Episode 244 -- December 2025 -- Part 2 AFP: American Family Physician

Summary

AFP: American Family Physician Podcast

Episode 244 – December 2025 – Part 2
Date: December 30, 2025
Contributors: Dr. Steve Brown (B), Dr. Justin Chediak (C), Dr. Rachel Dunn (D)

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Main Theme & Purpose

This episode presents clinical pearls reviewed by the University of Arizona College of Medicine-Phoenix Family Medicine Residency team. The panel reviews essential updates and evidence-based practices from the December 2025 issue of American Family Physician (AFP). Clinical topics include ankle sprain management, topical therapy for axillary hyperhidrosis, dementia evaluation, frailty scoring for hip fracture outcomes, heart failure with preserved ejection fraction (HFpEF) risk, and a rapid-fire round of clinical answers.

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Key Discussion Points & Insights

1. Management of Ankle Sprains (01:29–05:11)

• Delaying the Initial Exam

  • "Don't examine too early. Those first few days are one big, puffy mystery ankle. Like a water balloon with toes." (B, 01:59)
  • The clinical exam is most reliable at 4–7 days post-injury.
  • Key findings: lateral swelling, hematoma, ATFL tenderness, positive anterior drawer/talar tilt (Sensitivity: ↑ to 96%).

• Ordering X-rays

  • Apply Ottawa Ankle Rules: history of inability to bear weight or bony tenderness at critical sites (malleoli, navicular, base of the 5th metatarsal). Sensitivity ~91%.
  • "Order standard AP, lateral, and mortise views with weight bearing if possible." (B, 02:58)

• Acute Management

  • Pain control, joint protection (limited mobility 5–10 days), early movement/PT.
  • "Don't go wild on oral NSAIDs... Topical NSAIDs or acetaminophen work great." (B, 03:22)
  • Semi-rigid braces are superior to elastic wraps. PT should include proprioception, balance, and strength.

• Prevention & Return to Play

  • Bracing during sports and 8–12 weeks of PT; bracing for up to 12 months post-injury.
  • Physical impairments (proprioception, strength) raise reinjury risk.
  • PAASS framework for return to play: Pain, Ankle impairments, Athlete perception, Sensory motor control, Sports performance.

• Persistent Pain

  • Consider syndesmotic or osteochondral injuries; use squeeze test for syndesmotic sprains.
  • "Dynamic ultrasound can catch peroneal tendon subluxation." (B, 04:59)

Memorable moment:
"Sometimes I think the human ankle was designed specifically to be sprained. It's like evolution just said, lol, good luck."
(C, 01:39)

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2. Axillary Hyperhidrosis: Soft Pyronium Topical Gel (05:16–07:24)

• Two large RCTs included individuals ≥9 years old with primary axillary hyperhidrosis (>6 months).
• Sofpironium gel (12.45%) vs. vehicle, used nightly.
• Primary outcomes: ≥2-point improvement on disease scale or ≥70% reduction in sweat.
  • "By week six, about 38%... met both targets, compared with 18% in the control group. This gives a number needed to treat of about 5." (D, 06:14)
• Side effects: mild anticholinergic effects (dry mouth, blurred vision), local dermatitis.
• 4% withdrew due to side effects; counseling is important.
• Not yet widely available; cost may be prohibitive, but manufacturer coupons exist.

Quote:
"This local option with once daily bedtime use is appealing and the evidence level is high. Level 1B."
(C, 06:56)

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3. Evaluation of Suspected Dementia (07:44–10:43)

• Diagnosis must distinguish between aging and neurocognitive disorder.

  • Red flags: repeating questions, getting lost, difficulties in conversation/tasks, personality changes.
  • "Families usually notice these long before patients do. So a really good history from caregivers is essential." (B, 08:10)

• Initial screening tools:

  • Mini-Cog: three-word recall + clock drawing.
  • MIS (Memory Impairment Screen)
  • AD8: caregiver questionnaire.

• Further assessment if the screen is abnormal/gut feeling signals concern:

  • MOCA for mild cognitive impairment.
  • RUDAS for cultural/education barriers.

• Evaluation: review medications, physical/psychiatric exam, B12/folate, TSH, CBC, CMP.

• Imaging: non-contrast MRI preferred (CT if MRI unavailable).

• Consider mimics: depression, delirium, sleep apnea, B12 deficiency, alcohol use, infections (HIV, neurosyphilis).

Quote:
"Dementia evaluation is a marathon, not a sprint. It often takes multiple visits, careful discussions with families, and coordinated planning."
(D, 10:34)

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4. Frailty Scoring for Hip Fracture Outcomes (11:25–13:52)

• Frailty scoring recommended for ≥70yo admitted with hip fracture.

  • "Frail patients have higher risks of mortality and complications... They also stayed in the hospital about 2.6 days longer." (B, 12:08)
  • Poorer discharge function and higher risk of discharge to facilities.

• Instruments:

  • 26-item Frailty Index: comorbidities, cognition, nutrition, polypharmacy, mobility, incontinence, social vulnerability.
  • Cumulated Ambulation Score (CAS): out-of-bed, sitting, walking.

• Recommendation: Comprehensive risk assessment including frailty score and delirium screening.

Bottom line:
"Frailty scoring matters. It gives us better data, better conversations and hopefully better outcomes."
(C, 13:44)

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5. HFpEF Risk Prediction in Exertional Dyspnea (13:52–15:45)

• Heart Failure with preserved EF (≥50%), presents as exertional dyspnea.

• Three main risk-prediction tools:

  • H₂FPEF: Needs echo (filling pressure); AUC 0.886.
  • HFAPEf (from HFA/ESC): BNP thresholds, echo, exercise; AUC 0.90.
  • HFpEF-ABA: Only age, BMI, and a-fib history; AUC 0.81; usable without advanced tests.

• Tools aid diagnostic approach and streamline management.

Memorable moment:
"Rachel and Justin, I have an actual haiku. Oh, boy.
Short of breath. Struggle
Unknown. Fill Pressures Unsure.
Use tool. Breathe easy."
(B, 15:45)

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6. AFP Clinical Answers Speed Round (16:02–17:41)

• Ambulatory ECG vs. Echo for Palpitations:

  • Two weeks of EKG monitoring has highest yield-to-cost ratio.

• Initial Labs for Bleeding Disorders:

  • CBC, PT, PTT, peripheral smear, fibrinogen, ±vWD studies.

• Intermittent SSRIs for PMDD:

  • Acceptable alternative to continuous dosing.

• Acute Bacterial Arthritis in Kids:

  • Blood cultures before antibiotics, plain films, CRP for tracking. Don't delay antibiotics if ill-appearing. ESR/procalcitonin less useful.

• Anaphylaxis after Epi:

  • Not all require EMS; if resolution is quick and sustained, patients can be monitored at least an hour.

Quote:
"No. Conservative care can be considered after complete or near complete symptom resolution... patients should be monitored for at least an hour."
(D, 17:26)

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Notable Quotes & Memorable Moments

• On the frequency of ankle sprains:
  "Sometimes I think the human ankle was designed specifically to be sprained." – (C, 01:39)

• On the unpredictability of a newly injured ankle:
  "Those first few days are one big, puffy mystery ankle. Like a water balloon with toes." – (B, 01:59)

• On dementia evaluation:
  "Dementia evaluation is a marathon, not a sprint." – (D, 10:34)

• Poetry and humor (on HFpEF tool):
  "Short of breath. Struggle
  Unknown. Fill Pressures Unsure.
  Use tool. Breathe easy." – (B, 15:45)

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Segment Timestamps

• 00:31 – Intro/Hosts and episode structure
• 01:29 – Ankle sprain management
• 05:16 – Axillary hyperhidrosis topical gel evidence
• 07:44 – Dementia evaluation
• 11:25 – Frailty scoring for hip fracture outcomes
• 13:52 – HFpEF risk prediction rules
• 16:02 – Clinical Answers speed round

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This summary highlights clinical best practices and practical humor. For the full conversation and more nuanced discussion, listen to the episode.

Transcript

[A]

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 [e-mail] menopausecme.

[B]

Welcome to the American Family Physician podcast for part two of the December 2025 issue. I'm Steve.

[C]

I'm Justin.

[D]

And I'm Rachel.

[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 management of ankle sprains, axillary hyperhidrosis, dementia evaluation, frailty scoring, HFpEF wrist prediction and and AFP clinical answers.

[D]

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.

[B]

We're on a mission to living the.

[D]

Best From American Family Physician On a mission to live in the best, strong American family.

[B]

Okay, let's start things off with management of ankle sprains. Common questions and answers from Drs. Wu, Padilla, and Smith from the University of Florida.

[C]

You know, sometimes I think the human ankle was designed specifically to be sprained. It's like evolution just said. Lol. Good luck. I mean, I see them constantly in clinic and in my own life as well.

[D]

Oh, you know, honestly, same. So let's jump into our first question. What exam findings actually help us evaluate lateral ankle sprains?

[B]

The key is don't examine too early. Those first few days are one big, puffy mystery ankle. Like a water balloon with toes.

[A]

Exactly.

[C]

But at four to seven days, the findings get reliable. Lateral joint swelling, hematoma, ATFL tenderness, and a positive anterior drawer or talar Tilt sensitivity jumps from 71 to 96%. And specificity from a frankly offensive 33 to 84%. Yeah.

[D]

Oh, okay. And then please review the special test in the article. Your future patients will thank you. Or at least hopefully limp a little less.

[B]

Yes.

[C]

So.

[B]

All right, question two. When do we order ankle X rays?

[C]

Altogether now, children, Ottawa ankle rules.

[B]

Yes.

[D]

If the patient can't bear weight for four steps or has bony tenderness at the malleoli, navicular or base of the fifth metatars, order that X ray to rule out a fracture. Sensitivity is about 91%.

[B]

Just make sure you order standard anteroposterior lateral and mortise views with weight bearing, if possible. So you can get a good look at the base of the fifth metatarsal bone.

[C]

Perfect. All right. Question three. How do we manage acute ankle sprains.

[D]

Pain control, joint protection with limited mobility for five to 10 days and then followed by early functional activity and physical therapy. Boom.

[B]

And don't go wild on oral NSAIDs. Some evidence says that oral NSAIDs might slow healing. Topical NSAIDs or acetaminophen work great. And Tylenol works just as well as oral NSAIDs or opiates without all the side effects.

[C]

Compression helps swelling and semi rigid braces beat out elastic wraps with better protection and stability.

[D]

And physical therapy should focus on balance, range of motion, proprioception and strength. Basically all the things Justin lacks.

[C]

That's cool.

[B]

So, next question. How do we prevent future sprains?

[C]

Well, external support plus 8 to 12 weeks of PT. So bracing during sports can reduce inversion injuries by up to 70% and should be worn with all sporting activities for up to 12 months.

[D]

And physical therapy is critical because deficits in joint position, sense, range of motion and strength are all associated with functional instability.

[B]

Question 5. The question that all our athletes are asking us. When can an athlete return to play?

[C]

Use the PAASS framework?

[D]

Pain, ankle impairments, athlete perception, sensory motor control and sports performance. If they check those boxes, they can go back.

[C]

And last question. What if pain persists?

[B]

Think about a syndesmotic sprain, Taylor fracture, lateral tailor drome, osteochondral injury or peroneal tendon instability.

[D]

Get an X ray if you didn't before. And remember the squeeze test for syndesmotic injuries. Squeeze the mid calf and see if it recreates distal pain.

[B]

Consider CT or MRI for suspected Taylor injury. And dynamic ultrasound can catch peroneal tendon subluxation.

[D]

And that's it. Please take care of your ankles, everyone. We need them. The risk of the leg.

[C]

I'll never mentally recover from your insult. Rachel, no.

[B]

It's time for a poem. We all know poems are patient oriented evidence that matters. And this poem is entitled Soft puronium topical gel is effective for axillary hyperhidrosis. And this is from Dr. Slauson.

[D]

Our clinical question today. Is soft puronium or softra topical gel effective for improving primary axillary hyperhidrosis? For this article, there were two multi center randomized control trials that were pooled and they studied a 12.45% topical gel.

[C]

The study population was for those nine years and older with at least six months of symptoms. They randomized 701 participants to either soft pyronium Or a vehicle gel applied once nightly to each axilla.

[B]

The authors assess two co primary outcomes, at least a two point improvement on a validated disease severity scale where even a one point change is clinically meaningful and a greater than 70% reduction in measured sweat production.

[D]

Exactly by week six, about 38% of the treatment group met both targets, compared with 18% in the control group. This gives a number needed to treat of about 5, which is pretty impressive for hyperhidrosis.

[C]

Yeah, and follow up was strong, over 95%. It also helped that evaluators remained blinded, so the outcomes were well controlled.

[B]

What about tolerability? I saw that there could be a few anticholinergic type side effects like dry mouth, blurred vision and some application site dermatitis.

[D]

Yes, those did lead to withdrawals in 4% of treated patients versus none in the placebo group. Not terrible, but something to counsel families about. Especially since some users are adolescents.

[C]

Still, compared to systemic therapies, this local option with once daily bedtime use is appealing and the evidence level is high. Level 1B.

[D]

So bottom line, soft puronium gel works. It reduces sweat and disease severity meaningfully. While side effects do exist, they could potentially be manageable with proper counseling. However, this drug is not yet widely available and cost could be prohibitive for many patients. Although it does seem that there are some manufacturer coupons available.

[B]

Do they like put little vials under your armpits to measure the sweat? How do they actually measure?

[C]

It's like a treadmill stress test, but you just for your rpg, you just have like a Erlenmeyer flask under the axilla to catch all the perspiration.

[D]

Maybe it's like the paper towel commercials.

[B]

Yes. Next, evaluation of suspected dementia from Drs. Kramer, Johnson and Winslow from the University of Colorado.

[D]

Dementia is a major neurocognitive disorder, meaning cognitive decline that actually interferes with daily life. And the trickiest part, early signs can look a lot like normal aging, right?

[C]

Everyone misplaces their keys. But if someone can't retrace their steps or repeats the same questions, that's different.

[B]

Other subtle signs could be getting lost in familiar places, trouble with conversations, difficulty following recipes or bills, or personality changes. Families usually notice these long before patients do. So a really good history from caregivers is essential.

[D]

In primary care, our first step is using brief screening tools. The big ones are the minicog and the memory impairment screen or mis.

[C]

Minicog is my go to three word recall plus clock drawing.

[B]

And don't forget caregiver questionnaires like the AD8 which can pick up concerns that don't show up on a three minute screen.

[D]

If screening results are abnormal or even normal but your gut says something's off, you can move to more detailed testing such as the MOCA slums or rudos.

[C]

MOCA is great for mild cognitive impairment. Rudos is especially helpful in patients with limited formal education or cultural barriers.

[B]

And remember, mild cognitive impairment means impairment without major functional decline. It's not dementia, but it increases the risk of progression.

[C]

As we move on to our evaluation, a thorough history should be taken. And always review medications, anticholinergics, benzodiazepines, opioids, muscle relaxants. Basically, if it makes you sleepy, it's it might make your patient confused.

[D]

And don't forget a physical exam to assess vision, hearing, cardiovascular, nutritional and functional status, neurologic function and psychiatric status. As far as labs go, vitamin B12 and folate, thyroid studies, CBC and a CMP can help rule out underlying conditions. Further laboratory testing is based on clinical circumstances.

[B]

Imaging is next. A non contrast brain MRI is preferred to rule out strokes, masses or other structural causes. A CT is okay if MRI isn't available or safe.

[D]

Many things can mimic dementia. Consider other causes such as depression, delirium, sleep apnea, vitamin deficiencies, alcohol misuse or infectious etiologies such as HIV or neurosyphilis.

[C]

Consider delirium, especially if a patient has altered level of consciousness for fluctuating behavior changes and recent hospitalization or acute illness that's not dementia.

[B]

And if symptoms start before age 60, progress rapidly. Include hallucinations or the diagnosis just isn't clear. You might want to call your friendly neighborhood neurologist.

[D]

Dementia evaluation is a marathon, not a sprint. It often takes multiple visits, careful discussions with families, and coordinated planning.

[C]

Be sure to focus on the whole person by managing symptoms while supporting function and independence. And have open and honest discussions with the patient and families. We'll be right back.

[A]

The AFP Podcast is brought to you by the American Academy of Family Physicians and by the American Family Physician Journal. You enjoy listening to the AFP Podcast team discuss the journal. You can also read it in print or online. Plus, subscribers can earn over 130 CME credits per year. Subscription details can be found at afp.org afp subscribe.

[B]

Now. An FPIN Clinical Inquiry FPIN is the Family Physician's Inquiries Network, and this FPIN is entitled Frailty Scoring for Predicting Hip fracture outcomes from Drs. Richie Bay and Neher from Renton, Washington.

[C]

Alright, today's big does frailty Scoring in older adults actually help Predict hip fracture outcomes.

[D]

The short answer is yes. Pretty convincingly yes. Frailty scoring is recommended for adults over 70 who are hospitalized with a hip fracture. That's a strength of recommendation B based on a Meta analysis of 22 cohort studies with more than 74,000 patients and subsequent cohort studies.

[B]

And the numbers are not subtle. Frail patients have higher risks of mortality and complications with adjusted odds ratios of 1.87 and 1.37. They also stayed in the hospital about 2.6 days longer.

[C]

Plus they were much more likely to be discharged somewhere other than home. Unadjusted odds ratio 4.42.

[A]

Wow.

[C]

And had worse functional status at discharge.

[D]

Speaking of functional status, that was measured with the cumulated ambulation score or CAS physical therapists score. 3 Getting out of bed, sitting and walking with an aide 2 points if you do it independently, 1 if you need help, 0 if you can't.

[B]

Frailty itself was measured with a 26 item frailty index covering comorbidities, cognition, nutrition, polypharmacy, mobility, incontinence and social vulnerability. Basically the whole picture is considered.

[C]

And frailty wasn't just a short term issue. It was linked to poor function at discharge and four months later plus higher all cause mortality at 30 and 90 days.

[D]

Among those who died within 30 days, frailty was associated with deaths from cardiovascular disease, respiratory complications and multi organ failure.

[B]

So what do societies recommend? In 2020, the UK's association of Anesthetists put out a guideline for managing hip fracture patients. They recommended a multi component risk assessment Frailty Score, Delirium Screen and the Nottingham Hip Fracture score which predicts 30 day mortality.

[C]

Bottom line, frailty scoring matters. It gives us better data, better conversations and hopefully better outcomes.

[B]

Now we're going to talk about a point of care guide assessing the risk of heart failure with preserved ejection fraction in individuals with exertional dyspnea. This is from Dr. Segil, Townsend and Abel. The clinical question here how can patients with exertional dyspnea who are at risk of heart failure with preserved ejection fraction be identified? That's HFPEF for short.

[C]

Remember, HFPEF is heart failure with left ventricular ejection fraction of 50% or greater.

[D]

We now have effective treatments for HFpEF, so a tool that helps identify this would be useful for guiding evaluation and management.

[B]

You'll be so glad to know there are now at least three prediction rules. The first is the H2FPEF rule, which has an area under the curve of 0.886, which is pretty good. The test, however, requires that you have a filling pressure seen on echo.

[C]

The next tool, the hFape, comes from the European Society of Cardiology. That abbreviation stands for Are you ready? Heart failure association Pretest instrument. Echocardiography and natriuretic peptide Functional testing Final etiology.

[B]

Nice. That's 39 syllables, which is way too many for a test.

[C]

It's over two haikus.

[B]

Yeah.

[D]

This test uses different cutoffs for BNP and has an area under the curve of 0.90.

[B]

If you don't have an echo result or a BNP result, you. You might want to use the HFPEF ABA score.

[C]

Area under the curve in the derivation cohort was 0.81. This test uses only age, BMI and history of afib, so it's easy to use even without NECO or BMP. Increasing age or BMI increases the risk.

[D]

You can use this pre test probability tool to determine if an echo is needed.

[C]

Great. Hfpef ABA it is.

[B]

Rachel and Justin, I have an actual haiku. Oh, boy. Short of breath. Struggle Unknown. Fill Pressures Unsure. Use tool. Breathe easy.

[C]

Bravo.

[D]

Amazing.

[B]

Thank you.

[D]

Beautiful.

[B]

We're closing out today's episode with an AFP Clinical answers speed round. AFP Clinical answers are rapid fire answers to questions from previous issues of American Family Physician. So you all can see how well you remember previous episodes. Are you ready, Rachel?

[D]

Yes.

[B]

Okay. How does ambulatory ECG monitoring compare with echocardiography in investigating palpitations?

[D]

Ooh. Okay, so two weeks of EKG monitoring has the highest yield to cost ratio.

[B]

Justin, what are the initial recommended tests for evaluating suspected bleeding disorders?

[C]

Bone marrow biopsy, cbc, pt, ptt, peripheral blood smear, and fibrinogen levels. You can also consider Von Willebrand disease analysis.

[B]

Is intermittent dos of SSRIs an acceptable alternative to continuous dosing in premenstrual disorders?

[D]

Yes.

[B]

Justin, how should suspected acute bacterial arthritis in children be initially evaluated and managed?

[C]

Blood cultures before antibiotic treatment, plane radiography and consider CRP for monitoring treatment response. Do not measure ESR or serum procalcitonin and don't delay antibiotics in the ill appearing children.

[B]

Rachel, do all anaphylactic reactions treated with epinephrine require emergency medical services?

[D]

No. Conservative care can be considered after complete or near complete symptom resolution. If anaphylaxis is not severe and symptoms don't worsen or return after stabilization, patients should be monitored for at least an hour.

[B]

Nice. Thank you all for playing the AFP Clinical answers speed round.

[C]

I won. Justin won Be safe out there, everyone.

[D]

And have a happy New Year.

[B]

Send us your thoughts by emailing us at AFPPodcastAFP.org follow us on Instagram @AFP Journal.

[D]

Please subscribe and rate us wherever you get your podcasts.

[C]

Escuchanos en espanol A Revista medica a.

[D]

Fap Our podcast team is Jake Anderson, Puneet Baro, Steve Brown, Justin Chediak, Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg.

[C]

Elena Kelly, Chisum Okuagu, and Kari Stau.

[B]

Our sound and technical guru is Tyler Coles. Our theme song is written and recorded by family physicians Bill Dabs, Ryan Evans, and Justin Jenkins.

[C]

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

[D]

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