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Justin Chediak
The AFP Podcast is brought to you by the American Academy of Family Physicians and by the AFP's free on demand CME activity addiction treatment and care CME for family physicians Presenting the latest in managing Substance use disorders. Register@AFP.org sudcme.
Steve Brown
Welcome to the American Family Physician podcast for part two of the April 2026 issue. I'm Steve.
Justin Chediak
I'm Justin.
Kari Staus
I'm Kari.
Steve Brown
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 heat related illness, graduate medical education funding and primary care, foreign body ingestion in children, fall prevention, chronic constipation and oral corticosteroids in children.
Kari Staus
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
Steve Brown
from American Family Physician Automation Delivering the
Kari Staus
Best Strong American Family Physician
Steve Brown
before we start this episode, we'd like to clarify something on a topic related to the MMR and varicella vaccines from our last episode. The American Academy of Family Physicians recommends separate vaccines, not the combined MMRV for the first dose in children ages 12 to 47 months. They may be administered together as the combined MMRV if parents or caregivers express a preference. Now on to the episode. Let's start with heat related illnesses from Drs. Gower McNutt and Brian from Fort Bragg in North Carolina.
Kari Staus
All right, so it's April in Phoenix, so it feels appropriate to talk about heat related illness as we have reached record breaking heat this past month, especially
Steve Brown
now that we're facing increased human induced climate change. There was a review that found that for every 1.8 degrees Fahrenheit rise in hot temperatures or during heat waves, the risk of heat related illness morbidity increases by 18% and mortality increases by 35%.
Justin Chediak
Those are insane numbers. Makes you think about moving to Minnesota.
Kari Staus
Yeah, okay, but seriously, we're all at risk. Heat related illness is a spectrum with things like heat edema or rash at the mild end and heat stroke at the severe end. The general approach is to cool and hydrate the patient, but this looks different depending on the severity.
Justin Chediak
Okay, so say I go out and run five miles tomorrow, which I will never do and I have some swelling of my hands and my shoes are now tight.
Kari Staus
Well Justin, you probably have heat edema. This is A result of cutaneous vasodilation and accumulation of interstitial fluid. You may even have a heat rash and heat cramps associated. I'd recommend removing you from these high temps and allow evaporative cooling to do its thing.
Steve Brown
Okay, so let's say Justin instead decided to run a half marathon.
Justin Chediak
Ridiculous.
Steve Brown
And he comes to us and he's vomiting and short of breath and his core temperature is 102Fahrenheit.
Justin Chediak
More likely.
Kari Staus
Justin, why did you run a half marathon?
Steve Brown
Maybe you weren't prepared.
Kari Staus
Okay. He probably has heat exhaustion. This can be associated with hypovolemia and sodium depletion as well, and is usually associated with temps less than 104 degrees Fahrenheit.
Justin Chediak
So from my understanding, we treat heat exhaustion by removal from heat and with simple cooling. So things like ice packs, fanning, cold towels and ivy or oral fluids.
Kari Staus
Right, and it can even get confusing sometimes when there is some irritability, anxiety and disorientation. Because heat exhaustion can actually overlap a little with heat stroke. So when in doubt, start immediate cooling measures.
Steve Brown
Okay, so Justin now decides to hike the Grand Canyon rim to rim. And he comes back to the emergency department, and now he has a core body temperature of 104.4 Fahrenheit with agitation.
Kari Staus
Oh, gosh. Okay, so this we can definitely call heatstroke, which is usually associated with neurologic manifestations and temps greater than 104Fahrenheit. It is an emergency and we need to cool Justin within 30 minutes of recognition. We do this by submerging him in an ice cold water bath at 36.5 to 50 Fahrenheit to avoid long term neurologic sequelae such as seizures or coma.
Steve Brown
Yes, polar plunge.
Justin Chediak
Also important to note, aspirin, NSAIDs and dantrolene have no role in the treatment of heat stroke.
Kari Staus
Let's wrap up by discussing risk factors.
Justin Chediak
Well, I can't modify the fact that I'm a male.
Steve Brown
Yeah.
Justin Chediak
Which increases my risk. But improving acclimatization or progressively increasing exercise intensity and duration is very important. Other general risk factors include BMI greater than 25, poor sleep, pregnancy, several diseases, including cardiovascular and respiratory diseases, and some medications, including, but not limited to alcohol, anticholinergics, antihistamines, beta blockers, diuretics and stimulants.
Kari Staus
Stay safe out there, everybody. Especially you, Justin.
Justin Chediak
Never.
Steve Brown
Next, Graham center policy. One pager. Graduate medical education funding does not flow to primary care physician production. This is from Drs. Fenster Park, Hofstetter and Topmiller from Duke. And the Robert Graham center in Washington, D.C. i just love it when the title tells you the whole story.
Justin Chediak
Yeah, what's the. What's the TLDR here?
Steve Brown
Yeah. So the authors used several databases to find the association between Medicare, graduate medical education or GME funding distributed to each state and the percentage of new physician workforce entering primary care after five years.
Kari Staus
Primary care was defined as graduates of any of the family medicine, pediatrics, geriatrics or internal medicine. Hospitalists were excluded.
Justin Chediak
You all will be thrilled to know total GME funding was inversely related to new primary care physicians.
Steve Brown
Oh, geez.
Justin Chediak
There's a color coded map which shows the northeastern states receive high levels of GME funding but produce low levels of primary care.
Kari Staus
The northwestern states receive low GME funding but produce a relatively higher number of primary care physicians, about 70.8 per 100,000 people.
Steve Brown
This is still low compared to Canada, which produces 119 primary care physicians per 100,000 people.
Kari Staus
These estimates may be inflated because only 9.4% of internal medicine graduates practice primary care after Residency, and only 54% of pediatric residents remain in primary care.
Justin Chediak
So overall, only 24% of all physicians enter primary care.
Steve Brown
Okay, so what can we do to direct GME dollars to primary care?
Kari Staus
New funding for residencies should mandate a threshold of 30 to 50% of new positions for primary care.
Justin Chediak
GME funding should be distributed equitably to meet needs of the health care system.
Steve Brown
We need publicly available accountability measures to track GME fund.
Kari Staus
More equitable reimbursement policies are needed right now.
Justin Chediak
The GME disbursement is literally incentivizing production of subspecialists.
Steve Brown
Oh, boy. Now it's time for foreign body ingestion in children from doctors Valerio and Williamson from Uniformed Services and Travis Air Force Base.
Justin Chediak
All right, team, let's talk about the FBI.
Kari Staus
Excuse me. What?
Justin Chediak
Foreign body ingestion?
Steve Brown
No, that's not a real medical abbreviation.
Justin Chediak
You know, no one ever lets me have fun around here. Nope. So I guess I'll just have to swallow my pride. I can't take credit for that one. That's from Dr. Richards at the UT Knoxville Family Medicine Residency. Anyways, in 2023, there were over 100,000 reported cases. And the tricky part? Most kids are asymptomatic with normal exams and can't tell you what they've swallowed.
Kari Staus
So you're basically playing detective with zero clues.
Steve Brown
Yeah, exactly. First step is two view plane radiographs of the neck, chest and abdomen. These have high sensitivity for things like coins. They're cheap and they have less Radiation. If you don't see anything but suspicion is high, then you might need to
Justin Chediak
move to CT. Thankfully, most objects over 60% pass on their own. But there are choke points in the GI tract, so some do need intervention.
Kari Staus
Let's start with coins, the MVP of things kids swallow red flags for needing urgent EGD. Here are age under 6, located in the proximal or mid esophagus. Stuck longer than 12 hours or big, like quarter sized or bigger.
Steve Brown
And if they have complete obstruction symptoms, that's now emergent.
Justin Chediak
Coins in the stomach or small bowel can usually be watched for up to two weeks if they're low risk.
Kari Staus
Now, button batteries way scarier. They can cause tissue damage fast.
Steve Brown
On X ray, look for the double halo sign on AP or step off sign on lateral to distinguish from coin. But honestly, if it's unclear, treat it like a battery.
Justin Chediak
Yep, battery in the esophagus. Emergent EGD tissue damage can start in 15 minutes.
Kari Staus
And if it's past the stomach, management depends on risk. Multiple batteries, magnets, age under 6 or size greater than 14 millimeters. That determines EGD surgery or close outpatient monitoring.
Steve Brown
And don't forget honey at home if the kid's older than 1 and doesn't have swallowing issues. And sucralfate in the ED can help limit injury while you're getting them scoped.
Justin Chediak
All right, next up, magnets, AKA nightmare fuel.
Steve Brown
Oh, my.
Kari Staus
Multiple magnets can attract across bowel walls, leading to fistulas, perforation, sepsis, and even death.
Steve Brown
Multiple magnets equals emergent egd with no debate.
Justin Chediak
Single magnet in the esophagus. Urgent EGD on less symptomatic than emergent.
Kari Staus
If it's beyond the stomach loop in GI or surgery, symptomatic patients may need admission and intervention. Asymptomatic patients can sometimes go home with close imaging. Follow up.
Steve Brown
Last category is sharp objects. About one third of these cause perforation,
Justin Chediak
so if it's wider than 3 cm, it likely won't pass the esophagus. So EGD.
Kari Staus
And if in the stomach, urgency depends on symptoms and size.
Steve Brown
Beyond the duodenum, talk to surgery. The ileocecal region is the most common perforation site.
Justin Chediak
All right, so bottom line here, most pass, but the dangerous ones move fast. When in doubt, image early, escalate quickly, and don't underestimate the toddler with suspicious silence.
Steve Brown
We'll be right back.
Justin Chediak
The AFP podcast is brought to you by the American Academy of Family Physicians and by Chartnote Tired of pajama time, more physicians are turning to AI to simplify documentation. ChartNote is a HIPAA compliant platform designed for physicians. Its ambient AI Scribe listens during patient visits and drafts notes using custom templates that match your style. See how it works@chartnote.com
Steve Brown
now we have Cochrane for clinicians Fall Prevention Interventions for Older Adults in care facilities from Dr. Jean and Q from Penn State the
Kari Staus
clinical question this Cochrane seeks to answer is what interventions reduce falls among older adults living in care facilities.
Justin Chediak
And we care about this because residents of care facilities face significantly higher risk of falling compared to their community counterparts.
Steve Brown
The short answer here is that tailored interventions implemented with staff engagement reduce fall rate over 6 to 12 months and reduce fall risk after 10 to 12 months.
Kari Staus
And if interventions are not tailored to individual needs, there is probably little to no effect on fall rate at 6 to 12 months.
Justin Chediak
So what types of interventions did this Cochran review?
Kari Staus
Exercise as a standalone intervention does reduce the rate of falling, but after discontinuation of this intervention there was no difference observed in post intervention follow up medication
Steve Brown
optimization interventions did not demonstrate a difference in the rate or risk of falls,
Justin Chediak
but vitamin D supplementation was found to probably reduce the rate of falls among older adults. These studies that looked at vitamin D supplementation had participants with low baseline serum vitamin D levels, so this intervention is most applicable to older adults with vitamin D deficiency.
Steve Brown
Even increasing dairy intake through a dietitian assisted menu design may have reduced fracture risk.
Kari Staus
The CDC has an initiative called Stopping Elderly Accidents, Deaths and Injuries Steady for Short that aims to prevent falls by screening, assessment and intervention and provides free training and tools to help integrate fall prevention into routine clinical workflows.
Steve Brown
Steady for the Win Now a practice guideline Management of Chronic Constipation from the American Society of Colon and Rectal Surgeons. This is summarized by Dr. Arnold from the Naval Undersea Medical Institute in Connecticut. This guideline gets a score of 8 out of 8 on the G Trust Scorecard.
Kari Staus
It's based on a systematic review, focuses on patient oriented outcomes and the Chair and the majority of guideline panel have no conflicts of interest.
Justin Chediak
Why don't we go over some key recommendations? I'm asking for a friend.
Steve Brown
Okay. First a directed history and physical exam should be performed to rule out serious
Kari Staus
disease associated symptoms and stool frequency and quality can be helpful in determining the etiology.
Justin Chediak
We should first address modifiable behavioral factors like diet, medications and immobility.
Steve Brown
Talking now about management. First line treatment is increasing water and fiber consumption 85% of patients with normal transit constipation will be improved with dietary fiber.
Justin Chediak
Combined, soluble and insoluble fiber and oat bran are beneficial.
Kari Staus
Fiber is helpful in irritable bowel syndrome with constipation.
Steve Brown
Also, patients with slow colonic transit or outlet obstruction will likely benefit less from dietary interventions alone.
Justin Chediak
Use osmotic laxatives next. If dietary changes are not sufficient, a meta analysis showed polyethylene glycol is more effective than lactulose and pro tip Miralax tastes like nothing again. I heard from a friend.
Steve Brown
Stimulants like bisacoidal can be used for rescue therapy or second line treatment. And if those steps don't improve things, patients should be evaluated for outlet dysfunction or colonic motility concerns.
Kari Staus
The guideline discusses non surgical management for pelvic floor dysfunction or non relaxing puborectalis muscle.
Justin Chediak
And some anatomic abnormalities may benefit from surgery.
Steve Brown
We're going to wrap things up with a poem. Poems are patient oriented evidence that matters. All oral corticosteroids for children with acute asthma exacerbation appear to be equally effective. This is from Dr. Berry.
Justin Chediak
All right, Team Quick hitter today. Which oral steroid regimen is best for kids with acute egg exacerbations? Are we team dexamethasone or are we team prednisolone?
Steve Brown
And the answer is that it probably doesn't matter. Womp, womp.
Kari Staus
A network meta analysis looked at 11 RCTs with over 2000 kids in outpatient and ED settings and found no significant difference between dexamethasone and prednisolone regimens when it comes to preventing relapses.
Justin Chediak
Yeah, the main outcome they cared about was pretty practical. Did the kid come back within 14 days or another visit to the ED or clinic?
Kari Staus
Across 15 comparisons of six regimens, nobody really outperformed anybody else. So your choice can be more about convenience, tolerance and getting the kid to
Steve Brown
actually take it, which, let's be honest, might be the hardest endpoint of all.
Justin Chediak
A couple caveats though. No placebo or non steroid groups were included. So this is more of a which steroid and not a do steroids help? Type of study.
Kari Staus
And they didn't report harms, which, I don't know, feels like kind of important.
Steve Brown
Yeah. Also, the evidence quality wasn't amazing. Three studies had high risk of bias, four low and overall very low confidence in the results from the authors.
Justin Chediak
So, bottom line, for now, just pick the steroid your patient will actually take and don't overthink it.
Kari Staus
Send us your thoughts by emailing us@AFPpodcastafp.org
Steve Brown
follow on Instagram fpjournal. Please subscribe and rate us wherever you get your podcasts.
Justin Chediak
Escucha nos en espanol a revista medica a fap.
Kari Staus
Our podcast team is Jake Anderson, Puneet Barro, Steve Brown, Justin Chediak, Sarah Coles, Austin Cotter, Rachel Dunn, Emily Eisenberg, Elena Kelly, Chisum Okuwabu, and Kari Staus.
Steve Brown
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.
Justin Chediak
This podcast is brought to you by the residents and faculty of the University of Arizona College of Medicine, Phoenix Family Medicine Residency Program Programs.
Kari Staus
We'll talk to you soon for the next edition of the American Family Physician Podcast.
Steve Brown
Now everyone knows I'm constipated and don't like to run.
Justin Chediak
I'm really not paying a good immobility.
Kari Staus
Maybe you're constipated because you're immobile.
Justin Chediak
No, that's impossible.
Date: April 30, 2026
Hosts: Dr. Steve Brown, Dr. Justin Chediak, Dr. Kari Staus
Overview:
In this episode, the AFP Podcast resident and faculty team from the University of Arizona College of Medicine-Phoenix reviews essential clinical updates from the April 2026 issue of American Family Physician. The panel covers topics including heat-related illness, graduate medical education funding in primary care, foreign body ingestion in children, fall prevention in older adults, chronic constipation management, and comparative efficacy of oral corticosteroids for pediatric asthma exacerbations. The discussion balances clinical pearls, policy implications, and memorable anecdotes.
Key Insights:
Key Insights:
Key Insights:
Notable Quotes:
Key Insights:
Key Recommendations:
Key Insights:
Take-home message:
Justin Chediak: "For now, just pick the steroid your patient will actually take and don't overthink it." (16:53)
| Topic | Start Time | |-------------------------------------------|------------| | Heat-related illness | 02:11 | | Graduate medical education & primary care | 05:43 | | Foreign body ingestion in children | 07:47 | | Fall prevention in older adults | 11:46 | | Chronic constipation management | 13:26 | | Oral steroids for pediatric asthma | 15:27 |
This episode delivers actionable clinical pearls and engaging policy discussion across major ambulatory care topics. Listeners gain stepwise approaches to heat emergencies, evidence-based fall prevention, and a pragmatic review of constipation and asthma care, all with the interplay and humor characteristic of the AFP Podcast team. The recurring theme: focus on practical, patient-centered solutions while pushing for systemic improvements in public health and healthcare education.