AFP: American Family Physician Podcast

Episode 241 – November 2025, Part 1

Date: November 17, 2025
Hosts: Jake Anderson, Rachel Dunn, Justin Chettiak
Featuring: Faculty and residents, University of Arizona College of Medicine – Phoenix Family Medicine Residency

Episode Overview

This episode delivers a comprehensive review of key clinical updates featured in the November 2025 issue of American Family Physician. Topics range from navigating disorders of puberty and reducing childhood caries to new options for dry eye therapy, nuanced iron deficiency anemia management, amiloride as an alternative for resistant hypertension, and a sobering look at the evidence behind trauma-informed care. The tone remains practical, evidence-focused, and attuned to real-world clinical decision-making.

Disorders of Puberty: Distinguishing Normal from Abnormal (01:31–05:47)

Key Points & Clinical Insights

• Normal Puberty Milestones

  • Girls: Breast development (~10 years; range 8–13), menarche follows ~2.25 years later (~12.5 years)
  • Boys: Testicular enlargement (≥4 mL or ≥2.5 cm) at ~11.5 years (range 9.5–14)
  • Driven by the hypothalamic-pituitary-gonadal (HPG) axis

• Defining Abnormal Puberty

  • Precocious puberty:
    • Girls: Breast development before 8
    • Boys: Testicular enlargement before 9
  • Delayed puberty:
    • Girls: No breast development by 13, no menarche by 15
    • Boys: No testicular growth by 14

• Initial Evaluation

  • Growth charts, Tanner staging, mid-parental height, detailed family/medical history
  • Labs: Morning LH, FSH, TSH, testosterone/estradiol, left hand bone age X-ray

• Neuroimaging (MRI) Triggers:

  • Central precocious puberty: <6 years (girls), <9 years (boys), or neurological symptoms (headaches, seizures, vision changes) (03:35)

• Benign Variations

  • Premature thelarche, isolated breast tissue, premature adrenarche, transient “mini-puberty” after birth
  • Monitor every 3–6 months unless red flags: rapid progression, virilization, advanced bone age

• Etiology

  • True precocious puberty:
    • Central (80% idiopathic in girls, more often pathologic in boys)
    • Peripheral (CAH, tumors, McCune-Albright, exogenous steroids)
  • Delayed puberty:
    • Mostly constitutional (60% of boys, 30% of girls), hypogonadotropic hypogonadism, or primary gonadal failure (Turner/Klinefelter)

Notable Quote

• “Rule out benign variations before ordering extensive tests, but when in doubt, refer to pediatric endocrinology for unclear, progressive, or pathologic cases.” — Rachel Dunn (05:22)

Cochrane for Clinicians: Preventing Childhood Caries (05:47–08:09)

Clinical Question

• Does caregiver-targeted dietary/feeding advice reduce risk of early childhood caries?

Review Summary

• Included 23 RCTs (~25,000 children/caregivers), various interventions (06:06–06:55)
  • Only dietary and feeding practice advice reduced caries—15% decrease (NNT=15, moderate-certainty evidence)
  • Key focuses: bottle use, nighttime feeding, limiting sugary drinks
  • Interventions most effective when started in infancy
  • Crucial for socioeconomically disadvantaged families/limited dental access

Notable Quote

• “Waiting until after dental problems emerge is simply too late.” — Justin Chettiak (07:41)

STEPS: Perfluorohexyloctane Ophthalmic Solution (Meibo) for Dry Eye (08:09–12:28)

STEPS Framework

• Safety:

  • Comparable to saline; very low adverse events (only 1 dropout for irritation out of 614)
  • Remove contact lenses before use, wait 30 minutes before reinserting (08:49–09:35)

• Tolerability:

  • Equivalent to saline (1–3% blurred vision/redness), low discontinuation (09:40)

• Effectiveness:

  • Two RCTs (>1200 patients): meaningful improvement in dryness/discomfort vs. saline
  • Not compared to other dry eye treatments (only saline) (10:03–10:52)

• Price:

  • $850 for 3 ml bottle; much higher than other Rx drops ($650–$750/month) and OTC artificial tears (<$10/month) (11:05–11:30)

• Simplicity:

  • Four doses/day, 30-min wait for contact lens users; more frequent than other prescriptions (11:35)

Bottom Line

• “Although perfluorohexyl octane ophthalmic solution provides rapid symptom relief and appears to be well tolerated in clinical studies, its practical value may be limited by the high cost and four-times-per-day dosing, which is especially cumbersome for contact lens wearers.” — Rachel Dunn (11:58)

Iron Deficiency Anemia: Nuanced Diagnosis & Treatment (12:53–18:02)

Diagnostic Pearls

• Common & Often Subtle

  • Spectrum: from asymptomatic iron deficiency to overt anemia
  • Symptoms range from fatigue to SOB, often nonspecific
  • May signal underlying pathologies (e.g., GI bleed, malabsorption)

• Broad Differential

  • Menstrual loss, dietary deficiency, NSAIDs, CKD, GI causes, blood donation (14:00)

• Evaluation

  • Test for bleeding, H. pylori, celiac in all at-risk adults

  • Colon cancer screening in males/postmenopausal females

  • Use ferritin (most sensitive, but acute phase reactant), transferrin saturation, TIBC, consider inflammation

  • Diagnostic Cutoffs:

    • No inflammation: Ferritin <45 ng/mL, or ferritin 46–99 + transferrin sat <20%
    • With inflammation: Ferritin <100 ng/mL

Treatment Nuances

• Lower, Less Frequent Dosing Preferred

  • Historically high-dose iron TID, but “lower daily doses (15–20 mg elemental iron) are as effective and cause fewer adverse effects.” — Jake Anderson (15:53)
  • High/frequent dosing raises hepcidin, suppressing absorption for up to 48h
  • Every-other-day dosing may be superior for absorption and GI side effect profile

• IV Iron

  • Reserve for oral intolerance/nonresponse; rare but notable risks: hypersensitivity (<1%), hypophosphatemia (esp. ferric carboxymaltose)

Notable Quotes

• “Recognizing and treating [iron deficiency] early can improve quality of life and prevent complications.” — Justin Chettiak (13:31)
• “Follow up is essential. You should expect hemoglobin to rise by about 1 gram per deciliter over three to four weeks.” — Justin Chettiak (16:52)

POEM: Amiloride for Resistant Hypertension (18:02–19:54)

Study Overview

• Compared amiloride vs. spironolactone for resistant hypertension in RCT (n=118, ages 19–74); open-label, single-blinded
• Doses: Amiloride 5mg (doubled mid-study if goal not met and potassium allowed) vs. spironolactone 12.5mg (doubled similarly)
• Results:
  • Similar reductions in mean home systolic BP (~13.6 mmHg for spironolactone, ~14.7 mmHg for amiloride)
  • Amiloride had fewer androgen-related adverse events and lower risk of hyperkalemia

Clinical Implication

• “If your patient can’t tolerate spironolactone…the amiloride is a solid alternative.” — Rachel Dunn (19:43)
• “Bottom line: [Amiloride] is non-inferior…with fewer side effects.” — Justin Chettiak (19:54)

Editorial: The Evidence for Trauma-Informed Care (20:03–22:47)

Key Principles

• Trauma exposure impacts health — but evidence base is limited

  • 12 studies (16 publications, variety of settings/patients) showed high risk of bias, heterogeneity, and insufficient evidence of effectiveness for trauma-informed care (20:52)

• Pragmatic Recommendations:

  • Address comorbidities/adverse social determinants; connect patients with resources (21:55)
  • Prevent clinician burnout through collaborative, team-based care (22:12)
  • Employ clinical judgment in implementing trauma-informed approaches, tailoring to practice context

Notable Quotes

• “Implementation in clinical practice can sometimes outpace research evidence.” — Jake Anderson (21:41)
• “When deciding whether to implement any components of trauma informed care, clinicians can use clinical judgment within their specific settings to assess the potential net benefit.” — Rachel Dunn (22:22)

Notable Quotes & Memorable Moments

• “Waiting until after dental problems emerge is simply too late.” — Justin Chettiak (07:41)
• “Lower daily doses like 15 to 20 milligrams of elemental iron are as effective and cause fewer adverse effects.” — Jake Anderson (15:53)
• “Amiloride is non-inferior to spironolactone for resistant hypertension with fewer side effects.” — Justin Chettiak (19:54)
• “Implementation in clinical practice can sometimes outpace research evidence.” — Jake Anderson (21:41)

Timestamps for Major Segments

• Disorders of Puberty: 01:31–05:47
• Childhood Caries Prevention: 05:47–08:09
• Perfluorohexyloctane for Dry Eye (STEPS): 08:09–12:28
• Iron Deficiency Anemia: 12:53–18:02
• Amiloride vs. Spironolactone for Hypertension: 18:02–19:54
• Trauma-Informed Care Editorial: 20:03–22:47

Closing Notes

The hosts reinforce their focus on practical, evidence-based guidance for primary care, urge listeners to apply new clinical insights with context, and encourage engagement and feedback (23:06–23:51).