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AFP: American Family Physician Podcast
Episode 243 -- December 2025 -- Part 1 AFP: American Family Physician
00:25:06
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The AFP podcast is brought to you by the American Academy of Family Physicians and by the Buxbaum Siegler Institute for Clinical Excellence at the University of Chicago. Each year, the Buxbaum Siegler Institute recognizes extraordinary healthcare professionals through the National Clinical Excellence Award. To learn more about the award and to nominate a deserving clinician, visit buxbauminstitute. Uchicago. Edu. Welcome to the American Family Family Physician podcast for part one of the December 2025 issue. I'm Steve.
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I'm Chiso.
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And I'm Austin.
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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 cancer screening in older adults, an app for obstructive sleep apnea, NSAID induced ulcers and dyspepsia, hemorrhoids, late pregnancy bleeding, intensive glucose control in older patients, and Everybody's favorite holiday ICD10 codes.
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The opinions expressed in the podcast are.
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Our own and do not represent the.
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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.
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We're on a mission delivering the best.
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From American family living with that strong American physician.
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Okay, let's start with cancer screening in older adults from Drs. McClester, Brown, Adams and Halpert from the University of North Carolina.
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Perfect. Let's look at breast, prostate, cervical, colon and lung cancer screening recommendations in older adults.
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And remember that a screening's payoff doesn't come quickly. For for many cancers like colorectal or breast cancer, mortality benefits from screening often only appear after eight to 10 years.
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That means if a patient's life expectancy is limited, like because of comorbidities or frailty, then the patient may endure the immediate harms of screening like false positives, invasive follow up and risky medical interventions long before they could have any benefit in practice.
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This compels us to ask, does this patient realistically have enough life expectancy to benefit? If not, maybe we rethink routine screening.
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Yeah, we have to be aware of the middle aged patient with a terminal illness still receiving health maintenance recommendations that may include cancer screening based on their demographic and medical history.
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Right? And rather than operating on autopilot, have a clear conversation regarding whether it's necessary to go forward with screening in the first place.
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Chronological age by itself isn't a good cutoff. Older adults are a heterogeneous group. Some 78 year olds are active, healthy, while Others might have multiple illnesses.
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For example, a fit 75 or 80 year old with good functional status may still benefit from screening, while a 70 year old with serious comorbidities may not.
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So the decision should rest on overall health comorbidities, prior screening history and functional capacity, not just over 75. Stop screening.
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The American Geriatric Society recommends screening be considered if adults have a life expectancy of at least 10 years.
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And again, decisions regarding screening and intervention should be a shared decision with a frank discussion about benefits, risks and what matters to the patient.
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Some of our patients may value the reassurance that comes with a negative screen, but others may prioritize avoiding invasive tests or complications.
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And as practitioners, our role is to present the data, including the delayed benefit, possible harms and uncertain yield, and guide patients in deciding according to their values and goals.
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Before ordering more tests, we should check previous screening history. If a patient has had regular appropriate screenings and no concerning findings, especially now with an advancing age or comorbidity, repeating may cause more harm than benefit.
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Redundant screening may lead to over diagnosis, procedural risks or undue stress without improving outcomes.
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Not to mention, stats aren't super impressive with lung cancer. Specifically, the number needed to screen Individuals over 65 years old was 320 to prevent one lung cancer death and 210 to prevent one death from any cause.
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Yeah.
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Oof. And an evidence review commissioned by the USPSTF concluded that PSA based screening in 1000 Men 55 to 69 years old led to 100 diagnoses over 13 years and prevented 1.3 deaths without a reduction in all cause mortality.
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The USPSTF and the American Urological association do not recommend screening for men 70 and older for prostate cancer.
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Less is more?
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Absolutely.
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So to wrap up when considering cancer screening in older adults, think about life expectancy and time to benefit, individualize based on overall health, engage in shared decision making and review prior screening before repeating. Yeah, this is a holiday wrap up episode.
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See what you did there. Next up, Diagnostic Tests the Samsung Health Monitor app for the detection of obstructive sleep apnea. This is from Drs. Bryce and Oliva from across town, our friends at Abrazzo Family Medicine Residency and Midwestern right here in Phoenix.
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While no consumer tech has yet been used to diagnose or treat sleep disorders, the American Academy of Sleep Medicine still urges clinicians to understand the pros and cons of these devices.
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One example is the Samsung Health Monitor app on Samsung Smart Watches authorized by the FDA to market detection of signs of moderate to severe osa in adults 22 and older.
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Yeah, so our patients are definitely gonna come in asking us about this. And Samsung now is allowed to market the feature, but that doesn't make it clinically useful. Aust Is it actually accurate?
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A 2024 study with 51 participants analyzed how accurately Samsung smartwatch technology predicted apnea Hypoxia indices or AHiS. The AHi is a value from polysomnography used alongside symptoms to diagnose OSA.
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They reported areas under the curve above 0.8 for predicting AHIS greater than 5, 15 or 30 per hour.
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Okay.
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Accuracy improved further when combined with positive stop bang or Berlin questionnaires.
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Right. When these high risk questionnaires were paired with device predicted AHIs above 15, the positive likelihood ratios exceeded 20 for predicting OSA.
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Dang, that's a very high likelihood ratio. Remember, even over 10 for a positive likelihood ratio is very likely to change your management. And so while this app is not a replacement for polysomnography, the watches may help engage patients and triage among the patients that might need a sleep study. But they're like everything, not without downsides.
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Exactly. Variation between devices and proprietary algorithms will affect accuracy of this technology. And unlike full sleep studies, smartwatches can't measure airway obstruction or sleep disturbances titrate positive airway pressure.
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Bottom line, these smartwatches are an emerging tool, but they're still best used with validated screening questionnaires to help decide who truly needs polysomnography.
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Next, a Cochrane for clinicians Proton pump inhibitors to prevent NSAID induced ulcers and dyspepsia this is from Drs. John and Lawrence from Tampa, Florida. The clinical question here is are proton pump inhibitors or PPIs effective for preventing dyspepsia and gastric or duodenal ulcers in people with long term non steroidal anti inflammatory drug or NSAID use?
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Short answer? Probably, but let's provide a little more context. NSAIDs are widely prescribed, but their GI side effects ranging from dyspepsia to serious ulcers are a real concern. Austin, what does the evidence say about PPIs for these patients?
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Well, Chisam, the latest Cochrane review looked at over 8,700 patients across 12 randomized trials. Compared to placebo, PPIs like omeprazole and pantoprazole only slightly reduce dyspepsia symptoms and may improve quality of life. More importantly though, they reduce the risk of developing endoscopically confirmed gastric or duodenal ulcers. The number needed to treat to prevent one ulcer is 12 over about three to six months.
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Dang. Yeah, that's pretty helpful. But how about comparing them to misoprostol or H2 blockers?
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Honestly, the data is limited. One small study suggested PPIs might actually increase ulcer risk compared to H2 blockers. And and against misoprostol, a similar outcome was noted with a number needed to harm of nine over 12 weeks. Granted, both of these findings were considered low to very low quality evidence. So not super great. We did see in the study that compared PPIs to misoprostol that PPIs were much better tolerated with fewer adverse effects.
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So for most patients on long term NSAIDs, PPIs are a reasonable choice for GI protection. But we should individualize therapy, especially in high risk patients.
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Exactly.
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Well, are there any formal guidelines for PPI and NSAID co administration?
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There are guidelines from the American College of Gastroenterology still do recommend co administration of a PPI with NSAIDs as a gastroprotective measure as well as swapping selective COX2 inhibitors with non selective NSAIDs like ibuprofen if possible. We'll be right back.
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The AFP podcast is brought to you by the American Academy of Family Physicians and by menopause and perimenopause CME for family physicians. A new live stream from the AAFP. Join us April 23rd through the 24th. Find details@aafp.org MenopauseCME we have a practice guideline, management of hemorrhoids. This is a guideline from the American Society of Colon and rectal surgeons, from Drs. Arnold and Smith, from the Naval Undersea Medical Institute in Connecticut, and excitingly, this.
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Guideline gets a perfect score on the G Trust Scorecard. Woo.
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Wow. This guideline focuses on patient oriented outcomes, is based on a systematic review and the chair and the majority of panel members are free of conflicts of interest.
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Wow.
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Yeah. Maybe that's because it's hemorrhoids. So there's like not what would be a conflict of interest. So let's go over some recommendations from this guideline.
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Well, in patients with hemorrhoids, treat underlying constipation. Increasing fiber intake decreases persistent symptoms by 53%.
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That's impressive.
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And over the counter hemorrhoid creams can significantly improve pain, pruritus and swelling.
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In patients with persistent symptoms, we can recommend rubber band ligation. Rubber band ligation is superior to surgical removal to reduce pain and minimize complications.
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Injection sclerotherapy is also an option.
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Surgical options including excision may be considered.
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For painful thrombo, external hemorrhoids stapled Hemorrhoidopexy is not routinely recommended as a first line surgical treatment.
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So to summarize, increased fiber topical agents are effective to improve symptoms and rubber band ligation is a good first line intervention for persistent symptoms.
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And yay to the American Society of Colon and Rectal Surgeons for making a useful evidence based guideline.
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Nice. Next late pregnancy bleeding from Drs. Yankee Gurlay and Rosenfeld O' Toole from Albuquerque, New Mexico.
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Late pregnancy bleeding any vaginal bleeding after 20 weeks gestation has a wide range of etiologies and severities. Today we'll focus on the emergent placental abruption, placenta previa, vasa previa and uterine rupture.
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Most often patients present with a self limited episode of small volume bleeding. Initial workup includes vitals, electronic fetal monitoring, wet mount, STI testing and urinalysis. But what about physical exam and imaging.
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When you don't know the placental location? We absolutely should avoid digital cervical examination. Instead you can consider a sterile speculum exam and a transvaginal ultrasound as neither requires passing through the external os.
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So let's get started with placental abruption.
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Ooh, I remember this triad from the usmle Vaginal bleeding, pelvic or back pain and uterine hypertonia, right?
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Well, classically yes, but a 2014 study showed that all three occur together only 10% of the time. Yeah, a more common combination is vaginal bleeding plus abnormal fetal heart tracing occurring in 39% of cases. And because ultrasound has limited sensitivity, abruption remains a clinical diagnosis.
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Yeah, and to make it even more complicated, abruption can be acute or chronic and sometimes even concealed. Some patients may have no visible bleeding. So in the setting of non reassuring fetal monitoring, abruption should always be on your differential. So Chisam, what about management?
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Well Steve, since trauma is a major risk factor, even minor trauma warrants at least four hours of monitoring. For maternal and fetal distress and RH negative patients need a Kleihauer Betke test and appropriate Rhogam dosing.
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Next up, placenta previa. Prior cesarean delivery is the strongest risk factor. Patients typically present with painless bleeding and diagnosis is made on ultrasound. Those with ongoing bleeding or contractions should be hospitalized. Asymptomatic patients or those whose symptoms resolve may be managed closely as outpatients.
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When do we reassess placental location?
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Good question. So for asymptomatic patients with previously diagnosed previa, a Repeat ultrasound at 32 weeks is recommended. If the placenta previa persists, schedule C section between 36 and 37 weeks, 6 days. If the placental edge is 2 cm or more from the internal os, routine care and vaginal delivery are appropriate. But if someone with known previa presents with significant third trimester bleeding, urgent cesarean is indicated.
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Now for the arguably scarier previa. Vasa previa?
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Yeah, like placenta previa, it's usually diagnosed on ultrasound, but it can present catastrophically with bleeding and fetal distress after membrane rupture. When diagnosed prenatally, neonatal survival without significant morbidity is great, about 97%. If you diagnose it only after bleeding and membrane rupture, then the survival drops to 28%.
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To avoid this, anyone with placenta previa or a low lying placenta should have Doppler assessment at their 32 week ultrasound. If vasa previa is present or risk is high, plan cesarean between 34 and 37 weeks is recommended.
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And finally, uterine rupture now more common due to rising cesarean rates and increased use of oxytocin. It most often presents with fetal bradycardia or late decels or decelerations. Other clues include loss of fetal station, palpable fetal parts, abdominal pain or tachysystole.
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This is unsurprisingly, another true emergency Cesarean delivery should occur within 30 minutes and should not be delayed for ultrasound confirmation. Emergent hysterectomy may be necessary if repair isn't possible.
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In any cause of late pregnancy, bleeding, unstable maternal vitals or fetal distress may necessitate urgent delivery. So don't forget your hemorrhage management type and cross, two large bore IVs and massive transfusion protocol if needed.
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Hopefully never. Yeah, but if a preterm delivery is likely, give betamethasone between 24 and 34 weeks and consider it up to 37 weeks if delivery is expected within a week. But don't delay necessary emergent delivery for.
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Steroids Now Loun right Care Reducing overuse and underuse intensive glucose control in older patients with diabetes. This is from Drs. Lazarus and Roth with patients perspectives by Helen Haskell and John James. Okay, we have a case.
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I'm ready.
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This is an 82 year old patient with newly diagnosed diabetes and an A1C of 8.0%. The A1C inches up to 9 and you prescribe metformin and then the A1C goes down to 8.5. A family member is worried about this, so the patient goes to an endocrinologist. The endocrinologist prescribes glargine insulin, sitaglyptin Starts a continuous glucose monitor and maxes out the metformin and achieves an A1C 6%. The patient starts to feel dizzy, fatigue, occasional confusion and has an unsteady gait. Why does this patient feel so terrible? Stay tuned.
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Ooh.
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Well, let's go over some background. In 1998, the American Diabetes association, or ADA, lowered the cutoffs to diagnose diabetes. A new diagnosis of pre diabetes also.
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Has been introduced with this definition. Now, 75% of Americans older than 65 have either diabetes or so called pre diabetes.
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Yeah. And intensive glucose control does not increase longevity and does not improve macrovascular outcomes.
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Exactly. The ACCOR trial was discontinued because mortality rates increased in the intensive treatment group.
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And no subsequent randomized trials have shown benefits in patient oriented outcomes with intensive glucose control.
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So when it comes to your older patients, it seems there may be a U shaped curve with an ideal A1C of about 7.5%.
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And symptomatic hypoglycemia is increased with intensive treatment in older people with a six fold increase in hospitalization rates for hypoglycemia.
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Yeah, hypoglycemia is detrimental in older patients, leading to more falls, increase in dementia, and memory loss and functional decline.
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Yikes. And it's also unclear if continuous glucose monitors improve patient oriented outcomes. The ADA recommends continuous glucose monitors, but this is tainted by the fact that the ADA accepts funding from a maker of a continuous glucose monitoring system.
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So in patients over 65, more relaxed standards of glucose control are recommended.
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Yep. Data supports a more moderate approach.
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Continuous glucose monitors in older patients not taking insulin has not been shown to be beneficial and may cause harm.
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The patient perspective here encourages us to treat the patient, not the numbers, and keep the broad perspectives that make us the experts as family physicians.
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Chisam, how did the case resolve for our unfortunate 82 year old patient who definitely felt worse after going to an endocrinologist?
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Well, the primary care doctor stopped the continuous glucose monitor, stopped the insulin, stopped the sitagliptin and took back over care of the diabetes. A healthy diet and exercise was recommended along with a twice a year A1C measurement and the metformin. The patient felt much better when the A1C went back to 8.5.
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Nice patient centered care for the win again.
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Less is more.
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This episode of the American Family Physician podcast brought to you by the phrase less is more always.
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Okay, team, it's time to celebrate the holiday season with our favorite all new holiday ICD10 codes.
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Time for icy, icy, icy, icy weather.
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It's icy Icy. Icy.
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Time of the air Jump, flip and fly and stuff your toes, fall and break your. No. Ho ho. It's our favorite Icy.
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Sometimes you just don't know how to code for those unusual holiday occurrences. So we are here to help. Austin, what conditions do you worry about most at the holidays?
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Well, I usually wrap a lot of presents this time of year and it can be pretty dangerous.
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Yes, definitely.
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Look out for W26.2xxa contact with Edge of stiff paper. Initial encounter. Initial.
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If it's like a follow up visit, it's subsequent encounter. But the first time it's initial encounter.
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Right, right, right. Well, I love singing carols with my family, but I'm wary of R49.0 hoarseness.
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Yes.
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And unless you do all your shopping online, you might need to use caution to avoid v92.59 injury at shopping mall.
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Oof.
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Black Friday.
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Yes.
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For those of you winter sports lovers, you might need the code V00322 snow skier colliding with stationary objects.
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Not like another moving skier. Stationary.
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Right, right, right. Still specific. Or V98.3 Accident 2 on or involving a ski lift.
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Lots of options there.
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Exactly.
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There's all kinds of ways to have an accident related to a ski lift, apparently. And as the Knights of Hanukkah progress, you're more and more likely to get X08.8 burn by candle.
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Or if there's excessive dreidel spinning, there's R42 dizziness and giddiness.
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Yep.
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Look out for Santa Slay. V81 injury to an animal rider or occupant of an drawn vehicle that occurred in a collision with a pedestrian animal.
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Santa got run over.
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Yes, exactly. And if there's a red rider carbine action 200 shot range model air rifle under your Christmas tree, be on the lookout for S0590XA unspecified eye injury.
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You'll shoot your eye out.
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Some holiday plants are just not safe. Keep mistletoe out of reach of children and pets to avoid T 63.79 toxic effect of contact with poisonous plants.
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Yeah, I really love the Dickens classic A Christmas Carol. And the character Ebenezer Scrooge, he suffers from R45.4 irritability and he makes his employee Bob Cratchit suffer from Z59.87 material hardship due to limited financial resources.
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But.
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But then Scrooge finds the holiday spirit again after being visited by three ghosts. Clearly visual disturbances. H53.
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All right, hot take here. The Muppet Christmas Carol might be the best version.
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Definitely. Agreed. Maybe Michael Caine's best work ever.
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All right, Ramadan is not till February in 2026, but when fasting is over each day, you might need the code R68.81 early Sadie yeah, and just in.
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General, the holidays can be super stressful. We might all need Z 75.5 holiday.
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Relief care and many people are overdue for a break at the holidays and are suffering from Z 73.2 lack of relaxation and leisure.
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Thanks to everyone working to take care of patients over the holidays. Yes.
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Have a great holiday, everybody.
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Happy holiday.
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Happy holidays. Oh oh Icy, icy, icy, icy weather. Icy, icy, icy, icy Time of the air.
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Jump up and slide and snap your toes Fall and break your knuckle pose. It's our favorite Icy.
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Send us your thoughts by emailing us at AFPPodcastAFP.org follow us on Instagram at afpjournal.
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Please subscribe and rate us wherever you get your podcasts.
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Escuchanos en espanol A revista medica a fap. Our podcast team is Jake Anderson, Puneet Barro, Steve Brown, Justin Chetiak, Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisum Okuagu, and Kari Stauss.
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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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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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We'll talk to you soon for the next edition of the American Family Physician Podcast.