AFP Podcast Episode 236 (August 2025, Part 2) — Summary

Podcast: AFP: American Family Physician
Date: August 29, 2025
Hosts: Dr. Steve Brown, Dr. Puneet Barot, Dr. Emily Eisenberg
Theme: Key clinical updates from the August 2025 issue of AFP, with practical pearls for family physicians.

Episode Overview

This episode covers essential clinical updates from the August 2025 issue of American Family Physician, focusing on topics such as contraceptive counseling, delayed pushing in labor, management of bacterial vaginosis, outpatient care of premature infants, strategies for nocturnal leg cramps, and a rapid fire review of clinical answers. The resident and faculty hosts from University of Arizona College of Medicine-Phoenix bring a conversational, practical, and “patient-first” tone throughout, highlighting how new evidence and guidelines can improve everyday clinical practice.

Key Discussion Points and Insights

1. Quality Contraception Services: New National Guidelines

• [01:17] The CDC and HHS updated guidelines on contraceptive services to be more patient-centered and accessible.
• Patient experiences and values, not just medical eligibility, should guide method choice.
  • Puneet Barot: “The priority is connecting with patients where they are. Instead of rattling off birth control options like a menu, the focus is on patient experiences and their values.” (02:14)
• Stepwise Counseling Approach:
  • Build rapport
  • Elicit contraceptive preferences
  • Decide collaboratively
  • Keep physical exams minimal (often just blood pressure unless IUD requested)
  • Avoid unnecessary barriers (e.g., pelvic exams, pregnancy or STI tests unless indicated)
  • Emily Eisenberg: “Most patients do not even need a pelvic exam or STI testing prior to starting contraception. Hear hear.” (03:01)
• Use checklist to rule out pregnancy before starting contraception without test, reducing delays ([03:33])
• Access Improvements:
  • Prescribe 1-year supplies
  • Offer self-administered depot shots
  • Provide telehealth and walk-ins for easier access, and pre-prescribe emergency contraception ([04:32])
• Patient-Oriented Updates:
  • Offer lidocaine or paracervical block for IUD placement pain
  • Do not use misoprostol routinely for IUD placement due to side effects ([04:55])
  • Manage irregular bleeding through reassurance, NSAIDs, or brief estrogen use as appropriate
  • Emphasize ongoing access and patient satisfaction
  • Emily Eisenberg: “They give us practical tools that make the whole process so much smoother and can keep care truly patient satisfaction centered.” (05:54)

2. Delayed Pushing in Labor

• [06:12] FPIN Inquiry: Is delayed pushing helpful for nulliparous women with epidural?
• Findings:
  • Delayed pushing: longer second stage by ~46 minutes, less active pushing by ~28 minutes ([06:29])
  • But: associated with increased risk of maternal infection, postpartum hemorrhage, neonatal acidemia
  • Large 2018 RCT stopped early due to safety concerns ([06:58])
  • Some meta-analyses suggest possible reduction in assisted vaginal deliveries and fatigue, but these benefits are offset by increased risks ([07:18–07:48])
• Guideline Summary:
  • ACOG (2024): Start pushing when fully dilated; delayed pushing not recommended
  • NICE (UK): Delayed pushing up to 2 hours may reduce assisted delivery, but benefits vs risks must be weighed ([08:13])
  • Bottom Line: Use shared decision-making with patients.
  • Steve Brown: “The right answer is always. Shared decision making.” (08:51)

3. Bacterial Vaginosis: Partner Treatment Study

• [08:56] New evidence on treating male partners to prevent recurrent BV in women
  • Randomized trial: Partners treated with oral metronidazole and topical clindamycin
  • Key finding: Number needed to treat of 3 to prevent recurrence at 12 weeks
  • Results consistent across intention-to-treat and per protocol populations
  • Adverse effects rare, making partner treatment a practical option in stable couples ([09:45–10:32])
  • Puneet Barot: “Treating the partner not only helps with recurrent infection, but it also provides ease of mind for your patient.” (10:32)

4. Outpatient Care of the Premature Infant

• [11:21] Premature births (~10% in the US); outpatient care is multifaceted
• Discharge Planning:
  • Focus on caregiver education, primary care, unresolved issues, home planning, support services, and follow-up ([11:34])
  • Family engagement is essential
  • Car seat testing: recent data shows discontinuation doesn’t worsen outcomes—use car beds if unable to tolerate car seats ([12:01])
• Immunizations:
  • Follow chronological age for schedules
  • Rotavirus at 6–15 weeks; Hep B within 24 hrs (>2kg) or within 1 month (<2kg)
  • RSV prevention: Nirsevimab (Beyfortus) for high-risk infants; maternal vaccine (Abrysvo) extends passive immunity ([13:02–13:55])
• Growth & Nutrition:
  • Use Fenton growth chart until 50 weeks GA; then WHO chart with age correction until 24 months ([14:10])
  • Prefer breast milk; fortify as needed
  • Vitamin D and iron supplementation standard ([14:25–14:57])
• Complications:
  • Necrotizing enterocolitis, retinopathy, chronic lung disease, SIDS, and more ([15:15])
  • Emphasize early screening for neurodevelopmental issues ([15:59])
• Feeding/Reflux:
  • Conservative management (feeding & position) is first-line; thicken feeds as needed; formula options may help ([16:12])
  • Medications only if conservative fails; acid suppression rarely needed ([16:59])

5. Nocturnal Leg Cramps: Vitamin K2 as Treatment

• [17:29] RCT of adults aged 65+ with at least 2 nocturnal cramps weekly
  • Vitamin K2 group: Cramps decreased from 2.6/week to 0.96/week; placebo group increased to 3.6/week ([18:15])
  • Severeity/duration also improved, though not formally analyzed ([18:32])
  • Vitamin K2 (menaquinone 7): found in fermented soybeans, cheese; avoid in patients on warfarin
  • Steve Brown: “This trial suggests vitamin K2 could be an interesting option for older adults with frequent night cramps, although it didn’t measure sleep quality or overall quality of life.” (19:08)

6. Rapid Fire Clinical Answers ([19:23])

• Alzheimer's agitation: Music therapy, risperidone, brexpiprazole; avoid routine antipsychotics (20:01)
• De Quervain’s tenosynovitis: Tenderness, swelling dorsal thumb; positive Finkelstein test ([20:08])
• Meniscal tear: Surgery not superior to physical therapy ([20:33])
• Pet therapy: Reduces self-reported anxiety (mostly dogs, some cats, and horses) ([20:39])
• HSV confirmation: Viral PCR assay is gold standard for genital lesions ([20:50])
• Bone stress injuries: Low-risk sites (fibula, posteromedial tibia) can be managed conservatively ([21:13])

Notable Quotes & Memorable Moments

• On Contraceptive Access:
  • “Contraceptive counseling is such a major component of preventative health and something we do every day, these updates focus on making the process so much more patient centered and accessible.” — Emily Eisenberg (02:00)
• On Delayed Pushing:
  • “The right answer is always. Shared decision making.” — Steve Brown (08:51)
  • “Always.” — Emily Eisenberg (08:54)
• On BV Partner Treatment:
  • “Treating the partner not only helps with recurrent infection, but it also provides ease of mind for your patient.” — Puneet Barot (10:32)
• On Vitamin K2:
  • “This was new to me as well. ... People in the vitamin K2 group reported decreased duration and severity of their cramps as well, but the study did not formally analyze those outcomes.” — Emily Eisenberg (18:32)
  • “So we all need to be eating more miso and potentially some natto as well, right?” — Emily Eisenberg (19:03)

Timestamps for Important Segments

| Topic | Timestamp | |----------------------------------------------------|-------------| | Contraceptive counseling updates | 01:17–06:12 | | Delayed pushing in labor | 06:12–08:54 | | Bacterial vaginosis partner treatment (POEM) | 08:56–10:53 | | Outpatient care of premature infants | 11:21–17:29 | | Vitamin K2 for nocturnal leg cramps (POEM) | 17:29–19:18 | | Rapid-fire clinical answers | 19:23–21:31 |

Conclusion

A rich episode packed with practice-changing pearls, strong evidence summaries, and practical strategies—from patient-centered contraceptive counseling and nuanced labor management, to advances in care for premature infants and surprising options for managing leg cramps. The hosts combine evidence-based guidance with memorable, direct commentary and a collegial tone, making these updates both accessible and actionable for the busy family physician.