Apps can detect atrial fibrillation, but benefits and harms are uncertain

- Kenny Lin, MD, MPH

The March 15 issue of AFP included a recommendation statement from the U.S. Preventive Services Task Force (USPSTF) and Putting Prevention Into Practice case study on screening for atrial fibrillation with electrocardiography (ECG). The USPSTF concluded that current evidence is insufficient to assess the balance of benefits and harms of testing for atrial fibrillation in primary care patients without suggestive symptoms. In an accompanying editorial, Drs. John Mandrola and Andrew Foy discussed several potential downsides of ECG screening for atrial fibrillation: low prevalence, a high number needed to screen to prevent one stroke, high costs, false positive results, and uncertainty about the effects of anticoagulants in persons with subclinical atrial fibrillation.

At the American College of Cardiology meeting last week, Dr. Mandrola interviewed Dr. Mintu Turakhia, a co-principal investigator of the Apple Heart Study, regarding initial findings reported at the conference. More than 400,000 U.S. adults with Apple Watches installed an app that used an algorithm to analyze heart rate variability and notified users if five out of six samples over a 48-hour period suggested an irregular heart rate. Of the 2100 individuals (~0.5%) who received these notifications, the positive predictive value for ECG-confirmed atrial fibrillation was 84%. The app's sensitivity and false negative rate are unknown because users who did not receive notifications did not have ECG monitoring. Also, the study was not designed to evaluate health outcomes.

A planned pragmatic randomized trial will enroll adults age 65 years and older to determine if screening for atrial fibrillation and other heart rhythm abnormalities using the Apple Watch app leads to reduced stroke rates and/or improved cardiovascular health. In the meantime, family physicians will likely start seeing more patients for evaluation of possible cardiac rhythm abnormalities detected by wearable devices. A recent JAMA article reviewed the limitations of such devices at detecting atrial fibrillation, tachycardia, and bradycardia and offered a suggested approach to evaluation and management.

Connecting chronic stress and disease

- Jennifer Middleton, MD, MPH

The March 1 issue of AFP includes a feature article on "Gas, Bloating, and Belching: Approach to Evaluation and Management" which discusses the high prevalence of functional gastrointestinal disorders (FGIDs). The authors note that "[t]hese disorders are characterized by disordered motility and visceral hypersensitivity that are often worsened by psychological distress." FGIDs, of course, are far from the only conditions precipitated or worsened by stress; a new study out last week found a correlation between years of stressful employment and type 2 diabetes in women. Increasingly, a history of highly stressful experiences, such as interpersonal violence (IPV) and/or adverse childhood experiences (ACEs), has been linked to diabetes, cardiovascular disease, and cancer. Identifying and responding to our patients' stress, regardless of degree or cause, may help them to lead healthier lives.

A recent article in Annals of Family Medicine elucidates the relationship between stress and physical symptoms:

Chronic stress profoundly impacts the body’s cardiovascular, endocrine, and immune systems, increasing the risk of atherosclerosis, diabetes, and infection. Even when controlling for traditional risk factors, diseases like obesity, heart disease, asthma, and even certain cancers are more likely to occur in survivors of violence. The link between medical disease and history of abuse, however, is often obscured by the way these patients present: survivors rarely volunteer their histories of violence, often making somatic and nonspecific complaints the only tip-off to a deeper problem.

A willingness to explore our patients' sources of stress, and potentially dive into deeper issues, is a critical first step to making these connections. The BATHE technique is one way to explore these issues; there are also tools available to screen for a history of ACEs and/or IPV.

Several resources exist to help our patients respond to their stress. The American Academy of Pediatrics has information on their website to enable practices to become trauma-centered to better help patients with a history of ACEs. The National Domestic Violence Hotline website has resources for patients who are experiencing IPV, and additional local resources may be available in your area as well. Family physicians may choose to provide counseling in their offices and/or refer to a local counseling center. Basic stress management techniques can benefit most patients, regardless of the severity of their stress; familydoctor.org has a page on "Managing Daily Stress" with practical, simple steps.

Our willingness to engage with our patients' stressors, and normalize the strength of the mind-body connection, may help them improve their health-related quality of life. As family physicians who often have meaningful, long-standing relationships with our patients, we are well-suited to engage in these processes.

Guest Post: Family doctors can easily treat hepatitis B "in-house"

- Richard Andrews, MD, MPH

In 2008, I replaced another family physician as the sole physician at HOPE Clinic, a federally qualified health center in southwest Houston. The clinic was founded by members of the local Asian community to ensure that Asians would have a place to receive linguistically and culturally-appropriate medical care. From the outset, we treated anyone who came in the door, including many non-Asian patients. Due to our core mission, we cared for a large proportion of foreign-born patients from all over the world, speaking more than eighty different languages.

Many of our patients' countries of origin, including China, Vietnam, Myanmar, Iraq, and Nigeria, have a high (>= 8%) or intermediate (2-7%) prevalence of chronic hepatitis B (CHB), leading to a high prevalence in our patients. Initially, they were reflexively referred to hepatologists, but due to access and cost barriers, the community asked us to start treating hepatitis B right at HOPE.

I was an experienced, board-certified family physician, but I had never done any hepatitis B management. I sought training with local hepatologists, mostly through lectures and question-and-answer sessions, and gradually became comfortable with the vocabulary, epidemiology, concepts, and pharmacology of care for patients with hepatitis B.

Because of the HOPE Clinic's origins, most of our hepatitis B patients are of Asian ancestry. In the United States as a whole, roughly half of patients with CHB are of Asian descent, but in your community you might find a different ethnic/language mix. We are seeing an increasing number of non-Asian patients with CHB, including younger native-born Anglo patients with a history of unsafe drug use. Significantly, many American adults have not received hepatitis B vaccinations, leaving them susceptible to infection from sex, injection drug use, or snorting cocaine.

Different social approaches to drug use and addiction in some European countries (such as Portugal) have coincided with marked reductions in the number of new cases of viral hepatitis and HIV. Conversely, infection rates in Americans appear to be increasing. Now that a two-dose hepatitis B vaccine is available, family doctors have a valuable role to play in screening and immunizing susceptible patients, and in managing their patients with CHB.

Factors that make uncomplicated CHB care easy to learn for family physicians

Factor	Remarks
Many patients don’t need antiviral medications	These visits are particularly simple
Very few medications are used, usually just one at a time	1.       Entecavir 2.       Two forms of tenofovir:  TAF or TDF 3.       Interferon use is rare at primary care level 4.       Older medications not used in USA due to resistance
Medications are well tolerated	One pill per day, side effects are uncommon
Medications are effective	Most patients achieve viral levels below the limits of detection, viral resistance is uncommon.
Straightforward liver cancer surveillance	RUQ abdomen ultrasound and serum AFP every six months in cirrhotics. Other patients:  RUQ u/s + AFP q 6-12 mos. based on guidelines. Consider CT/MRI as appropriate
Infrequent visits needed	Once patient is established, 2-3 visits per year is a typical pattern
Telehealth/telemedicine	The availability of free online-video specialist consultation is increasing. Example:  check for availability in your region, at https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/ Though there are only two listed ECHO hepatitis B-specific programs in the USA, there are 64 infectious disease programs, many of which include viral hepatitis
Knowing when to refer	Decompensated cirrhosis:  ascites, esophageal variceal bleed, hepatic encephalopathy, bacterial peritonitis, hepatorenal syndrome, liver cancer.

Minimizing "spring forward" sleep disruptions

- Jennifer Middleton, MD, MPH

For most of the United States, next weekend marks the transition to Daylight Savings Time (DST), when we’ll “spring forward” an hour over the night of March 10 to allow for our dawns to start later and our daylight to last longer into the evening. While the pros and cons of DST continue to be debated, the health risks from disrupted sleep schedules certainly fall into the cons. Preparing in advance may help mitigate these negative effects.

Moving our clocks forward one hour may not seem like a big transition, but disrupted sleep schedules and sleep latency may last for at least a week afterward. An increased prevalence of heart attacks is noted in the United States the Monday after DST begins, as are an increased number of work-related injuries. A review of Australian suicide rates found an increase after DST arrives in the spring. Parents of young children, along with caregivers for developmentally disabled and cognitively impaired individuals, can struggle to transition their loved ones to a new time schedule. 

Sleep experts recommend beginning the transition at least a week prior to the official start of DST, gradually shifting bedtimes and wake-up times by 10-15 minutes every couple of days. Catching up any pre-existing sleep deficit before the DST transition can help, as can getting plenty of sunlight in the morning and dimming lights in the evening. 

Emphasizing good sleep hygiene is also important, as reviewed in this AFP article on the “Management of Common Sleep Disorders.” Minimizing late day caffeine and alcohol use, along with evening screen time, can help improve sleep quality year-round. For children struggling with sleep issues, this AFP article on “Common Sleep Disorders in Children” provides guidance regarding age-appropriate norms and strategies. Both of these articles are in the AFP By Topic on Sleep Disorders in Adults and the AFP By Topic on Sleep Disorders in Children, respectively, each of which also include useful patient education materials.