AFP: American Family Physician Podcast

Episode 233 – July 2025, Part 1

Date: July 15, 2025
Host/Contributors: Jake Anderson, Kari Stauss, Puneet Bharot, Elena Kelly (residents/faculty, University of Arizona College of Medicine – Phoenix)
Contributing Editor: Dr. Steven Brown

Overview

In this episode, the team discusses key clinical pearls from the July 2025 issue of American Family Physician. Featured topics include: managing foreign bodies in the ear, nose, and throat; updates on topical anti-inflammatories for eczema; the utility and risks of intravenous antihypertensives in hospitalized adults; best practices for developmental screening; practical applications of dialectical behavior therapy (DBT) in primary care; and recent evidence for universal RSV prophylaxis in infants.
The presenters deliver guidance for frontline family physicians, share their own clinical experiences, and highlight patient-oriented evidence for improved everyday practice.

Key Discussion Points and Insights

1. Foreign Bodies in the Ear, Nose, and Throat

[01:16–07:20]

• Prevalence & Risks: Foreign bodies in the ear, nose, and throat are common, especially in children but also in adults. Timely, safe removal is crucial to avoid complications.
• Ear Foreign Bodies
  • Common objects: beads, toys, insects, food, cotton.
  • Evaluation: Initial otoscopy for object identification and canal/membrane assessment.
  • Removal depends on: patient cooperation, visualization, and choice of technique (instrumentation/irrigation).
  • Key caution: "Do not use irrigation for batteries, absorbent materials, or fully occlusive objects." (Kari Stauss, 03:53)
  • For suspected tympanic membrane perforation or severe pain, "do not pass go"—refer.
• Nasal Foreign Bodies
  • Symptoms: often asymptomatic but may present with unilateral epistaxis, purulent discharge, or mouth breathing.
  • Removal: usually with instruments; ENT referral if above inferior turbinate or for button batteries.
  • Memorable case: “Preseptal cellulitis...was all being spurred by a button battery that was up the nose that they’d missed.” (Jake Anderson, 05:00)
  • “Parent’s kiss” technique: Caregiver blows into the child’s mouth while holding the unaffected naris—the maneuver is about 60% effective ([05:32–06:17]).
• Throat Foreign Bodies
  • Always a medical emergency if airway compromised. Immediate intervention for obstruction; if partial, look for stridor/choking/respiratory difficulty.
  • Automatic referral to ED with possible sedation and endoscopic removal (especially for batteries).

2. Topical Anti-Inflammatories for Eczema (Cochrane Review)

[07:20–09:59]

• Main findings: Most effective treatments for atopic dermatitis are topical steroids, Janus kinase inhibitors, and calcineurin inhibitors.
  • “The most benefit was topical calcineurin inhibitors such as tacrolimus, and then topical corticosteroids, then finally Janus kinase inhibitors.” (Elena Kelly, 08:16)
• Potency matters: Very potent topical corticosteroids outperformed others in continuous outcome studies; tacrolimus a runner-up.
• Side effects: Local reactions most common with calcineurin and PDE4 inhibitors. No increased pigment changes with any. Short-term steroid use (≤3 weeks) did not increase skin thinning, but long-term use (6–60 months) showed some atrophy.
• Cost: “A 60-gram tube of clobetasol is less than half of the same amount of tacrolimus and about 88 times less expensive than ruxolitinib, which is a Janus kinase inhibitor.” (Kari Stauss, 09:40)
• Guideline alignment: “Studies are still needed...Overall, though, topical corticosteroids and topical calcineurin inhibitors are in line with recommendations from the American Academy of Allergy, Asthma and Immunology.” (Kari Stauss, 09:59)

3. Intravenous Antihypertensives in Hospitalized Non-Cardiac Adults

[10:17–13:30]

• Clinical Inquiry: Does treating hospital inpatients for hypertension with IV antihypertensives improve outcomes?
• Evidence review: Multiple large cohort studies reviewed.
  • Harm identified: “Use of IV antihypertensives...is associated with significant harm.” (Elena Kelly, 10:53)
    • Increased risk of myocardial infarction
    • Greater acute kidney injury
    • Higher incidences of stroke, ICU transfers, mortality, and longer length of stay (Puneet Bharot, 12:14, 12:50)
  • Risks increase with the number of doses given.
• Guidelines: The American Heart Association does not support IV antihypertensive therapy for asymptomatic hypertension in hospitalized, non-cardiac patients. Emphasize close outpatient follow-up if started.
• Take Home: Avoid reflexive use of IV antihypertensives in the hospital for patients without acute symptoms.

4. Approach to Developmental Screening and Surveillance

[14:00–17:01]

• Why screen? Early identification and intervention for developmental delay improves patient outcomes; therapy improves autism outcomes (Elena Kelly, 14:20).
• Surveillance vs. Screening
  • Surveillance: Ongoing observation, tracking developmental milestones (not formally validated for effectiveness).
  • Screening: Use of standardized tools (e.g., Ages & Stages, MCHAT) at specified well-child visits.
    • AAP recommends universal screening at 9, 18, 30 months and autism-specific screening at 18 & 24 months (Elena Kelly, 15:20).
    • The USPSTF rates evidence as insufficient to mandate universal screening.
  • Consider sex-specific differences (Puneet Bharot, 15:53).
• Equity consideration: Increased detection can worsen wait times for services, especially in marginalized populations ([16:05]).
• Referral pathways: All states must provide evaluation/treatment through IDEA; referral focus varies by age group (Jake Anderson, 16:49).
• Role of PCP: Ongoing follow-up ensures appropriate diagnosis, intervention, and developmental tracking.

5. Dialectical Behavior Therapy (DBT) in Primary Care

[17:13–19:53]

• Context: Many adults with depression do not access care; family physicians are vital touchpoints.
• What is DBT? Developed for chronic suicidality; now effective in borderline personality disorder, PTSD, adolescent self-harm/suicidality.
• Implementation in primary care: Even a single five-minute encounter can introduce DBT skills while patients await specialist care (Elena Kelly, 18:59).
• Example skill: Box breathing (inhale-hold-exhale-hold for 4 seconds each, repeat).
  • “You can even practice that with the patient right there in the exam room.” (Jake Anderson, 19:18)
• Resources: “Doing Dialectical Behavior Therapy” by Kerner, free apps (e.g., Simple DBT Skills, Diary Card, DBT Coach), and dialecticalbehaviortherapy.com ([19:53]).

6. Universal RSV Prophylaxis in Infants: Real-World Results

[20:16–21:54]

• Study: Spain implemented universal RSV prophylaxis for infants using nirsevimab.
• Results:
  • “A 57.5% decrease in episodes of lower respiratory tract infections and a 59.2% decrease in acute bronchiolitis to 63.1% decrease in related hospital admissions ICU admissions.” (Puneet Bharot, 21:16)
• Population-level benefit: Evidence supports substantial impact on pediatric respiratory illness and hospitalization rates.
• Evidence quality: Level 2B (population-based retrospective cohort); other factors may contribute, but effects are large (Elena Kelly, 21:35).

Notable Quotes & Memorable Moments

• On unusual nasal foreign body complications:
  “Preseptal cellulitis...was all being spurred by a button battery that was up the nose that they’d missed.” — Jake Anderson ([05:00])
• On the “parent’s kiss” technique for nasal foreign bodies:
  “Surprisingly, it’s about 60% successful, so definitely worth a try if you’re worried about a foreign body in the nares.” — Elena Kelly ([05:47])
• On topical steroid cost:
  “A 60-gram tube of clobetasol is less than half of the same amount of tacrolimus and about 88 times less expensive than ruxolitinib.” — Kari Stauss ([09:40])
• On IV antihypertensives in hospital:
  “Use of IV antihypertensives in these patients increases the risk of acute kidney injury by approximately 1.5 times, and it also doubles the risk of myocardial injury and inpatient mortality.” — Elena Kelly ([12:27])
• On DBT in primary care:
  “These interactions can take as little as five minutes, depending on patient understanding symptoms and their presenting challenges.” — Elena Kelly ([18:34])
• On the impact of universal RSV prophylaxis:
  “Holy cow, those are some big relative improvements.” — Jake Anderson ([21:33])

Summary Table: Important Segments & Timestamps

| Topic | Speakers | Timestamps | |-------------------------------------------|-----------------------------|-------------| | Foreign Bodies Ear/Nose/Throat | Entire Panel | 01:16–07:20 | | Topical Anti-inflammatories for Eczema | Entire Panel | 07:20–09:59 | | IV Antihypertensives in Hospitalized pts | Entire Panel | 10:17–13:30 | | Developmental Screening & Surveillance | Entire Panel | 14:00–17:01 | | Dialectical Behavior Therapy in Primary | Entire Panel | 17:13–19:53 | | Universal RSV Prophylaxis Impact | Entire Panel | 20:16–21:54 |

Conclusion

This episode delivers high-yield updates across diverse topics commonly encountered in primary care. Highlights include pearls for recognizing and managing foreign bodies, evidence-based eczema treatments with a pragmatic lens on cost and safety, a cautionary tale regarding inpatient antihypertensive practice, nuanced developmental screening guidance, practical DBT skills for mental health in primary care, and major public health gains via universal RSV prophylaxis.
The panel’s conversational tone, clinical anecdotes, and focus on actionable, patient-oriented evidence make this episode especially valuable for busy clinicians.