The spread in time and space of COVID-19 pandemic waves: the Italian experience from mortality data analyses.

Introduction: Italy was the first European country affected by COVID-19. Thanks to governmental containment measures (9 March 2020), the spread of COVID-19 was limited. However, in this context, accurate data assessment is crucial and mortality is a more reliable indicator of the virus spread compared to the count of positive cases. This study aimed to retrospectively evaluate the impact of the pandemic in different areas of Italy using the time series analysis of official deaths and excess COVID-19 deaths. Methods: Mortality data (23 February-30 April 2022) by Istituto Nazionale di Statistica (ISTAT) were analyzed, including four waves of COVID-19. Previous mortality data (January 2015-November 2019) were used to estimate a Poisson regression model of the pre-pandemic mortality pattern and derive the excess COVID-19 deaths as the difference between the actual deaths number and the extrapolation of the previous mortality pattern to the pandemic period, separately for Northern, Central, and Southern Italy, to compare the impact of mortality across time periods and geographical areas. Results: Estimated excess compared with official COVID-19 mortality shows that, during the first wave, there was an underestimation of deaths. COVID-19 mortality rate almost doubled the official rate in the North (1.60‰ vs. 0.86‰) and nearly tripled it in the South (0.22‰ vs. 0.08‰). In late 2020-early 2021, official and estimated mortality curves are closer, displaying just a small gap at the start of the second wave. During the fourth wave (end of 2021-early 2022), Northern and Central Italy show reasonable agreement; the South presents a large relative underestimation of deaths (+90% increase), with a large increase in its excess deaths national quota, 9% in the first wave to 42% in the fourth. Discussion: The results provide a measure of the COVID-19 excess deaths and an unbiased estimate of Italian mortality rates. In the first wave, the gap between official COVID-19 and excess mortality was particularly high and lockdown measures may have reduced the spread of the infection. In the fourth wave, the gap for the South increases again, probably because the healthcare system may not have coped with the prolonged pressure of the pandemic, or for a decreased compliance with the official paper-based mortality surveillance system that could be overcome in the future by digitalizing the process.

Effects of cannabis smoking on the respiratory system: A state-of-the-art review.

The diminished perception of the health risks associated with the consumption of cannabis (marijuana) lead to a progressive increase in its inhalational use in many countries. Cannabis can be smoked through the use of joints, spliffs and blunts, and it can be vaporised with the use of hookah or e-cigarettes. Delta-9 tetrahydrocannabinol (THC) is the main psychoactive component of cannabis smoke but contains numerous other substances. While the recreational use of cannabis smoking has been legalised in several countries, its health consequences have been underestimated and undervalued. The purpose of this review is to critically review the impact of cannabis smoke on the respiratory system. Cannabis smoke irritates the bronchial tree and is strongly associated with symptoms of chronic bronchitis, with histological signs of airway inflammation and remodelling. Altered fungicidal and antibacterial activity of alveolar macrophages, with greater susceptibility to respiratory infections, is also reported. The association with invasive pulmonary aspergillosis in immunocompromised subjects is particularly concerning. Although cannabis has been shown to produce a rapid bronchodilator effect, its chronic use is associated with poor control of asthma by numerous studies. Cannabis smoking also represents a risk factor for the development of bullous lung disease, spontaneous pneumothorax and hypersensitivity pneumonitis. On the other hand, no association with the development of chronic obstructive pulmonary disease was found. Finally, a growing number of studies report an independent association of cannabis smoking with the development of lung cancer. In conclusion, unequivocal evidence established that cannabis smoking is harmful to the respiratory system. Cannabis smoking has a wide range of negative effects on respiratory symptoms in both healthy subjects and patients with chronic lung disease. Given that the most common and cheapest way of assumption of cannabis is by smoking, healthcare providers should be prepared to provide counselling on cannabis smoking cessation and inform the public and decision-makers.

Thirdhand Smoke Knowledge, Beliefs and Behaviors among Parents and Families: A Systematic Review.

Families play a primary role in protecting children. Thirdhand smoke (THS) is an underestimated public health issue, and health effects correlated to its exposition are emerging. The aim of this systematic review was to analyze papers focusing on knowledge, beliefs, and behaviors regarding THS among parents, families, and caregivers, published until May 2022 on MEDLINE, CINAHL, EMBASE, and the Cochrane Library. Critical appraisal of the included studies was conducted by two independent reviewers using the Joanna Briggs Institute Critical Appraisal tool. Out of the 97 articles, 8 were included in this review (two from the USA, one from Europe, and five from Asia). Although there were no restrictions on the date of publication, all the articles were published in the last 10 years, underlining that THS is an emerging concept. They were characterized by relevant heterogeneity in the study design and assessment tools. The results showed that percentages of parents who believed that THS is harmful ranged from 42.4% to 91%, but parental awareness was not always associated with the adoption of a home- and car-smoking ban or healthy behaviors. Further research is needed to understand the resistance and problems faced by parents who are aware of THS risks but unable to improve good practices.

Translation and validation of the Italian version of the incivility in nursing education-revised scale.

BACKGROUND: Incivility in nursing education is present worldwide and impacts all those involved and the teacher-student relationship. The revised Incivility in Nursing Education (INE-R) is a validated and reliable instrument to measure academic incivility, but it is not available in Italian language. The aim of the study was to translate and validate the INE-R tool with an Italian sample. METHODS: The INE-R was translated from English into Italian, culturally adapted and piloted for content and linguistic clarity. The questionnaire was administered online to Nursing Faculty (NF) and Nursing Students (NS) of Sapienza University of Rome to assess uncivil behaviors and their frequency of occurrence. The psychometric properties of the Italian version were investigated. RESULTS: 79 Italians participated, of which 63.3 % were NS. Four-factor models provided the best fit for NF and NS scales. The models explained 78.2 % (NF) and 73.2 % (NS) of the variance of the scales. The Root Mean Square Error of Approximation for both models was 0.07, indicating an acceptable fit. INE-R reliability for all 48 NF and NS incivility items was 0.962 and 0.954, respectively. Measuring the degree of incivility and establishing codes of conduct were recommended. CONCLUSIONS: Incivility in nursing education negatively impacts the teaching-learning environment and could cause emotional or physical distress for those involved. Zero-tolerance policy regarding incivility, routine evaluation, and raising awareness among students and faculty could improve the quality of academic settings. The Italian INE-R is a valid and reliable tool that can be used to evaluate incivility in Italian nursing programs.

The clinical impact of continued smoking in patients with breast and other hormone-dependent cancer: A systematic literature review.

We conducted a systematic review of studies that investigated whether quitting smoking at or around diagnosis improves survival of patients with hormone-dependent cancers (HDC). Nine studies published in 2013-2022 were included. Studies were very diverse in terms of design, definition of quitters and continued smokers, and prevalence of prognostic factors other than smoking cessation (e.g. patients' demographics, tumour characteristic, and treatments). For breast, ovarian, and endometrial cancer, all included studies found that quitters had better overall, disease specific, and disease-free survival than continued smokers. For prostate cancer, there was no evidence of an association of smoking cessation with improved survival. This literature review provided suggestive evidence that female smokers diagnosed with cancer of the breast, ovary, or endometrium may improve their chances of surviving by stopping smoking. Smoking cessation counselling should become part of standard oncological care for these patients and integrated into breast cancer screening programs.

The Association of Tobacco Smoking, Second-hand Smoke, and Novel Tobacco Products With COVID-19 Severity and Mortality in Italy: Results From the COSMO-IT Study.

BACKGROUND: Despite the robust evidence of an excess risk of coronavirus disease 2019 (COVID-19) severity and mortality in ever smokers, the debate on the role of current and ex-smokers on COVID-19 progression remains open. Limited or no data are available on the link between electronic cigarette (e-cigarette), heated tobacco product (HTP) and second-hand smoke (SHS) exposure and COVID-19 progression. To fill this knowledge gap, we undertook the COvid19 and SMOking in ITaly (COSMO-IT) study. METHODS: A multi-centre longitudinal study was conducted in 2020-2021 in 24 Italian hospitals on a total of 1,820 laboratory-confirmed COVID-19 patients. We estimated multivariable odds ratios (OR) and 95% confidence intervals (CI) to quantify the association between smoking-related behaviours (ie, smoking status, e-cigarette and HTP use, and SHS exposure) and COVID-19 severity (composite outcome: intubation, intensive care unit admission and death) and mortality. RESULTS: Compared to never smokers, current smokers had an increased risk of COVID-19 mortality (OR 2.17; 95% CI, 1.06-4.41). E-cigarette use was non-significantly associated to an increased risk of COVID-19 severity (OR 1.60; 95% CI, 0.96-2.67). An increased risk of mortality was observed for exposure to SHS among non-smokers (OR 1.67; 95% CI, 1.04-2.68), the risk being particularly evident for exposures of ≥6 hours/day (OR 1.99; 95% CI, 1.15-3.44). CONCLUSION: This multicentric study from Italy shows a dismal COVID-19 progression in current smokers and, for the first time, in SHS exposed non-smokers. These data represent an additional reason to strengthen and enforce effective tobacco control measures and to support smokers in quitting.

SARS-CoV-2 Infection in San Patrignano, the Largest European Drug Rehabilitation Community.

BACKGROUND: Studies on SARS-CoV-2 conducted in confined settings for prolonged times allow researchers to assess how the coronavirus spreads. San Patrignano (SP), Italy, is the largest European drug rehabilitation facility. METHODS: Between 15 October and 31 December 2020, all SP residents were tested for SARS-CoV-2. We analyzed the relationships between individual characteristics and being SARS-CoV-2-positive. Three selected predictive models were used to calculate the number of expected hospitalizations. For each model, we summed the estimated individual risks to obtain the expected number of hospitalizations in our sample, and we tested whether the observed and expected numbers differed. RESULTS: Of 807 residents, 529 (65.6%) were SARS-CoV-2-positive. Of these 323 (61.1%) were symptomatic. A strong relationship was found between being positive and living connections (p-value < 0.001). No statistically significant relationship was found with age, sex, smoking history, or comorbidities. Although 9 to 17 hospitalizations were expected, no hospitalizations were observed (p-value < 0.001). No one died of COVID-19. CONCLUSIONS: The peculiar characteristics of SP residents or the SP environment might at least partially explain the null hospitalization rates. Despite the extreme uniqueness of our population and despite the protected environment and all precautions that were taken, the fact that the virus was able to circulate and infect a large portion of the population highlights the fundamental role of social interactions in the spread of the disease.

The Prognostic Impact of Quitting Smoking at or around Diagnosis on the Survival of Patients with Gastrointestinal Cancers: A Systematic Literature Review.

Cigarette smoking is a strong risk factor for the occurrence of gastrointestinal cancers, and a substantial proportion of newly diagnosed patients is made up of active smokers, yet the impact of smoking cessation at or around diagnosis on the clinical course of these cancers (whose prognosis is often unfavourable) has never been summarized to date. We reviewed studies published until 30 April 2022 that investigated whether smoking cessation at or around diagnosis favourably affects the clinical course of gastrointestinal cancers patients. Six studies were included for colorectal cancer patients, which provided limited yet suggestive evidence that quitters may have longer disease-specific survival compared to continued smokers. Only one study each focused on patients with gastric or HBV-positive liver cancer (both reporting a survival advantage for quitters vs. continued smokers), while we found no eligible studies for patients with cancer at other sites within the digestive system. More research is urgently needed to expand the evidence on the topic, given the potentially major clinical implications for these patients. Moreover, health professionals should provide the necessary smoking cessation support to any smoker who is undergoing diagnostic work-up or treatment for gastrointestinal cancer.

Cigarette Smoking and Human Gut Microbiota in Healthy Adults: A Systematic Review.

The intestinal microbiota is a crucial regulator of human health and disease because of its interactions with the immune system. Tobacco smoke also influences the human ecosystem with implications for disease development. This systematic review aims to analyze the available evidence, until June 2021, on the relationship between traditional and/or electronic cigarette smoking and intestinal microbiota in healthy human adults. Of the 2645 articles published in PubMed, Scopus, and Web of Science, 13 were included in the review. Despite differences in design, quality, and participants' characteristics, most of the studies reported a reduction in bacterial species diversity, and decreased variability indices in smokers' fecal samples. At the phylum or genus level, the results are very mixed on bacterial abundance both in smokers and non-smokers with two exceptions. Prevotella spp. appears significantly increased in smokers and former smokers but not in electronic cigarette users, while Proteobacteria showed a progressive increase in Desulfovibrio with the number of pack-years of cigarette (p = 0.001) and an increase in Alphaproteobacteria (p = 0.04) in current versus never smokers. This attempt to systematically characterize the effects of tobacco smoking on the composition of gut microbiota gives new perspectives on future research in smoking cessation and on a new possible use of probiotics to contrast smoke-related dysbiosis.

Can Physical Activity Influence Human Gut Microbiota Composition Independently of Diet? A Systematic Review.

Evidence suggests that physical activity (PA) influences the human gut microbiota composition, but its role is unclear because of dietary interference. The aim of this review is to clarify this issue from this new perspective in healthy individuals. Articles analyzing intestinal microbiota from fecal samples by 16S rRNA amplicon sequencing were selected by searching the electronic databases PubMed, Scopus, and Web of Science until December 2020. For each study, methodological quality was assessed, and results about microbiota biodiversity indices, phylum and genus composition, and information on PA and diet were considered. From 997 potentially relevant articles, 10 met the inclusion criteria and were analyzed. Five studies involved athletes, three were performed on active people classified on the basis of habitual PA level, and two among sedentary subjects undergoing exercise interventions. The majority of the studies reported higher variability and prevalence of the phylum Firmicutes (genera Ruminococcaceae or Fecalibacteria) in active compared to inactive individuals, especially in athletes. The assessment of diet as a possible confounder of PA/exercise effects was completed only in four studies. They reported a similar abundance of Lachnospiraceae, Paraprevotellaceae, Ruminococcaceae, and Veillonellaceae, which are involved in metabolic, protective, structural, and histological functions. Further studies are needed to confirm these findings.

Smoking prevalence among healthcare workers in Italy, PASSI surveillance system data, 2014-2018.

INTRODUCTION: Data on smoking among Italian Health Personnel (HP) from PASSI surveillance system from 2014-2018 were analysed. MATERIALS AND METHODS: Among 169,678 working-age respondents, smoking prevalence was estimated among 1,253 Medical Doctors (MDs), 4,840 Non-Medical HP (NMHP), 87,749 Non-HP (NHP) and multivariate analysis was conducted. RESULTS: Current smokers were 23.0% among HP. Smoking prevalence in MDs (16.0%) was significantly lower than those observed in NMHP (25.3%) and NHP (28.6%). A declining trend was detected in all three groups and was more evident among MDs: from 20.8% in 2014 to 11.5% in 2018. Amongst MDs, smoking was significantly associated with male gender (Adjusted Odds Ratio, AdjOR=1.61), younger age (AdjOR=2.00), residing in South (AdjOR=1.71). Among NMHP, smoking prevalence was associated with low economic condition (AdjOR=1.54) and non-university education. DISCUSSION AND CONCLUSIONS: To further reduce smoking in HP, it is necessary to develop specific training courses in educational curricula.

Direct imaging evidences of metal inorganic contaminants traced into cigarettes.

Today, environmental health research on toxicological adverse effects of metal-inorganic materials diffused by cigarettes represents a new challenge for assessing new health risks directly related to the critical chemical-size features of the particles. Therefore, morpho-chemical analyses of hazardous particles become critical in response to the distinctive assumptions about the origin, evolution, and coexisting phases. Here, we report a detailed investigation through direct microscopy imaging of metal-inorganic contaminants for one traditional and two heat-not-burn commercial cigarettes of three different brands. Chemical-size studies revealed the critical presence of heavy metal-inorganic nanostructured microparticles on both paper and filter components of the cigarette, before and after smoking. The direct experimental imaging evidenced on how hazardous particles evolved in mass-size forming coexisting multi-phases of large agglomerate because of the persistence and accumulative effect of the heating puffing. The estimated porosity of the unsuitable engineered filters validated the allowed migration of micrometric pollutants independently from their intrinsic size-shape property. Furthermore, the inappropriate design of the filters made it an adverse sponge reservoir capable of collecting all possible hazardous chemical agents potentially toxic. These substantial results strongly support experimentally the tremendous effect of the smoke capable of transporting and manipulating a high amount of elusive particles, as a particles heat carrier.

Immunogenicity of Viral Vaccines in the Italian Military.

Military personnel of all armed forces receive multiple vaccinations and have been doing so since long ago, but relatively few studies have investigated the possible negative or positive interference of simultaneous vaccinations. As a contribution to fill this gap, we analyzed the response to the live trivalent measles/mumps/rubella (MMR), the inactivated hepatitis A virus (HAV), the inactivated trivalent polio, and the trivalent subunits influenza vaccines in two cohorts of Italian military personnel. The first cohort was represented by 108 students from military schools and the second by 72 soldiers engaged in a nine-month mission abroad. MMR and HAV vaccines had never been administered before, whereas inactivated polio was administered to adults primed at infancy with a live trivalent oral polio vaccine. Accordingly, nearly all subjects had baseline antibodies to polio types 1 and 3, but unexpectedly, anti-measles/-mumps/-rubella antibodies were present in 82%, 82%, and 73.5% of subjects, respectively (43% for all of the antigens). Finally, anti-HAV antibodies were detectable in 14% and anti-influenza (H1/H3/B) in 18% of the study population. At mine months post-vaccination, 92% of subjects had protective antibody levels for all MMR antigens, 96% for HAV, 69% for the three influenza antigens, and 100% for polio types 1 and 3. An inverse relationship between baseline and post-vaccination antibody levels was noticed with all the vaccines. An excellent vaccine immunogenicity, a calculated long antibody persistence, and apparent lack of vaccine interference were observed.

Safety of Multiple Vaccinations and Durability of Vaccine-Induced Antibodies in an Italian Military Cohort 5 Years after Immunization.

We previously examined the safety and immunogenicity of multiple vaccines administered to a military cohort, divided into two groups, the first composed of students at military schools, thus operating inside the national borders for at least 3 years, and the other formed of soldiers periodically engaged in a 9-month-long mission abroad (Lebanon). In the current study, we analyzed 112 individuals of this cohort, 50 pertaining to the first group and 62 to the second group, in order to examine the possible late appearance of side effects and to calculate the half-life of the induced antibodies. Moreover, the possible involvement of B-cell polyclonal activation as a pathogenetic mechanism for long term antibody persistence has even been explored. No late side effects, as far as autoimmunity and/or lymphoproliferation appearance, have been noticed. The long duration of the vaccine induced anti-HAV antibodies has been confirmed, whereas the antibodies induced by tetravalent meningococcal polysaccharide vaccine have been found to persist above the threshold for putative protection for a longer time, and anti-tetanus, diphtheria, and polio 1 and 3 for a shorter time than previously estimated. No signs of polyclonal B-cell activation have been found, as a possible mechanism to understand the long antibody persistence.

The "Polonium In Vivo" Study: Polonium-210 in Bronchial Lavages of Patients with Suspected Lung Cancer.

Few studies have reported on polonium-210, a decay breakdown product of radon-222 and lead-210, in human lungs and there has been no study in patients with suspected lung cancer. The main aim of this "Polonium in vivo" study was to evaluate polonium-210 radioactivity in bronchopulmonary systems of smoker, ex-smoker and never smoker patients with suspected lung cancer. Alpha-spectrometric analyses were performed on bronchial lavage (BL) fluids from two Italian hospitals in 2013-2016. Socio-demographic, smoking, occupational and spirometric characteristics, lung cancer confirmation and histologic type and radon-222 concentration in patients' homes were collected. Seventy BL samples from never (n = 13), former (n = 35) and current smokers (n = 22) were analyzed; polonium-210 was detected in all samples from current and former smokers and in 54% of samples from never smokers (p < 0.001; median values: 1.20, 1.43 and 0.40 mBq, respectively). Polonium-210 levels were significantly higher in COPD versus no COPD patients (median value: 3.60 vs. 0.97 mBq; p = 0.007); former and current smokers, without and with COPD, had significantly increased polonium-210 levels (p = 0.012); 96% of confirmed versus 69% of non-confirmed lung cancer patients recorded detectable polonium-210 levels (p = 0.018). A polonium-210 detectable activity was measured in BL samples from all current and former smokers. Polonium-210 in the lungs could be the result of lead-210 entrapment, which, with its half-life of 22 years, could provide a continuous emission of alpha radioactivity, even many years after quitting, thus proposing a possible explanation for the onset of lung cancer, particularly in former smokers.

The prevalence of musculoskeletal disorders and low back pain among Italian nurses: An observational study.

BACKGROUND AND AIM OF THE WORK: Musculoskeletal disorders and low back pain have negative impact amongst Italian nurses who work in hospital. Nursing staff are known to be at risk of developing back disorders, where low back pain has a prevalence from 16% to 60% in the world. This study aims to determine the prevalence of musculoskeletal disorders and low back pain among nurses who working in a Roman hospital. METHODS: Cross sectional study was carried out in an Italian hospital and the Nordic Musculoskeletal Questionnaire-IRSST was administered to 256 registered nurses. Logistic regression analyses were performed to understand risk factors associated with pain. RESULTS: Nurses reported different locations of pain related to musculoskeletal disorders. The prevalence of low back pain was 90.2% during life, 80% during the last year and 44.5% during the last week. Female sex increases the risk of being affected by low back pain (OR = 2.07, 95% CI= 1.00-4.32). CONCLUSIONS: Musculoskeletal disorders and low back pain are reported by the majority of nurses interviewed, and a higher prevalence is observed in women. Pain does not depend on the amount of years of work, nor on age or body mass index. In order to assess the prevalence of low back pain carefully, it is recommended to study a greater number of Italian nurses in different hospitals.

Psychological Distress in Patients with Autoimmune Arthritis during the COVID-19 Induced Lockdown in Italy.

Lockdowns imposed by governments worldwide as a way to limit the spread of severe atypical respiratory syndrome-coronavirus-2 (SARS-CoV2) have had heavy psychological and economic consequences. Arthritis patients are a vulnerable population at an increased risk of peritraumatic stress. This could be due to several reasons, including the fear of shortage of medicine and difficulty receiving periodical medical checks. In the present case-control study, psychological distress in patients with autoimmune arthritis during the coronavirus disease 2019 (COVID-19) pandemic were investigated. An electronic survey was conducted to gather information on the perceived change in the emotional state, general health (GH), fatigue, joint pain, and disease activity during the lockdown, in 100 patients with autoimmune arthritis and 100 controls. Mental health status was measured using the Depression, Anxiety and Stress Scale (DASS-21). The COVID-19 Peritraumatic Distress Index (CPDI) was used to assess the frequency of peritraumatic stress disorders related to COVID-19. Patients reported a significant worsening of perceived GH (36% vs. 7%; p < 0.001), a significantly higher mean CPDI score (p < 0.001) than controls. Using multivariate analysis, arthritis patients had significantly higher CPDI scores (+3.67 points; p = 0.019), independent of depression, anxiety, and stress symptoms, comorbidities, and sociodemographic and lifestyle characteristics. Logistic regression analysis showed that the risk of reporting worsened GH was 9-fold higher in patients than controls (p < 0.001). Patients with autoimmune arthritis are at higher risk of psychological distress related to COVID-19 pandemic; thus targeted intervention should be designed to strengthen coping capacity in this vulnerable population.

Covid-19 and the role of smoking: the protocol of the multicentric prospective study COSMO-IT (COvid19 and SMOking in ITaly).

The emergency caused by Covid-19 pandemic raised interest in studying lifestyles and comorbidities as important determinants of poor Covid-19 prognosis. Data on tobacco smoking, alcohol consumption and obesity are still limited, while no data are available on the role of e-cigarettes and heated tobacco products (HTP). To clarify the role of tobacco smoking and other lifestyle habits on COVID-19 severity and progression, we designed a longitudinal observational study titled COvid19 and SMOking in ITaly (COSMO-IT). About 30 Italian hospitals in North, Centre and South of Italy joined the study. Its main aims are: 1) to quantify the role of tobacco smoking and smoking cessation on the severity and progression of COVID-19 in hospitalized patients; 2) to compare smoking prevalence and severity of the disease in relation to smoking in hospitalized COVID-19 patients versus patients treated at home; 3) to quantify the association between other lifestyle factors, such as e-cigarette and HTP use, alcohol and obesity and the risk of unfavourable COVID-19 outcomes. Socio-demographic, lifestyle and medical history information will be gathered for around 3000 hospitalized and 700-1000 home-isolated, laboratory-confirmed, COVID-19 patients. Given the current absence of a vaccine against SARS-COV-2 and the lack of a specific treatment for -COVID-19, prevention strategies are of extreme importance. This project, designed to highly contribute to the international scientific debate on the role of avoidable lifestyle habits on COVID-19 severity, will provide valuable epidemiological data in order to support important recommendations to prevent COVID-19 incidence, progression and mortality.