AFP Podcast Episode 232 — June 2025, Part 2

Date: June 30, 2025
Host: Steve Brown (with Marian Dawson, Nadia Mohamed, et al.)
Source: University of Arizona College of Medicine–Phoenix Family Medicine Residency

Episode Overview

This action-packed episode covers a range of high-yield topics from the June 2025 issue of American Family Physician, focusing on practical, evidence-based clinical pearls. Topics include nocturia evaluation and management, risk assessment tools for atrial fibrillation, fracture prevention with zolendronate, the diagnosis and management of endometrial cancer, diabetes-related foot infections, and a new at-home STI testing kit for gonorrhea and chlamydia. The hosts weave in humor, quick mnemonics, and actionable tips for primary care.

Key Discussion Points & Insights

1. Nocturia: Evaluation and Management

Timestamps: [01:29] – [05:05]

• Definition & Importance:
  • Nocturia is clinically significant when patients wake two or more times per night.
    — Nadia Mohamed [01:37]: “Nocturia has been associated with decreased quality of life, increased risk of depression, cognitive impairment, and mortality due to the sleep disruption.”
• Risk Factors & Etiology:
  • Medications (diuretics), age, diabetes, heart failure, sleep apnea.
  • Four mechanisms: overnight urine production ↑, storage capacity ↓, incomplete emptying, or sleep disorder.
• Diagnostic Tools & Approach:
  • Use the TANGO questionnaire to assess etiology.
  • Urinalysis to rule out UTI, hematuria, glucosuria, proteinuria.
  • Recommend bladder diary and frequency/volume charts.
• Management:
  • Conservative: Timing of diuretics, limiting fluids (esp. 2-3 hours pre-bed), manage comorbidities, restrict caffeine/alcohol, compression stockings, leg elevation, pelvic floor PT.
  • Pharmacotherapy:
    • Check post-void residual before meds.
    • Desmopressin for overactive bladder (be cautious of hyponatremia, esp. in those >65; lower doses for women.)
    • Anticholinergics/antimuscarinics/beta-adrenergics—use with care in older adults.
    • Topical estrogen for postmenopausal women.
  • Referral: Urology/urogynecology for persistent cases.
• Memorable Mnemonic:
  • Marian Dawson’s “888 Rule” [05:04]: “Eight hours of sleep, eight hours of fluids, and then hold for eight hours to improve your nocturia.”

2. Assessing Risk of Developing Atrial Fibrillation

Timestamps: [05:05] – [07:20]

• Three Tools Reviewed:
  1. CHARGE-AF
     • 13 predictors incl. EKG; validated but only fair accuracy.
  2. Framingham HSAF
     • Seven predictors, easier in clinic, needs EKG; slightly better than CHARGE-AF.
  3. HARMS2AF
     • Seven risk factors, no EKG needed, largest dataset (300,000+), best accuracy and generalizability.
     • Categorizes risk from <1% to 18%.
• Bottom Line:
  — Nadia Mohamed [07:06]: “If you needed a quick point of care tool... the HARMS2AF risk score is the most convenient and the most accurate tool to use.”

3. Zolendronate for Fracture Prevention in Women

Timestamps: [07:20] – [09:47]

• Clinical Question: Does zolendronate, given once or twice over 10 years in women 50–60 with T-score 0 to -2.5, reduce fracture risk?
• Study Findings:
  • Vertebral fractures: 6% (zolendronate) vs 11% (placebo), NNT = 21–22.
  • Any fracture: NNT = 13 (zolendronate once), NNT = 9 (twice).
  • Major osteoporotic fractures: NNT = 14.
  • Single infusion yields most benefits over 10 years.
  • No cases of jaw osteonecrosis or atypical femoral fractures.
• Quote:
  — Steve Brown [09:30]: “That is a pretty good case for fire and forget. For fracture prevention, you get almost all the fracture prevention from a single infusion of zolendronate... between the ages of 50 and 60.” — Nadia Mohamed [09:43]: “That is really remarkable.”

4. Endometrial Cancer — Rapid Evidence Review

Timestamps: [10:14] – [13:54]

• Epidemiology: More common in postmenopausal women, but can occur at any age.
• Risk: 1 in 11 with postmenopausal bleeding harbor cancer; 85% of cancers present with abnormal uterine bleeding.
• Risk Factors: Unopposed estrogen, Lynch syndrome, obesity, tamoxifen, nulliparity, estrogen-producing tumors.
• Diagnosis:
  • First-line: Endometrial biopsy or pelvic ultrasound (best: transvaginal + transabdominal w/ Doppler).
  • Transvaginal stripe <4mm in postmenopausal women = very low cancer risk.
  • Biopsy is highly accurate but can miss patchy disease (<50% lining).
  • If suspicion stays high, next step is D&C (more tissue; higher risk/cost).
  • Focal US lesions → hysteroscopy for targeted biopsy.
• Staging & Treatment:
  • Sentinel lymph node biopsy for staging.
  • Stage 1: TAH-BSO if low grade; ovaries may be spared if fertility desired.
  • Stage 2: Includes cervical stroma; add radiation/clinical trials.
  • Stages 3/4: Local or distant spread — surgery, chemo, immunotherapy, radiation as indicated.
  • 5-year survival: Stage 1 (95%), Stage 3 (70%), Stage 4 (19%).
• Disparities:
  • Overall survival: White women 83%, Black women 62%.
• Summary:
  — Marian Dawson [13:54]: “Endometrial cancer is very treatable if caught early.”

5. Diabetes-Related Foot Infections — Guideline Highlights

Timestamps: [13:58] – [15:53]

• Guideline Score: 7/8 (lacks broad developmental group).
• Key Recommendations:
  • Use foot ulcer classification (see Table 1 in article).
  • For soft tissue infection, culture tissue preferred over wound swab.
  • For osteomyelitis diagnosis: Combine probe-to-bone test, plain X-rays, inflammatory markers (ESR, CRP, procalcitonin). MRI if uncertain.
  • Probe-to-bone: Sensitivity 87%, specificity 83%.
  • Consider bone biopsy if osteomyelitis suspected.
  • Half of diabetic foot ulcers are NOT infected — avoid overuse of antibiotics.
  • Use narrow antibiotics for mild, broad for complicated/severe.
  • Urgent surgery for severe infection (gangrene, abscess, etc).
• Pearl:
  — Marian Dawson [15:41]: “Urgent surgical consultation is recommended for moderate or severe infection with extensive gangrene, deep abscess or other worrying some findings.”

6. At-home Gonorrhea & Chlamydia Testing: The Simple 2 Test

Timestamps: [15:53] – [18:14]

• What is it?
  • FDA-approved at-home nucleic acid amplification test (NAAT) for adults 18+; not for known exposures.
• Advantages:
  • Privacy, autonomy, convenience; reduces stigma; increases testing reach.
• Accuracy:
  • Chlamydia: Sens ≥94%, Spec ≥97%.
  • Gonorrhea: Sens ≥91%, Spec ≥97%.
  • High positive likelihood ratios (>30), low negative (<0.1).
• Sample:
  • Vaginal swab (higher sensitivity) for those with vaginas, urine for those with penises.
• Logistics:
  • Results online in 2–5 days.
  • Positive gonorrhea results: requires in-person office visit for treatment.
  • Chlamydia treatment may be arranged by manufacturer.
  • Cost: $99 per test (not included in insurance; may be a barrier).
  • WHO now recommends self-collected STI testing to increase access.
• Quotes: — Steve Brown [17:45]: “Wow.” — Marian Dawson [17:49]: “Cost can be a barrier... $99 for a single test.” — Steve Brown [17:54]: “Bottom line here is that the Simple 2 home test can be a useful test for interested patients.”

Memorable Quotes & Moments

• Nocturia: “The 888 Rule” mnemonic
  Marian Dawson [05:04]: “Eight hours of sleep, eight hours of fluids, and then hold for eight hours to improve your nocturia.”
• Fracture Prevention: “Fire and Forget”
  Steve Brown [09:30]: “That is a pretty good case for fire and forget. For fracture prevention, you get almost all the fracture prevention from a single infusion of zolendronate... between the ages of 50 and 60.”
• Risk Tool Choice:
  Nadia Mohamed [07:06]: “HARMS2AF risk score is the most convenient and the most accurate tool to use.”
• On disparities in endometrial cancer:
  Nadia Mohamed [13:26]: “...the overall survival rate for endometrial cancer is 83% in white women and 62% in Black women, which is one of the largest disparities in all cancers.”
• At-home STI testing reality check:
  Marian Dawson [17:47]: “It is not [included in the price].” Nadia Mohamed [17:48]: “Absolutely not.”

Suggested Timestamps for Key Segments

| Topic | Start – End Timestamps | |--------------------------------------------------------|------------------------| | Nocturia: Evaluation & Management | [01:29] – [05:05] | | Atrial Fibrillation: Risk Assessment Tools | [05:05] – [07:20] | | Zolendronate for Fracture Prevention | [07:20] – [09:47] | | Endometrial Cancer: Rapid Review | [10:14] – [13:54] | | Diabetes-Related Foot Infections: Guideline Highlights | [13:58] – [15:53] | | At-home Gonorrhea/Chlamydia Testing (Simple 2) | [15:53] – [18:14] |

Takeaways

• Always start nocturia workups with a solid history and conservative management.
• Use the HARMS2AF score (no EKG needed) for quick, accurate AFib risk estimation.
• A single zolendronate infusion can significantly reduce future fracture risk in women 50–60 with normal/osteopenic bone density.
• Early evaluation and prompt biopsy are crucial in abnormal uterine bleeding and endometrial cancer prevention.
• For diabetic foot infections, focus on clinical findings + targeted diagnostics, with judicious antibiotic use.
• New options like at-home STI testing can improve access, but costs and follow-up logistics remain important.

For more clinical pearls and details, see the full June 2025 issue of American Family Physician or visit aafp.org.