The social and professional image of the nurse: results of a survey during the Covid-19 pandemic. / L'immagine sociale e professionale dell'infermiere: risultati di una survey durante la Pandemia Covid-19.

INTRODUCTION: Although nursing today is an intellectual profession to all intents and purposes, thesocial and professional image gap has not yet been bridged. Also, in the rest of the world, the social image of the nurse suffers from some stereotypes, not only perpetuated by a wrong knowledge on the part of the population but also fostered by the mass media (commentary, cinema, television series). OBJECTIVE: To investigate the perception of students at the University of Piemonte Orientale about the nursing profession. METHODS: A survey was conducted using an online questionnaire sent during the period of the health emergency linked to COVID-19 (from 18 August to 15 September 2020). RESULTS: 662 questionnaires were analysed. It was investigated how students describe nurses and whether that description would have been the same even before the COVID-19 health emergency. Furthermore, it was assessed which gender they consider most suited for the profession and whether the mass media has influenced their view of nurses. The students described the nurse with adjectives such as "expert / capable", "courteous / polite" and "welcoming / listening oriented" and stated that they would use the same terms even before the health emergency. The majority of the sample then believed that there is no more suitable gender to fill the role of nurse and that TV series or news reports have positively influenced their perception. However, only a small percentage of the sample would have considered the idea of becoming a nurse. DISCUSSION: A positive view of nurses emerged to overcome gender stereotype and a greater confidence in their technical-professional abilities. The data also highlight that the positive view of the nursing profession is not a consequence of the "publicity" provided by the media during COVID-19 emergency, which represented nurses as "heroes" of the National Health System.

May an incidental finding on chest CT be a predictor of access in intensive care unit? Role of hepatic steatosis in patients affected by SARS-CoV-2.

Background: Due to the high prevalence of hepatic steatosis (HS), the aim of the study is to verify the frequency of HS incidentally detected in chest computed tomography (CT) imaging in our population affected by SARS-CoV-2 and to investigate its association with the severity of the infection and outcome in terms of hospitalization. Design and methods: We retrospectively analyzed 500 patients with flu syndrome and clinically suspected of having Sars-CoV-2 infection who underwent unenhanced chest CT and have positive RT-PCR tests for Sars-CoV-2 RNA. Two radiologists both with >5 years of thoracic imaging experience, evaluated the images in consensus, without knowing the RT-PCR results. Liver density was measured by a region of interest (ROI), using a liver attenuation value ≤40 Hounsfield units (HU). Results: On 480 patients, 23.1% (111/480) had an incidental findings of HS on chest CT. The steatosis group, included 83 (74.7%) males and 28 (25.3%) females. Patients with HS were more likely to be hospitalized in the intensive care unit (ICU). On univariate analysis, there is a correlation between probability to be intubate (access in the ICU) and HS: patients with HS are twice as likely to be intubated (OR 2.04, CI 95% 1.11-3.73). Conclusion: Chest CT is an important diagnostic tool for COVID-19 and can provide information about the prognosis of the disease. HS can easily be detected on chest CT taken for the diagnosis of the COVID-19 disease, is an important sign for a poor prognosis and possible predictor of admission in ICU.

Teledermoscopy in the Diagnosis of Melanocytic and Non-Melanocytic Skin Lesions: NurugoTM Derma Smartphone Microscope as a Possible New Tool in Daily Clinical Practice.

Background: Due to the COVID-19 pandemic, teledermoscopy has been increasingly used in the remote diagnosis of skin cancers. In a study conducted in 2020, we demonstrated a potential role of an inexpensive device (NurugoTM Derma) as a first triage to select the skin lesions that require a face-to-face consultation with dermatologists. Herein, we report the results of a novel study that aimed to better investigate the performance of NurugoTM. Objectives: (i) verify whether the NurugoTM can be a communication tool between the general practitioner (GP) and dermatologist in the first assessment of skin lesions, (ii) analyze the degree of diagnostic-therapeutic agreement between dermatologists, (iii) estimate the number of potentially serious diagnostic errors. Methods: One hundred and forty-four images of skin lesions were collected at the Dermatology Outpatient Clinic in Novara using a conventional dermatoscope (instrument F), the NurugoTM (instrument N), and the latter with the interposition of a laboratory slide (instrument V). The images were evaluated in-blind by four dermatologists, and each was asked to make a diagnosis and to specify a possible treatment. Results: Our data show that F gave higher agreement values for all dermatologists, concerning the real clinical diagnosis. Nevertheless, a medium/moderate agreement value was obtained also for N and V instruments and that can be considered encouraging and indicate that all examined tools can potentially be used for the first screening of skin lesions. The total amount of misclassified lesions was limited (especially with the V tool), with up to nine malignant lesions wrongly classified as benign. Conclusions: NurugoTM, with adequate training, can be used to build a specific support network between GP and dermatologist or between dermatologists. Furthermore, its use could be extended to the diagnosis and follow-up of other skin diseases, especially for frail patients in emergencies, such as the current pandemic context.

18 months computed tomography follow-up after Covid-19 interstitial pneumonia.

BACKGROUND: Our aim is to evaluate the possible persistence of lung parenchyma alterations, in patients who have recovered from Covid-19. DESIGN AND METHODS: We enrolled a cohort of 115 patients affected by Covid-19, who performed a chest CT scan in the Emergency Department and a chest CT 18 months after hospital discharge. We performed a comparison between chest CT scan 18 months after discharge and spirometric data of patients enrolled. We obtained quantitative scores related to well-aerated parenchyma, interstitial lung disease and parenchymal consolidation. A radiologist recorded the characteristics indicated by the Fleischner Society and "fibrotic like" changes, expressed through a CT severity score ranging from 0 (no involvement) to 25 (maximum involvement). RESULTS: 115 patients (78 men, 37 women; mean age 60.15 years old ±12.52). On quantitative analysis, after 18 months, the volume of normal ventilated parenchyma was significantly increased (16.34 points on average ±14.54, p<0.0001). Ground-glass opacities and consolidation values tend to decrease (-9.80 and -6.67 points, p<0.0001). On semiquantitative analysis, pneumonia extension, reactive lymph nodes and crazy paving reached statistical significance (p<0.0001). The severity score decreased by 2.77 points on average (SD 4.96; p<0.0001). There were not statistically significant changes on "fibrotic-like" changes correlated with level of treatment and there was not a statistically significant correlation between CT lung score and spirometric results obtained 18 months after discharge. CONCLUSIONS: Patients recovered from Covid-19 seem to have an improvement of ventilated parenchyma and "fibrotic-like" alterations. The level of treatment does not appear to influence fibrotic changes.

Lung vessel volume evaluated with CALIPER software is an independent predictor of mortality in COVID-19 patients: a multicentric retrospective analysis.

INTRODUCTION: Computer-Aided Lung Informatics for Pathology Evaluation and Ratings (CALIPER) software has already been widely used in the evaluation of interstitial lung diseases (ILD) but has not yet been tested in patients affected by COVID-19. Our aim was to use it to describe the relationship between Coronavirus Disease 2019 (COVID-19) outcome and the CALIPER-detected pulmonary vascular-related structures (VRS). MATERIALS AND METHODS: We performed a multicentric retrospective study enrolling 570 COVID-19 patients who performed a chest CT in emergency settings in two different institutions. Fifty-three age- and sex-matched healthy controls were also identified. Chest CTs were analyzed with CALIPER identifying the percentage of VRS over the total lung parenchyma. Patients were followed for up to 72 days recording mortality and required intensity of care. RESULTS: There was a statistically significant difference in VRS between COVID-19-positive patients and controls (median (iqr) 4.05 (3.74) and 1.57 (0.40) respectively, p = 0.0001). VRS showed an increasing trend with the severity of care, p < 0.0001. The univariate Cox regression model showed that VRS increase is a risk factor for mortality (HR 1.17, p < 0.0001). The multivariate analysis demonstrated that VRS is an independent explanatory factor of mortality along with age (HR 1.13, p < 0.0001). CONCLUSION: Our study suggests that VRS increases with the required intensity of care, and it is an independent explanatory factor for mortality. KEY POINTS: • The percentage of vascular-related structure volume (VRS) in the lung is significatively increased in COVID-19 patients. • VRS showed an increasing trend with the required intensity of care, test for trend p< 0.0001. • Univariate and multivariate Cox models showed that VRS is a significant and independent explanatory factor of mortality.

Georeferencing of COVID-19 Positive Nasopharyngeal Swabs to Support Emergency Management in an Area of Northern Italy

Spatial distribution heterogeneity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been observed in several countries. While previous studies have covered vast geographic areas, detailed analyses on smaller territories are not available to date. The aim of our study was to understand the spatial spread of SARS-CoV-2 in a province of Northern Italy through the analysis of positive nasopharyngeal (NP) swabs. The study was conducted on subjects who lived in the province of Alessandria with at least one positive NP swab between 2 March and 22 December 2020. To investigate if clustering occurred, the proportion of SARS-CoV-2 positive subjects over the total number of residents in each small administrative subregion was calculated and then mapped. A total of 17,260 subjects with at least one positive NP swab were included;the median age was 54 years (Interquartile range 38–72) and 54.9% (n = 9478) of our study population were female. Among the 192 towns scanned, 26 showed a prevalence between 5% and 7.5%, one between 7.5% and 10% and two with more than 10% positive swabs. The territories with a higher prevalence of positive subjects were located in areas with at least one nursing home and potential clusters were observed within these structures. The maps produced may be considered a useful and important monitoring system to identify areas with a significant and relevant diffusion of SARS-CoV-2.

Nursing evaluation during treatment with helmet continuous positive airway pressure in patients with respiratory failure due to COVID-19 pneumonia: A case series.

BACKGROUND: During COVID-19 outbreak, with the increasing number of patients presenting with acute respiratory failure, a large use of non invasive positive pressure ventilation was done in the emergency departments and medical wards despite the lack of recommendations. OBJECTIVES: This study describes the clinical characteristics of patients presenting to the hospital with acute respiratory failure due to COVID-19 related pneumonia undergoing treatment with helmet continuous positive airway pressure (CPAP) with a strict nursing evaluation and monitoring. METHODS: A case series study enrolling adult patients admitted to an emergency department of an Italian hospital with acute respiratory failure due to COVID-19 pneumonia from March 18th to April 18th, 2020, was conducted. Only patients who strictly followed a local CPAP protocol were enrolled. RESULTS: A total of 52 patients were included in this study. Thirty-eight patients (73%) were judged eligible for endotracheal intubation (ETI). Eighteen (34.6%) were intubated. Sixteen (30.8%) patients died: seven (38.9%) and nine (26.5%) in the eligible-for-ETI and non eligible-for-ETI group, respectively. The median hospital length of stay was different in the ETI and non-ETI group: 26 days (interquartile range [IQR]: 16-37) vs 15 days [IQR 9-17] (p = 0.005). The median invasive mechanical ventilation time was 11 days [IQR 7-21] with an ICU length of stay of 14.5 days [IQR 10-28]. During the CPAP trial, among patients eligible for ETI variations over time for positive end-expiratory pressure (p = 0.003) and respiratory rate (p = 0.059) were found between intubated and non-intubated patients. CONCLUSIONS: A short closed monitored CPAP trial could be considered for acute respiratory failure due to COVID-19 pneumonia before considering ETI. A progressive positive end-expiratory pressure titration should target reduction in a patient's respiratory rate. More studies are needed to evaluate the efficacy and predictors of failure of CPAP and non-invasive positive pressure ventilation in patients with acute respiratory failure due to COVID-19 pneumonia.

Mycotic infection prevalence among patients undergoing bronchoalveolar lavage with search of SARS-CoV-2 after two negative nasopharyngeal swabs.

The evidence that severe coronavirus disease 2019 (COVID-19) is a risk factor for development of mycotic respiratory infection with an increased mortality is rising. Immunosuppressed are among the most susceptible patients andAspergillusspecies is the most feared superinfection. In this study we evaluated mycotic isolation prevalence on bronchoalveolar lavage (BAL) of patients who underwent bronchoscopy in search of severe acute respiratory coronavirus 2 (SARS-CoV-2) RNA. Moreover, we described the clinical characteristics and main outcomes of these patients. We included 118 patients, 35.9% of them were immunosuppressed for different reasons: in 23.7% we isolated SARS-CoV-2 RNA, in 33.1% we identified at least one mycotic agent and both in 15.4%. On BAL we observed in three casesAspergillusspp, in six casesPneumocystisand in 32Candidaspp. The prevalence of significant mold infection was 29.3% and 70.7% of cases were false positive or clinically irrelevant infections. In-hospital mortality of patients with fungal infection was 15.3%. The most frequent computed tomography (CT) pattern, evaluated with the Radiological Society of North America consensus statement, among patients with a mycotic pulmonary infection was the atypical one (p< 0.0001). Mycotic isolation on BAL may be interpreted as an innocent bystander, but its identification could influence the prognosis of patients, especially in those who need invasive investigations during the COVID-19 pandemic; BAL plays a fundamental role in resolving clinical complex cases, especially in immunosuppressed patients independently from radiological features, without limiting its role in ruling out SARS-CoV-2 infection.

Seroprevalence of SARS-CoV-2 Among Workers in Northern Italy.

BACKGROUND: The spread of severe acute respiratory coronavirus 2 (SARS-CoV-2) among active workers is poor known. The aim of our study was to evaluate the seroprevalence of immunoglobulin G (IgG) among a convenience sample of workers and to identify high-risk job sectors during the first pandemic way. METHODS: We conducted a cross-sectional study among workers tested for SARS-CoV-2 between 28 March and 7 August 2020, recorded by a private healthcare center located in North-West Italy. Association among seroprevalence and demographic and occupational variables was evaluated using chi square test and the seroprevalence and 95% confidence intervals (CI) were calculated. RESULTS: We collected the results for 23568 serological tests from a sample of 22708 workers from about 1000 companies. Median age was 45 years and about 60% of subjects were male. The overall seroprevalence was 4.97% [95%CI 4.69-5.25]. No statistical difference was found among gender while seroprevalence was associated with subjects' age, geographical location, and occupational sector. Significantly higher values of positivity were observed for the logistics sector (31.3%), weaving factory (12.6%), nursing homes (9.8%), and chemical industry (6.9%) workers. However, we observed some clusters of cases in single companies independently from the sector.Then, a detailed focus on 940 food workers shown a seroprevalence of 5.21% [95%CI 3.79-6.63] and subjects who self-reported COVID-19 symptoms and who worked during lockdown had a higher probability of being infected (p < 0.001). CONCLUSIONS: Data obtained might be useful for future public health decision; more than occupation sector, it seems that failure on prevention system in single companies increase the SARS-CoV-2 transmission.

High Seroprevalence of SARS-CoV-2 among Healthcare Workers in a North Italy Hospital.

BACKGROUND: Healthcare workers (HCWs) have been the key players in the fight against the coronavirus disease 2019 (COVID-19) pandemic. The aim of our study was to evaluate the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG anti-bodies. METHODS: We conducted a cross-sectional study among workers of two hospitals and Territorial Medical and Administrative services in Northern Italy. From 8 May to 3 June 2020, 2252 subjects were tested. Seroprevalence and 95% confidence interval (CI) were calculated for all individuals who were stratified by job title, COVID-19 risk of exposure, direct contact with patients, unit ward, and intensity of care. RESULTS: Median age was 50 years, and 72% of subjects were female. The overall seroprevalence was 17.11% [95% CI 15.55-18.67]. Around 20% of healthcare assistants were seropositive, followed by physicians and nurses (16.89% and 15.84%, respectively). HCWs with high risk of exposure to COVID-19 were more frequently seropositive (28.52%) with respect to those with medium and low risks (16.71% and 12.76%, respectively). Moreover, personnel in direct contact had higher prevalence (18.32%) compared to those who did not (10.66%). Furthermore, the IgG were more frequently detected among personnel of one hospital (19.43%). CONCLUSION: The high seroprevalence observed can be partially explained by the timing and the population seroprevalence; the study was conducted in an area with huge spread of the infection.

COVID-19 Diagnosis in Case of Two Negative Nasopharyngeal Swabs: Association between Chest CT and Bronchoalveolar Lavage Results.

See also the editorial by Little in this issue.

SARS-CoV-2 Detection on Bronchoalveolar Lavage: An Italian Multicenter experience.

BACKGROUND: Bronchoscopy with bronchoalveolar lavage (BAL) during the SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) pandemic should be reserved to a limited number of clinical indications. The yield of BAL for the diagnosis of suspected or confirmed pulmonary SARS-CoV-2 infection is still unknown. OBJECTIVES: We aimed to evaluate the diagnostic ratio of BAL in detecting SARS-CoV-2 pulmonary infection in patients undergoing bronchoscopy for different indications as well as describe the clinical, radiological, and endoscopic characteristics of patients with SARS-CoV-2 on BAL. METHOD: We conducted a multicenter retrospective study including all patients who underwent bronchoscopy for the detection of SARS-CoV-2 on BAL. Clinical, computed tomography (CT), endoscopic, and microbiologic data were gathered from March 16th to May 27th, 2020. RESULTS: 131 patients were included. Bronchoscopy was performed for suspected SARS-CoV-2 infection (65.5%), alternative diagnosis (12.9%), suspected superinfections (19.8%), and lung atelectasis (1.5%). SARS-CoV-2 was isolated on BAL 43 times (32.8%) and the highest isolation rate was in patients with suspected SARS-CoV-2 infection (74.4%); 76% of positive patients had a double-negative nasopharyngeal swab. Peripheral, posterior and multilobar CT opacities were more frequent in SARS-CoV-2 patients, and the number of CT findings was higher in positive patients, particularly those with suspected SARS-CoV-2 infection. We recorded a progressive reduction of SARS-CoV-2 isolation during the observation period. CONCLUSIONS: In our centers, the rate of detection of SARS-CoV-2 on BAL in patients with suspected infection was 37.2%. The agreement of BAL with nasopharyngeal swabs was high; CT alterations could predict the pretest probability of SARS-CoV-2 infection, but suspicion of viral infection should be always considered.