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AFP: American Family Physician Podcast
Episode 240 -- October 2025 -- Part 2 AFP: American Family Physician
00:19:28
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A
The AFP Podcast is brought to you by the American Academy of Family Physicians and by Mayo Clinic. Mayo Clinic proudly supports this AFP podcast. Mayo Clinic Family Medicine puts patients first by pursuing innovations that change lives and the future of care. Learn more about joining our team@jobs.mayoclinic.org FamilyMedicine.
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B
Welcome to the American Family Physician podcast for part two of the October 2025 issue. I'm Steve.
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C
I'm Alaina.
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And I'm Austin.
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B
We are residents and faculty, mostly residents from the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we're going to talk about overuse of colorectal cancer screening, depression practice guidelines, anticoagulation in hospitalized patients with COVID 19 slipped, capital femoral epiphysis, left atrial appendage, closure in atrial fibrillation after ablation, and venous thromboembolism.
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The opinions expressed in the podcast are our own and do not represent the opinions of the American Academy of Family Physicians. The editor of American Family Physician or Banner Health do not use this podcast for medical advice. Instead, see your own family doctor for medical care delivering the best, strong American.
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B
Damaged physician all right, let's start with Loun Right Overuse of colorectal cancer screening and surveillance this is from Drs. Roth and Lazarus with patient's perspective from Helen Haskell and John James.
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Multiple medical societies endorse colonoscopy as a first line screening option for average risk adults to starting at 45 or 50 and continuing to age 75.
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Potential advantages of colonoscopy include that it has 95% sensitivity, can detect and remove precancerous adenomas, and has longer screening intervals between tests.
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Other screening options, including stool tests, are available.
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There are harms associated with colonoscopy.
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A 2023 systematic review found a 30 day risk of serious bleeding 16 to 36 per 10,000 scopes and perforation 7.6 to 8.5 per 10,000 scopes.
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Rates of complications of colonoscopy are significantly higher in patients over 75 and these patients are also less likely to benefit from screening.
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Screening colonoscopies are overused 17 to 25% of the time.
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A big cause of this overuse is lack of adherence to evidence based guidelines for screening intervals.
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Table 1 has a great review of screening intervals depending on findings on initial colonoscopy.
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More than 2 million unnecessary colonoscopies are performed annually in the US leading to serious harm in about 9,000 patients.
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Yikes.
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Yeah, the patient perspective Comments Note that there are stories of people having to go to the emergency department for alarming symptoms because GI doctors are too busy doing screening colonoscopies.
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We can work with our patients and GI colleagues to make sure our patients are getting appropriate colonoscopies at appropriate intervals.
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Shared decision making is always the right answer. The best screening test is the one that gets done.
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Yep. Please welcome some special guests.
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I'm Dakota Wise here with my program director, podcast founder and editor, Dr. Sarah Coles. Today we're talking about our recent practice guidelines article, Management of Major Depressive Disorder in Guidelines from Canmat.
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Hey Dakota, and thanks. This update from the Canadian Network for Mood and Anxiety Treatments I think is a really useful guideline for family physicians. It's practical and it recognizes that depression management isn't a one size fits all. Importantly, it meets all but one of the criteria for guidelines we can trust using the G Trust Scorecard. Unfortunately, there were many conflicts of interest for the guideline authors.
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One of the most important take home points is to tailor treatment to severity for mild depression, low to moderate intensity exercise for 30 to 40 minutes 3 to 4 times per week for a minimum of of 9 weeks as a first line monotherapy. Psychotherapy can also be tried before medication. For most patients, the optimal amount of psychotherapy is 12 to 16 sessions and twice weekly sessions are associated with better outcomes than sessions once weekly or less.
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And for moderate to severe depression, combination therapy that is Psychotherapy plus an antidepressant is more effective than either alone. SSRIs, SNRIs, bupropion and mirtazapine remain the go to first line medications. And I found it really interesting that bupropion, escitalopram, mirtazapine, paroxetine, sertraline and extended release of enlafaxine have evidence of superior efficacy. The guideline also really hits home the importance of measuring outcomes systematically.
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Yeah, that's where the PHQ9 comes in. The guideline emphasizes using it not just at diagnosis, but to track response over time. If the symptoms do not improve by at least 20% in the initial four weeks of treatment, there is a low likelihood of response or remission at 8 to 12 weeks and at that point treatment should be switched or dose increased.
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F
Exactly. And here's something that I thought was interesting and new. Consider augmentation earlier rather than endlessly switching those SSRIs. Adding an atypical antipsychotic like aripiprazole can reduce the time to patient response or remission rate. For patients with an inadequate response to an antidepressant although it does carry a higher risk for side effects.
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I like that this approach keeps us focused on progress and partnership, actually following how patients are doing instead of just waiting for things to get better on their own.
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And I feel like I would be remiss. Not to mention the importance of Integrated Behavioral Healthcare Collaborative care, which is a specific model of integrated behavioral health care, has been found to reduce symptoms and suicidal ideation.
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Once a patient achieves treatment response, then we focus on maintaining symptom remission with the lowest effective dose for a minimum of 6 to to 12 months.
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That about sums it up. Back to you Steve.
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Next we have a poem. Poems are patient oriented evidence that matters. Anticoagulation decreases mortality in patients hospitalized with COVID 19 from Dr. Shaughnessy all right.
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The clinical question here is does therapeutic anticoagulation decrease mortality in patients hospitalized with COVID 19?
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This meta analysis included 11 RCTs of about 6,000 patients in the included studies. Most patients required little or no oxygen treatment. It was found that therapeutic dose anticoagulation with low molecular weight heparin or unfractionated heparin reduced 28 day mortality with an odds ratio of 0.77 compared with prophylactic dose anticoagulation with a number needed to treat of 48.
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Wow.
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Yeah. Well, what's the bottom line?
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Patients hospitalized with COVID 19 who do not require oxygen therapy benefit from therapeutic or high dose treatment which reduces 28 day mortality compared with prophylactic or low dose treatment. However, the caveat is that major bleeding is more common with therapeutic doses and this is high quality level 1A evidence.
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Wow. Yeah.
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We'll be right back.
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A
The AFP podcast is brought to you by the American Academy of Family Physicians and by molescan. Molescan by healthcert Education offers online skin cancer certificate courses for North American primary care practitioners. More information and access to a free short course is available@molescan.com Next, let's talk.
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About Slipped Capital Femoral Epiphysis A rapid evidence review from Drs. Webb Lu Bo, live from Louisiana State University.
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For the next segment, in honor of the spooky season, we have a truly frightening chief complaint to review a 12 year old boy with distal thigh and knee pain. Dun dun dun. Where do we even begin with this one? The differential for those symptoms is a mile long.
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Well, I think a good place to start would be to read through our rapid evidence review on Slipped Capital Femoral Epiphysis or scfi.
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Slipped Capital Femoral Epiphysis Definitely a scary diagnosis. Not to Miss. And a favorite question on all step and board exams.
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Definitely.
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SCFY is slippage of the femoral neck at the growth plate. And like our example, 12 year old most often occurs in preteens and early teenagers. Obesity is a risk factor, but no causal relationship has been demonstrated. Presentations can vary with poorly localized hip, groin, buttock, knee, or low back pain that increases with activity. If slippage is significant, then the patient may be limping on presentation. Steve, what do you expect on exam?
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Nothing is completely diagnostic, but Trendelenburg gait, leg length inequality, loss of internal hip rotation, and non specific pain on hip palpation are all possibilities. Some patients will have pain with Fader. That's passive flexion, adduction and internal hip rotation. Or or a positive Drayman sign, external rotation and abduction of the affected hip when the hip is passively flexed.
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Okay, if physical exam can't give us our diagnosis, what's our next move?
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Well, the next best step is plain X rays, best obtained with both an anteroposterior pelvis view and frog leg lateral views. And if the imaging is normal, but you still strongly suspect scfi, then MRI is the preferred next step.
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All right, great. So what's next, Austin? Now that we've got our diagnosis?
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Well, immediately our patient should be made non weight bearing and urgently referred to an orthopedic surgeon familiar with treating scfi.
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Do we try to relocate the hip, like with large joint dislocations?
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Absolutely not. Do not pass go, do not collect $200. Forced relocation can restrict blood supply and potentially lead to avascular necrosis.
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That is scary.
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Urgent referral for surgical intervention is always the step after diagnosis. And if the injury is unstable? Well, sending them over to the emergency room for admission and surgery within 24 hours is vital.
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Wait, what do you mean by unstable?
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Well, if the patient is unable to bear weight even with crutches, then the SCFA is typically considered unstable and should be quickly addressed given the significantly higher risk of complications like osteonecrosis. Rates as high as 50%.
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Oh, wow.
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Okay, so we've sent him to the hospital. He's gotten a surgery. Now what?
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Well, I know he's going to be mad at us, but experts recommend a stepwise rehabilitation ranging from 4.5 months to 6 months or longer. So he won't be back to playing soccer anytime soon. And we're going to need to keep an eye on that contralateral hip as well. Up to 60% of patients develop involvement of the opposite side.
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However, prophylactic pinning of a contralateral Hip is controversial and not universally recommended. Lastly, we could consider an endocrine workup for him given common coexistence of endocrine disorders in scfi. Phew. Yeah, that was a lot moral of the story. For scfi, obtain plain X ray, make non weight bearing and refer urgently to orthopedic surgery.
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Nice.
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Good.
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B
Next we have a poem. Poems are patient oriented evidence that matters. And this poem is entitled after ablation for atrial fibrillation. Left atrial appendage closure is superior to oral anticoagulation. This is from Dr. Abel. This poem comes from the option trial, a single blinded randomized controlled from Wanzi et al. That compares left atrial appendage closure with oral anticoagulation.
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Exciting. We always love a good poem in family medicine. Yes. So what question were the author specifically.
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Aiming to answer with this study in evaluating efficacy? They asked p patients who have undergone catheter ablation for atrial fibrillation. I is left atrial appendage closure with a device non inferior to c oral anticoagulation in O reducing death, stroke or systemic embolism Pico Their safety endpoints included major and non major bleeding events.
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All right, so what were the methods of the study?
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All right, so about 1,600 patients who were candidates for oral anticoagulation and had undergone catheter ablation for AFIB were balanced and randomized to receive a left atrial appendage closure with the watchman for this study or oral anticoagulation as chosen by their physician. 86% of those patients received DOACs. Patients who received the device did receive three months of oral anticoagulation plus aspirin followed by nine months of aspirin.
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And Alaina, what were the results?
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At 36 months, the watchman device was non inferior to oral anticoagulation for the grouped primary outcome of death, stroke and embolism. Additionally, devices were non inferior when it came to major bleeding events. When analyzing major non procedural bleeds and non major bleeds together, the device arm was found to be superior and the study authors calculated a number needed to treat of 10 or over three years to prevent one bleeding event when compared to the oral anticoagulation group.
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All right, Austin, so bring this home for us.
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So with a level of evidence of 1B, pretty good implantation of a left atrial appendage closure device allows for only three months of oral anticoagulation, is non inferior when compared to prolonged oral anticoagulation and reduces the risk of non major bleeding with an NNT of 10 patients in a three year period.
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Okay, we're going to close things out with a topic near and dear to our hearts in family medicine. Venous Thromboembolism Diagnosis and Treatment. This is from Drs. Nasir, Brumbaugh and Weil from Penn State.
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Venous thromboembolism, or VTE, includes both deep venous thrombosis, or DVT, and pulmonary embolism, or PE. DVT usually occurs in the lower extremities and presents with unilateral pain, warmth, redness and swelling. Pe, on the other hand, might cause chest pain, shortness of breath, tachypnea, syncope, or cough.
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Many patients have multiple risk factors. Some of the risk factors are hereditary, such as factor V Leiden, which is the most common hereditary risk factor, while others are acquired, like cases of recent surgery or malignancy.
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So how is VT eliagnosed? That's often the challenge. Symptoms can be vague and mimic so many other conditions.
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Once VTE is suspected, the next step is to estimate pretest probability using a validated rule such as the Wells criteria for DVT or pe. This helps classify patients as low, moderate, or high risk and guides the next steps.
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You guys know that I'm like super nerdy and so venous thromboembolism is my favorite example of how using pretest probability to make clinical decisions dramatically changes your diagnostic approach. It's like an EBM nerd stream come true.
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Your absolute favorite? Yes when should we be checking a D dimer versus going straight to imaging?
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For patients with a low pretest probability of dvt, start with a D dimer. If it's negative, you've ruled out dvt.
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Nice.
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For low to moderate probability of pe, a negative D dimer also excludes pe. If the patient has a moderate or high probability for dvt, begin with a compression ultrasound. If that's negative, check a D dimer and if the D dimer is positive, repeat the ultrasound in seven days.
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Okay? For pe, after using the WELLS or another validated tool, use the PE rule out criteria or PERK in low probability cases. If the perk results are positive, this is in your low probability cases, get a D dimer, and if that's positive, then you can move on to CT pulmonary angiography. For moderate probability, you can start with a D dimer test. For high probability, proceed directly to CT angiography.
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If ultrasound isn't feasible, CT or Mr. Venography can also diagnose DVT. And while ventilation perfusion scans can detect PE. They're usually reserved for patients who can't undergo CT angio.
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All right, now that we've confirmed the diagnosis, let's move on to treatment. Therapy depends on the patient's comorbidities and the extent of the clot burden and the severity of symptoms. The simplified PE Severity Index helps determine whether outpatient management is appropriate for Most.
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Acute uncomplicated DVTS and low risk PEs. Outpatient treatment with a direct oral anticoagulant or DOAC is preferred unless contraindicated. If a patient can't take anticoagulation, an IVC filter may be considered. However, for patients with hemodynamic or respiratory instability, critical limb ischemia, and high bleeding risk, they may warrant hospitalization. In some instances, thrombectomy or thrombolysis may be necessary.
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Now we're in our DOAC era, not having to monitor frequent labs is a huge win. So, Austin, how long is the treatment duration?
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Well, for the primary treatment phase, that's about three to six months, long enough for clot resolution and to lower the risk of recurrence.
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And what about preventing the next clot?
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Well, continuing anticoagulation after a first unprovoked VT el, a recurrent event, or VT EL related to chronic risk factor.
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You could literally talk for an hour about how to decide how long to treat each patient with anticoagulation.
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Let's not.
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Okay, so our key takeaways Clinicians should use validated prediction tools and D dimer testing to guide imaging and diagnosis of VTE. Treatment typically involves three to six months of anticoagulation, with DOACs preferred for most uncomplicated cases.
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Send us your thoughts by emailing us@AFPpodcastafp.org.
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Follow on Instagram fpjournal. Please subscribe and rate us wherever you get your podcasts.
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Escuchanos en espanol A Revista medica a.
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Fap Our podcast team is Jake Anderson, Puneet Baro, Steve Brown, Justin Chetiak, Sarah.
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Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg.
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F
Elena Kelly, Chisum Okuagu, and Kari Staus.
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Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabbs, Ryan Evans, and Justin Jenkins.
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B
This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs.
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D
We'll talk to you soon for the next edition of the American Family Physician Podcast.