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Patients with Coronavirus-associated disease-2019 (COVID-19) display alterations of the hemostatic system and the presence of a prothrombotic status frequently leading to vascular complications. However, the impact of COVID-19 on platelet activity, aggregation and agglutination still needs to be clarified. We measured total levels of von Willebrand factor (vWF) and vWF binding to the platelet glycoprotein (Gp) complex (GPIb-IX-V), in a cohort of COVID-19 patients admitted to the intensive care unit of our Institution. Moreover, we evaluated platelet aggregation in response to agonists (ADP, collagen, arachidonic acid) and platelet agglutination in response to ristocetin. We found that levels of vWF antigen and the active form of vWF binding to platelets (vWF:RCo), were markedly increased in these patients. These results were associated with higher agglutination rates induced by ristocetin, thereby indirectly indicating an increased capability of vWF to bind to platelets. Conversely, we found that platelet aggregation in response to both ADP and collagen was lower in COVID-19 patients compared to healthy volunteers. This study shows that COVID-19 is associated with increased vWF-induced platelet agglutination but reduced platelet responsivity to aggregation stimuli. Our findings have translational relevance since platelet adhesion to vWF may represent a marker to predict possible complications and better delineate therapeutic strategies in COVID-19 patients. Electronic Supplementary Material The online version of this article (10.1007/s11239-020-02339-6) contains supplementary material, which is available to authorized users.

Background Patients with coronavirus disease 2019 (Covid-19) may experience venous thrombosis while data regarding arterial thrombosis are sparse. Methods Prospective multicenter study in 5 hospitals including 373 patients with Covid-19-related pneumonia. Demographic data, laboratory findings including coagulation tests and comorbidities were reported. During the follow-up any arterial or venous thrombotic events and death were registered. Results Among 373 patients, 75 (20%) had a thrombotic event and 75 (20%) died. Thrombotic events included 41 venous thromboembolism and 34 arterial thrombosis. Age, cardiovascular disease, intensive care unit treatment, white blood cells, D-dimer, albumin and troponin blood levels were associated with thrombotic events. In a multivariable regression logistic model, intensive care unit treatment (Odds Ratio [OR]: 6.0; 95% Confidence Interval [CI] 2.8–12.6; p p = 0.022); and albumin levels (OR: 0.49; 95% CI 0.28–0.87; p = 0.014) were associated with ischemic events. Age, sex, chronic obstructive pulmonary disease, diabetes, heart failure, coronary heart disease, intensive care unit treatment, in-hospital thrombotic events, D-dimer, C-reactive protein, troponin, and albumin levels were associated with mortality. A multivariable Cox regression analysis showed that in-hospital thrombotic events (hazard ratio [HR]: 2.72; 95% CI 1.59–4.65; p p = 0.001), and albumin (HR: 0.447; 95% CI 0.277–0.723; p = 0.001) predicted morality. Conclusions Covid-19 patients experience an equipollent rate of venous and arterial thrombotic events, that are associated with poor survival. Early identification and appropriate treatment of Covid-19 patients at risk of thrombosis may improve prognosis.

I experienced the case of an elderly patient with dementia who had recurrent respiratory failure due to the abuse of a transdermal fentanyl patch. Opioids have been recently used in patients with moderate-to-severe chronic non-cancer pain and in those with cancer pain in palliative care [1].

To compare the effects of asthma and COPD on health status (HS) in elderly patients, and to assess the correlation between disease-specific and generic instruments assessing HS.Multicenter, cross-sectional, observational study.The Salute Respiratoria nell'Anziano (respiratory health in the elderly) Study network of outpatient departments.One hundred ninety-eight asthma patients and 230 COPD patientsor = 65 years old.HS was assessed by the Saint George's Respiratory Questionnaire (SGRQ) and five generic outcomes: Barthel's index, 6-min walk test, mini mental state examination, geriatric depression scale (GDS), and quality-of-sleep index. Independent correlates of SGRQ scores were assessed by logistic regression. Patients were considered to have a "good" HS or "poor" HS according to whether they did or did not perform worse than 75% of the corresponding population of asthma or COPD patients, on at least two of the five generic outcomes.On average, COPD patients had poorer HS than asthma patients on the SGRQ. Only polypharmacy (more than three respiratory drugs) and diagnosis of COPD qualified as independent correlates of the SGRQ score. The SGRQ "Activity" and "Impacts" scores shared the following independent correlates: polypharmacy, Barthel's index92, and GDS6. Further correlates were waist/hip ratio1 for the Activity score, and age and occiput-wall distance9 cm for the Impacts score. All sections of the SGRQ except for the Symptoms score could significantly distinguish patients with good HS and poor HS.Individual dimensions of HS recognize different determinants. COPD outweighs asthma as a cause of distressing respiratory symptoms. A high degree of concordance exists between SGRQ and generic health outcomes, except for the Symptoms dimension in COPD patients.

Background: Paravertebral injection of ozone is an established clinical practice for the treatment of Low Back Pain (LBP). The role of Ultrasound Guidance (USG) in mini invasive procedures has become important in many clinical practice thanks to the greater precision this technique can add. As matter of fact, a large volume of ozone in a single administration may have some adverse or side effects. In this study we wanted to verify if the use of USG in Oxygen/ Ozone (O2/O3) infiltrations could allow the administration of a smaller volume of gas mixture, increasing the safety and the comfort of the procedure itself, obtaining however similar or better results in pain decrease. Methods: We compared two groups of 25 patients affected by LBP, undergoing 10 infiltrations of O2/O3, by using USG (group U) or only anatomical landmarks (group AL). Pain intensity, by calculating Visual Analogical Scale (VAS) difference before and after the treatment, and the discomfort were evaluated in both groups. Results: The mean of the VAS before the treatment was 6.44 in group U and 6.48 in group AL. The mean of the VAS after the treatment was 2.22 in group U and 3.04 in group AL. The mean of discomfort rate was 2.84 in group U and 5.44 in group AL. The number of patients with unbearable discomfort was 0 in group U and 7 in group AL. Conclusions: As many other treatment, also paravertebral injections of O2/O3 benefits of the advantages of the US device which makes this treatment safer and more accurate.

The purpose of this study was to assess whether different stages of chronic obstructive pulmonary disease (COPD) severity defined according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria correlate with meaningful differences in health status. A total of 381 COPD patients, aged 73+/-6 yrs, were classified in the five GOLD stages. Disease-specific (St George Respiratory Questionnaire (SGRQ)) and generic indexes of health status were measured in all patients. Multivariate analysis of covariance or Kruskal Wallis tests were used to compare health status indexes across the spectrum of GOLD stages of COPD severity. GOLD stages of COPD severity significantly differed in SGRQ components and Barthel's index, but not in the indexes assessing cognitive and affective status and quality of sleep. The largest variation in health status was observed at the transition from stage IIa to stage IIb, while there were no other significant differences between consecutive stages. Both female sex and comorbidity were associated with a greater impact of COPD on the health status. In conclusion, the upper limit of stage IIb (forced expiratory volume in one second of 49%) marks a threshold for dramatic worsening of health status. Progression of chronic obstructive pulmonary disease severity from stage 0 to stage IIa does not correspond to any meaningful difference in health status.

Whether chronic obstructive pulmonary disease (COPD) carries a risk of cognitive dysfunction prior to the onset of arterial hypoxemia is not known. Our objective was to assess both the prevalence and main correlates of subclinical cognitive dysfunction in older patients with non-hypoxemic COPD.Home-dwelling non-demented subjects over 64 years of age consecutively attending 24 outpatient Departments of Respiratory Medicine or Geriatrics because of COPD (N = 233), asthma (N = 203), non-obstructive bronchitis (N = 92) or chronic non-respiratory and non-dementing diseases (controls, N = 1080) underwent a multidimensional assessment. Cognitive status was assessed by the Mini-Mental State Examination (MMSE). Independent correlates of MMSE24 were identified by logistic regression analysis. In order to limit the confounding effect of collinearity between COPD group membership and the 6' walked distance, a properly designed multivariate analysis was performed.Prevalence of MMSE24 ranged from 16.7% (controls) to 21.9% (COPD). Education9 years (Odds Ratio = 1.56, Confidence Intervals = 1.22-1.98), a score6 on the 15-item Geriatric Depression Scale (OR = 1.37, CI = 1.16-1.62). a 6' walked distance242 m (OR = 1.22, CI = 1.02-1.45), a Barthel Index greater than 80 (OR = 1.48, CI = 1.03-2.14) and a Forced Vital Capacity inferior to 80% of the predicted value (OR = 1.17, CI = 1.09-1.38) qualified as independent correlates of MMSE24. The multivariate analysis confirmed that groups had comparable MMSE scores.Non-hypoxemic COPD did not increase the risk of subclinical cognitive dysfunction in an older population.

Background and aims: The impact of chronic airway disease on the health status of elderly patients is only to some extent explained by indexes of airflow limitation. The present study was designed to assess to what extent: 1) asthma, chronic obstructive pulmonary disease (COPD) and chronic bronchitis with normal FEV1 (simple bronchitis) differ in their impact on health status; 2) health status depends upon non-respiratory factors. Methods: A total of 1601 outpatients over 65 - 198 with asthma, 228 with COPD, 91 with simple bronchitis, and 1084 with non-respiratory illnesses (control group) -were studied by collection of five health status indexes and multidimensional assessment. Discriminant analysis was used to identify health status profiles of groups. Demographic, anthropometric, clinical and respiratory function correlates of selected health status profiles were identified. Results: Only 26 and 28% of asthma and COPD patients vs 43% of simple bronchitis and 50% of non-respiratory patients showed group-specific health status profiles. These profiles were characterized by lower 6-min walked distance and greater index of disturbed sleep in asthmatics, and by worse performance on Barthel Index, 6-min walking test and Mini-Mental State Examination in COPD patients. More severe bronchial obstruction, a greater index of comorbid-ity and a longer occiput-wall distance characterized COPD patients with the worst health status. Conclusions: The health status of elderly patients with COPD or asthma is highly heterogeneous. On average, COPD is characterized by more severe physical impairment, and asthma by poorer quality of sleep. Comorbidity and severity of bronchial obstruction, but not age, contribute toward defining a subset of COPD patients with the worst health status.

STUDY OBJECTIVES: This study investigated to what extent a diagnosis of COPD is erroneously made or the disease remains unrecognized in elderly asthmatic patients, and identified factors leading to misdiagnosis and underdiagnosis of asthma in such patients. DESIGN: A multicenter study involving 24 Italian pulmonary or geriatric institutions. PATIENTS: One hundred twenty-eight asthmatic patients (98 women, 76.6%) aged 73 +/- 6.4 years (mean +/- SD) were selected from the cohort of the Salute Respiratoria nell'Anziano (respiratory health in the elderly) study. METHODS: All patients underwent a clinical evaluation that included clinical history and spirometry with a bronchodilator test. A diagnosis of asthma was based on criteria proposed by international guidelines adapted to the elderly population. A multidimensional geriatric assessment was performed to estimate physical and cognitive impairments and mood state. Finally, the diagnosis of respiratory disease previously made by a doctor, if any, was recorded. RESULTS: Of asthmatic patients, COPD had been improperly diagnosed in 19.5%, whereas 27.3% of asthmatic patients did not report any previous diagnosis of asthma. The main correlates of misdiagnosis were older age and disability. Conversely, underdiagnosis was associated with better functional conditions, expressed by spirometry, even when wheezing or a significant response to the bronchodilator test occurred. CONCLUSIONS: Asthma in the elderly is frequently confused with COPD. Misdiagnosis can be related to older age and to greater degree of disability. Asthma in patients with mild functional impairment may be underdiagnosed in spite of overt respiratory symptoms suggestive of asthma.