Episode 241 -- November 2025 -- Part 1 AFP: American Family Physician

Summary

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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

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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.

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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)

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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)

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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)

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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)

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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)

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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)

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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)

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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

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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).

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Transcript

[Podcast Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the Permanente Medical Group Incorporated. Looking for competitive salary and benefits package with flexible schedules, the Permanente Medical Group's multidisciplinary practice is calling. We provide moving and relocation allowance, Northern California home buying assistance and the work life balance you deserve. Visit Northern California.Permanente.org.

[Jake Anderson]

Welcome to the American Family Physician podcast for part one of the November 2025 issue. I'm Jake.

[Rachel Dunn]

I'm Rachel.

[Jake Anderson]

And I'm Chisung and we are residents and faculty, mostly residents, of the University of Arizona College of Medicine, Phoenix Family Medicine Residency. Today on the podcast we'll talk about disorders of puberty, childhood caries, perfluorohexyl octane iron deficiency, anemia, amelioride and trauma informed care.

[Rachel Dunn]

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. We're on a mission delivering the best from American family.

[Jake Anderson]

First up, we have a main topic, Disorders of Common Questions and Answers, and it comes to us from Drs. Brown and Fogelman from Lancaster General Hospital Family Medicine Residency Program in Pennsylvania. Important note here. When we say boys in this article, we're talking about assigned male at birth, and when we say girls, we're talking assigned female at birth.

[Rachel Dunn]

We are discussing disorders of puberty, how to distinguish normal variation from conditions requiring evaluation or referral.

[Justin Chettiak]

Let's start with what's normal in girls. Breast development, or thelarchy, usually begins around age 10, ranging from eight to 13 years. Menarche follows about two and a quarter years later, typically around age 12 and a half. For boys, puberty starts with testicular enlargement reaching at least 4 mils or 2.5 centimeters around age 11 and a half, usually between 9 and a half and 14 years.

[Jake Anderson]

Exactly. And these milestones are driven by the hypothalamic pituitary gonadal axis, pulsatile release of gonadotropin releasing hormone from the hypothalamus stimulates the anterior pituitary to secrete LH and fsh, which then promote gonadal hormone production, estradiol in girls, and testosterone in boys.

[Rachel Dunn]

Okay, so when do we call puberty abnormal?

[Justin Chettiak]

Great question. We consider precocious puberty when the larche starts before age 8 in girls, or testicular enlargement before age 9 in boys. Delayed puberty means no breast development by 13 or no menarche by 15 in girls and no testicular growth by 14 in boys. Initial evaluation includes growth charts, mid parental height, Tanner staging and a detailed family and medical history. If findings aren't consistent with the benign pattern, we order labs early morning lh, fsh, tsh, total testosterone or estradiol, and a left hand bone age X ray.

[Jake Anderson]

And when should we think about neuroimaging?

[Rachel Dunn]

So, MRI of the brain with contrast is indicated for central precocious puberty in girls under 6, boys under 9, or in any child with neurologic symptoms such as headaches, seizures or vision changes.

[Jake Anderson]

And what about benign early variations?

[Justin Chettiak]

Good question. Common benign variants include premature thelarche, isolated breast tissue before age 8, usually self limited premature adrenarche, early pubic or axillary hair, body odor or acne without other pubertal signs, mini puberty of infancy, transient activation of the HPG axis after birth. These conditions can usually be monitored every three to six months unless red flags appear, like rapid progression, virilization or advanced bone age.

[Rachel Dunn]

Okay, so what causes true precocious puberty?

[Jake Anderson]

Well, it can be central, meaning gonadotropin dependent or peripheral gonadotropin independent. Central precocious puberty is often idiopathic in girls, about 80% of cases, but more often pathologic in boys. Peripheral causes include congenital adrenal hyperplasia, ovarian or Adrenal tumors, McCune Albright syndrome, or exposure to exogenous sex steroids.

[Rachel Dunn]

Oh, okay, interesting. What about delayed puberty?

[Justin Chettiak]

Most commonly, it's constitutional. Delay of growth and puberty, which accounts for about 60% of delayed cases in boys and 30% in girls. But we must also consider hypogonadotropic hypogonadism from hypothalamic pituitary or systemic disease, and primary gonadal failure, as in Turner or Klinefelter syndromes.

[Rachel Dunn]

Okay, so in summary, rule out benign variations before ordering extensive tests, but when in doubt, refer to pediatric endocrinology for unclear progressive or pathologic cases. Recognizing normal development and its deviations ensures early intervention prevents any psychosocial distress that can be associated and preserves growth potential.

[Jake Anderson]

Next up, we have a Cochrane for clinicians, and it comes to us from another doc out of Lancaster General hospital family medicine, Dr. Marco Cunucelli.

[Rachel Dunn]

The clinical question is, does providing dietary and feeding practice advice to primary caregivers reduce the risk of early childhood caries in children?

[Jake Anderson]

This Cochrane review included 23 randomized controlled trials with over 25,000 primary caregivers and their children. Eight caregiver targeted interventions were assessed during pregnancy or infancy for their ability to prevent early childhood caries in children up to age 6 years old.

[Rachel Dunn]

Okay, so these included dietary and feeding practice advice, breastfeeding promotion, dietary advice alone, combined oral hygiene, dietary and feeding practice advice, prenatal vitamin D supplementation, maternal antimicrobial tooth varnish treatments such as chlorhexidine, maternal xylitol chewing gum use which is an antimicrobial chewing gum and combine caregiver education with maternal dental care.

[Justin Chettiak]

In true primary care fashion, dietary and feeding practice advice was the only intervention to reduce early childhood caries. This intervention showed a 15% decrease in early childhood caries relative to standard of care.

[Jake Anderson]

That's awesome. This intervention demonstrated a relative risk of 0.85 translates to a number needed to treat a 15 to prevent caries and it's moderate certainty evidence. This intervention also might slightly reduce meaning decayed missing and filled surfaces index. However, this was lower certainty Overall advice.

[Rachel Dunn]

Anchored on bottle use, nighttime feeding and limiting sugary drinks which should all be incorporated into routine anticipatory guidance.

[Justin Chettiak]

The review also highlighted that interventions initiated early, ideally during infancy, were more successful at reducing caries. Waiting until after dental problems emerge is simply too late.

[Rachel Dunn]

Many of the studies also took place in socioeconomically disadvantaged populations where the burden of early childhood carries is highest. This underscores the importance of targeting interventions towards families with limited dental access or higher social risk.

[Jake Anderson]

We have a steps. Remember listeners, STEPS stands for safety, tolerability, effectiveness, price, simplicity. Awesome and it's the perfect framework for considering new drugs. This one looks at perfluorohexyloctane ophthalmic solution brand name Meebo for dry eye and it comes to us from pharmacist and physician team of Dr. Negro and Lishnack from the University of Connecticut.

[Justin Chettiak]

It is a water and preservative free drop that forms a stable moisture retaining layer on the surface of the eye to prevent tear evaporation.

[Jake Anderson]

All right, let's jump in. Rachel, tell us about safety.

[Rachel Dunn]

Good news. It actually has a safety profile comparable to that of hypotonic saline. In two studies each lasting eight weeks, participants using the solution four times daily in both eyes reported no serious ocular or non ocular adverse events and a 52 week extension trial found the same. One of the 614 participants did experience severe eye irritation that led to treatment discontinuation. There is a theoretical risk, as with many ophthalmic products, of interference with contact lenses. So for patients who Wear contact lenses. Lenses should be removed before using the solution, and patients should wait at least 30 minutes after application before reinserting them.

[Jake Anderson]

I think you already answered my next question, but talk to me more about t tolerability.

[Justin Chettiak]

Well, it's well tolerated and its safety profile is consistent with long term use up to one year. As with saline, about 1% to 3% of patients using the solution will experience blurred vision and conjunctival redness. Discontinuation rates were comparable with those of saline.

[Jake Anderson]

All right, so it sounds pretty safe and tolerable. How effective is it?

[Rachel Dunn]

It has been evaluated in two studies of more than 1200 patients with dry eye. The studies used a visual analog scale of 0 to 100 points to rate patient level of eye dryness and discomfort, with 100 points indicating maximal discomfort. The baseline average scores were 67 and 65 points, respectively, and they defined a reduction or difference in scores of 10 points or greater as clinically meaningful.

[Justin Chettiak]

Participants reported significantly greater improvement in dry ice scores with perfluorohexaloctane ophthalmic solution compared with hypotonic saline. These reductions in the eye dryness scores observed in the short term were confirmed to continue in the 52 week extension trial. Importantly, it has not been studied head to head with treatments other than saline.

[Jake Anderson]

Okay, so it's safe, tolerable and sounds effective, at least when compared with hypotonic saline drops. It's an eye job, though, so I'm worried about the price tag. Rip the band aid off here, Rachel.

[Rachel Dunn]

Yeah, you're right to be worried. The retail price of one 3 ML bottle is approximately $850. In comparison, prescription ophthalmic cyclosporine and Lefidigrast or Zidra cost between 650 and $750 per month. Artificial tears, on the other hand, typically cost less than $10 per month.

[Jake Anderson]

Ouch. Okay, so, so lastly, is it at least simple?

[Justin Chettiak]

Well, one drop into the affected eye four times per day, so, you know, take that with what you will. Other prescription treatments for dry eyes typically are used twice daily, and artificial tears may need to be used multiple times during the day. And we mentioned the 30 minute wait time for contact lens wearers before they can put their contacts back in.

[Jake Anderson]

Bottom line it for us, Rachel.

[Rachel Dunn]

Although perfluorohexyloctane 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. It hasn't been compared to other available remedies beyond saline. And so for now, as the authors of this steps conclude, it's hard to justify widespread adoption.

[Jake Anderson]

We'll be back after these messages.

[Podcast Announcer]

The AFP podcast is brought to you by the American Academy of Family Physicians and by the Permanente Medical Group Incorporated. Looking for competitive salary and benefits package with flexible schedules, the Permanente Medical Group's multidisciplinary practice is calling. We provide moving and relocation allowance, Northern California home buying assistance, and the work life balance you deserve. Visit Northern California.Permanente.org.

[Jake Anderson]

We have another main topic, iron deficiency anemia, and it comes to us from doctors Latimer, Basie and Lane. So iron deficiency anemia seems like a pretty straightforward topic, right? But it's often more nuanced than I think I realize.

[Justin Chettiak]

That's right. This article revisits how we diagnose, manage and think about this very common condition.

[Jake Anderson]

So iron deficiency anemia remains the most common type of anemia worldwide. It affects a broad range of patients, from young children to older adults, and its symptoms are often nonspecific, like fatigue, pallor, shortness of breath, reduced exercise tolerance.

[Justin Chettiak]

Exactly. The article points out that iron deficiency can exist even before anemia develops. Recognizing and treating it early can improve quality of life and prevent complications.

[Rachel Dunn]

And while iron deficiency anemia might seem routine, it can sometimes be a marker of something more serious, like gastrointestinal bleeding or malabsorption. That's why this topic deserves our ongoing attention.

[Justin Chettiak]

When it comes to evaluation, it is critical to think broadly when you see anemia or symptoms suggestive of iron deficiency.

[Jake Anderson]

While menstrual blood loss and dietary deficiency are common causes, they're not the only ones. Chronic GI blood loss, NSAID use, chronic kidney disease, malabsorption syndromes, and even frequent blood donation can all contribute to iron deficiency.

[Rachel Dunn]

Oh yeah, okay, that makes sense. Evaluation in adults should assess for bleeding H. Pylori infection and celiac disease in adult males and postmenopausal women especially, Evaluation for occult gastrointestinal bleeding should occur, including colon cancer screening if appropriate.

[Justin Chettiak]

The American Gastroenterological association recommends bidirectional endoscopy, including an EGD and colonoscopy to evaluate asymptomatic men, postmenopausal women with IDA or iron deficiency anemia. These patients have up to a 9% risk of GI malignancy.

[Jake Anderson]

Ferritin is our most sensitive test for iron deficiency, but it's also an acute phase reactant. So if your patient has inflammation, infection, chronic disease, ferritin levels may appear normal even in the presence of iron deficiency.

[Justin Chettiak]

So to add some explicit parameters in adult patients without inflammation, a ferritin level less than 45 nanograms per milliliter or a ferritin level of 46 to 99 nanograms per milliliter plus a transferrin saturation of less than 20% is diagnostic of iron deficiency. In patients with inflammation, a ferritin level of less than 100 nanograms per milliliter is diagnostic. So evaluating patients with a full panel, ferritin, transferrin saturation, serum iron and total iron binding capacity and interpreting those values alongside the clinical picture is crucial in diagnosis. When it comes to treatment, management should focus on both effectiveness and patient adherence.

[Jake Anderson]

Oral iron remains first line therapy for patients with iron deficiency anemia. The traditional dosage of ferrous sulfate was 325mg with 65mg of elemental iron three times a day though, which feels like a lot. Fortunately, we've challenged the status quo and now see that lower daily doses like 15 to 20 milligrams of elemental iron are as effective and cause fewer adverse effects.

[Rachel Dunn]

In fact, high doses and frequent doses of oral iron is counterproductive because of increased hepcidin levels not to get too into the weeds of biochemistry, but higher doses of iron lead to increased hepcidin levels and actually results in suppression of iron absorption for up to 48 hours. Because of this, starting with lower doses and prescribing every other day, dosing of oral iron can actually be more effective at increasing serum iron levels. This ultimately improves absorption and reduces GI.

[Justin Chettiak]

Effects and follow up is essential. You should expect hemoglobin to rise by about 1 gram per deciliter over three to four weeks. If that doesn't happen, reassess Is the patient taking the medication? Is there ongoing bleeding? Could there be an absorption problem?

[Jake Anderson]

Patients who are adherent to oral therapy but have a suboptimal response should be transitioned to intravenous therapy. IV iron can also be used in patients who can't tolerate oral dosing with consideration of IV iron, hypersensitivity reactions and hypophosphatemia are documented adverse effects. Incidence of hypersensitivity is less than 1%, thankfully in these newer formulations and and tends to be associated with risk factors such as a previous reaction to IV iron, fast infusion rate and history of multiple drug allergies.

[Justin Chettiak]

Hypophosphatemia is usually mild and transient but should be evaluated in patients who develop fatigue, bone pain or muscular weakness after infusion. Ferric carboxymaltose is the formulation associated with the most severe form of hypophosphatemia.

[Jake Anderson]

Guys, we have a poem and this one comes to us from EBM guru Dr. David Slauson.

[Rachel Dunn]

Our question is is amilioride non inferior to spironolactone for resistant hypertension?

[Justin Chettiak]

Spironolactone is effective but can cause unwanted adverse effects including hyperkalemia, gynecomastia and menstrual irregularities. Right.

[Jake Anderson]

So this study out of a government and foundation funded trial randomized 118 adults aged 19 to 74 with resistant hypertension. Everyone met the usual diagnostic criteria for hypertension.

[Rachel Dunn]

They compared open label spironolactone at 12.5 mg daily to amiluride. 5 mg doses were doubled mid study if the blood pressure wasn't at goal or if the potassium levels allowed and.

[Justin Chettiak]

The target goal mean home systolic blood pressure under 130 millimeters of mercury.

[Jake Anderson]

Follow up on this study was pretty impressive. So 97% of patients at 12 weeks followed up. And the results? Both groups had similar reductions. About 13.6 millimeters mercury of blood pressure reduction for spironolactone and 14.7 millimeters mercury for amiluride. Statistically no difference.

[Justin Chettiak]

So amelioride held its own and with.

[Rachel Dunn]

Fewer adverse effects, amiliorides much less common to cause those androgen related issues and hyperkalemia.

[Jake Anderson]

Design wise this was a single blinded randomized control trial with good internal validity, concealed allocation and they did an intention to treat analysis. So they gave this a level of evidence 1b.

[Rachel Dunn]

It's pretty good clinically. That means if your patient can't tolerate spironolactone such as experiencing breast tenderness or high potassium, then amiluride is a solid alternative.

[Justin Chettiak]

Bottom line is non inferior to spironolactone for resistant hypertension with fewer side effects.

[Jake Anderson]

We're going to wrap this episode up with an editorial. Trauma Informed Evidence and pragmatic approaches from doctors Win Fang, Behrens and Butler from Minnesota.

[Rachel Dunn]

Exposure to trauma, whether it's community violence, interpersonal violence or child maltreatment, has been associated with many adverse mental and physical health outcomes.

[Justin Chettiak]

Trauma informed care, which is defined as a set of principles that reflects awareness of trauma exposure and its effects, is essential to better understand the landscape of trauma informed care. The Agency for Health Care Research and Equality contracted with the Minnesota Evidence Based Practice center to produce the 2025 report Trauma Informed Care A Systematic review sponsored by the National Institute of mental health.

[Rachel Dunn]

Twelve studies from 16 publications met criteria for inclusion in the systematic review. Most of the studies included staff training on trauma informed care that ranged from a single two hour session to multiple sessions spanning 12 months. Study populations included children, adolescents and adults in the U.S. canada and Switzerland in various settings including residential homes, psychiatric hospitals, primary care and child welfare services.

[Justin Chettiak]

Unfortunately, all of the studies identified were assessed to have high risk of bias and high variability across interventions, which precluded quantitative synthesis. And even more unfortunate, the evidence was insufficient to reach any conclusions about the effects of trauma informed care for any outcome.

[Jake Anderson]

As the authors point out, this is a reminder that implementation in clinical practice can sometimes outpace research evidence. However, in the absence of a clear evidence base, there are some pragmatic approaches that the authors recommend.

[Rachel Dunn]

First, when working with patients who have a history of trauma, clinicians can consider the comorbidities associated with trauma, such as adverse social determinants of health, and offer to connect patients with available resources such as behavioral health and community organizations.

[Justin Chettiak]

Second, to prevent occupational burnout and compassion fatigue in delivering trauma informed care, clinicians need to rely on a collaborative integrative team approach.

[Rachel Dunn]

Lastly, 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. Depending on the clinical settings and prevalence of trauma related conditions, it may be advisable to implement systems level changes or incorporate more trauma informed communication strategies into daily practice.

[Jake Anderson]

The editorial includes some great resources, including statements on trauma informed care from medical organizations including RAAFP and examples of trauma informed care models.

[Justin Chettiak]

Send us your thoughts by emailing [e-mail].

[Jake Anderson]

Follow on Instagram fpjournal. Please subscribe and rate us wherever you get your podcasts.

[Rachel Dunn]

Escucanos en espanol a revista Medica a.

[Justin Chettiak]

F a PE Our podcast team is Jake Anderson, Puneet Bharot, Steve Brown, Justin Chettiak, Sarah Coles, Austin Cotter, Rachel Dunn.

[Rachel Dunn]

Emily Eisenberg, Elena Kelly, Chisholm Okuwagu, and Kari Stauss.

[Justin Chettiak]

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.

[Jake Anderson]

This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Programs.

[Justin Chettiak]

We'll talk to you soon for the next edition of the American Family Physician Podcast.