AFP: American Family Physician Podcast

Episode 240 – October 2025, Part 2

Date: October 31, 2025
Hosts: Steve, Alaina, Austin (Residents & Faculty, University of Arizona College of Medicine-Phoenix)

Episode Overview

This episode features a practical, evidence-based roundup of current clinical topics for family physicians, focusing on:

• Overuse of colorectal cancer screening
• Practice guidelines for the management of depression
• Anticoagulation in hospitalized COVID-19 patients
• Slipped capital femoral epiphysis (SCFE)
• Left atrial appendage closure after atrial fibrillation ablation
• Diagnosis and treatment of venous thromboembolism

Contributing editor: Dr. Steven Brown.

Key Discussion Points & Insights

1. Overuse of Colorectal Cancer Screening and Surveillance

From Drs. Roth and Lazarus, with patient perspectives

• Guidelines: Colonoscopy is endorsed as a first-line screening test for adults aged 45–75 (01:45).
• Advantages: 95% sensitivity, can detect/remove adenomas, offers longer intervals between tests (01:56).
• Harms: 30-day risks of serious bleeding (16–36/10,000) and perforation (7.6–8.5/10,000) (02:15).
• Risks Increase with Age: Higher complication rates in patients over 75, who benefit less from screening (02:29).
• Overuse Issue: 17–25% of colonoscopies are unnecessary, mainly due to guideline non-adherence (02:38, 02:42).
• Impact: Over 2 million unnecessary colonoscopies yearly in the US, causing serious harm in ~9,000 patients (02:54).
• Patient Perspective: Some patients face delays in care due to overbooked GI practices (03:03).

Notable Quotes:

• "More than 2 million unnecessary colonoscopies are performed annually in the US leading to serious harm in about 9,000 patients." – Alaina (02:54)
• "We can work with our patients and GI colleagues to make sure our patients are getting appropriate colonoscopies at appropriate intervals." – Steve (03:13)
• "Shared decision making is always the right answer. The best screening test is the one that gets done." – Austin (03:20)

2. Practice Guidelines: Management of Major Depressive Disorder (Canmat Update)

With guests Dakota Wise & Dr. Sarah Coles

• Guideline Highlights: Practical, recognizes need for individual tailoring of depression management (03:43).

• Conflicts of Interest: Noted concern among the guideline authors (03:43).

• Treatment by Severity:

  • Mild depression: Recommend exercise (30–40 min, 3–4x/week for ≥9 weeks) and/or psychotherapy before medication; 12–16 sessions optimal, preferably 2x/week (04:05).
  • Moderate to severe: Combination of psychotherapy + antidepressant most effective (04:36).
    • Preferred meds: SSRIs, SNRIs, bupropion, mirtazapine (highlighted: bupropion, escitalopram, paroxetine, sertraline, venlafaxine XR) (04:36).

• Outcome Measurement:

  • Use PHQ-9 not just for diagnosis but to track progress (05:04).
  • <20% symptom improvement in 4 weeks → consider switching/increasing treatment (05:04).

• Augmentation: Consider adding agents (e.g., aripiprazole) earlier, rather than repeatedly switching SSRIs (05:25).

• Integrated Care: Collaborative care models found to reduce symptoms and suicidal ideation (05:54).

• Maintenance: Continue effective dose for 6–12 months after remission (06:05).

Notable Quotes:

• "One of the most important take home points is to tailor treatment to severity." – Dakota (04:05)
• "Combination therapy that is psychotherapy plus an antidepressant is more effective than either alone." – Dr. Coles (04:36)
• "Use the PHQ-9 not just at diagnosis, but to track response over time." – Dakota (05:04)
• "Consider augmentation earlier rather than endlessly switching those SSRIs." – Dr. Coles (05:25)
• "Integrated Behavioral Healthcare...has been found to reduce symptoms and suicidal ideation." – Dr. Coles (05:54)

3. Anticoagulation in Hospitalized COVID-19 Patients

“POEM” segment – evidence from Dr. Shaughnessy

• Clinical Question: Does therapeutic anticoagulation decrease mortality in hospitalized COVID-19 patients? (06:32)
• Evidence: Meta-analysis of 11 RCTs (~6,000 patients). Most needed little/no oxygen (06:40).
• Findings: Therapeutic-dose heparin reduces 28-day mortality vs. prophylactic dose (OR: 0.77; NNT = 48) (06:40).
• Caveat: Major bleeding risk increases with higher doses (07:10).
• Evidence Level: 1A (highest quality) (07:10).

Notable Quotes:

• "Therapeutic dose anticoagulation...reduced 28 day mortality with an odds ratio of 0.77 compared with prophylactic dose anticoagulation with a number needed to treat of 48." – Alaina (06:40)
• "Major bleeding is more common with therapeutic doses and this is high quality level 1A evidence." – Alaina (07:10)

4. Slipped Capital Femoral Epiphysis (SCFE)

Rapid Evidence Review from Drs. Webb, Lubo, et al.

• Presentation: 12-year-old boy with thigh/knee pain; consider SCFE, especially in preteens/teens (08:08).

• Risk Factors: Obesity raises risk, but no proven causality (08:41).

• Symptoms: Poorly localized hip/groin/buttock/knee/lower back pain, worse with activity; limping if severe (08:41).

• Exam Findings: Trendelenburg gait, leg length inequality, loss of hip rotation, pain on palpation, positive "FADIR" or Drehmann sign (09:06).

• Diagnosis: Start with bilateral (AP and frog-leg) pelvic X-rays; if negative but suspicion remains, obtain MRI (09:38).

• Immediate Action: Make patient non-weight bearing and urgently refer to ortho; do NOT attempt closed reduction (09:55–10:07).

• Surgical Timing: Unstable SCFE (unable to bear weight, even with crutches) needs admission and surgery within 24h due to avascular necrosis risk up to 50% (10:30).

• Recovery: Rehab is slow (4.5–6 months); monitor opposite hip (contralateral involvement in up to 60%) (10:47).

• Prophylaxis: Routine pinning of opposite hip is controversial (11:05).

• Endocrine Workup: Consider due to frequent related disorders (11:05).

Notable Quotes:

• "Do not pass go, do not collect $200. Forced relocation can restrict blood supply and potentially lead to avascular necrosis." – Austin (10:07)
• "For SCFE, obtain plain X-ray, make non-weight bearing and refer urgently to orthopedic surgery." – Alaina (11:30)

5. Left Atrial Appendage Closure After Atrial Fibrillation Ablation

“POEM” from Dr. Abel, based on the OPTION trial by Wanzi et al.

• Clinical Question: Is left atrial appendage (LAA) closure after ablation non-inferior to oral anticoagulation for preventing death/stroke/systemic embolism? (12:05)
• Study Design: 1,600 post-ablation AFib patients randomized to LAA closure (Watchman device) vs. oral anticoagulation (mostly DOACs) (12:38).
• Results:
  • LAA closure was non-inferior for primary outcomes at 36 months (13:07).
  • Also non-inferior for major bleeding.
  • Device was superior regarding major non-procedural and non-major bleeding (NNT = 10 over 3 years for one fewer bleed) (13:07).
• Practical Implication: Device allows for a shorter course of anticoagulation (3 months), is as effective for hard outcomes, and reduces non-major bleeding (13:42).
• Evidence Strength: Level 1B (13:42).

Notable Quotes:

• "The device arm was found to be superior ... NNT of 10 over three years to prevent one bleeding event." – Alaina (13:07)
• "Pretty good: implantation of a left atrial appendage closure device ... is non inferior when compared to prolonged oral anticoagulation and reduces the risk of non major bleeding." – Austin (13:42)

6. Venous Thromboembolism: Diagnosis and Treatment

From Drs. Nasir, Brumbaugh, and Weil (Penn State)

• Definitions: VTE = DVT + PE (14:15).

• Presenting Symptoms:

  • DVT: Unilateral leg pain, red, swollen, warm
  • PE: Chest pain, SOB, tachypnea, syncope, cough (14:36)

• Risk Factors: Hereditary (e.g., Factor V Leiden), acquired (recent surgery, cancer) (14:36).

• Diagnosis:

  • Estimate pre-test probability with Wells criteria (for both DVT and PE) (14:58).
  • Low risk DVT: D-dimer first; if negative, DVT ruled out (15:32).
  • Moderate/high risk DVT: Start with compression US; if negative, check D-dimer and repeat US in 7 days if needed (15:40).
  • For PE: Use Wells/other tool, then PERC for low risk; then D-dimer, then CTA if positive. Moderate risk: D-dimer first. High risk: Go straight to CTA (16:00).
  • Alternative imaging (CT/MR venography, VQ scan) if US/CTA not feasible (16:29).

• Treatment:

  • Outpatient DOAC for most acute, uncomplicated DVTs/low-risk PEs (16:44).
  • IV filters only if anticoagulation contraindicated.
  • Hospitalize if unstable or high complication risk. Thrombectomy/thrombolysis reserved for select severe cases (17:00).
  • Main course: 3–6 months anticoagulation (17:41).
    • Extended duration for unprovoked/recurrent/chronic risk factor cases is debated (17:51).

Notable Quotes:

• "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." – Alaina (18:08)

Timestamps for Key Segments

• Colorectal Cancer Screening Overuse: 01:28 – 03:25
• Depression Guidelines (Canmat): 03:30 – 06:14
• Anticoagulation in COVID-19 (POEM): 06:19 – 07:31
• Slipped Capital Femoral Epiphysis: 07:57 – 11:30
• LAA Closure after AF Ablation (POEM): 11:32 – 14:02
• Venous Thromboembolism (DVT/PE) Review: 14:02 – 18:08

Memorable Moments & Takeaways

• The “yikes” exchange on overused colonoscopies:
  “More than 2 million unnecessary colonoscopies ... leading to serious harm in about 9,000 patients.” – Alaina (02:54)
  “Yikes.” – Steve (03:02)

• Playful caution about SCFE:
  “Do not pass go, do not collect $200. Forced relocation can restrict blood supply...” – Austin (10:07)

• The show's clinical nerd energy on evidence-based VTE diagnosis:
  “Venous thromboembolism is my favorite example of how using pretest probability... is like an EBM nerd stream come true.” – Steve (15:12)

Summary Table of Clinical Pearls

| Topic | Key Takeaway | |-------------------------------------------|------------------------------------------------------------------------------------------------------| | Colorectal Cancer Screening | Adhere to guideline-driven intervals to avoid harm from overuse | | Depression Practice Guidelines (Canmat) | Tailor treatment to severity; measure outcomes; combine therapies for moderate/severe cases | | COVID-19 & Anticoagulation | High-dose (therapeutic) anticoagulation reduces mortality; balanced against bleeding risk | | Slipped Capital Femoral Epiphysis (SCFE) | Diagnose early with X-ray, make non-weight bearing, refer immediately, avoid bedside reduction | | Post-AFib Ablation: LAA Closure | LAA closure is a non-inferior/superior alternative to prolonged anticoagulation for select patients | | Venous Thromboembolism | Use Wells criteria/D-dimer for diagnosis; DOACs preferred, 3–6 months' duration for most uncomplicated cases |

This episode is a valuable, evidence-informed resource for family physicians, covering common and high-impact clinical questions with practical takeaways and a collaborative, educational tone.