Episode 249 | March 2026 | Part 1 American Family Physician

Summary

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AFP Podcast Episode 249 | March 2026, Part 1 – Summary

Podcast: AFP: American Family Physician Podcast
Date: March 16, 2026
Hosts: Drs. Jake Anderson, Kari Staus, Steve Brown, and others
Main Theme:
This episode covers clinical updates from the March 2026 issue of American Family Physician. The team discusses key points on intranasal epinephrine for emergencies, acute and chronic urticaria, bleeding risk assessment in older adults on DOACs, the diagnosis and prevention of meningitis, optimal colorectal cancer screening outreach, and dental fluorosis risk with topical fluoride.

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1. Intranasal Epinephrine for Type 1 Allergic Reactions

Based on review by Drs. Wolf and Fournier (Lowell Community Health Center, MA)
[01:21 – 05:18]

Key Points

• Intranasal epinephrine (Nefi) is now available as an emergency option for treating type 1 allergic reactions (like anaphylaxis) in patients aged 4+ weighing at least 15 kg.
  • Quote: “We have another option other than intramuscular epinephrine for emergency treatment of type 1 allergic reactions like anaphylaxis.” (Jake Anderson, 01:21)
• Safety: Not directly compared to IM forms; similar side effects. Patients with nasal abnormalities were excluded from studies.
  • Quote: “The big distinct thing to know is that patients with underlying structural and anatomic nasal conditions were not included...should be prescribed another form of epinephrine.” (Steve Brown, 02:20)
• Tolerability: Common adverse effects are mild and transient (nasal discomfort, headache), with some differences in adults and children. Preference over IM injections not established.
• Effectiveness: No studies in actual anaphylaxis; only pharmacokinetic/dynamic equivalence in healthy volunteers.
  • Quote: “It’s unethical to induce anaphylaxis for study, which is fair.” (Jake Anderson, 03:34)
• Price: Comparable to or higher than EpiPen; not a cost-saving alternative.
• Practicality: Comes with two nasal sprays; dose based on weight; requires second dose at 5 minutes if no improvement.
• Bottom Line: Appropriate only for needle-phobic patients; otherwise, IM remains standard.

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2. Acute and Chronic Urticaria: Diagnosis & Management

Based on review by Drs. Semenya, Pienkowski, Bhatnagar (Nashville, TN)
[05:18 – 10:21]

Key Points

• Definitions:
  • "Urticaria" = condition; "hives/wheals" = lesions.
  • Self-limited, but can signal anaphylaxis or underlying disease.
• Case: 35-year-old with three weeks of intermittent hives, no systemic symptoms.
  • Quote: “Hives or wheels are the lesions themselves...caused by histamine release from mast cells in the derm.” (Steve Brown, 06:02)
• Causes & Mimics:
  • Classic triggers: Medications, foods, infections.
  • Consider mimics: Insect bites, viral exanthems, contact dermatitis, etc.
  • Consider rare causes: Autoimmune progesterone dermatitis.
• Classification:
  • Acute (<6 weeks) vs. Chronic (>6 weeks).
  • Workup rarely needed unless "red flags".
  • Quote: “Even though three weeks feels like a long time, this is still considered acute urticaria. Anything under six weeks...” (Steve Brown, 07:38)
• Treatment (Acute):
  • First-line: Second-generation H1 antihistamines (cetirizine, fexofenadine), up to 4x dosing.
  • Avoid NSAIDs (may worsen urticaria).
  • Short steroid bursts: evidence not robust.
  • Topicals and heat avoidance may help symptoms.
  • Quote: “NSAIDs can actually worsen urticaria by reducing prostaglandin E2, which inhibits mast cell activation.” (Steve Brown, 08:05)
• Chronic Urticaria:
  • Spontaneous vs. Inducible; often idiopathic.
  • Step-up therapy: Add first-gen antihistamines or leukotriene antagonists.
  • Omalizumab is FDA-approved for antihistamine-refractory chronic urticaria.
  • European guidelines: Go directly to omalizumab after second-gen antihistamine failure.
  • Avoid long-term systemic steroids.

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3. Bleeding Risk Assessment for DOACs in Older Adults

Point-of-Care Guide by Dr. Mark A. Bell
[10:21 – 12:54]

Key Points

• Clinical Question: Which patients aged 80+ on DOACs have higher bleeding risk?
• Shortcomings of Existing Scores:
  • HAS-BLED, ATRIA, ORBIT mostly developed in younger cohorts, mainly with warfarin.
  • Poor sensitivity, not validated for DOACs in oldest old.
  • Quote: “These scores also have failed to validate well...sensitivity of less than 50% for detecting hemorrhage.” (Jake Anderson, 11:03)
• A4C Risk Score:
  • Developed in 80+ population on rivaroxaban for AFib.
  • Factors: Age, anemia, low albumin, amiodarone use, low creatinine clearance.
  • Better performs than HAS-BLED in validation.
  • Example: An 86-year-old with only age as risk—classified low risk (~6% annual major bleed risk vs. 15% annual stroke risk).
  • Quote: “He has one point for his age on the A4C risk score and is classified as a low risk for major bleeding which is 6% in the next year.” (Kari Staus, 12:06)

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4. Meningitis: Diagnosis, Treatment, and Prevention

By Drs. Krebs, Durden, Segill (University of Florida)
[13:25 – 17:42]

Key Points

• Etiology:
  • Viral: ~60% of cases (enteroviruses most common).
  • Bacterial: S. pneumoniae, N. meningitidis, H. flu type B, Group B strep.
• Risk Factors: Age extremes, asplenia, HIV, complement deficiency, pregnancy.
• Classic Presentation: Fever, headache, neck stiffness, altered mental status; but may be incomplete.
  • "Koenig and Brudzinski signs: low sensitivity. Don’t rely on them." (Kari Staus, 14:20)
• Diagnosis:
  • Suspected cases: Emergent referral, lumbar puncture for CSF analysis.
  • If LP delayed >1 hour, start empiric antibiotics before LP.
  • Diagnostics: CSF cell count, glucose, protein, Gram stain, culture, PCR.
• Empiric Treatment:
  • Ceftriaxone or cefotaxime; add ampicillin if listeria risk (age >60, pregnancy, immunosuppressed).
  • Add vancomycin for high pneumococcal resistance.
  • Dexamethasone at antibiotic initiation in patients >2 months old improves outcomes.
  • Quote: “Be sure to start those antibiotics within an hour.” (Jake Anderson, 15:16)
• Prevention:
  • Vaccines: ACWY meningococcal (11–12 y/o + booster at 16), pneumococcal and Hib series as per guidelines.
  • Post-exposure prophylaxis: Meningococcus (cipro, rifampin, ceftriaxone; azithro if Cipro resistance). For H. flu, use rifampin in exposed, unvaccinated, or immunocompromised children.
  • No routine prophylaxis for pneumococcus except in children <5 with asplenia/sickle cell (daily penicillin).
  • Takeaway: "Don’t rely on classic meningeal signs because they have low sensitivity. Start antibiotics within one hour if you suspect meningitis…" (Kari Staus, 17:14)

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5. Colorectal Cancer Screening Outreach: What Works Best?

POEM by Dr. David Slauson
[17:42 – 19:24]

Key Points

• Question: What is the most effective way to increase colorectal cancer screening in 45–49-year-olds?
• RCT Results (N>20,000 adults):
  • Four groups: Mailed FIT kit, portal invitation for FIT, invitation for colonoscopy, or choice between FIT/colonoscopy.
  • Screening completion at six months:
    • Mailed FIT: 26.2%
    • Portal/text with FIT only: 16.4%
    • Colonoscopy only: 14.5%
    • Active choice (FIT or colonoscopy): 17.4%
  • Simply mailing the test is the most effective strategy—likely reduces patient “decision fatigue.”
  • Quote: “The practical takeaway for this age group, putting the kit in the mailbox may work better than putting a reminder in the inbox.” (Jake Anderson, 19:24)

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6. Topical Fluoride in Children & Risk of Dental Fluorosis

Cochrane for Clinicians by Drs. Soto Soto and Reddy Cooper
[19:45 – 21:33]

Key Points

• Concern: Will fluoride toothpaste cause unsightly fluorosis in children?
• Evidence:
  • Higher toothpaste fluoride concentration (≥1000 ppm) slightly increases risk.
  • Unclear/inconclusive: frequency of brushing or amount of toothpaste.
  • Most fluorosis is mild/cosmetic; cavities can be severe/harmful.
• Recommendations:
  • ADA: Use water <2y/o; consult dentist before fluoride. Panel disagrees, noting that even in youngest, fluoride in moderation is safe.
    • “Fluoride from the start. I don’t know why the American Dental association says that, but anywho, if fluoride toothpaste is used, a smear for children younger than 2 and a pea size amount for ages 2 to 6 is appropriate.” (Jake Anderson, 21:17)
• Bottom Line:
  • Fluoride toothpaste prevents cavities; moderate concentrations and age-appropriate dosing minimizes fluorosis risk.

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Notable Quotes & Memorable Moments

• “It’s unethical to induce anaphylaxis for study, which is fair.” (Jake Anderson, 03:34)
• “NSAIDs can actually worsen urticaria by reducing prostaglandin E2, which inhibits mast cell activation.” (Steve Brown, 08:05)
• “These scores also have failed to validate well... sensitivity of less than 50% for detecting hemorrhage.” (Jake Anderson, 11:03)
• “Don’t rely on classic meningeal signs because they have low sensitivity. Start antibiotics within one hour if you suspect meningitis…” (Kari Staus, 17:14)
• “The practical takeaway... putting the kit in the mailbox may work better than putting a reminder in the inbox.” (Jake Anderson, 19:24)
• “Fluoride from the start. I don’t know why the American Dental association says that, but anywho…” (Jake Anderson, 21:17)

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Time-Stamped Key Segments

• Intranasal Epinephrine: 01:21–05:18
• Urticaria: 05:18–10:21
• Bleeding Risk Score (A4C): 10:21–12:54
• Meningitis: 13:25–17:42
• Colorectal Cancer Screening: 17:42–19:24
• Topical Fluoride/Dental Fluorosis: 19:45–21:33

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For Clinicians:
This episode delivers evidence-based, practical insights into new allergy treatment options, urticaria management, evaluating bleeding risk, urgent meningitis care, cancer screening outreach, and safe fluoride use in pediatrics. It’s filled with pearls and pragmatic advice for everyday primary care practice.

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Transcript

[Podcast Host]

The AFP podcast is brought to you by the American Academy of Family Physicians and by Elation health elation, the 2026 Best in Class winner for small practice EHR PM delivers an AI native EHR and billing platform built for modern primary care. It streamlines workflows, simplifies billing, and supports success across all payment models. Learn [e-mail] af.

[Steve Brown]

Foreign.

[Jake Anderson]

Welcome to the American Family Physician podcast for part one of the March 2026 issue. I'm Jake.

[Kari Staus]

I'm Kari.

[Jake Anderson]

I'm Emily and we are residents and faculty, mostly residents, of the University of Arizona College of Medicine, Phoenix Family Medicine residency programs. Today on the podcast we'll talk about intranasal epinephrine, urticaria, bleeding risk score, calculator, meningitis, colorectal cancer screening, and topical fluoride.

[Steve Brown]

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.

[Jake Anderson]

We're on a mission, delivering the best. We're kicking things off with the steps Intranasal Epinephrine for emergency treatment of type 1 allergic reactions and it comes to us from doctors Wolf and Fournier from Lowell Community Health center in Massachusetts. So interesting news to me. It sounds like you guys are already familiar with this, but we have another option other than intramuscular epinephrine for emergency treatment of type 1 allergic reactions like anaphylaxis.

[Kari Staus]

That's right, Jake. Name brand Nefi is intranasal epinephrine that is labeled for use in patients 4 years and older that weigh at least 15 kg.

[Jake Anderson]

So we'll walk through the steps here and decide whether it's really a possible replacement for those painful intramuscular stabs.

[Steve Brown]

First, we've got safety. Nasal epinephrine has not been compared directly with other methods of epinephrine administration to determine its relative safety and but the safety concerns are similar to those of other epinephrine treatment methods. The big distinct thing to know is that patients with underlying structural and anatomic nasal conditions were not included in clinical pharmacology studies of this drug and should be prescribed another form of epinephrine.

[Kari Staus]

So next, after safety, we talk about tolerability. This is where nasal should shine over an intramuscular injection. The most common adverse effects are dose related and transient and include nasal discomfort and headache. Other adverse effects in adults also include rhinorrhea, dizziness, nausea, vomiting and throat irritation. Children may experience nasal congestion, intranasal paresthesia, epistaxis, dry throat, fatigue, or even feelings of jitteriness. We don't know necessarily if this is preferable to IM methods or not.

[Steve Brown]

For E effectiveness, we are a bit limited on drawing a strong conclusion because intranasal epinephrine has not been directly studied in people actually experiencing severe allergic reactions.

[Jake Anderson]

Yeah, they point out that it's hard to study because the need for its use in a severe allergic reaction is rare and it's unethical to induce anaphylaxis

[Steve Brown]

for study, which is fair. So go figure. All research on the effectiveness of intranasal epinephrine has been conducted in healthy subjects evaluated the pharmacokinetics and pharmacodynamics in comparison with other methods of administration. They concluded that the pharmacokinetics and the pharmacodynamics are similar to those of autoinjectors like EpiPen.

[Kari Staus]

For price we are all painfully aware of the price concerns around epinephrine autoinjectors. Unfortunately, the intranasal NEFI is no different, with estimates of $615 for 1 milligram per 0.1 milliliter and $725 for 2 milligrams per 0.1 milliliter. In comparison, the price of an EpiPen is approximately $650 for 0.3 milligrams per 0.3 milliliters and the generic epinephrine autoinjector ranges from 2 to $300.

[Steve Brown]

And lastly, from a simplicity standpoint, intranasal epinephrine is packaged in a carton with two single use nasal spray applicators, doses determined based on weight. Each carton contains two sprays because a second dose should be given in the same nostril five minutes after initial administration. If there is no improvement or if symptoms worsen, to use it, the nozzle of the applicator is inserted into the nasal canal and a firm press of the plunger delivers the full dose. Storage temperature requirements are similar to the autoinjectors, meaning it can't be left in extreme temperatures like a refrigerator or a vehicle in Phoenix.

[Jake Anderson]

So bottom line is that nasal epinephrine is an alternative to injectable forms of emergency epinephrine and might be a good option. But really, just for a patient that's resistant to using needles, that's really the only use case. All right, guys, we're staying on the topic of allergies and we have a main topic Acute and chronic urticaria. It comes to us from Drs. Semenya Pienkowski, Ann Bhatnagar from Nashville, Tennessee.

[Kari Staus]

Let's walk through a case. Let's say a 35 year old woman presents with three weeks of hives. She's otherwise healthy, takes no medications and her vitals are normal. First, some terminology. What exactly are hives and how do they differ from urticaria?

[Steve Brown]

It's a great place to start. Urticaria is the term for the condition. Hives or wheels are the lesions themselves. They're well circumscribed. Erythematous edematous plaques caused by histamine release from mast cells in the derm. Urticaria is often self limited, but it also can be a manifestation of anaphylaxis or some other underlying condition.

[Jake Anderson]

All right, so back to our patient. Her only symptom is this intensely pruritic rash that comes on every few days, lasts two to six hours and then resolves spontaneously. She's got no shortness of breath or abdominal pain. She denies any new detergents, lotions, medications, supplements, no recent illnesses, no travel.

[Kari Staus]

You hit my whole hpi. Are there any specific clues that would push us towards a particular underlying cause?

[Steve Brown]

So medication changes or food exposures are classic triggers. Systemic symptoms can also point you in a direction like cold. Intolerance with weight gain might suggest hypothyroidism and high risk sexual behavior. IV drug use may prompt evaluation for hep, B, C or hiv. To rule out a cryoglobulinemia if symptoms flare premenstrually. Consider autoimmune progesterone dermatitis, which honestly, I'd never heard of before.

[Jake Anderson]

Yeah, what about mimics? What else could resemble urticaria?

[Steve Brown]

A whole lot. Insect bites, drug eruptions, viral exanthems, contact dermatitis, pityriasis, rosea amongst several others. But our patient's presentation seems pretty consistent with urticaria.

[Kari Staus]

So how are we going to classify her condition and what do we need for further workup?

[Steve Brown]

Even though three weeks feels like a long time, this is still considered acute urticaria. Anything under six weeks if the patient is stable with a reassuring history and exam like our patient, no further workup is really needed. Most cases, acute and chronic, are idiopathic.

[Jake Anderson]

That is a long time to be itchy. Our patient is pretty uncomfortable when symptoms occur. She asks what treatment is available. She also wonders if ibuprofen would help since it reduces inflammation.

[Steve Brown]

First line treatment for acute urticari is a second generation H1 antihistamine. Since they're less sedating than first generation. You can actually increase the dose up to four times standard dosing if needed. Short steroid bursts are sometimes used, but evidence is mixed on if it's truly efficacious or not. NSAIDs can actually worsen urticaria by reducing prostaglandin E2, which inhibits mast cell activation. So avoid them. Topicals don't help and minimizing heat and tight clothing can reduce symptoms.

[Kari Staus]

Okay, so let's fast forward one month. Our patient returns with persistent symptoms. She's tried both cetirizine and fexofenadine at quadruple dosing with only mild improvement. No clear triggers. Lab work including cbc, esr, crp, total ige, TSH is all unremarkable.

[Jake Anderson]

So this meets criteria for chronic urticaria. Now it's more than six weeks. Are there further classifications for chronic urticaria?

[Steve Brown]

Yeah, good question. So, unlike acute urticaria, which is often self limited, chronic urticaria is categorized as inducible, meaning there's a specific stimulus that triggers the symptoms or spontaneous without any sort of obvious trigger. Chronic spontaneous urticaria is further classified as having a known cause, such as autoimmunity or infection, or without a known cause.

[Kari Staus]

So our patient likely has chronic spontaneous urticaria without an identifiable cause. How are we going to proceed?

[Steve Brown]

So if she's already maxed out on a second generation antihistamine, you can add a first generation antihistamine like hydroxyzine or doxepin or even a leukotriene receptor antagonist. If symptoms continue, then definitely referring to a specialist is appropriate. Omalizumab Zolair is FDA approved for antihistamine refractory chronic spontaneous urticaria. Notably, European guidelines recommend going straight to omalizumab after failure of high dose second generation antihistamines rather than adding other agents first. Long term systemic steroids are not recommended.

[Jake Anderson]

So even if she falls into the 80 to 90% of patients with idiopathic chronic urticaria, there's still a stepwise management approach and real hope for symptom control.

[Steve Brown]

Definitely

[Jake Anderson]

moving right along. We have a point of care guide looking at bleeding risk, and it comes to us from Dr. Mark A. Bell.

[Kari Staus]

The clinical question being considered here is in people 80 years and older taking a direct oral anticoagulant or a DOAC who is at increased risk for major hemorrhage.

[Steve Brown]

Dr. Abel points out that although DOACs might be well suited for older patients due to their lower bleeding risk than warfarin and them being more convenient to take. The risk of major bleeding does increase with age and older patients may consider alternative therapies such as left atrial appendage closure if they have a significantly higher risk of bleeding.

[Jake Anderson]

Unfortunately, the several bleeding risk scores that we have, including the HAS bled, the atria, the orbit, they were all developed in younger populations with a mean age of between 71 to 76. These scores also have failed to validate well, with some studies showing a sensitivity of less than 50% for detecting hemorrhage. And importantly, these older risk scores were actually largely derived in patients taking warfarin or other vitamin K antagonists. So quite a few limitations in steps

[Kari Staus]

the A4C risk score this was developed in a population of people 80 years and older with a heavy burden of comorbidities who were taking rivaroxaban for atrial fibrillation.

[Steve Brown]

It's a five factor score. It considers age, anemia, low albumin, amiodarone use and low creatinine clearance to predict bleeding risk. In both the derivation population and validation population, researchers found it to be more accurate than previous risk scores including the HAS bled.

[Kari Staus]

The specific cutoffs and point system for the A4C risk score is outlined in a table in the article, but let's walk through an example. An 86 year old patient develops atrial fibrillation. He has normal kidney function and isn't anemic. His serum albumin is 4.2 grams per deciliter or 42 grams per liter and he does not take amiodarone. Therefore, he has one point for his age on the A4C risk score and is classified as a low risk for major bleeding which is 6% in the next year. The risk of stroke in patients 85 years and older with atrial fibrillation is more than 15% per year, so he elects to start a DOAC. Back after this.

[Podcast Host]

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 we have a main topic,

[Jake Anderson]

Aseptic and Bacterial Meningitis Diagnosis, Treatment and Prevention and it comes to us from doctors Krebs, Durden and Segill from University of Florida.

[Kari Staus]

Meningitis is a spectrum from self limited viral illness to life threatening bacterial infection. Thanks to vaccines though, bacterial meningitis has decreased dramatically, especially from H influenza type B, but rapid recognition and treatment still remain critical.

[Steve Brown]

Viral causes account for up to 60% of cases, most commonly in terroviruses. Bacterial causes we worry about in primary care include Streptococcus pneumoniae, Neisseria meningitidis, H, flu type B, and group B, strep.

[Jake Anderson]

And of course, risk factors matter. Asplenia, hiv, complement deficiencies, complement inhibiting, monoclonal antibodies, pregnancy and age extremes are all important risk factors.

[Kari Staus]

Clinically, adults often present with fever, headache, neck stiffness and altered mental status, but they may lack one or more mental status. Changes occur in up to 69% Koenig and Brudzinski signs Low sensitivity Don't rely

[Steve Brown]

on them Petechial rash?

[Jake Anderson]

Think meningococcus in infants, symptoms are nonspecific. Irritability, feeding difficulty, lethargy fever may be absent. Even bulging fontanelle or petechiae should heighten concern.

[Kari Staus]

All great points. You cannot rule out meningitis on exam alone. Suspected cases need emergent referral in lumbar puncture. Speaking of lp, Emily, can you tell us more?

[Steve Brown]

So diagnostics hinge on lumbar puncture with csf, cell count, glucose protein, gram stain, culture and pcr. If that LP will be delayed more than one hour, start empiric antibiotics first.

[Jake Anderson]

Empiric therapy includes ceftriaxone or CEFT photaxime. Add ampicillin if there's listeria risk, meaning pregnancy, age over 60 or immunocompromised state. Add vancomycin if there's high local pneumococcal resistance and be sure to start those antibiotics within an hour.

[Steve Brown]

Also, dexamethasone should be given at antibiotic initiation in patients older than two months with suspected bacterial meningitis because it improves mortality and neurologic outcomes.

[Kari Staus]

Let's pivot to prevention, where family medicine shines. Vaccination has nearly eliminated H flu type B in high income countries. The current vaccine recommendations are as follows. Quadrivalent meningococcal conjugate vaccine or the ACWY routine vaccination at age 11 to 12 with a booster at age 16 pneumococcal vaccination in children under 5 or in adults 50 and older and Hib series at 24 plus or minus 6 months plus a booster at 12 to 15 months.

[Jake Anderson]

Now let's talk post exposure prophylaxis.

[Steve Brown]

Another high yield area for meningococcus. Give chemoprophylaxis to close contacts, including household members, roommates, childcare contacts or anyone exposed to oral secretions. Options include cipro, rifampin or ceftriaxone. Use azithromycin in areas with Cipro resistance.

[Jake Anderson]

For H flu type B, use rifampin. Indications include household members less than four years who are not fully vaccinated, household members less than 18 years who are immunocompromised or in childcare settings with two or more cases in 60 days. All attendees should receive prophylaxis.

[Steve Brown]

There's no routine prophylaxis for pneumococcal contacts. However, children less than five with a splenia or sickle cel receive daily penicillin

[Kari Staus]

prophylaxis, so some take home. Don't rely on classic meningeal signs because they have low sensitivity. Start antibiotics either ceftriaxone or ceftotaxime within one hour if you suspect meningitis and add ampicillin if there is risk for listeria and add dexamethasone in patients older than 2 months for bacterial cases. Finally, vaccination is our strongest preventative tool, so keep practicing Evidence based vaccination Guys,

[Jake Anderson]

we have a poem and this one comes to us from Dr. David Slauson.

[Kari Staus]

Here's a question we face daily in primary care. What's the most effective outreach strategy to help our patients complete colorectal cancer screening? This randomized trial tried to answer that specifically for adults aged 45 to 49.

[Steve Brown]

Researchers looked at more than 20,000 average risk adults in a large US health system and randomized them to four groups. Three of the groups received an invitation to the patient portal with three text reminders, but each were presented with a different screening option. One group was asked to either complete a fifth test or defer screening. Another group was asked to either schedule a colonoscopy or defer screening. The third group was offered a choice between fit or colonoscopy or defer, and the fourth group was simply mailed a

[Jake Anderson]

fit kit using an intention to treat analysis, meaning that patients were analyzed in in the groups they were originally assigned to regardless of whether they engaged with the outreach or not. Screening completion at six months was highest in the Maled fit group at 26.2%. Completion was lower in the active choice groups, 16.4% for fit only, 14.5% for colonoscopy only, and 17.4% for fit or colonoscopy.

[Kari Staus]

So even when patients were explicitly prompted to choose screening or defer, fewer completed screening compared with those who simply received a kit in the mail.

[Steve Brown]

That's nearly a 10% absolute increase just by changing the outreach method, making screening the easier path, seemingly by reducing decision fatigue, substantially improved Follow through.

[Jake Anderson]

The practical takeaway for this age group, putting the kit in the mailbox may work better than putting a reminder in the inbox. All right, we're going to wrap this episode up with a Cochrane for clinicians, and it comes to us from doctors Soto Soto and Reddy Cooper from Pennsylvania.

[Kari Staus]

We are talking about topical fluoride and whether it causes dental fluorosis in children.

[Jake Anderson]

So fluoride toothpaste clearly reduces cavities. Good. But parents worry about mottling or discoloration of permanent teeth, otherwise known as fluorosis.

[Steve Brown]

So the key threshold to Remember is about 0.06 milligram per kilogram per day, which is associated with increased fluorosis risk.

[Kari Staus]

This Cochrane review included over 32,000 children and mostly observational studies, so the certainty of evidence is low to very low.

[Jake Anderson]

The most consistent finding was that higher fluoride concentrations in toothpaste increase fluorosis risk compared to lower concentrations. That makes sense.

[Steve Brown]

For example, toothpaste with 1,000 parts per million or more compared with around 500 parts per million was associated with higher risk of fluorosis in moderate certainty studies.

[Kari Staus]

In contrast, evidence about brushing frequency or the amount of toothpaste used was very uncertain and inconclusive.

[Jake Anderson]

So brushing more than twice daily versus less than twice daily has not been reliably shown to increase fluorosis risk.

[Steve Brown]

And using more toothpaste versus less has not shown consistent evidence of increased risk either.

[Kari Staus]

Most fluorosis is mild and cosmetic, while untreated cavities can lead to pain, infection and systemic complications.

[Steve Brown]

The American Dental association recommends brushing with water for children younger than two years and consulting a dentist before starting fluoride toothpaste.

[Jake Anderson]

Totally disagree with that fluoride from the start. I don't know why the American Dental association says that, but anywho, if fluoride toothpaste is used, a smear for children younger than 2 and a pea size amount for ages 2 to 6 is appropriate.

[Kari Staus]

Bottom line, fluoride prevents cavities, higher concentrations may slightly increase cosmetic fluorosis risk, and moderation with age appropriate dosing is.

[Jake Anderson]

Send us your thoughts by emailing [e-mail]

[Podcast Host]

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[Jake Anderson]

Escuchenos en Espanol A Revista America A

[Podcast Host]

fap Our podcast team is Jake Anderson, Puneet Barot, Steve Brown, Justin Chettiak, Sarah

[Jake Anderson]

Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Alaina Kelly, Chisum Okuagu, and Kari Staus.

[Kari Staus]

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[Jake Anderson]

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[Kari Staus]

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