. We validated the models on an independent cohort of 93 consecutive patients with dysphagia undergoing EGDS with biopsies at 2 different centers. Models' performance was assessed by area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV and NPV). The models were integrated into a point-of-care software package., Results: The model trained on clinical data alone showed an AUC of 0.90 and a sensitivity, specificity, PPV, and NPV of 0.90, 0.75, 0.80, and 0.87, respectively, for the diagnosis of EoE in the external validation cohort. The model trained on a combination of clinical and endoscopic data showed an AUC of 0.94, and a sensitivity, specificity, PPV, and NPV of 0.94, 0.68, 0.77, and 0.91, respectively, in the external validation cohort., Conclusion: Our software-integrated models (https://webapplicationing.shinyapps.io/PointOfCare-EoE/) can be used at point-of-care to improve the diagnostic workup of EoE and optimize resources allocation., (Copyright © 2024. Published by Elsevier Inc.)

Patient safety is a major concern in medicine. Approximately, 4 million infants die each year worldwide and 23% of these deaths are caused by perinatal asphyxia. To prevent the long-term damage of asphyxia, the resuscitation flowchart must be perfectly and promptly performed. However, high effectiveness in performing resuscitation can only be achieved and maintained if the algorithm is frequently executed. Therefore, maintaining a high level of patient care is difficult in some remote centres. The aim of this study was to evaluate the effectiveness of a new organizational model of care-network between Hub & Spoke hospitals to improve both the safety of the newborns in hospitals with a low number of births and the well-being of operators. Our project, NEO-SAFE (NEOnatal SAFety and training Elba), began in 2017 and involved the neonatal intensive care unit and the NINA Center of the Pisa University Hospital (hub) and the Hospital of Elba Island (spoke). It consisted of a continuous training program, both with 'classic' training course and 'on-job tutoring' (on side and remotely), of the health workers at spoke (i.e. nurses, midwives, and paediatricians). All four milestones of the study design were achieved. During the project, NINA Center instructors organized training courses for the staff in Portoferraio. These courses were based on learning technical and non-technical skills in a training course of increasing difficulty. Staff training needs were also monitored during the project by means of periodic questionnaires, sentinel events, and specific requests. The curve described by the rate of newborns transfer to the Pisa neonatal intensive care unit (hub) shows a monotonous decreasing trend line. On the other hand, this project allowed operators to develop greater self-confidence and greater safety in managing emergency situations, reducing stress for them and improving patient safety. The project allowed the creation of a safe, effective, low-cost, and reproducible organizational model for centres with a low number of births. Moreover, the tele-medicine approach is an important improvement in the assistance and is a window on the future., (© The Author(s) 2023. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Serious games, and especially digital game based learning (DGBL) methodologies, have the potential to strengthen classic learning methodology in all medical procedures characterized by a flowchart (e.g., neonatal resuscitation algorithm). However, few studies have compared short- and long-term knowledge retention in DGBL methodologies with a control group undergoing specialist training led by experienced operators. In particular, resident doctors' learning still has limited representation in simulation-based education literature., Objective: A serious computer game DIANA ( DI gital A pplication in N ewborn A ssessment) was developed, according to newborn resuscitation algorithm, to train pediatric/neonatology residents in neonatal resuscitation algorithm knowledge and implementation (from procedure knowledge to ventilation/chest compressions rate). We analyzed user learning curves after each session and compared knowledge retention against a classic theoretical teaching session., Methods: Pediatric/neonatology residents of the Azienda Ospedaliera Universitaria Pisana (AOUP) were invited to take part in the study and were split into a game group or a control group; both groups were homogeneous in terms of previous training and baseline scores. The control group attended a classic 80 min teaching session with a neonatal trainer, while game group participants played four 20 min sessions over four different days. Three written tests (pre/immediately post-training and at 28 days) were used to evaluate and compare the two groups' performances., Results: Forty-eight pediatric/neonatology residents participated in the study. While classic training by a neonatal trainer demonstrated an excellent effectiveness in short/long-term knowledge retention, DGBL methodology proved to be equivalent or better. Furthermore, after each game session, DGBL score improved for both procedure knowledge and ventilation/chest compressions rate., Conclusions: In this study, DGBL was as effective as classic specialist training for neonatal resuscitation in terms of both algorithm memorization and knowledge retention. User appreciation for the methodology and ease of administration, including remotely, support the use of DGBL methodologies for pediatric/neonatology residents education., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Bardelli, Del Corso, Ciantelli, Del Pistoia, Lorenzoni, Fossati, Scaramuzzo and Cuttano.)

Background: In recent years, medical training has significantly increased the use of simulation for teaching and evaluation. The retraining of medical personnel in Italy is entrusted to the program of Continuous Education in Medicine, mainly based on theoretical training. The aim of this study is to assess whether the use of a new sensorized platform for the execution of the neonatal intubation procedure in simulation environment can complement theoretical retraining of experienced health professionals., Methods: Neonatal intubation tests were performed using a commercial manikin and a modified video-laryngoscope by the addition of force and position sensors, which provide the user with feedback when the threshold is exceeded. Two categories carried out the simulation tests: anesthesiologists and pediatricians. The categories were divided into three groups each, and various configurations were tested: the first group of both specialists carried out the tests without feedback (i.e. control groups, gr. A and A1), the second groups received sound and visual feedback from the instrument (gr. B and B1) and the third ones had also the support of a physician expert in the use of the instrument (gr. C and C1). The instrumentation used by pediatricians was provided in a playful form, including a game with increasing difficulty levels., Results: Both in the case with feedback only and in the case with humans support, anesthesiologists did not show a specific trend of improvement. Pediatricians, in comparison with anesthesiologists, showed a positive reaction to both the presence of feedback and that of experienced personnel. Comparing the performance of the two control groups, the two categories of experienced doctors perform similar forces. Pediatricians enjoyed the "Level Game", through which they were able to test and confront themselves, trying to improve their own performance., Conclusions: Our instrument is more effective when is playful and competitive, introducing something more than just a sound feedback, and allowing training by increasing levels. It is more effective if the users can adapt their own technique to the instrument by themselves, without any external help.

Already during embryonic development, the heart and the lung are thoroughly connected organs. Their interdependence allows our survival in the terrestrial environment by coupling cardiac output and gas exchange. The knowledge on developmental processes involving stem and progenitor cells is crucial to understand the onset of human cardiopulmonary diseases. The precise identification of various adult endogenous progenitors is still incomplete. Thus, caution should be exercised on newly available stem cell-based treatments until specific mechanisms of action are disclosed. The objective is to provide in the nearest future feasible and safer cell therapeutics for the complex pathological condition of human cardiopulmonary diseases. In this paper, we highlight the significant knowledge advancement concerning stem and progenitor cells in the cardiopulmonary field: from embryonic development to adult progenitors until early preclinical models for cardiopulmonary regeneration.

The interactions between stem cells and their surrounding microenvironment are pivotal to determine tissue homeostasis and stem cell renewal or differentiation and regeneration in vivo . Ever since they were postulated in 1978, stem cell niches have been identified and characterized in many germline and adult tissues. Comprehensive studies over the last decades helped to clarify the critical components of stem cell niches that include cellular, extracellular, biochemical, molecular, and physical regulators. This knowledge has direct impact on their inherent regenerative potential. Clinical applications demand readily available cell sources that, under controlled conditions, provide a specific therapeutic function. Thus, translational medicine aims at optimizing in vitro or in vivo the various components and complex architecture of the niche to exploit its therapeutic potential. Accordingly, the objective is to recreate the natural niche microenvironment during cell therapy process development and closely comply with the requests of regulatory authorities. In this paper, we review the most recent advances of translational medicine approaches that target the adult stem cell natural niche microenvironment for regenerative medicine applications.

Cardiovascular diseases, including heart failure, are the most frequent cause of death annually, even higher than any other pathologies. Specifically, patients who suffer from myocardial infarction may encounter adverse remodeling processes of the heart that can ultimately lead to heart failure. Prognosis of patients affected by heart failure is very poor with 5-year mortality close to 50 %. Despite the impressive progress in the clinical treatment of heart failure in recent years, heart transplantation is still required to avoid death as the result of the inexorable decline in cardiac function. Unfortunately, the availability of donor human hearts for transplantation largely fails to cover the number of potential recipient requests. From this urgent unmet clinical need the interest in stem cell applications for heart regeneration made its start, and has rapidly grown in the last decades. Indeed, the discovery and application of stem and progenitor cells as therapeutic agents has raised substantial interest with the objective of reversing these processes, and ultimately inducing cardiac regeneration. In this scenario, the role of biobanking may play a remarkable role to provide cells at the right time according to the patient's clinical needs, mostly for autologous use in the acute setting of myocardial infarction, largely reducing the time needed for cell preparation and expansion before administration.

Rationale: According to the immortal DNA strand hypothesis, dividing stem cells selectively segregate chromosomes carrying the old template DNA, opposing accumulation of mutations resulting from nonrepaired replication errors and attenuating telomere shortening., Objective: Based on the premise of the immortal DNA strand hypothesis, we propose that stem cells retaining the old DNA would represent the most powerful cells for myocardial regeneration., Methods and Results: Division of human cardiac stem cells (hCSCs) by nonrandom and random segregation of chromatids was documented by clonal assay of bromodeoxyuridine-tagged hCSCs. Additionally, their growth properties were determined by a series of in vitro and in vivo studies. We report that a small class of hCSCs retain during replication the mother DNA and generate 2 daughter cells, which carry the old and new DNA, respectively. hCSCs with immortal DNA form a pool of nonsenescent cells with longer telomeres and higher proliferative capacity. The self-renewal and long-term repopulating ability of these cells was shown in serial-transplantation assays in the infarcted heart; these cells created a chimeric organ, composed of spared rat and regenerated human cardiomyocytes and coronary vessels, leading to a remarkable restoration of cardiac structure and function. The documentation that hCSCs divide by asymmetrical and symmetrical chromatid segregation supports the view that the human heart is a self-renewing organ regulated by a compartment of resident hCSCs., Conclusions: The impressive recovery in ventricular hemodynamics and anatomy mediated by clonal hCSCs carrying the "mother" DNA underscores the clinical relevance of this stem cell class for the management of heart failure in humans.

Background: Although progenitor cells have been described in distinct anatomical regions of the lung, description of resident stem cells has remained elusive., Methods: Surgical lung-tissue specimens were studied in situ to identify and characterize human lung stem cells. We defined their phenotype and functional properties in vitro and in vivo., Results: Human lungs contain undifferentiated human lung stem cells nested in niches in the distal airways. These cells are self-renewing, clonogenic, and multipotent in vitro. After injection into damaged mouse lung in vivo, human lung stem cells form human bronchioles, alveoli, and pulmonary vessels integrated structurally and functionally with the damaged organ. The formation of a chimeric lung was confirmed by detection of human transcripts for epithelial and vascular genes. In addition, the self-renewal and long-term proliferation of human lung stem cells was shown in serial-transplantation assays., Conclusions: Human lungs contain identifiable stem cells. In animal models, these cells participate in tissue homeostasis and regeneration. They have the undemonstrated potential to promote tissue restoration in patients with lung disease. (Funded by the National Institutes of Health.).

Multipotent mesenchymal stromal cells (MSCs) are a type of adult stem cells that can be easily isolated from various tissues and expanded in vitro. Many reports on their pluripotency and possible clinical applications have raised hopes and interest in MSCs. In an attempt to unify the terminology and the criteria to label a cell as MSC, in 2006 the International Society for Cellular Therapy (ISCT) proposed a standard set of rules to define the identity of these cells. However, MSCs are still extracted from different tissues, by diverse isolation protocols, are cultured and expanded in different media and conditions. All these variables may have profound effects on the selection of cell types and the composition of heterogeneous subpopulations, on the selective expansion of specific cell populations with totally different potentials and ergo, on the long-term fate of the cells upon in vitro culture. Therefore, specific molecular and cellular markers that identify MSCs subsets as well as standardization of expansion protocols for these cells are urgently needed. Here, we briefly discuss new useful markers and recent data supporting the rapidly emerging concept that many different types of progenitor cells are found in close association with blood vessels. This knowledge may promote the necessary technical improvements required to reduce variability and promote higher efficacy and safety when isolating and expanding these cells for therapeutic use. In the light of the discussed data, particularly the identification of new markers, and advances in the understanding of fundamental MSC biology, we also suggest a revision of the 2006 ISCT criteria.

Rationale: The turnover of cardiomyocytes in the aging female and male heart is currently unknown, emphasizing the need to define human myocardial biology., Objective: The effects of age and gender on the magnitude of myocyte regeneration and the origin of newly formed cardiomyocytes were determined., Methods and Results: The interaction of myocyte replacement, cellular senescence, growth inhibition, and apoptosis was measured in normal female (n=32) and male (n=42) human hearts collected from patients 19 to 104 years of age who died from causes other than cardiovascular diseases. A progressive loss of telomeric DNA in human cardiac stem cells (hCSCs) occurs with aging and the newly formed cardiomyocytes inherit short telomeres and rapidly reach the senescent phenotype. Our data provide novel information on the superior ability of the female heart to sustain the multiple variables associated with the development of the senescent myopathy. At all ages, the female heart is equipped with a larger pool of functionally competent hCSCs and younger myocytes than the male myocardium. The replicative potential is higher and telomeres are longer in female hCSCs than in male hCSCs. In the female heart, myocyte turnover occurs at a rate of 10%, 14%, and 40% per year at 20, 60, and 100 years of age, respectively. Corresponding values in the male heart are 7%, 12%, and 32% per year, documenting that cardiomyogenesis involves a large and progressively increasing number of parenchymal cells with aging. From 20 to 100 years of age, the myocyte compartment is replaced 15 times in women and 11 times in men., Conclusions: The human heart is a highly dynamic organ regulated by a pool of resident hCSCs that modulate cardiac homeostasis and condition organ aging.

Stem cells contribute to innate healing and harbor a promising role for regenerative medicine. Stem cell banking through long-term storage of different stem cell platforms represents a fundamental source to preserve original features of stem cells for patient-specific clinical applications. Stem cell research and clinical translation constitute fundamental and indivisible modules catalyzed through biobanking activity, generating a return of investment.

Rationale: Chronic rejection, accelerated coronary atherosclerosis, myocardial infarction, and ischemic heart failure determine the unfavorable evolution of the transplanted heart in humans., Objective: Here we tested whether the pathological manifestations of the transplanted heart can be corrected partly by a strategy that implements the use of cardiac progenitor cells from the recipient to repopulate the donor heart with immunocompatible cardiomyocytes and coronary vessels., Methods and Results: A large number of cardiomyocytes and coronary vessels were created in a rather short period of time from the delivery, engraftment, and differentiation of cardiac progenitor cells from the recipient. A proportion of newly formed cardiomyocytes acquired adult characteristics and was integrated structurally and functionally within the transplant. Similarly, the regenerated arteries, arterioles, and capillaries were operative and contributed to the oxygenation of the chimeric myocardium. Attenuation in the extent of acute damage by repopulating cardiomyocytes and vessels decreased significantly the magnitude of myocardial scarring preserving partly the integrity of the donor heart., Conclusions: Our data suggest that tissue regeneration by differentiation of recipient cardiac progenitor cells restored a significant portion of the rejected donor myocardium. Ultimately, immunosuppressive therapy may be only partially required improving quality of life and lifespan of patients with cardiac transplantation.

Primitive cells capable of generating small resistance arterioles and capillary structures in the injured myocardium have been identified repeatedly. However, these cells do not form large conductive coronary arteries that would have important implications in the management of the ischemic heart. In the current study, we determined whether the human heart possesses a class of progenitor cells that regulates the growth of endothelial cells (ECs) and smooth muscle cells (SMCs) and vasculogenesis. The expression of vascular endothelial growth-factor receptor 2 (KDR) was used, together with the stem cell antigen c-kit, to isolate and expand a resident coronary vascular progenitor cell (VPC) from human myocardial samples. Structurally, vascular niches composed of c-kit-KDR-positive VPCs were identified within the walls of coronary vessels. The VPCs were connected by gap junctions to ECs, SMCs, and fibroblasts that operate as supporting cells. In vitro, VPCs were self-renewing and clonogenic and differentiated predominantly into ECs and SMCs and partly into cardiomyocytes. To establish the functional import of VPCs, a critical stenosis was created in immunosuppressed dogs, and tagged human VPCs were injected in proximity to the constricted artery. One month later, there was an increase in coronary blood flow (CBF) distal to the stenotic artery, resulting in functional improvement of the ischemic myocardium. Regenerated large, intermediate, and small human coronary arteries and capillaries were found. In conclusion, the human heart contains a pool of VPCs that can be implemented clinically to form functionally competent coronary vessels and improve CBF in patients with ischemic cardiomyopathy.

Redox effector protein-1 (Ref-1) plays an essential role in DNA repair and redox regulation of several transcription factors. In the present study, we examined the role of Ref-1 in maintaining the redox status and survivability of adult cardiac stem cells challenged with a subtoxic level of H2O2 under inhibition of Ref-1 by RNA interference. Treatment of cardiac stem cells with a low concentration of H2O2 induced Ref-1-mediated survival signaling through phosphorylation of Akt. However, Ref-1 inhibition followed by H2O2 treatment extensively induced the level of intracellular reactive oxygen species (ROS) through activation of the components of NADPH oxidase, like p22( phox ), p47( phox ), and Nox4. Cardiac differentiation markers (Nkx2.5, MEF2C, and GATA4), and cell death by apoptosis were significantly elevated in Ref-1 siRNA followed by H2O2-treated stem cells. Further, inhibition of Ref-1 increased the level of p53 but decreased the phosphorylation of Akt, a molecule involved in survival signaling. Treatment with ROS scavenger N-acetyl-L-cysteine attenuated Ref-1 siRNA-mediated activation of NADPH oxidase and cardiac differentiation. Taken together, these results indicate that Ref-1 plays an important role in maintaining the redox status of cardiac stem cells and protects them from oxidative injury-mediated cell death and differentiation.

Observations of distant supernovae indicate that the Universe is now in a phase of accelerated expansion the physical cause of which is a mystery. Formally, this requires the inclusion of a term acting as a negative pressure in the equations of cosmic expansion, accounting for about 75 per cent of the total energy density in the Universe. The simplest option for this 'dark energy' corresponds to a 'cosmological constant', perhaps related to the quantum vacuum energy. Physically viable alternatives invoke either the presence of a scalar field with an evolving equation of state, or extensions of general relativity involving higher-order curvature terms or extra dimensions. Although they produce similar expansion rates, different models predict measurable differences in the growth rate of large-scale structure with cosmic time. A fingerprint of this growth is provided by coherent galaxy motions, which introduce a radial anisotropy in the clustering pattern reconstructed by galaxy redshift surveys. Here we report a measurement of this effect at a redshift of 0.8. Using a new survey of more than 10,000 faint galaxies, we measure the anisotropy parameter beta = 0.70 +/- 0.26, which corresponds to a growth rate of structure at that time of f = 0.91 +/- 0.36. This is consistent with the standard cosmological-constant model with low matter density and flat geometry, although the error bars are still too large to distinguish among alternative origins for the accelerated expansion. The correct origin could be determined with a further factor-of-ten increase in the sampled volume at similar redshift.

Background: The stromal vascular fraction (SVF) is a heterogeneous cell population derived from the adipose tissue. There is still a lack of information concerning the characterization of the cell subpopulations constituting the SVF as well as its mesenchymal and haematopoietic potential. Furthermore there are great variations in its phenotypical characterization., Methods: Composition of SVF was investigated by FACS analysis, cytological and "in vitro" assays. We studied CD34+ population by combining FACS with human CFC (colony-forming-cell haematopoietic assay). The endothelial fraction was investigated by quantifying the co-expression of specific markers (CD146, CD105, CD31 and UEA-1). Mesenchymal potential was assessed by CFU-F assay and cultured AT-MSC were characterized by a 5-color FACS analysis. The multipotent differentiation potential (osteogenic, adipogenic and chondrogenic) was investigated both at cellular and molecular level., Results: We identified in the SVF two CD34+ populations with a marked difference in the intensity of antigen expression, the majority of the cells expressing CD34 at low intensity. Moreover, two CD146+ cell populations were clearly distinguishable in the SVF:a CD146 dim accounting for 9.9% of the total SVF cells and a CD146+ bright cell population accounting for about 39.3%. The frequency of CFC clones was comparable with the one reported for peripheral blood. Endothelial cells account for about 7.7% of the SVF cells. AT-MSC differenced in the osteogenic adipogenic and chondrogenic lineage., Conclusion: The SVF is not a homogeneous cell population, and its final composition could be influenced both by the flow cytometric technique analysis and the SVF extraction steps. The CFU-F frequency in the SVF was 1/4880, a value about seven times greater than the data reported for bone marrow. The antigenic profile of AT-MSC was comparable with bone-marrow derived MSC. AT-MSC were able to differentiate along the osteogenic adipogenic and chondrogenic lineages. The data here reported, further contribute to the characterization of SVF, a tissue providing an alternative as a source of MSC for clinical applications.

To understand the evolution of galaxies, we need to know as accurately as possible how many galaxies were present in the Universe at different epochs. Galaxies in the young Universe have hitherto mainly been identified using their expected optical colours, but this leaves open the possibility that a significant population remains undetected because their colours are the result of a complex mix of stars, gas, dust or active galactic nuclei. Here we report the results of a flux-limited I-band survey of galaxies at look-back times of 9 to 12 billion years. We find 970 galaxies with spectroscopic redshifts between 1.4 and 5. This population is 1.6 to 6.2 times larger than previous estimates, with the difference increasing towards brighter magnitudes. Strong ultraviolet continua (in the rest frame of the galaxies) indicate vigorous star formation rates of more than 10-100 solar masses per year. As a consequence, the cosmic star formation rate representing the volume-averaged production of stars is higher than previously measured at redshifts of 3 to 4.

The region 6q27 from human chromosome 6 has been reported to contain one or more tumor suppressor genes on the basis of cytogenetic, molecular and functional studies. We have recently carried out a detailed analysis of a candidate gene from 6q27 to evaluate its putative role as a tumor suppressor gene involved in ovarian cancer pathogenesis. The RNASET2 gene was shown to behave as a class II tumor suppressor and abolish the tumorigenic potential of an ovarian cancer-derived cell line. In this study, we have started the cellular and biochemical characterization of RNASET2 and showed that it is a secreted glycoprotein. Moreover, we have extended our previous studies by evaluating the effect of RNASET2 on the metastatic behavior of the highly-invasive ovarian cancer cell line HEY3MET2. From such analysis, RNASET2 was found to significantly decrease the metastatic potential of this cell line in vivo. Moreover, RNASET2-mediated suppression of tumorigenesis and metastasis was not affected by a double point mutation targeted to the putative ribonuclease catalytic sites, suggesting that tumor suppression by RNASET2 is not mediated by its ribonuclease activity. The potential biological implications of this unexpected finding are discussed in relation to the current evolutionary models.