General population screening for atrial fibrillation with an automated rhythm-detection blood pressure device.

BACKGROUND: Screening strategies to diagnose previously undetected atrial fibrillation (AF), especially silent AF (SAF), in at-risk populations may help reduce the number of strokes. We prospectively assessed the incidence rate of AF, including SAF, using an automated AF-detection capable sphygmomanometer in the General Practitioner (GP) setting. METHODS: This was a population-based prospective study of unselected general population of ≥65 years without prior AF. Participating GPs were requested, in the period February 2018-April 2019, to record all AF diagnoses including those derived from the AF-detection capable sphygmomanometer and confirmed by 12­lead ECG or ECG Holter in asymptomatic patients. RESULTS: Overall, 14,987 patients assisted by 76 GPs accumulated 16,838 patient-years of follow up. The incidence rate of AF was 2.25% patient-years (95%CI 2.03-2.48). AF was more frequently detected in male, older, overweight, and patients with prior stroke, congestive heart failure, and chronic kidney disease. One in four patients had device-detected SAF (0.56% patient-years, 95%CI 0.46-0.69). Age, overweight, and the number of annual visits, were independent predictors of both SAF and AF. In addition, congestive heart failure, mitral valve disease were independent predictors of AF. Due to the interaction between blood pressure and age the risk of AF increased exponentially after 75 years of age in patients with higher systolic blood pressure values. CONCLUSION: We found a higher than previously reported incidence rate of AF possibly by capturing SAF. Our simple protocol might be feasible in large-scale screening for AF and SAF in routine GP care.

The burden of frailty in older people visiting GPs in Veneto and Sicily, Italy.

Context: In Italy, little is known about the territorial distribution of the frailty status. Aims: To compare frailty- and multimorbidity-prevalence in the elderly population of two Italian regions. Methods: This study examined randomized samples of elderly (both community dwelling and institutionalized) assisted by general practitioners. Frailty was evaluated through the CSHA-Scale, multimorbidity through the Charlson-Score. The relation between frailty and multimorbidity was studied through a logistic model. Both crude and standardized prevalences were calculated. Results: One hundred and sixteen physicians assisted 176,503 patients highly representative of Italian people. In a randomized sample of 4,531 older people, the sex-age-standardized prevalence of Frailty (standard population: Italy) was 25.74% (24.63-26.85%). Age-standardized prevalence for males was 20.08% (18.46-21.71%) and 30.00% (28.54-31.57%) for females. Using the sex-age-standardization pooled sample, the prevalence of frailty was significantly higher in Sicily than Veneto (28.74% [27.03-30.46%] vs 22.30% [20.94-23.67%]. This study did not find differences in the prevalence of multimorbidity: Veneto 20.76% (19.21-22.31%); Sicily 22.05% (20.33-23.77%). Both "to be female" and "to live in Sicily" were shown to be predictors of frailty OR for being female = 1.64 (1.42-1.88); OR for living in Sicily = 1.27 (1.11-1.46). Multimorbidity was an independent frailty-predictor only for those aged < 85: OR of Charlson Index ≥ 4 for ages < 85 = 3.44 (2.88-4.11), OR for ages ≥ 85 = 1.44 (0.97-2.12). Limitations: (1) This study considered patients assisted by doctors, not a random sample of the general population. (2) The cross-sectional nature of the study limits the interpretation of the relationships between frailty and multi-morbidity. (3) Few covariates were available for our multivariate models. Conclusions: More than 1/4 of elderly persons are shown to be frail (1/5 of males and 1/3 of females). Frailty is more frequent in Sicily, while multimorbidity does not differ between the two regions. This could be due to regional differences in the organization of care networks dedicated to elderly patients.

Prevalence of frailty in older people in Veneto (Italy).

Context: Both frailty and multimorbidity are strong predictors of clinical endpoints for older people. In Italy, the interventions targeting chronicity are mainly based on the treatment of diseases: sufficient epidemiological literature is available about these strategies. Less is known about the territorial distribution of the frailty status. Aims: To estimate the prevalence of frailty in older people (65+) and to evaluate the relationship between frailty and multimorbidity. Methods and material: A group of general practitioners working in Veneto (Italy) was enrolled on a voluntary basis. Older individuals were both community dwelling and institutionalized patients, that is, the older people normally followed by Italian general practitioners. A centrally randomized sample was extracted from the pool of physician-assisted elderly. Each doctor evaluated the frailty status through the CSHA Clinical Frailty Scale and the multimorbidity status through the Charlson score (Frailty = CSHA Clinical Frailty Scale's score >4; serious multimorbidity = Charlson score ≥4). Prevalence and its confidence interval (CI) 95% were evaluated through the Agresti's method for proportions. The relation between frailty and multimorbidity was studied through a logistic regression model adjusted for age and sex. Results: Fifty-three physicians were enrolled, whose population of elderly individuals (N = 82919) was highly representative of the population of Veneto. The prevalence of frailty in the randomized sample of 2407 older people was 23.18% (CI 95%: 21.53%-24.91%). Sex was shown to be a strong predictor of frailty (female status OR = 1.58 p < .0001) and multimorbidity was shown to be an independent predictor only for individuals <85 years of age. Conclusions: In Veneto, more than 20% of elderly people are frail. Physicians should pay close attention to frailty and multimorbidity because both are important prognostic factors toward clinical endpoints relevant to territorial care. The CSHA Clinical Frailty Scale (easy and quick) should become part of their professional routine.

The systematic review of randomized controlled trials of PCSK9 antibodies challenges their "efficacy breakthrough" and the "lower, the better" theory.

BACKGROUND: A Cochrane review with meta-analysis showed controversial results about the efficacy of PCSK9 antibodies in the prevention of cardiovascular diseases. This review gives the opportunity to test the relationship between LDL-C levels and cardiovascular events. METHODS: The authors analyzed the relationship between the calculated LDL-C lowering and the risk of all-cause mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, any adverse event, cardiovascular events and cardiovascular disease mortality. RESULTS: No beneficial relationship was found between LDL-C lowering and cardiovascular events explored by meta-regression; instead, there was a trend toward harm. For any of the other outcomes there was no significant association between LDL-C lowering and risk. Furthermore, the authors calculated the efficacy that would be expected through the LDL-C lowering showed in the meta-analysis, considering widely accepted predictions. These were respected only for stroke, while the observed efficacy on other cardiovascular events was significantly lower than the expected, and no significant result was observed at all for fatal outcomes. A separate meta-analysis of trials recruiting familial hypercholesterolemia patients have showed a tendency to harm for almost all outcomes. CONCLUSIONS: The relationship between LDL-C lowering and cardiovascular events has not showed any significant association (and even a tendency toward harm), challenging the "lower the better" theory. A separate meta-analysis of trials recruiting familial hypercholesterolemia patients has showed a tendency to harm for all outcomes with PCSK9 antibodies. Therefore, at the moment, the data available from randomized trials does not clearly support the use of these antibodies.

An unusual presentation of zollinger-ellison syndrome.

Zollinger-Ellison syndrome is an often progressive, persistent and frequently life-threatening disease, described for the first time as characterized by ulceration of the upper jejunum, hypersecretion of gastric acid and non-beta islet cell tumors of the pancreas; this syndrome is due to the hypersecretion of gastrin. We report a case of Zollinger-Ellison syndrome presenting as severe esophagitis evolving in stenosis, which demonstrates how a delayed diagnosis may induce risk of disease spreading. In this setting new diagnostic approaches, such as somatostatin receptor scanning and positron emission tomography with 68 Ga-labeled octreotide, could be particularly useful, as well as further new therapeutic options, such as molecular targeted treatments and peptide receptor radionuclide therapy, though surgery is currently the only form of curative treatment, and the role of the therapeutic options mentioned needs to be clarified by forthcoming studies.