http://therapeuticseducation.org Evidence-Based Therapeutics Made Practical and Fun Sat, 31 Jul 2010 00:44:45 +0000 http://wordpress.org/?v=2.9.2 en hourly 1 The Therapeutics Education Collaboration (TEC) podcast is a weekly presentation where practitioners can get evidence-based drug therapy content that is practical, entertaining and promotes healthy scepticism. The information presented, is useful and relevant to physicians, pharmacists, nurses, physician assistants and other health professionals, and can easily be incorporated into day-to-day practice. The podcast is presented by Dr. James McCormack, Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia and Dr Michael Allan, Associate Professor in the Department of Family Practice at the University of Alberta. For more about us and to get the show notes for each episode, visit our website at www.therapeuticseducation.org Dr James McCormack and Dr Michael Allan no Dr James McCormack and Dr Michael Allan podcast@therapeuticseducation.org podcast@therapeuticseducation.org (Dr James McCormack and Dr Michael Allan) Therapeutics Education Collaboration Where practitioners can get evidence-based drug therapy content that is practical, entertaining and promotes healthy scepticism. therapeutics, education, medicine, medical, physicians, pharmacists, evidence, family practice, scepticism, drugs, nurses http://therapeuticseducation.org/podcasting/TECPodcastLogo144.jpg http://therapeuticseducation.org http://therapeuticseducation.org/2010/07/29/episode-96-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-2/ http://therapeuticseducation.org/2010/07/29/episode-96-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-2/#comments Thu, 29 Jul 2010 18:08:22 +0000 james http://therapeuticseducation.org/?p=1635 http://therapeuticseducation.org/2010/07/29/episode-96-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-2/feed/ 0 acetaminophen,bedrest,exercise,gabapentin,low back pain,muscle relaxants,NSAIDs,opioids,TENS,traction,yoga In episode 96, Mike and James continue on with the discussion around evidence for low back pain treatment. They discuss things like traction, heat, exercise and bedrest and then finally get into drugs - not personally of course, at least not much, In episode 96, Mike and James continue on with the discussion around evidence for low back pain treatment. They discuss things like traction, heat, exercise and bedrest and then finally get into drugs - not personally of course, at least not much, but into the discussion  of which ones work and by how much. We conclude with an expert discussion of experts and suggest that experts are not necessarily experts when it comes to evidence. Show notes 1) Traction Cochrane 2007;2:CD003010 2) Heat and ice Cochrane 2006;1:CD004750 3) Lumbar support Cochrane 2008;2:CD001823 4) Transcutaneous electrical nerve stimulation Cochrane 2008;4:CD003008 5) Exercise Cochrane 2005;3:CD000335 6) Bedrest Cochrane 2004;4:CD001254 7) Yoga and transcutaneous electrical stimulation Ann Intern Med 2007;147:492-504 8) Acetaminophen Eur Spine J 2008;17:1423-30 9) NSAIDs Cochrane 2008;1:CD000396 10) Opioids Cochrane 2007; 3:CD004959 Ann Intern Med 2007;146:116-27 11) Muscle relaxants Ann Intern Med 2007;147:505-14 12) Benzodiazepines Ann Intern Med 2007;147:505-14 13) Gabapentin N Engl J Med 2009;361:1963-71 14) GPs with special interest in back pain tend to not know the evidence Spine 2009;34:1218–26             Dr James McCormack and Dr Michael Allan no 40:18 http://therapeuticseducation.org/2010/07/21/episode-95-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-1/ http://therapeuticseducation.org/2010/07/21/episode-95-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-1/#comments Thu, 22 Jul 2010 03:20:12 +0000 TEC http://therapeuticseducation.org/?p=1627 http://therapeuticseducation.org/2010/07/21/episode-95-making-the-treatment-of-low-back-pain-less-of-a-pain-in-the-derriere-%e2%80%93-part-1/feed/ 0 acupuncture,back pain,low back pain,massage,MRI,spinal manipulation In episode 95, Mike and James look at the issue of non-specific low back pain and deal with concepts around diagnosis and we find out that x-rays aren’t that useful but MRI’s in the right patient population can play a role. In episode 95, Mike and James look at the issue of non-specific low back pain and deal with concepts around diagnosis and we find out that x-rays aren’t that useful but MRI’s in the right patient population can play a role. We then start to look at the available evidence for treatment (massage, acupuncture, spinal manipulation) and at the end Mike tries to give James a two-handed neck massage and in retaliation James does acupuncture on Mike with a harpoon. Show notes 1) Guidelines on back pain TOP Back Guideline American College Guideline Ann Intern Med 2007; 147:478-91 Ann Intern Med 2007;147:505-14 (meds) Ann Intern Med 2007;147:492-504 (non-meds) Summary of guidelines BMJ 2006; 332:1430-4 Evidence-based Series (non-medication) on Back Pain Spine 2009, 34:1066-77 and 1078-93 and 1094-1109 2) Imaging – x-ray, CT and MRI BMJ 2001;322:400-5 Lancet 2009;373:463-72 JAMA 2003;289:2810–8 MRI likelihood ratios Condition Positive Likelihood ratio Negative Likelihood ratio Herniated Disc 1.1 - 33 0 – 0.93 Stenosis 3.2 - ? 0.1 – 0.14 Cancer 8.3 - 31 0.07 – 0.19 Infection 12 0.04 Ann Intern Med 2002;137:586-97 BMJ 2006;332:1430-4 Ann Intern Med 2007;147:478-91 4) Massage Cochrane 2008; 4: CD001929 5) Acupuncture Ann Intern Med. 2005 Apr 19;142(8):651-63 Cochrane 2005; 1:CD001351 6) Spinal manipulation Cochrane 2004; 1: CD000447 Dr James McCormack and Dr Michael Allan no 33:19 http://therapeuticseducation.org/2010/07/14/episode-94-more-questions-posed-and-more-answers-composed-benzos-serotonin-syndrome-big-pressures-and-low-doses/ http://therapeuticseducation.org/2010/07/14/episode-94-more-questions-posed-and-more-answers-composed-benzos-serotonin-syndrome-big-pressures-and-low-doses/#comments Wed, 14 Jul 2010 21:24:36 +0000 TEC http://therapeuticseducation.org/?p=1604 http://therapeuticseducation.org/2010/07/14/episode-94-more-questions-posed-and-more-answers-composed-benzos-serotonin-syndrome-big-pressures-and-low-doses/feed/ 1 benzodiazepines,clopidogrel,high blood pressure,serotonin syndrome In episode 94, we get to yet more listener questions and provide vague, yet deep and thoughtful answers. We talk about the use of benzodiazepines, serotonin syndrome, buspirone, 'urgent' hypertension and pontificate even more on low doses. In episode 94, we get to yet more listener questions and provide vague, yet deep and thoughtful answers. We talk about the use of benzodiazepines, serotonin syndrome, buspirone, 'urgent' hypertension and pontificate even more on low doses. Mike and James realise that while low is often a good way to start, all their podcasts to date start of with high expectations yet end with not much more of an effect than placebo. Show notes 1) Effects of Treatment on Morbidity in Hypertension - Results in Patients With Diastolic Blood Pressures Averaging 115 Through 129 mm Hg JAMA 1967;202:1028-34 (http://jama.ama-assn.org/cgi/content/abstract/202/11/1028) 2) Effect of Propranolol in Mild Hypertension Lancet 1966;288:1148-50 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(66)90471-5/fulltext) 3) Clopidogrel See episode 90 (http://therapeuticseducation.org/2010/06/18/episode-90-zoster-pain-and-the-pain-of-using-ppis-with-clopidogrel/) Dr James McCormack and Dr Michael Allan no 36:11 http://therapeuticseducation.org/2010/07/07/episode-93-questions-posed-answers-decomposed-n-and-v-statins-asa-and-alzheimers/ http://therapeuticseducation.org/2010/07/07/episode-93-questions-posed-answers-decomposed-n-and-v-statins-asa-and-alzheimers/#comments Wed, 07 Jul 2010 20:18:30 +0000 TEC http://therapeuticseducation.org/?p=1601 http://therapeuticseducation.org/2010/07/07/episode-93-questions-posed-answers-decomposed-n-and-v-statins-asa-and-alzheimers/feed/ 0 alzheimer's,asa,haloperidol,nausea and vomiting,statins In episode 93, we once again get back to listener questions. We explore everything from haloperidol for nausea and vomiting, to statin dosing, ASA in diabetics, and finally Alzheimer's drugs. Towards the end, In episode 93, we once again get back to listener questions. We explore everything from haloperidol for nausea and vomiting, to statin dosing, ASA in diabetics, and finally Alzheimer's drugs. Towards the end, James and Mike realise that listener questions are too hard and they make up some easy ones of their own yet still struggle. Show notes 1) Low dose haloperidol for nausea and vomiting Anesthesiology 2004;101:1454-63 (http://journals.lww.com/anesthesiology/Fulltext/2004/12000/Is_Low_dose_Haloperidol_a_Useful_Antiemetic___A.28.aspx) 2) ASA in diabetics See episode 65 for a discussion of the use of ASA in diabetics (http://therapeuticseducation.org/2009/09/09/episode-65-a-clot-a-clot-i-want-it-not-primary-prevention-with-antiplatelets/)   Dr James McCormack and Dr Michael Allan no 32:56 http://therapeuticseducation.org/2010/07/02/episode-92-bupropion-for-sex-and-surgery-for-ms/ http://therapeuticseducation.org/2010/07/02/episode-92-bupropion-for-sex-and-surgery-for-ms/#comments Fri, 02 Jul 2010 07:55:51 +0000 TEC http://therapeuticseducation.org/?p=1589 http://therapeuticseducation.org/2010/07/02/episode-92-bupropion-for-sex-and-surgery-for-ms/feed/ 3 bupropion,Mike Kolber,multiple sclerosis,sexual dysfunction,Tina Korownyk In episode 92, we do a final session with our two family physician friends and colleagues, Mike K and Tina K. We start off with Tina discussing some satisfying evidence for the use of bupropion in women with low sexual desire which causes sexually rela... In episode 92, we do a final session with our two family physician friends and colleagues, Mike K and Tina K. We start off with Tina discussing some satisfying evidence for the use of bupropion in women with low sexual desire which causes sexually related personal distress. In the second part Mike K in a slightly less satisfying way  looks at the recent evidence surrounding vascular surgery for a treatment of multiple sclerosis. To conclude this 3-part series we all stop talking, to the satisfaction of all our listeners. Show notes 1) Bupropion for sex BJU Int 2010 Feb 11. [Epub ahead of print] (http://www3.interscience.wiley.com/journal/123280001/abstract) 2) Surgery for multiple sclerosis J Neurol Sci 2009;282:21–7 (http://www.ncbi.nlm.nih.gov/pubmed/19144359) J Vasc Surg 2009;50:1348-58 (http://www.ncbi.nlm.nih.gov/pubmed/19958985) Dr James McCormack and Dr Michael Allan no 28:01 http://therapeuticseducation.org/2010/06/23/episode-91-a-potpourri-of-osteoporosis-stuff/ http://therapeuticseducation.org/2010/06/23/episode-91-a-potpourri-of-osteoporosis-stuff/#comments Wed, 23 Jun 2010 19:14:37 +0000 TEC http://therapeuticseducation.org/?p=1577 http://therapeuticseducation.org/2010/06/23/episode-91-a-potpourri-of-osteoporosis-stuff/feed/ 3 bone density,Mike Kolber,osteoporosis,Tina Korownyk In episode 91, yet again we bring in Mike K and Tina K to help us out with some very useful clinical information surrounding the issue of bone density and osteoporosis. We look at studies from the BMJ (Bowel Medical Journal), In episode 91, yet again we bring in Mike K and Tina K to help us out with some very useful clinical information surrounding the issue of bone density and osteoporosis. We look at studies from the BMJ (Bowel Medical Journal), one of Mike A's favourite journal, and we all agree that simple models should be used and repeat BMDs are basically not needed. Unfortunately we also come to the realisation that in a similar fashion, Mike A and James are basically not needed for the podcast as they are too simple. Show notes 1) Simple models vs more complex models - simple is just as good Arch Intern Med 2009;169:2087-94 (http://archinte.ama-assn.org/cgi/content/abstract/169/22/2087) 2) Repeat bone density - is it needed - likely not BMJ 2009;338:b2266 (http://www.bmj.com/cgi/content/abstract/338/jun23_2/b2266) Osteopor Int 2005;16:842-8 (http://www.springerlink.com/content/ytntmuwq6jpaw6mw) 3) Only measure BMD once Arch Intern Med 2007;167:155-60 (http://archinte.ama-assn.org/cgi/content/abstract/167/2/155) 4) An RCT of vertebroplasty for vertebral fractures NEJM 2009;361:557-68 (http://content.nejm.org/cgi/content/short/361/6/557) Dr James McCormack and Dr Michael Allan no 38:14 http://therapeuticseducation.org/2010/06/18/episode-90-zoster-pain-and-the-pain-of-using-ppis-with-clopidogrel/ http://therapeuticseducation.org/2010/06/18/episode-90-zoster-pain-and-the-pain-of-using-ppis-with-clopidogrel/#comments Fri, 18 Jun 2010 16:52:32 +0000 james http://therapeuticseducation.org/?p=1564 http://therapeuticseducation.org/2010/06/18/episode-90-zoster-pain-and-the-pain-of-using-ppis-with-clopidogrel/feed/ 2 clopidogrel,Mike Kolber,PPIs,Tina Korownyk,zoster In episode 90, Mike and James solicit the mainly brilliant, but always delightful help of Mike Kolber and Tina Korownyk. We talk about what to do for the chronic pain that can be associated with Herpes zoster and we have a quick look at the old and new... In episode 90, Mike and James solicit the mainly brilliant, but always delightful help of Mike Kolber and Tina Korownyk. We talk about what to do for the chronic pain that can be associated with Herpes zoster and we have a quick look at the old and new data surrounding the area of PPIs and platelet inhibitors. Mike and James cap off the podcast by deciding that Mike and Tina do a way better job than they do so they sell the podcast to the new duo for a brand name PPI and a generic cup of coffee. Show notes 1) Chronic pain - dual therapy gabapentin plus nortriptyline Lancet 2009;374:1252-61 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61081-3/abstract) 2) Clopidogrel and PPIs JAMA 2009;301:937-44 (http://jama.ama-assn.org/cgi/content/abstract/301/9/937) CMAJ 2009;180:713-8 (http://canadianmedicaljournal.ca/cgi/content/full/180/7/713) Lancet 2009; 374: 989–97 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61525-7/abstract) Circulation 2009;120:2322-9 (http://circ.ahajournals.org/cgi/content/short/120/23/2322) Circulation 2009;120;2310-2 (http://circ.ahajournals.org/cgi/content/extract/circulationaha;120/23/2310) COGENT (http://www.theheart.org/article/1007145.do ) 3) Duration of clopidogrel N Engl J Med 2010;362:1374-82 (http://content.nejm.org/cgi/content/short/362/15/1374)   Dr James McCormack and Dr Michael Allan no 41:33 http://therapeuticseducation.org/2010/06/09/episode-89-warts-and-all-part-three-of-the-new-zealand-experience/ http://therapeuticseducation.org/2010/06/09/episode-89-warts-and-all-part-three-of-the-new-zealand-experience/#comments Wed, 09 Jun 2010 21:27:00 +0000 james http://therapeuticseducation.org/?p=1543 http://therapeuticseducation.org/2010/06/09/episode-89-warts-and-all-part-three-of-the-new-zealand-experience/feed/ 4 In episode 89, Mike and James finish the Bruce Arroll trilogy, but, as with Star Wars we hope there will be more at a later date. We talk about herpes zoster, depression, anxiety, corns, warts and the benefits of making making house calls, In episode 89, Mike and James finish the Bruce Arroll trilogy, but, as with Star Wars we hope there will be more at a later date. We talk about herpes zoster, depression, anxiety, corns, warts and the benefits of making making house calls, phone calls and drugectomies. At the end of the podcast both Mike and James decide to make a house call to Bruces's house when they go to New Zealand and hope they will get prescribed high doses of very decent wine. Show notes None as we really just talked about concepts and approaches and avoided evidence as much as possible. Dr James McCormack and Dr Michael Allan no 27:35 http://therapeuticseducation.org/2010/06/02/episode-88-a-hodgepodge-from-down-under-smoking-asa-antibiotics-nsaids-warfarin-spironolactone/ http://therapeuticseducation.org/2010/06/02/episode-88-a-hodgepodge-from-down-under-smoking-asa-antibiotics-nsaids-warfarin-spironolactone/#comments Wed, 02 Jun 2010 18:26:54 +0000 TEC http://therapeuticseducation.org/?p=1535 http://therapeuticseducation.org/2010/06/02/episode-88-a-hodgepodge-from-down-under-smoking-asa-antibiotics-nsaids-warfarin-spironolactone/feed/ 1 bronchitis,bruce arroll,losartan,NSAIDs,spironolactone In episode 88, James and Mike continue their conversation with Bruce Arroll from down under and cover a broad range of topics from smoking to antibiotics for acute bronchitis, warfarin, and spironolactone. At the end of the podcast Bruce and Mike decid... In episode 88, James and Mike continue their conversation with Bruce Arroll from down under and cover a broad range of topics from smoking to antibiotics for acute bronchitis, warfarin, and spironolactone. At the end of the podcast Bruce and Mike decide that much of what James has to say is up and over the top. Show notes 1) Stopping smoking benefit Chest 2007;131:446–52 (http://chestjournal.chestpubs.org/content/131/2/446) 2) Low-dose aspirin in patients with stable cardiovascular disease Am J Med 2008;121:43-9 (http://www.amjmed.com/article/S0002-9343(07)00985-0/abstract) 3) Losartan – 50 vs 150 mg Lancet 2009;374:1840-8 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61913-9/abstract) 4) Antibiotics for COPD Acute Exacerbation Cochrane 2006;2:CD004403 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004403/abstract.html) 5) Many patients unaware of GI risk from NSAIDs J Rheumatol 2005;32:2218-24 (http://www.jrheum.com/subscribers/05/11/2218.html) 6) Spironolactone for resistant hypertension AJH 2003;16:925–30 (http://www.nature.com/ajh/journal/v16/n11/abs/ajh2003173a.html) Journal of Hypertension 2007;25:891-4 (http://journals.lww.com/jhypertension/pages/articleviewer.aspx?year=2007&issue=04000&article=00023&type=abstract)   Dr James McCormack and Dr Michael Allan no 32:46 http://therapeuticseducation.org/2010/05/27/episode-87-increasing-the-likelihood-you-will-use-likelihood-ratios/ http://therapeuticseducation.org/2010/05/27/episode-87-increasing-the-likelihood-you-will-use-likelihood-ratios/#comments Thu, 27 May 2010 18:19:48 +0000 TEC http://therapeuticseducation.org/?p=1527 http://therapeuticseducation.org/2010/05/27/episode-87-increasing-the-likelihood-you-will-use-likelihood-ratios/feed/ 0 likelihood ratios,sore throat,Strep throat In episode 87, Mike and James bring up the unlikely issue of likelihood ratios. As they knew they would likely have difficulty discussing this, they bring in the expert help of Bruce Arroll from New Zealand who really likes our podcast. In episode 87, Mike and James bring up the unlikely issue of likelihood ratios. As they knew they would likely have difficulty discussing this, they bring in the expert help of Bruce Arroll from New Zealand who really likes our podcast. We also like what he does as he has published so many useful articles in the area of rational therapeutics. However, at the end, the likelihood that any of this made sense is about 1.01, which is likely similar to the end result for most of the podcasts. 1) Simplifying Likelihood Ratios For pre-test probabilities between 10% and 90% a positive test with an: LR of 2 - increases the probability by 15% (absolute increases) LR of 5 - increases the probability by 30% LR of 10 - increases the probability by 45% LR of 0.5 - decreases the probability by 15% (absolute decreases) LR of 0.2 - decreases the probability by 30% LR of 0.1 - decreases the probability by 45% J Gen Intern Med 2002;17:647-50 2) Likelihood Ratio of a Positive Test Result 1-2 - "Poor" 2-5 "Small - Moderate" 5-10 "Good" >10 "Excellent (Rule in)" 3) Likelihood Ratio of a Negative Test Result 1 – 0.5 "Poor" 0.5 – 0.2 "Small -Moderate" 0.2 – 0.1 "Good" < 0.1 "Excellent (Rule out)" 4) Examples of some useful LRs Phalen Test positive (Carpal Tunnel): LR = 1.3 Shifting Dullness present (Ascites): LR = 2.3 Patient Reporting Fever (>38 Temp): LR = 4.9 Interstitial Edema on Chest X-Ray (CHF): LR = 12.7 Ottawa Ankle Rules (Ankle #) negative: LR = 0.08 Canadian C-Spine Rules (C-spine #) negative LR = 0.013 (vs NEXUS LR = 0.25) For children age 3-15 - throat swab for GABHS LR +ve test = 2.9 LR -ve test = 0.04 JAMA 2000;283:3110-7 J Gen Intern Med 1988:423-8 Ann Emerg Med 1996:27:693-5 Am J Med 2004; 116: 363-8 BMJ 2003;326:417 NEJM 2003; 349: 2510-8 5) A clinical score to reduce unnecessary antibiotic use in patients with sore throat CMAJ 1998;158:75-83 Dr James McCormack and Dr Michael Allan no 45:29 http://therapeuticseducation.org/2010/05/07/drugectomies-dtc-2010/ http://therapeuticseducation.org/2010/05/07/drugectomies-dtc-2010/#comments Fri, 07 May 2010 17:15:22 +0000 TEC http://therapeuticseducation.org/?p=1464 http://therapeuticseducation.org/2010/05/07/drugectomies-dtc-2010/feed/ 1 Adil Virani,anxiety,Bob Rangno,depression,diabetes,drugectomies,high blood pressure This week we have something slightly different for you. This pseudopodcast is a recording from our most recent drug therapy course held here in Vancouver in April 2010. Typically on the last afternoon of the course we get a panel together to discuss is... This week we have something slightly different for you. This pseudopodcast is a recording from our most recent drug therapy course held here in Vancouver in April 2010. Typically on the last afternoon of the course we get a panel together to discuss issues that are of importance to health care professionals who “use’”drugs. The panel this year consisted of James McCormack, Mike Allan, Tracy Monk – a great family physician, Adil Virani, a Pharm D who has helped us out on previous podcasts with psych related issues, John Sloan, a family physician who you heard a few podcasts ago when we talked about the frail elderly, Bob Crossland a really no nonsense evidence-based internist from Salt Spring Island, and our good friend Bob Rangno, a clinical pharmacologist who has also helped us out with a number of podcasts. This year we decided to have a discussion on how to do drugectomies. To do this, we reviewed a number of cases ranging from patients on diabetes drugs, patients with depression, epilepsy, patients on benzodiazepines, and finally a patient on multiple high blood pressure drugs. Dr James McCormack and Dr Michael Allan no 1:33:24 http://therapeuticseducation.org/2010/05/05/episode-86-alzheimers-unforgettable-podcasts-part-iii-the-final-tease/ http://therapeuticseducation.org/2010/05/05/episode-86-alzheimers-unforgettable-podcasts-part-iii-the-final-tease/#comments Wed, 05 May 2010 17:49:15 +0000 TEC http://therapeuticseducation.org/?p=1433 http://therapeuticseducation.org/2010/05/05/episode-86-alzheimers-unforgettable-podcasts-part-iii-the-final-tease/feed/ 2 AD 2000,alzheimer's,dementia,donepezil,galantamine,Laurie Mallery,rivastigmine In episode 86, James, Mike and Laurie finish of the discussion of Alzheimer's by reviewing more clinical trial data and try to tease out if there are any differences between the available therapies but in essence struggle to tease out if there is a ben... In episode 86, James, Mike and Laurie finish of the discussion of Alzheimer's by reviewing more clinical trial data and try to tease out if there are any differences between the available therapies but in essence struggle to tease out if there is a benefit over placebo. James then teases both Mike and Laurie into giving the definitive answer on these therapies and they tease the audience with their answer. Show notes 1) Cholinesterase inhibitor summaries Cochrane Database Syst Rev. 2006;(1):CD001190 (http://www2.cochrane.org/reviews/en/ab001190.html) CMAJ 2003;169:557-64 (http://www.cmaj.ca/cgi/content/full/169/6/557) 2) Non-industry funded study - AD 2000 Lancet 2004;363:2105-15 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1B-4CPK0DC-6&_user=1022551&_coverDate=06%2F26%2F2004&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=f803a6bc5e0b289ab8909a4935e2803f) 3) Is one agent better than another? Lancet Neurol 2004;3:622:26 (http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(04)00883-X/abstract) Therapeutics Letter 2005; 56:1-4 (http://www.ti.ubc.ca/node/44) Cochrane Database Syst Rev. 2006;(1):CD005593 (http://www2.cochrane.org/reviews/en/ab005593.html) Ann Intern Med 2008;148;379-97 (http://www.annals.org/content/148/5/379.abstract) 4) Galantamine summary Cochrane Database Syst Rev. 2006 ;(1):CD001747 (http://www2.cochrane.org/reviews/en/ab001747.html) 5) Rivastigmine Cochrane Database Syst Rev. 2009;(2):CD001191 (http://www2.cochrane.org/reviews/en/ab001191.html) 6) Other therapies Nicergoline Cochrane Database Syst Rev. 2001;(4):CD003159 (http://www2.cochrane.org/reviews/en/ab003159.html) Hydergine Cochrane Database Syst Rev. 2001;(2):CD000359 (http://www2.cochrane.org/reviews/en/ab000359.html) Propentofylline Cochrane Database Syst Rev. 2003;(2):CD002853 (http://www2.cochrane.org/reviews/en/ab002853.html) Nimodipine Cochrane Database Syst Rev. 2002;(3):CD000147 (http://www2.cochrane.org/reviews/en/ab000147.html) Huperzine A Cochrane Database Syst Rev. 2008;(2):CD005592 (http://www2.cochrane.org/reviews/en/ab005592.html) Clioquinol: no clear benefit Cochrane Database Syst Rev. 2006;(1):CD005380 (http://www2.cochrane.org/reviews/en/ab005380.html) Omega 3 polyunsaturated fatty acids: no good evidence. Cochrane Database Syst Rev. 2006;(1):CD005379 (http://www2.cochrane.org/reviews/en/ab005379.html) Melatonin: No clear benefit Cochrane Database Syst Rev. 2006;(1):CD003802 (http://www2.cochrane.org/reviews/en/ab003802.html) Alpha lipoic acid: No Trials (http://www2.cochrane.org/reviews/en/ab004244.html)Cochrane Database Syst Rev. 2004;(1):CD004244 (http://www2.cochrane.org/reviews/en/ab004244.html) Folic acid: No effect Cochrane Database Syst Rev. 2003;(4):CD004514 (http://www2.cochrane.org/reviews/en/ab004514.html) Vinpocetine (herbal): Maybe but data limited Cochrane Database Syst Rev. 2003;(1):CD003119 (http://www2.cochrane.org/reviews/en/ab003119.html) Vitamin B6: No benefit Cochrane Database Syst Rev. 2003;(4):CD004393 (http://www2.cochrane.org/reviews/en/ab004393.html) Vitamin B12: Unclear Cochrane Database Syst Rev. 2003;(3):CD004326 (http://www2.cochrane.org/reviews/en/ab004326.html) Lecithin: No benefit Cochrane Database Syst Rev. 2003;(3):CD001015 (http://www2.cochrane.org/reviews/en/ab001015.html) Ibuprofen: No evidence Cochrane Database Syst Rev. 2003;(2):CD004031 (http://www2.cochrane.org/reviews/en/ab004031.html) Acetyl-L-carnitine: 1 scale of many: unlikely benefit Cochrane Database Syst Rev. 2003;(2):CD003158 (http://www2.cochrane.org/reviews/en/ab003158.html) Statins: No evidence Cochrane Database Syst Rev. 2001;(4):CD003160 (http://www2.cochrane.org/reviews/en/ab003160.html) Selegiline: Mixed but very limited benefit Cochrane Database Syst Rev. 2003;(1):CD000442 (http://www2.cochrane.org/reviews/en/ab000442.html) Hormone replacement therapy: No benefit Cochrane Database Syst Rev. 2002;(3):CD003799 Dr James McCormack and Dr Michael Allan no 29:24 http://therapeuticseducation.org/2010/04/28/episode-85-alzheimers-unforgettable-podcasts-part-ii-the-scales-and-the-studies/ http://therapeuticseducation.org/2010/04/28/episode-85-alzheimers-unforgettable-podcasts-part-ii-the-scales-and-the-studies/#comments Wed, 28 Apr 2010 22:17:27 +0000 TEC http://therapeuticseducation.org/?p=1427 http://therapeuticseducation.org/2010/04/28/episode-85-alzheimers-unforgettable-podcasts-part-ii-the-scales-and-the-studies/feed/ 4 alzheimer's,cholinesterase inhibitors,dementia,donepezil,Laurie Mallery,memantine,rivastigmine In episode 85, James and Mike delve into the studies, the scales and some of the treatments for Alzheimer's. We once again have geriatrician Laurie Mallery help us out. By the end of the podcast, we find out the evidence shows a weak benefit, In episode 85, James and Mike delve into the studies, the scales and some of the treatments for Alzheimer's. We once again have geriatrician Laurie Mallery help us out. By the end of the podcast, we find out the evidence shows a weak benefit, the emotional need for a treatment is strong and when you have these two things working together, a la  Mike and James, confusion reigns but out of the fog comes a somewhat reasonable approach. Show notes 1) Memantine Cochrane Database Syst Rev. 2006;(2):CD003154 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003154/frame.html) 2) Cholinesterase inhibitiors Cochrane Database Syst Rev. 2006;(1):CD001190 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001190/frame.html) Cochrane Database Syst Rev 2000;(4):CD001191 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001191/frame.html) CMAJ 2003;169: 557-64 (http://www.cmaj.ca/cgi/content/full/169/6/557) Dr James McCormack and Dr Michael Allan no 32:54 http://therapeuticseducation.org/2010/04/22/episode-84-alzheimers-unforgettable-podcasts-part-i-the-diagnosis/ http://therapeuticseducation.org/2010/04/22/episode-84-alzheimers-unforgettable-podcasts-part-i-the-diagnosis/#comments Thu, 22 Apr 2010 17:04:54 +0000 TEC http://therapeuticseducation.org/?p=1421 http://therapeuticseducation.org/2010/04/22/episode-84-alzheimers-unforgettable-podcasts-part-i-the-diagnosis/feed/ 0 alzheimer's,Laurie Mallery,MMSE In episode 84, James and Mike start to look at the difficult area of dementia from both the diagnosis and treatment perspective. Given that Mike and James often get confused during the podcasts and forget things, we've engaged an expert in this area, In episode 84, James and Mike start to look at the difficult area of dementia from both the diagnosis and treatment perspective. Given that Mike and James often get confused during the podcasts and forget things, we've engaged an expert in this area, geriatrician Laurie Mallery. Mike starts off by questioning James' mental function but this is not an issue as Laurie provides 3 mnemonics that are very easy to use for the diagnosis and evaluation  of Alzheimer's disease. Show notes 1) A CURE FROM IRAN  - pneumonics to help diagnose and stage Alzheimer's disease CURE (patient) - modified from the Brief Cognitive Rating Scale Mild - Current Events Moderate - USA president (or Canadian PM) Severe - Relatives (Spouse or children names forgotten) Very Severe - Everything forgotten FROM (questions for care-giver) Function Repetitive questioning Onset (Acute or Slowly progressive) Memory IRAN (questions to care-giver about function) - modified from the FAST (Functional Assessment Staging Tool) Mild - IADL (Impaired) Moderate- Repetitive Dressing Severe - ADL's impaired Very Severe - Non-ambulatory & Non-Verbal 2) Accuracy of the mini-mental state examination - MMSE Mixed results by setting: Positive LR = 16.2 – 5.9 Negative LR = 0.3 – 0.17 Best Case scenario: 19.3 and 0.16 J Psychiatr Res 2009;43:411-31 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T8T-4SV12WC-1&_user=1022551&_coverDate=01%2F31%2F2009&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=fbdfc1ce2575e9dbf38fa6476743d479)   Dr James McCormack and Dr Michael Allan no 29:47 http://therapeuticseducation.org/2010/04/14/episode-83-gabapentin-and-bioidentical-hormones-a-look-at-all-the-data/ http://therapeuticseducation.org/2010/04/14/episode-83-gabapentin-and-bioidentical-hormones-a-look-at-all-the-data/#comments Wed, 14 Apr 2010 20:09:46 +0000 TEC http://therapeuticseducation.org/?p=1403 http://therapeuticseducation.org/2010/04/14/episode-83-gabapentin-and-bioidentical-hormones-a-look-at-all-the-data/feed/ 2 bioidentical hormones,cihr,gabapentin In episode 83, Mike and James tackle two very different and difficult areas of controversy. Mike looks at the data surrounding the use of gabapentin and off-label uses including chronic pain, and James tackles the lack of data surrounding the use of bi... In episode 83, Mike and James tackle two very different and difficult areas of controversy. Mike looks at the data surrounding the use of gabapentin and off-label uses including chronic pain, and James tackles the lack of data surrounding the use of bioidentical hormones. At the end of the podcast James develops breast tenderness and complains so much that Mike decides to take gabapentin for the pain associated with James' complaining. Show notes 1) Off-label trials of gabapentin N Engl J Med 2009;361:1963-71 (http://content.nejm.org/cgi/content/short/361/20/1963) 2) CIHR trials CMAJ 2004;171:735-40 (http://www.cmaj.ca/cgi/content/abstract/171/7/735) 3) Gabapentin for pain Therapeutics Initiative Letter 2009 (July – Dec) (http://www.ti.ubc.ca/PDF/75.pdf) 4) Pregabalin First CEDAC report (http://www.cadth.ca/media/cdr/complete/cdr_complete_Lyrica_Jan26-06.pdf) Final recommendation (http://www.cadth.ca/media/cdr/complete/cdr_complete_Lyrica%20Resubmission_September_25-2009.pdf) 5) Systematic review of bioidentical hormones Postgrad Med 2009;121:1-13 (http://www.postgradmed.com/index.php?art=pgm_01_2009?article=1949) Dr James McCormack and Dr Michael Allan no 45:01 http://therapeuticseducation.org/2010/04/07/episode-82-lost-faith-in-surrogates-yet-accord-challenges-beliefs-again/ http://therapeuticseducation.org/2010/04/07/episode-82-lost-faith-in-surrogates-yet-accord-challenges-beliefs-again/#comments Wed, 07 Apr 2010 18:11:30 +0000 TEC http://therapeuticseducation.org/?p=1387 http://therapeuticseducation.org/2010/04/07/episode-82-lost-faith-in-surrogates-yet-accord-challenges-beliefs-again/feed/ 2 In episode 82, James and Mike discuss the latest results from the ACCORD trial. While the results really showed no difference between the groups, these results should make a difference in what you do. During much of the podcast, In episode 82, James and Mike discuss the latest results from the ACCORD trial. While the results really showed no difference between the groups, these results should make a difference in what you do. During much of the podcast, Mike does an unbelievable impersonation of a parrot but, we aren't sure if anyone will notice that difference. Show notes 1) ACCORD - glucose lowering NEJM 208;358:2545-9 (http://content.nejm.org/cgi/content/full/358/24/2545) 2) ACCORD - blood pressure lowering NEJM 2010:10.1056/NEJMoa1001286 (http://content.nejm.org/cgi/content/full/NEJMoa1001286) 3) ACCORD - cholesterol lowering with fenofibrate NEJM 2010:10.1056/NEJMoa1001282 (http://content.nejm.org/cgi/content/full/NEJMoa1001282) 3) FIELD - fenofibrate Lancet 2005;366:1849-61 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67667-2/abstract) 3) Studies, systematic reviews and meta-analyses of fibrates Am Heart J 2007;154:943-53 (http://www.ahjonline.com/article/S0002-8703(07)00592-3/abstract) Am J Med 2009; 122: 962.e1-962.e8 (http://www.amjmed.com/article/S0002-9343(09)00490-2/abstract) J Am Coll Cardiol 2005;45:185–97 (http://www.ncbi.nlm.nih.gov/pubmed/15653014) Arch Intern Med. 2005;165:725-730 (http://archinte.ama-assn.org/cgi/content/abstract/165/7/725) Int J Cardiol 2009; doi:10.1016/j.ijcard.2008.11.211 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T16-4VMX80F-1&_user=1022551&_coverDate=02%2F18%2F2009&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1331401975&_rerunOrigin=google&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=0f9a75b78db8ee8fc4c231755067aafd)   Dr James McCormack and Dr Michael Allan no 20:18 http://therapeuticseducation.org/2010/03/24/episode-81-new-studies-about-vit-kinr-pud-gabhs-and-statins/ http://therapeuticseducation.org/2010/03/24/episode-81-new-studies-about-vit-kinr-pud-gabhs-and-statins/#comments Wed, 24 Mar 2010 16:24:00 +0000 TEC http://therapeuticseducation.org/?p=1365 http://therapeuticseducation.org/2010/03/24/episode-81-new-studies-about-vit-kinr-pud-gabhs-and-statins/feed/ 3 H pylori,statins,steroids,Strep throat,vitamin k,warfarin In episode 81, Mike and James talk about new studies. They run the gamut from Vitamin K, sequential therapy for peptic ulcer disease, single dose steroids for Strep throat and yet another meta-analysis of statin therapy. In episode 81, Mike and James talk about new studies. They run the gamut from Vitamin K, sequential therapy for peptic ulcer disease, single dose steroids for Strep throat and yet another meta-analysis of statin therapy. At the end we clearly demonstrate our skill at critical appraisal by recommending Vitamin K for ulcers, sequential antibiotic therapy for primary prevention, steroids for INR problems, statins for Strep throat (come on, you knew statins would work for this) and a kick in the ass for Chris our producer. Show notes 1) Vitamin K and warfarin Ann Intern Med 2009;150:293-300 (http://www.annals.org/content/150/5/293.abstract) 2) Sequential therapy for PUD - 10 days Amer J Gastro 2009;104:3069-79 (http://www.nature.com/ajg/journal/vaop/ncurrent/abs/ajg2009555a.html#abs) 3) Single dose steroids for sore throat BMJ 2009;339:b2976 (http://www.bmj.com/cgi/content/abstract/339/aug06_2/b2976) 4) More meta-analyses for statins Circulation 2010;121:1069-77 (http://circ.ahajournals.org/cgi/content/abstract/121/9/1069) BMJ 2009;338:b2376 ( <div>http://www.bmj.com/cgi/content/abstract/338/jun30_1/b2376</div> <p>) Dr James McCormack and Dr Michael Allan no 30:13 http://therapeuticseducation.org/2010/03/22/episode-80-listener-comments-and-questions-with-an-attempt-at-answers-part-ii/ http://therapeuticseducation.org/2010/03/22/episode-80-listener-comments-and-questions-with-an-attempt-at-answers-part-ii/#comments Mon, 22 Mar 2010 21:46:53 +0000 TEC http://therapeuticseducation.org/?p=1354 http://therapeuticseducation.org/2010/03/22/episode-80-listener-comments-and-questions-with-an-attempt-at-answers-part-ii/feed/ 3 asa,ezetimibe,glucose monitoring,niacin,Peter Loewen,salbutamol,torcetrapib,warfarin In episode 80, Mike and James continue getting back to listener questions. We discuss such topics as glucose monitoring, ezetimibe, niacin, nebulised salbutamol and niacin with uncanny intuitive insight coupled with a degree of emotional sensitivity ra... In episode 80, Mike and James continue getting back to listener questions. We discuss such topics as glucose monitoring, ezetimibe, niacin, nebulised salbutamol and niacin with uncanny intuitive insight coupled with a degree of emotional sensitivity rarely encountered in podcasts. We then wake up and get Peter Loewen to help answer a difficult question on oral anticoagulants. Show notes 1) Self-monitoring of blood glucose ESMON BMJ 2008;336:1174-7 (http://www.bmj.com/cgi/content/abstract/336/7654/1174) DiGEM BMJ 2008;336:1177-80 (http://www.bmj.com/cgi/content/abstract/336/7654/1177) CADTH - thorough review of the  issue of glucose monitorin (http://www.cadth.ca/media/pdf/C1109_bgts_summary_report_e.pdf)g 2) Ezetimibe ENHANCE N Engl J Med 2008;358:1431-43 (http://content.nejm.org/cgi/content/abstract/358/14/1431) SEAS N Engl J Med 2008;359:1343-56 (http://content.nejm.org/cgi/content/abstract/359/13/1343) Cancer data N Engl J Med 2008;359:1357-66 (http://content.nejm.org/cgi/content/abstract/359/13/1357) 3) Ezetimibe vs niacin - niacin better? ARBITER 6–HALTS N Engl J Med 2009;361:2113-22 (http://content.nejm.org/cgi/content/short/361/22/2113) 4) Torcetrapib - worsens outcomes N Engl J Med 2007;357:2109-22 (http://content.nejm.org/cgi/content/abstract/357/21/2109) 5) Niacin Coronary drug project Eur J Clin Pharmacol 1991;40 [Suppl 1]: S49-S51 (http://www.springerlink.com/content/g350686w77404t47/) 6) Anticoagulation issues SARS (ASA, ASA+warf, ASA+ticlopidine) post ACS+stent NEJM 1998;339:1665-71 (http://content.nejm.org/cgi/reprint/339/23/1665.pdf) Registry of AF patients on OAC at time of PCI+stent JACC 2008;51:818–25 (http://content.onlinejacc.org/cgi/reprint/51/8/818.pdf) Registry of OAC patients (various indications) post PCI+DES J Intern Med 2008;264:472-80 (http://www.ncbi.nlm.nih.gov/pubmed/18624903) Registry of OAC patients (various indications) post PCI+stent J Invasive Cardiol 2006;18:162-4 (http://www.ncbi.nlm.nih.gov/pubmed/16729401?dopt=Abstract) Dr James McCormack and Dr Michael Allan no 33:42 http://therapeuticseducation.org/2010/03/17/episode-79-listener-comments-and-questions-with-an-attempt-at-answers/ http://therapeuticseducation.org/2010/03/17/episode-79-listener-comments-and-questions-with-an-attempt-at-answers/#comments Wed, 17 Mar 2010 20:32:02 +0000 TEC http://therapeuticseducation.org/?p=1339 http://therapeuticseducation.org/2010/03/17/episode-79-listener-comments-and-questions-with-an-attempt-at-answers/feed/ 0 listener questions,metformin,risk assessment,statins,Strep throat,UKPDS In episode 79, Mike and James get back to trying to answer questions posed by our wonderful listeners. We both, in our own minds, give wonderful, thoughtful and sensitive answers to issues associated with diabetes, statins, metformin, strep throat etc. In episode 79, Mike and James get back to trying to answer questions posed by our wonderful listeners. We both, in our own minds, give wonderful, thoughtful and sensitive answers to issues associated with diabetes, statins, metformin, strep throat etc. Unfortunately, our producer Chris edited all these out and you are left with a lot of ranting and raving from the duo. At the end of the podcast, James and Mike realise Chris has been editing all the podcasts this way and they go searching for a new producer. Show notes Tools for practice (http://www.acfp.ca/tfp_original.php) Statins overall benefit chart (http://therapeuticseducation.org/?attachment_id=435) University of Edinburgh Cardiovascular Risk Calculator (http://cvrisk.mvm.ed.ac.uk/calculator/calc.asp) 1) UKPDS 34 metformin Lancet 1998;352:854-65 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07037-8/abstract) 2) ATLAS 3164 patients with class II to IV heart failure randomised to receive either 2.5 to 5.0 mg daily or 32.5 to 35 mg daily of lisinopril for approx 4 years Circ 1999;100:2312-8 (http://circ.ahajournals.org/cgi/content/full/100/23/2312) 3) Statin dose meta-analysis response CMAJ 2008;178:576-84 (http://www.cmaj.ca/cgi/content/abstract/178/5/576) 4) Metformin Vit B12 deficiency Arch Intern Med 2006;166:1975-79 (http://archinte.ama-assn.org/cgi/content/abstract/166/18/1975) 5) Strep test Ped Emerg Care 2001;17:272-8 (http://journals.lww.com/pec-online/Citation/2001/08000/Rapid_strep_tests_in_the_emergency_department__An.14.aspx) 10% prevalence - PPV of 53% and a NPV of 97% 40% prevalence – PPV of 87% and a NPV of 82% 6) Scoring system for strep throat CMAJ 1998;158:75-83 (http://www.cmaj.ca/cgi/content/abstract/158/1/75) CMAJ 2000; 163:811-15 (http://www.cmaj.ca/cgi/content/abstract/163/7/811) Dr James McCormack and Dr Michael Allan no 30:00 http://therapeuticseducation.org/2010/03/10/episode-78-the-frail-elderly-treat-symptoms-first-last-and-in-the-middle-part-iii/ http://therapeuticseducation.org/2010/03/10/episode-78-the-frail-elderly-treat-symptoms-first-last-and-in-the-middle-part-iii/#comments Wed, 10 Mar 2010 20:54:37 +0000 TEC http://therapeuticseducation.org/?p=1285 http://therapeuticseducation.org/2010/03/10/episode-78-the-frail-elderly-treat-symptoms-first-last-and-in-the-middle-part-iii/feed/ 1 benzodiazepines,combative,frail elderly,John Sloan,opioids,pain,sleep In episode 78, the final one on the frail elderly, Mike and James, with John Sloan, deal with what is really important to the frail elderly, and that is symptom control. We discuss pain and opioids, sleep and benzos, In episode 78, the final one on the frail elderly, Mike and James, with John Sloan, deal with what is really important to the frail elderly, and that is symptom control. We discuss pain and opioids, sleep and benzos, and combativeness and whatever seems to work - but all in very low doses. To cap of this final episode on the frail elderly, Mike and James forget to plug John's book and he experiences great pain, he can't sleep and becomes quite combative, but fortunately Mike and James have listened to this podcast and know what to do. Show notes 1) Selective reporting of gabapentin NEJM 2009, 361:1963-71 (http://nejm.highwire.org/cgi/content/abstract/361/20/1963) (http://therapeuticseducation.org/wp-content/uploads/2010/02/A-Bitter-Pill.jpg) A Bitter Pill - By John Sloan (http://www.amazon.ca/Bitter-Pill-John-Sloan/dp/1553654552) Dr James McCormack and Dr Michael Allan no 29:47 http://therapeuticseducation.org/2010/03/02/episode-77-the-frail-elderly-blood-pressure-is-good-part-ii/ http://therapeuticseducation.org/2010/03/02/episode-77-the-frail-elderly-blood-pressure-is-good-part-ii/#comments Tue, 02 Mar 2010 16:14:42 +0000 TEC http://therapeuticseducation.org/?p=1270 http://therapeuticseducation.org/2010/03/02/episode-77-the-frail-elderly-blood-pressure-is-good-part-ii/feed/ 1 frail elderly,high blood pressure,John Sloan In episode 77, Mike and James stop waxing philosophically and get specific about therapeutics and the frail elderly. Once again we get our friend and colleague John Sloan to help us navigate through this evidence-free zone. In episode 77, Mike and James stop waxing philosophically and get specific about therapeutics and the frail elderly. Once again we get our friend and colleague John Sloan to help us navigate through this evidence-free zone. We specifically talk about how to deal with the patient on 47 drugs and what to do about blood pressure, cholesterol, osteoporosis, and type 2 diabetes. To wrap it all up Mike, James and John do a no-analgesia drugectomy on each other and, other than a bit of whining, seem to do OK. Show notes 1) HYVET - Treatment of Hypertension in Patients 80 Years of Age or Older NEJM 2008;358:1887-98 (http://content.nejm.org/cgi/content/abstract/358/18/1887) (http://therapeuticseducation.org/wp-content/uploads/2010/02/A-Bitter-Pill.jpg) A Bitter Pill - By John Sloan (http://www.amazon.ca/Bitter-Pill-John-Sloan/dp/1553654552) Dr James McCormack and Dr Michael Allan no 37:00 http://therapeuticseducation.org/2010/02/24/episode-76-the-frail-elderly-philosophy-first-part-i/ http://therapeuticseducation.org/2010/02/24/episode-76-the-frail-elderly-philosophy-first-part-i/#comments Wed, 24 Feb 2010 18:42:41 +0000 TEC http://therapeuticseducation.org/?p=1258 http://therapeuticseducation.org/2010/02/24/episode-76-the-frail-elderly-philosophy-first-part-i/feed/ 0 frail elderly,John Sloan In episode 76, Mike and James explore the topic of the treatment of the frail elderly. To do this properly, we bring in an "expert", Dr John Sloan, who has spent the majority of his practice driving to the homes of the frail elderly and taking care of ... In episode 76, Mike and James explore the topic of the treatment of the frail elderly. To do this properly, we bring in an "expert", Dr John Sloan, who has spent the majority of his practice driving to the homes of the frail elderly and taking care of them. In the first of three episodes on this topic, we philosophize on the general issues of how to deal, or not deal, with the frail elderly - symptoms first, and then if you have any left over time deal with the other issues. At the end, Mike tells James he is closer to being a frail elderly person than he is and decides it's important to get all of James' lab values to what he had when he was age 19. Show notes Not many notes this week because there isn't much evidence surrounding the frail elderly (http://therapeuticseducation.org/wp-content/uploads/2010/02/A-Bitter-Pill.jpg) A Bitter Pill - By John Sloan (http://www.amazon.ca/Bitter-Pill-John-Sloan/dp/1553654552) Dr James McCormack and Dr Michael Allan no 29:49 http://therapeuticseducation.org/2010/02/16/episode-75-starting-insulin-and-stopping-pain-or-is-it-stopping-insulin-and-starting-pain/ http://therapeuticseducation.org/2010/02/16/episode-75-starting-insulin-and-stopping-pain-or-is-it-stopping-insulin-and-starting-pain/#comments Tue, 16 Feb 2010 22:43:45 +0000 TEC http://therapeuticseducation.org/?p=1243 http://therapeuticseducation.org/2010/02/16/episode-75-starting-insulin-and-stopping-pain-or-is-it-stopping-insulin-and-starting-pain/feed/ 0 acetaminophen,diabetes,insulin,NSAIDs,pain,Tina Korownyk In episode 75, Mike and James get together with Tina one more time to talk about two topics that have nothing to do with each other (starting insulin in type II diabetics and treating acute musculoskeletal pain in children). However, In episode 75, Mike and James get together with Tina one more time to talk about two topics that have nothing to do with each other (starting insulin in type II diabetics and treating acute musculoskeletal pain in children). However, through the magic of podcasts we transition seamlessly from one topic to the other without any pain and without having to start insulin. Be amazed.  At the end, Mike and James are thrilled they got through yet another podcast, but it was painful and at the end we were both hypoglycemic. Show notes 1) Tools for Practice (http://www.topalbertadoctors.org/informed_practice/tools_for_practice.html)2) Using insulin in a type 2 diabetic - complicated versus less complicated regimens 4-T study N Engl J Med 2009;361:1736-47 (http://content.nejm.org/cgi/content/short/361/18/1736) APOLLO Lancet 2008;371:1073–84 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60485-7/abstract) INITIATE Diabetes Care 2005;28:260-5 (http://care.diabetesjournals.org/content/28/2/260.abstract) JDDM Diabetes Res Clin Pract 2008;79:171-6 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T5Y-4R00F93-1&_user=1022551&_coverDate=01%2F31%2F2008&_rdoc=30&_fmt=high&_orig=browse&_srch=doc-info(%23toc%235015%232008%23999209998%23677877%23FLA%23display%23Volume)&_cdi=5015&_sort=d&_docanchor=&_ct=39&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=c548ffca77e187a27c2e9d36e593514c) 3) Pain control for musculoskeletal injuries in children Single dose - ibuprofen vs acetaminophen vs codeine Pediatrics 2007;119:460-7 (http://pediatrics.aappublications.org/cgi/content/abstract/119/3/460) Ibuprofen vs acetaminophen plus codeine Acad Emerg Med 2009;16:711-16 (http://www3.interscience.wiley.com/journal/122512495/abstract) Ann Emerg Med 2009;54:553-60 (http://www.annemergmed.com/article/S0196-0644(09)00612-X/abstract) Dr James McCormack and Dr Michael Allan no 34:35 http://therapeuticseducation.org/2010/02/10/episode-74-vitamin-a-b-c-not-d-and-e-not-all-letters-are-created-equal/ http://therapeuticseducation.org/2010/02/10/episode-74-vitamin-a-b-c-not-d-and-e-not-all-letters-are-created-equal/#comments Wed, 10 Feb 2010 08:11:09 +0000 TEC http://therapeuticseducation.org/?p=1234 http://therapeuticseducation.org/2010/02/10/episode-74-vitamin-a-b-c-not-d-and-e-not-all-letters-are-created-equal/feed/ 0 CRP,homocysteine,Tina Korownyk,Vitamin B,Vitamin C,Vitamin E In episode 74, Mike (Bert) and James (Ernie), along with Tina (Betty Lou) continue their stroll down medical Sesame Street and take a look at the evidence behind Vitamins (Letters) A,B,C, and E. Lo and behold, In episode 74, Mike (Bert) and James (Ernie), along with Tina (Betty Lou) continue their stroll down medical Sesame Street and take a look at the evidence behind Vitamins (Letters) A,B,C, and E. Lo and behold, they find that not all letters are created equal and some are even quite bad. At the end, both Mike and James join the Cookie Monster for some Vitamin enriched (just D that is) treats and, they get Tina to pay. Show notes 1) Tools for Practice (http://www.topalbertadoctors.org/informed_practice/tools_for_practice.html) 2) Two systematic reviews shows increased mortality for beta-carotene, Vitamin A, Vitamin E, but not for selenium and Vitamin C JAMA 2007;297:842-57 (http://jama.ama-assn.org/cgi/content/abstract/297/8/842) Cochrane Database Syst Rev 2008;(2):CD007176 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD007176/frame.html) 3) BMI – not too fat and not too skinny Lancet 2006;368:666–78 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69251-9/abstract) J Am Geriatr Soc 2010;58:234–41 (http://www3.interscience.wiley.com/journal/123265340/abstract) 4) Vitamin B (folic acid) and homocysteine – 1 positive trial, 3 negative trials JAMA 2002; 288:973-9 (http://jama.ama-assn.org/cgi/content/full/288/8/973) N Engl J Med 2004;350:2673-81 (http://content.nejm.org/cgi/content/abstract/350/26/2673) JAMA 2004;291:565-75 (http://jama.ama-assn.org/cgi/content/full/291/5/565) J Am Coll Cardiol 2003;41:2105-13 (http://content.onlinejacc.org/cgi/content/abstract/41/12/2105) 4) Measuring hsCRP—An Important Part of a Comprehensive Risk Profile or a Clinically Redundant Practice? PLoS Med 2010;7:e1000196 (http://www.plosmedicine.org/article/fetchArticle.action?utm_medium=feed&utm_campaign=Feed%3A+plosmedicine%2FNewArticles+%28PLoS+Medicine%3A+New+Articles%29&utm_source=feedburner&articleURI=info%3Adoi%2F10.1371%2Fjournal.pmed.1000196) Dr James McCormack and Dr Michael Allan no 22:54 http://therapeuticseducation.org/2010/02/02/episode-73-vitamin-d-dose-diet-and-dermatologists-part-ii/ http://therapeuticseducation.org/2010/02/02/episode-73-vitamin-d-dose-diet-and-dermatologists-part-ii/#comments Tue, 02 Feb 2010 21:10:29 +0000 TEC http://therapeuticseducation.org/?p=1224 http://therapeuticseducation.org/2010/02/02/episode-73-vitamin-d-dose-diet-and-dermatologists-part-ii/feed/ 7 Tina Korownyk,vitamin D In episode 73, we try to put Vitamin D levels into context and Tina Korownyk once again is here to help us decipher the evidence for Vitamin D supplementation when it comes to fractures, falls and overall mortality. At the end of the podcast Mike, In episode 73, we try to put Vitamin D levels into context and Tina Korownyk once again is here to help us decipher the evidence for Vitamin D supplementation when it comes to fractures, falls and overall mortality. At the end of the podcast Mike, James and Tina don their swim gear and go outside without sunscreen on to make some Vitamin D, although Mike and Tina quickly realise they live in Edmonton and it's wintertime. Show notes 1) CRP paper by Mike and James PloS article - Measuring hsCRP—An Important Part of a Comprehensive Risk Profile or a Clinically Redundant Practice? (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000196) 2) Meta-analyses of Vitamin D and impact on fractures, falls and mortality Arch Intern Med 2009;169:551-6 (http://archinte.ama-assn.org/cgi/content/abstract/169/6/551) JAMA 2004;291:1999-2006 (http://jama.ama-assn.org/cgi/content/abstract/291/16/1999) Arch Intern Med 2007;167:1730-7 (http://archinte.ama-assn.org/cgi/content/abstract/167/16/1730) BMJ 2010;340:b5463 (http://www.bmj.com/cgi/content/abstract/340/jan12_1/b5463) 3) Toxicity of Vitamin D Am J Clin Nutr 2007;85:6-18 (http://www.ajcn.org/cgi/content/full/85/1/6) 4) Sun and Vitamin D3 J Clin Endo Metab 2009;94:1092–3 (http://jcem.endojournals.org/cgi/content/full/94/4/1092) Dr James McCormack and Dr Michael Allan no 32:26 http://therapeuticseducation.org/2010/01/27/episode-72-we%e2%80%99re-back-with-vitamin-d-vim-and-vigor/ http://therapeuticseducation.org/2010/01/27/episode-72-we%e2%80%99re-back-with-vitamin-d-vim-and-vigor/#comments Thu, 28 Jan 2010 05:58:14 +0000 TEC http://therapeuticseducation.org/?p=1214 http://therapeuticseducation.org/2010/01/27/episode-72-we%e2%80%99re-back-with-vitamin-d-vim-and-vigor/feed/ 4 Tina Korownyk,vitamin D In episode 72, we find out what Mike has really been doing for the last 3 months by testing his Vitamin D level and finding it to be abnormally high. This leads us, along with our always charming guest Dr. Tina Korownyk, In episode 72, we find out what Mike has really been doing for the last 3 months by testing his Vitamin D level and finding it to be abnormally high. This leads us, along with our always charming guest Dr. Tina Korownyk, to a discussion of the proper use of Vitamin D levels and what they really mean. At the end of the podcast James and Mike both agree to do podcasts more often than every three months. Show notes 1) Different reference Vitamin D levels BC  Biomedical Labs (http://www.bcbio.com/uploadedFiles/Physicians/Physician_Test_Information/Normal_Ranges/Laboratory%20Adult%20Reference%20Intervals.pdf) The Vitamin D Society (http://www.vitamindsociety.org/) 2) “the most-ordered hormone assay in the United States” J Clin Endocrinol Metab 2009;94:1092–3 (http://jcem.endojournals.org/cgi/content/full/94/4/1092) 3) Vitamin D levels Calgary CMAJ 2002;166(12):1517-24 (http://www.cmaj.ca/cgi/content/full/166/12/1541) (http://www.cmaj.ca/cgi/content/full/166/12/1541) Average levels Am J Clin Nutr 2008;88:558S-564s (http://www.ajcn.org/cgi/content/abstract/88/2/558S) 4) Multiple health outcomes and Vitamin D levels - nonvertebral fractures, hip fractures, periodontal disease, balance, colon cancer, falls Am J Clin Nutr 2006;84:18–28 (http://www.ajcn.org/cgi/content/abstract/84/1/18) BMJ 2009;339:b3692 (http://www.bmj.com/cgi/content/abstract/339/oct01_1/b3692) Arch Intern Med 2009;169:551-61 (http://archinte.ama-assn.org/cgi/content/abstract/169/6/551) JAMA 2005;293:2257-2264 (http://jama.ama-assn.org/cgi/content/abstract/293/18/2257 ) “whether an individual is found to have low or normal vitamin D status is a function of the laboratory used” J Clin Endocrin Metab 2004;89:3152-7 (http://jcem.endojournals.org/cgi/content/abstract/89/7/3152) 5) Variability Differences between the mean values of labs was 38% Ost Int 1999;9:394-7 (http://www.springerlink.com/content/1qp2hv1w6fqxu8ce/?p=bdb0480ce7454f7b81cddd76156daaa6&pi=1) Mean relative uncertainties between labs were 19.4%, 16.0%, and 11.3% Ost Int 2009 - 9 September 2009 –Online (http://www.springerlink.com/content/n40k4x267683q3h6/) Within patient variability - 15-20% Ost Int 1998 8:222–30 (http://www.springerlink.com/content/k10l9c27lj4la6cl/?p=524a00291cd74b74b24244f3205e9d3d&pi=4) Dr James McCormack and Dr Michael Allan no 23:48 http://therapeuticseducation.org/2009/12/18/an-update-some-gingerbread-drug-levels-and-more-wineing-please/ http://therapeuticseducation.org/2009/12/18/an-update-some-gingerbread-drug-levels-and-more-wineing-please/#comments Fri, 18 Dec 2009 07:24:55 +0000 TEC http://therapeuticseducation.org/?p=1121 http://therapeuticseducation.org/2009/12/18/an-update-some-gingerbread-drug-levels-and-more-wineing-please/feed/ 3 alcohol,aminoglycosides,drug levels,pharmacokinetics,phenytoin,theophylline In this pseudopodcast, James let's you know what is likely going to be happening with the podcasts and Bob and James, with limited success, make pharmacokinetics and drug levels interesting. - Show Notes 1) Aminoglycoside levels and the lack of evidenc... In this pseudopodcast, James let's you know what is likely going to be happening with the podcasts and Bob and James, with limited success, make pharmacokinetics and drug levels interesting. Show Notes 1) Aminoglycoside levels and the lack of evidence Clin Inf Dis 1992;14:320-9 (http://www.ncbi.nlm.nih.gov/pubmed?term=%22Clinical+infectious+diseases+%3A+an+official+publication+of+the+Infectious+Diseases+Society+of+America%22%5BJour%5D+AND+14%5Bvolume%5D+AND+320%5Bpage%5D+AND+1992%5Bpdat%5D) (http://www.ncbi.nlm.nih.gov/pubmed?term=%22Clinical+infectious+diseases+%3A+an+official+publication+of+the+Infectious+Diseases+Society+of+America%22%5BJour%5D+AND+14%5Bvolume%5D+AND+320%5Bpage%5D+AND+1992%5Bpdat%5D)Pharmacotherapy 2000;20:1524-7 (http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.20.19.1524.34864) 2) Alcohol and PK J Phar Exp Ther 1971 178:567-79 (http://jpet.aspetjournals.org/content/178/3/567.abstract) Br J Clin Pharmacol 1981;12:667-73 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1401959/?tool=pubmed) 3) A link to a talk James gave in November 2009 LDL, HDL, A1C, SBP, CRP, BMI, BMD and Other Four Letter Words: Let’s Put the “Value” Back into Guidelines (http://therapeuticseducation.org/wp-content/uploads/2009/05/Facseminar.mp4) Dr James McCormack and Dr Michael Allan no 44:26 http://therapeuticseducation.org/2009/10/21/episode-71-pbs-psa-and-you-a-plea-a-pledge-and-a-prostate/ http://therapeuticseducation.org/2009/10/21/episode-71-pbs-psa-and-you-a-plea-a-pledge-and-a-prostate/#comments Wed, 21 Oct 2009 20:00:11 +0000 TEC http://therapeuticseducation.org/?p=1103 http://therapeuticseducation.org/2009/10/21/episode-71-pbs-psa-and-you-a-plea-a-pledge-and-a-prostate/feed/ 7 Mike Kolber,pledge,psa In episode 71, James starts off with a plea for a pledge and then the “Two Mikes” discuss the whole issue of what to do with the new evidence around PSA screening. We find out that if you believed in it before you'll likely continue believing and if yo... In episode 71, James starts off with a plea for a pledge and then the “Two Mikes” discuss the whole issue of what to do with the new evidence around PSA screening. We find out that if you believed in it before you'll likely continue believing and if you didn't believe in it you will still think that way - isn't evidence wonderful? At the end James hopes you will continue to believe the podcast should continue. Show Notes 1) Drop James an email at jmccorma@interchange.ubc.ca 2) The two latest studies on PSA screening NEJM 2009;360:1310-19 (http://content.nejm.org/cgi/content/abstract/360/13/1310) NEJM 2009;360:1320-8 (http://content.nejm.org/cgi/content/abstract/360/13/1320) 3) A useful PSA screening document ICES 2002 – PSA physician reference document (http://www.ices.on.ca/file/Prostate-specific%20Antigen%20(PSA)%20screening%20in%20asymptomatic%20men.pdf) - a pdf Dr James McCormack and Dr Michael Allan no 19:51 http://therapeuticseducation.org/2009/10/14/episode-70-more-studies-you-need-to-know-about-part-ii/ http://therapeuticseducation.org/2009/10/14/episode-70-more-studies-you-need-to-know-about-part-ii/#comments Wed, 14 Oct 2009 20:08:58 +0000 TEC http://therapeuticseducation.org/?p=1090 http://therapeuticseducation.org/2009/10/14/episode-70-more-studies-you-need-to-know-about-part-ii/feed/ 2 asthma,inhaled corticosteroids,LABA,long acting beta agonists,Mike Kolber,prednisone In episode 70, we continue with the “Two Mikes” and discuss a number of issues surrounding asthma treatment. We debate back and forth on the use of LABAs and their use alone or in combination and then come to complete agreement on the duration of predn... In episode 70, we continue with the “Two Mikes” and discuss a number of issues surrounding asthma treatment. We debate back and forth on the use of LABAs and their use alone or in combination and then come to complete agreement on the duration of prednisone for acute exacerbations. During the podcast James tries to steal the mic away and gets into trouble with Mike because Mike thought James was trying to steal Mike away from Mike. Show Notes 1) LABAs in patients with asthma – risks and benefits Cochrane 2008;4:CD006923 (http://www.cochrane.org/reviews/en/ab006923.html) Cochrane 2008;3:CD006363 (http://www.cochrane.org/reviews/en/ab006363.html) Cochrane 2009;2:CD006924 (http://www.cochrane.org/reviews/en/ab006924.html) Cochrane 2009;3:CD006922 (http://www.cochrane.org/reviews/en/ab006922.html) NEJM 2009;360:1592-95 (http://content.nejm.org/cgi/content/extract/360/16/1592) 2) Short course (3 days) of oral steroids for asthma exacerbations Medical Journal of Australia 2008;189:306–10 (http://www.mja.com.au/public/issues/189_06_150908/cha10113_fm.html) 3) Doubling the dose of inhaled corticosteroids provides no benefit but what about quadrupling the dose? Lancet 2004;363:271-5 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)15384-6/abstract) Thorax 2004;59:550–6 (http://thorax.bmj.com/cgi/content/abstract/59/7/550) Am J Respir Crit Care Med 2009;180:598-602 (http://ajrccm.atsjournals.org/cgi/content/abstract/180/7/598) Dr James McCormack and Dr Michael Allan no 30:15 http://therapeuticseducation.org/2009/10/07/episode-69-more-studies-you-need-to-know-about/ http://therapeuticseducation.org/2009/10/07/episode-69-more-studies-you-need-to-know-about/#comments Wed, 07 Oct 2009 20:46:21 +0000 TEC http://therapeuticseducation.org/?p=1081 http://therapeuticseducation.org/2009/10/07/episode-69-more-studies-you-need-to-know-about/feed/ 1 asthma,GERD,meniscal tears,Mike Kolber,osteoarthritis,PPIs,proton pump inhibitor In episode 69, the “Two Mikes” are back at it and they use their mics to dispense some really great prescriptive advice for patients with asthma and no heart burn pain and backs and knees which do have pain. In episode 69, the “Two Mikes” are back at it and they use their mics to dispense some really great prescriptive advice for patients with asthma and no heart burn pain and backs and knees which do have pain. James sits back and goes along for the ride but develops back and knee pain by the end, and the Mikes recommend a full body CT scan. Show Notes 1) In patients with uncontrolled asthma and no GERD, the use of a PPI does not improve asthma symptoms N Engl J Med 2009;360:1487-99 (http://content.nejm.org/cgi/content/abstract/360/15/1487) 2) The use of PPIs and other GERD treatment in patients with asthma and acid-reflux symptoms shows no benefit in asthma symptoms Chest 2005;128:1128–35 (http://chestjournal.chestpubs.org/content/128/3/1128.abstract) Cochrane Review 2003, No.: CD001496 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001496/abstract.html) 2) Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes Lancet 2009;373:463–72 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60172-0/abstract) 3) Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age N Engl J Med 2008;359:1108-15 (http://content.nejm.org/cgi/content/abstract/359/11/1108) 4) Arthroscopic surgery for osteoarthritis of the knee – no benefit N Engl J Med 2002;347:81-8 (http://content.nejm.org/cgi/content/abstract/347/2/81) Dr James McCormack and Dr Michael Allan no 32:37 http://therapeuticseducation.org/2009/09/30/episode-68-the-heart-of-the-matter-for-stroke-prevention-in-atrial-fibrillation/ http://therapeuticseducation.org/2009/09/30/episode-68-the-heart-of-the-matter-for-stroke-prevention-in-atrial-fibrillation/#comments Wed, 30 Sep 2009 18:22:29 +0000 TEC http://therapeuticseducation.org/?p=1055 http://therapeuticseducation.org/2009/09/30/episode-68-the-heart-of-the-matter-for-stroke-prevention-in-atrial-fibrillation/feed/ 0 afib,asa,aspirin,atrial fibrillation,CHADS2,clopidogrel,dabigatran,Peter Loewen,vitamin k,warfarin In episode 68, we get to the “heart of the matter” of stroke prevention for atrial fibrillation. We find out from Peter Loewen, that it is all a numbers game, and he gives us the tools to deal with this issue. In episode 68, we get to the “heart of the matter” of stroke prevention for atrial fibrillation. We find out from Peter Loewen, that it is all a numbers game, and he gives us the tools to deal with this issue. We talk about warfarin and ASA and clopidogrel with respect to their benefits and harms. At the end of the podcast Peter tells us about dabigatran, which obviates all the messages we provide in this podcast. Mike develops an intracranial bleed during the podcast, Peter and James act concerned but continue on because that is what Mike would have wanted. Show Notes 1) Estimating the risk of strokes in a patient with atrial fibrillation CHADS2 score JAMA 2001;285:2864-70 (http://jama.ama-assn.org/cgi/content/abstract/285/22/2864) A useful electronic resource from peterloewen.com Web-based calculator (http://www.vhpharmsci.com/sparc/) 2) Warfarin versus ASA in atrial fibrillation patients > 75 yrs old Lancet 2007;370:493–503 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(07)61233-1/abstract) 3) Clopidogrel and atrial fibrillation ACTIVE W Clopidogrel plus ASA versus warfarin (in patients suitable for warfarin) Lancet 2006;367:1903-12 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68845-4/abstract) ACTIVE A ASA plus clopidogrel vs ASA (in patients not suitable for warfarin) NEJM 2009;360:2066-78 (http://content.nejm.org/cgi/content/abstract/360/20/2066) 4) Vitamin K supplementation for labile INRs Blood 2007;109:2419-23 (http://bloodjournal.hematologylibrary.org/cgi/content/abstract/109/6/2419) 5) Brief stops in warfarin – what do you do? Cohort studies (no RCT yet, will get when BRIDGE finished) Arch Intern Med 2008;168:63-9 (http://archinte.ama-assn.org/cgi/content/full/168/1/63) Mayo Clin Proc 2008;83:639-45 (http://www.mayoclinicproceedings.com/content/83/6/639.abstract) 6) Dabigatran versus warfarin for stroke prevention in atrial fibrillation RE-LY N Engl J Med 2009;361:1139-51 (http://content.nejm.org/cgi/content/abstract/361/12/1139) Dr James McCormack and Dr Michael Allan no 41:13 http://therapeuticseducation.org/2009/09/23/episode-67-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-stroke-prevention-with-antiplatelets/ http://therapeuticseducation.org/2009/09/23/episode-67-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-stroke-prevention-with-antiplatelets/#comments Thu, 24 Sep 2009 00:04:55 +0000 TEC http://therapeuticseducation.org/?p=1043 http://therapeuticseducation.org/2009/09/23/episode-67-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-stroke-prevention-with-antiplatelets/feed/ 2 asa,clop,clopidogrel,dipyridamole,H pylori,proton pump inhibitor,warfarin In episode 67, we address ischemic stroke of arterial origin and go over some core therapies (ASA, dipyridamole, clopidogrel and warfarin).  We also discuss complications of anti-thrombotics and the options for patients with a GI bleed on ASA. In episode 67, we address ischemic stroke of arterial origin and go over some core therapies (ASA, dipyridamole, clopidogrel and warfarin).  We also discuss complications of anti-thrombotics and the options for patients with a GI bleed on ASA.  Although Peter attempts to guide us through the maze of evidence, all three of us get lost and have trouble finding our way back. Mike rightly corrects James about one of his comments and James responds in a purely professional manner. Show Notes 1) ASA post-stroke – low dose ATTC 2009 Lancet 2009;373:1849–60 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract) 2) Clopidogrel versus ASA CAPRIE Lancet 1996;348:1329–39 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)09457-3/abstract) 3) ASA and clopidogrel versus clopidogrel CHARISMA NEJM 2006;354:1706-17 (http://content.nejm.org/cgi/content/abstract/354/16/1706) MATCH Lancet 2004;364:331–37 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)16721-4/abstract) 4) ASA versus warfarin post-stroke WARSS NEJM 2001;345:1444-51 (http://content.nejm.org/cgi/content/abstract/345/20/1444) 5) Dipyridamole plus ASA ESPS-2 Thromb Res 1998;92:S1-S6 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T1C-3VWNBJ7-1G&_user=1022551&_coverDate=09%2F15%2F1998&_rdoc=1&_fmt=high&_orig=browse&_srch=doc-info(%23toc%234887%231998%23999079998.8998%2368826%23FLA%23display%23Volume)&_cdi=4887&_sort=d&_docanchor=&_ct=4&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=1fef698417c3ae10f5de65b76bea28d7) ESPRIT Lancet 2006;367:1665-75 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)68734-5/abstract) peterloewen.com (http://www.peterloewen.com/PeterLoewen.com/Wrote_files/Stroke%20Prevention%20Algorithm%205.61-Loewen.pdf) PRoFESS NEJM 2008;359:1238-51 (http://content.nejm.org/cgi/content/abstract/359/12/1238) 7) GI bleeding and ASA PPI added to ASA versus clopidogrel alone NEJM 2005; 352:238-44 (http://content.nejm.org/cgi/content/abstract/352/3/238) H. pylori eradication versus proton pump inhibitor NEJM 2001;344:967-73 (http://content.nejm.org/cgi/content/abstract/344/13/967) H. pylori eradication plus proton pump inhibitor versus H. pylori eradication alone NEJM 2002;346:2033-8 (http://content.nejm.org/cgi/content/abstract/346/26/2033) Clopidogrel plus a PPI – interaction or not CMAJ 2009;180:713-8 (http://www.cmaj.ca/cgi/content/abstract/180/7/713) Dr James McCormack and Dr Michael Allan no 37:25 http://therapeuticseducation.org/2009/09/16/episode-66-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-prevention-with-antiplatelets/ http://therapeuticseducation.org/2009/09/16/episode-66-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-prevention-with-antiplatelets/#comments Wed, 16 Sep 2009 20:00:33 +0000 TEC http://therapeuticseducation.org/?p=1033 http://therapeuticseducation.org/2009/09/16/episode-66-a-clot-a-clot-i-want-it-not-%e2%80%93-secondary-prevention-with-antiplatelets/feed/ 2 asa,aspirin,CHARISMA,clopidogrel,CURE,secondary prevention In episode 66, we embark on a journey of epic proportions; at least relative to our understanding.  With the help of Peter Loewen, we outline the anti-platelet options in secondary prevention of heart disease. In episode 66, we embark on a journey of epic proportions; at least relative to our understanding.  With the help of Peter Loewen, we outline the anti-platelet options in secondary prevention of heart disease.  We discuss at length the use ASA and clopidogrel but also touch on additional agents like warfarin, dipyridamole and others.  Where the evidence is clear, we create opacity and where it is gray, we go dark. Both Mike and Peter end up in a quagmire and James offers them help by throwing them a string of one-liners and a bottle of low-dose ASA. Show Notes Secondary prevention with antiplatelets 1) ATTC Meta-analysis – aspirin in primary and secondary resistance Lancet 2009;373:1849–60 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract) 2) CURE trial – clopidogrel added to aspirin NEJM 2001;345:494-502 (http://content.nejm.org/cgi/content/abstract/345/7/494) 3) Anti-platelets in patients with a history of vascular disease or other predisposing condition - absolute benefit - 3.6% over 2 years (combined CVD events) BMJ 2002;324:71-86 (http://www.bmj.com/cgi/content/abstract/324/7329/71) 4) Low-dose aspirin - absolute benefit - around 3.3% combined CVD events and 1.5% mortality over 3 yrs Am J Med 2008;121:43-9 (http://www.amjmed.com/article/S0002-9343(07)00985-0/abstract) 5) CHARISMA - Clopidogrel and aspirin vs aspirin N Engl J Med 2006; 354:1706-17 (http://content.nejm.org/cgi/content/abstract/354/16/1706) 6) Half of the benefit of clopidogrel occurs in the first month of use Clopidogrel for the treatment of adult patients following acute coronary syndrome Therapeutics Initiative Review (http://www.ti.ubc.ca/node/446) Dr James McCormack and Dr Michael Allan no 29:57 http://therapeuticseducation.org/2009/09/09/episode-65-a-clot-a-clot-i-want-it-not-primary-prevention-with-antiplatelets/ http://therapeuticseducation.org/2009/09/09/episode-65-a-clot-a-clot-i-want-it-not-primary-prevention-with-antiplatelets/#comments Wed, 09 Sep 2009 20:10:19 +0000 TEC http://therapeuticseducation.org/?p=1017 http://therapeuticseducation.org/2009/09/09/episode-65-a-clot-a-clot-i-want-it-not-primary-prevention-with-antiplatelets/feed/ 2 asa,aspirin,CAPRIE,CHARISMA,clopidogrel,diabetes,JPAD,Peter Loewen,POPADAD,PPP,primary prevention In episode 65, we start back at it with a discussion of using antiplatelets to decrease the chance of MIs and strokes. In this podcast, we cover the whole primary prevention aspect of these agents and we bring in our good friend and colleague Peter Loe... In episode 65, we start back at it with a discussion of using antiplatelets to decrease the chance of MIs and strokes. In this podcast, we cover the whole primary prevention aspect of these agents and we bring in our good friend and colleague Peter Loewen to help us with the numbers. Mike claims he, as a family doctor, is usually able to make a diagnosis of gender in his patients but refuses to do so in James' case. Show Notes 1) Primary Prevention with ASA (women and men) JAMA 2006;295:306-13 (http://jama.ama-assn.org/cgi/content/abstract/295/3/306) ATTC 2009 Lancet 2009;373:1849–60 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60503-1/abstract) 2) ASA in Type II diabetics (primary prevention) POPADAD study BMJ 2008;337:a1840 (http://www.bmj.com/cgi/content/abstract/337/oct16_2/a1840) JPAD study JAMA 2008;300:2134-41 (http://jama.ama-assn.org/cgi/content/abstract/300/18/2134) PPP study Diabetes Care 2003;26:3264-72 (http://care.diabetesjournals.org/content/26/12/3264.abstract) Canadian Diabetes Guideline (specifically, ASA) Can J Diabet 2008;32:S102-06 (http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf) 3) Adding Clopidogrel to ASA in primary Prevention CHARISMA Study (primary prevention sub-group) NEJM 2006;354:1706-17 (http://content.nejm.org/cgi/content/abstract/354/16/1706) 4) Peripheral vascular disease Clopidogrel CAPRIE Lancet 1996;348:1329-39 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)09457-3/abstract) 5) Peter Loewen peterloewen.com Pharmacotherapy for ischemic stroke prevention (http://www.peterloewen.com/PeterLoewen.com/Wrote_files/Stroke%20Prevention%20Algorithm%205.61-Loewen.pdf) Dr James McCormack and Dr Michael Allan no 29:40 http://therapeuticseducation.org/2009/08/26/a-two-week-break-but-dont-despair/ http://therapeuticseducation.org/2009/08/26/a-two-week-break-but-dont-despair/#comments Wed, 26 Aug 2009 16:29:53 +0000 TEC http://therapeuticseducation.org/?p=963 http://therapeuticseducation.org/2009/08/26/a-two-week-break-but-dont-despair/feed/ 0 The No-show Notes - Listen to the panel discussion from last year's 20th Annual Drug Therapy Course You can listen to it directly or download the mp3 file and listen to it at your leisure. - Learn more about the Annual Drug Therapy Course Next year's A... The No-show Notes Listen to the panel discussion from last year's 20th Annual Drug Therapy Course (http://therapeuticseducation.org/wp-content/uploads/2009/08/DTC09-discussion.mp3)You can listen to it directly or download the mp3 file and listen to it at your leisure. Learn more about the Annual Drug Therapy Course (http://therapeuticseducation.org/annual-drug-therapy-course/) Next year's Annual Drug Therapy Course is in Vancouver on April 9/10, 2010 - we would love to have you attend. Dr James McCormack and Dr Michael Allan no 1:50 http://therapeuticseducation.org/2009/08/19/episode-64-more-listener-questions-with-answers-leaving-more-questions-part-ii/ http://therapeuticseducation.org/2009/08/19/episode-64-more-listener-questions-with-answers-leaving-more-questions-part-ii/#comments Wed, 19 Aug 2009 17:03:16 +0000 TEC http://therapeuticseducation.org/?p=975 http://therapeuticseducation.org/2009/08/19/episode-64-more-listener-questions-with-answers-leaving-more-questions-part-ii/feed/ 5 atenolol,felodipine,high blood pressure,UKPDS In episode 64, we finish off the listener questions and comments and clarify the murkiness, or murkify the clariness, around a number of cardiovascular issues. By the end of the podcast, both Mike and James are heavier because they eat up all the "swee... In episode 64, we finish off the listener questions and comments and clarify the murkiness, or murkify the clariness, around a number of cardiovascular issues. By the end of the podcast, both Mike and James are heavier because they eat up all the "sweet" comments made by their listeners. Show Notes 1) BMJ hypertension meta-analysis BMJ 2009;338:b1665 (http://www.bmj.com/cgi/content/abstract/338/may19_1/b1665) 2) Atenolol lowers blood pressure but no effect on cardiovascular outcomes Lancet 2004;364:1684–9 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17355-8/abstract) 3) First-line drugs for hypertension Cochrane Review (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001841/frame.html) 4) UKPDS spin (http://www.bmj.com/cgi/content/extract/320/7251/1720) BMJ 2000;320:1720-3 (http://www.bmj.com/cgi/content/extract/320/7251/1720) 5) Effect of intensive control of glucose on cardiovascular outcomes - meta-analysis Lancet 2009;373:1765–72 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60697-8/abstract) 6) Felodipine and cardiovascular outcomes (http://journals.lww.com/jhypertension/toc/2005/12000) J Hypertens 2005;23:2157-72 (http://journals.lww.com/jhypertension/toc/2005/12000) Dr James McCormack and Dr Michael Allan no 37:31 http://therapeuticseducation.org/2009/08/12/episode-63-more-listener-questions-with-answers-leaving-more-questions/ http://therapeuticseducation.org/2009/08/12/episode-63-more-listener-questions-with-answers-leaving-more-questions/#comments Wed, 12 Aug 2009 20:04:01 +0000 TEC http://therapeuticseducation.org/?p=972 http://therapeuticseducation.org/2009/08/12/episode-63-more-listener-questions-with-answers-leaving-more-questions/feed/ 2 BMI,obesity,orlistat,weight loss In episode 63, we again let the listeners take control as we try to deal with the excellent questions and comments that come our way. We get into a heavy discussion around issues of weight and weight loss. Mike asks James a number of questions that mak... In episode 63, we again let the listeners take control as we try to deal with the excellent questions and comments that come our way. We get into a heavy discussion around issues of weight and weight loss. Mike asks James a number of questions that make him squirm and James thanks him because fidgeting is a great way to burn calories. Show Notes 1) InfoPOEMS Essential Evidence Plus (http://www.essentialevidenceplus.com/product/features_dailyip.cfm) 2) Association between authors' published positions and their financial relationships with manufacturers NEJM 1998; 338: 101-6 (http://content.nejm.org/cgi/content/abstract/338/2/101) 3) J or U shape curve for BMI and mortality Lancet 2009;373:1083-96 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60318-4/abstract) 4) Orlistat  - the setting effects the results Effect in primary care study J Int Med 2000; 248: 245-54 (http://www3.interscience.wiley.com/journal/119187863/abstract) Effect in tertiary care study JAMA 1999;281:235-42 (http://jama.ama-assn.org/cgi/content/abstract/281/3/235) 5) Comparison of weight loss diets N Engl J Med 2009;360:859-873 (http://content.nejm.org/cgi/content/abstract/360/9/859) 6) Fidgeting burns calories Science 2005;307:584-6 (http://www.sciencemag.org/cgi/content/abstract/307/5709/584) Dr James McCormack and Dr Michael Allan no 32:39 http://therapeuticseducation.org/2009/08/05/episode-62-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-the-end/ http://therapeuticseducation.org/2009/08/05/episode-62-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-the-end/#comments Wed, 05 Aug 2009 20:00:36 +0000 TEC http://therapeuticseducation.org/?p=913 http://therapeuticseducation.org/2009/08/05/episode-62-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-the-end/feed/ 11 asa,diabetes,fibrates,statins In episode 62, the eighth and final podcast in our tome on the treatment of type-2 diabetes, we talk about cholesterol and ASA. Statins have evidence of benefit, around 3-4% absolute risk reductions over 5 years, In episode 62, the eighth and final podcast in our tome on the treatment of type-2 diabetes, we talk about cholesterol and ASA. Statins have evidence of benefit, around 3-4% absolute risk reductions over 5 years, other drugs for cholesterol have little if any evidence of benefit, and there is evidence of no benefit from taking ASA. We come up with an overall synopsis; increase activity, eat good food, use metformin, then maybe sulfonylureas, thiazides/ACE inhibitors for BP, statins but don’t measure cholesterol, and no ASA. Both James and Mike collapse from exhaustion and leave the final word to Chris their producer. Show Notes 1) Statin meta-analyses Lancet 2008;371:117-25 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60104-X/abstract) Table of data (http://therapeuticseducation.org/wp-content/uploads/2009/05/statin-meta-analysis.jpg) Another table of data (http://therapeuticseducation.org/wp-content/uploads/2009/05/5-yr-statin-synopsis.jpg) 2) Fibric acid derivatives FIELD Lancet 2005;366:1849-61 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67667-2/abstract) Fibrate meta-analysis Arch Intern Med 2005;165:725-30 (http://archinte.ama-assn.org/cgi/content/abstract/165/7/725) 3) ASA – no benefit in diabetics JAMA 2008;300:2134-41 (http://jama.ama-assn.org/cgi/content/abstract/300/18/2134) BMJ 2008;337:a1840 (http://www.bmj.com/cgi/content/abstract/337/oct16_2/a1840) Diabetes Care 2003;26:3264-72 (http://care.diabetesjournals.org/content/26/12/3264.abstract) Dr James McCormack and Dr Michael Allan no 27:15 http://therapeuticseducation.org/2009/07/29/episode-61-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vii/ http://therapeuticseducation.org/2009/07/29/episode-61-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vii/#comments Wed, 29 Jul 2009 20:00:33 +0000 TEC http://therapeuticseducation.org/?p=912 http://therapeuticseducation.org/2009/07/29/episode-61-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vii/feed/ 2 ACEI,ALLHAT,ARB,diabetes,HOT,MICROHOPE,STENO,UKPDS In the 61st episode, the seventh podcast in our thesis on type-2 diabetes, we get off the topic of glucose and talk about STENO and blood pressure treatments. We decide the bottom line is control of blood pressure with low doses of thiazides and ACE in... In the 61st episode, the seventh podcast in our thesis on type-2 diabetes, we get off the topic of glucose and talk about STENO and blood pressure treatments. We decide the bottom line is control of blood pressure with low doses of thiazides and ACE inhibitors with no tolerance for side effects. Mike’s blood pressure goes up with some of James’ suggestions but high doses of reserpine, methyldopa and clonidine calm him down. Show Notes 1) STENO N Engl J Med 2008;358:580-91 (http://content.nejm.org/cgi/content/abstract/358/6/580) 2) Blood pressure trials UKPDS 38 BMJ 1998;317:703-13 (http://www.bmj.com/cgi/content/abstract/317/7160/703) HOT Trial Lancet 1998;351:1755-62 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)04311-6/abstract) Do ACEI/ARBs uniquely protect the kidney – No? Lancet 2005;366:2026-33 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67814-2/abstract) ALLHAT JAMA 2002;288:2981-97 (http://jama.ama-assn.org/cgi/content/abstract/288/23/2981) Low doses of ACEI – most of the BP effect is from low doses Cochrane Library (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003823/frame.html) MICROHOPE Lancet 2000;355:253-59 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(99)12323-7/abstract) Dr James McCormack and Dr Michael Allan no 31:43 http://therapeuticseducation.org/2009/07/22/episode-60-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vi/ http://therapeuticseducation.org/2009/07/22/episode-60-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vi/#comments Wed, 22 Jul 2009 20:00:19 +0000 TEC http://therapeuticseducation.org/?p=911 http://therapeuticseducation.org/2009/07/22/episode-60-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-vi/feed/ 11 acarbose,diabetes,fluoxetine,glitazones,HbA1c,insulin,UKPDS,weight loss In episode 60, the sixth podcast in our saga on type-2 diabetes, we talk about what to do when metformin is not enough and get to the evidence surrounding other blood glucose lowering treatments. We fumble around in a pretty much evidence-free zone. In episode 60, the sixth podcast in our saga on type-2 diabetes, we talk about what to do when metformin is not enough and get to the evidence surrounding other blood glucose lowering treatments. We fumble around in a pretty much evidence-free zone. James develops a bad case of hypoglycemia during the podcast because he hasn’t eaten since the start of the diabetes section of these podcasts; Mike comes to his aid by prescribing a low dose of a chocolate bar and eats the rest of it himself. Show Notes 1) UKPDS (recent results) NEJM 2008;359:1577-89 (http://content.nejm.org/cgi/content/abstract/359/15/1565) Table of results (http://therapeuticseducation.org/wp-content/uploads/2009/05/ukpds-10-yr-follow-up.jpg) 2) Fluoxetine, orlistat, sibutramine for weight loss in type-2 diabetics Arch Intern Med 2004;164:1395–404 (http://archinte.ama-assn.org/cgi/content/abstract/164/13/1395) 3) Acarbose for impaired glucose tolerance JAMA 2003;290:486-94 (http://jama.ama-assn.org/cgi/content/abstract/290/4/486) 4) Glitazones meta-analyses JAMA 2007;298:1180-8 (http://jama.ama-assn.org/cgi/content/abstract/298/10/1180) JAMA 2007;298:1189-95 (http://jama.ama-assn.org/cgi/content/abstract/298/10/1189) Table of results (http://therapeuticseducation.org/wp-content/uploads/2009/05/glitazone.jpg) 5) Risks of an elevated A1c Link to table (http://therapeuticseducation.org/wp-content/uploads/2009/05/ukpds-risk.jpg) 6) Long acting insulin analogues – no advantage CMAJ 2009;180:385-97 (http://www.cmaj.ca/cgi/content/abstract/180/4/385) Dr James McCormack and Dr Michael Allan no 26:31 http://therapeuticseducation.org/2009/07/15/902/ http://therapeuticseducation.org/2009/07/15/902/#comments Wed, 15 Jul 2009 20:00:22 +0000 TEC http://therapeuticseducation.org/2009/07/15/902/ http://therapeuticseducation.org/2009/07/15/902/feed/ 0 diabetes,metformin,UKPDS In episode 59, the fifth podcast in our diatribe on type-2 diabetes, we finally get to the evidence surrounding specific treatments. The importance of lifestyle is discussed and then the rest of the time is spent talking about the who, what, why, where, In episode 59, the fifth podcast in our diatribe on type-2 diabetes, we finally get to the evidence surrounding specific treatments. The importance of lifestyle is discussed and then the rest of the time is spent talking about the who, what, why, where, and when’s of metformin. James asks lots of rhetorical questions and Mike tries to answer them in a grandiloquent way. Show Notes 1) UKPDS (original trial) Lancet 1998;352:854-65 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(98)07037-8/abstract) 2) UKPDS (recent results) NEJM 2008;359:1577-89 (http://content.nejm.org/cgi/content/abstract/359/15/1565) 3) Metformin’s contraindications should be contraindicated CMAJ 2005;173:502-4 (http://www.cmaj.ca/cgi/content/full/173/5/502) Dr James McCormack and Dr Michael Allan no 28:54 http://therapeuticseducation.org/2009/07/08/episode-58-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-iv/ http://therapeuticseducation.org/2009/07/08/episode-58-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-iv/#comments Wed, 08 Jul 2009 20:00:30 +0000 TEC http://therapeuticseducation.org/?p=850 http://therapeuticseducation.org/2009/07/08/episode-58-type-2-diabetes-%e2%80%93-how-sweet-it-isn%e2%80%99t-%e2%80%93-part-iv/feed/ 6 ACCORD,ADVANCE,diabetes,HbA1c,Jillian Popel,UKPDS,VADT In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) - podcasts #9 and #38 did this in more detail. In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) - podcasts #9 (http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/) and #38 (http://therapeuticseducation.org/2009/01/28/episode-38-new-trials-you-need-to-know-about/) did this in more detail. At the end of the podcast, Mike identifies many of James’ flaws, but does it with compassion and kindness; at least he says he does. Show Notes 1) Does tight glycemic control burden patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return? Ann Int Med 2009;150:803-8 (http://www.annals.org/cgi/content/abstract/150/11/803) 2) ACCORD and ADVANCE studies Click here for a synopsis of the results (http://therapeuticseducation.org/?attachment_id=450) N Engl J Med 2008 358:2545-2559 (http://content.nejm.org/cgi/content/abstract/358/24/2545) N Engl J Med 2008 358:2560-2572 (http://content.nejm.org/cgi/content/abstract/358/24/2560) Also listen to Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet (http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/) 3) VADT trial N Engl J Med 2009;360:129-39 (http://content.nejm.org/cgi/content/abstract/360/2/129) Also listen to Episode 38: New trials you need to know about (http://therapeuticseducation.org/2009/01/28/episode-38-new-trials-you-need-to-know-about/) 4) Glucose lowering meta-analysis – do the results support the conclusions? Lancet 2009; 373:1765-72 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60697-8/abstract) 5) UKPDS data BMJ 2000;320:1720-3 (http://www.bmj.com/cgi/content/full/320/7251/1720) 6)UKPDS – 10 year update (recent results) Click here for a synopsis of the results (http://therapeuticseducation.org/?attachment_id=462) (http://therapeuticseducation.org/?attachment_id=462)NEJM 2008;359:1577-89 (http://content.nejm.org/cgi/content/abstract/359/15/1577) Dr James McCormack and Dr Michael Allan no 22:47 http://therapeuticseducation.org/2009/07/01/823/ http://therapeuticseducation.org/2009/07/01/823/#comments Wed, 01 Jul 2009 20:00:36 +0000 TEC http://therapeuticseducation.org/2009/07/01/823/ http://therapeuticseducation.org/2009/07/01/823/feed/ 0 diabetes,DiGEM,ESMON,glucose monitoring,HbA1c,Jillian Popel In episode 57, we continue yet again with the topic of type 2 diabetes. In this podcast, we talk about monitoring HbA1C, self-monitoring of blood glucose and, diabetes education in general. We hear Jillian Popel suggest not only is self-monitoring of g... In episode 57, we continue yet again with the topic of type 2 diabetes. In this podcast, we talk about monitoring HbA1C, self-monitoring of blood glucose and, diabetes education in general. We hear Jillian Popel suggest not only is self-monitoring of glucose not really useful when it comes to overall glucose control, it in fact might be harmful. We also discuss what we think diabetes education should really focus upon. Finally, after 56 episodes, Mike and James actually agree on an issue, but it was just that all complaints about any of the content in the podcasts should be sent directly to Jillian. Show Notes 1) Self-monitoring of blood glucose ESMON BMJ 2008;336:1174-7 (http://www.bmj.com/cgi/content/abstract/336/7654/1174) DiGEM BMJ 2008;336:1177-80 (http://www.bmj.com/cgi/content/abstract/336/7654/1177) 2) Calculating cardiovascular risk for type 2 diabetics UKPDS risk engine (http://www.dtu.ox.ac.uk/index.php?maindoc=/riskengine) 3) Diabetes education – Cochrane reviews http://www.cochrane.org/reviews/en/ab005268.html">Individual patient education for people with type 2 diabetes mellitus (http://www.cochrane.org/reviews/en/ab005268.html) Group based training for self-management strategies in people with type 2 diabetes mellitus (http://www.cochrane.org/reviews/en/ab003417.html) Dr James McCormack and Dr Michael Allan no 28:02 http://therapeuticseducation.org/2009/06/24/episode-56-type-2-diabetes-how-sweet-it-isn%e2%80%99t-part-ii/ http://therapeuticseducation.org/2009/06/24/episode-56-type-2-diabetes-how-sweet-it-isn%e2%80%99t-part-ii/#comments Wed, 24 Jun 2009 20:00:25 +0000 TEC http://therapeuticseducation.org/?p=811 http://therapeuticseducation.org/2009/06/24/episode-56-type-2-diabetes-how-sweet-it-isn%e2%80%99t-part-ii/feed/ 3 diabetes,HbA1c,Jillian Popel,UKPDS Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. In addition, we talk about other things to look at in the evaluation of type 2 diabetes and Jillian Popel again joins us for the ride. She is quite shocked by what she hears about how "absolutely low" the renal risks associated with type 2 diabetics really are. She is also quite shocked by most of what Mike and James have to say in general, but that's a whole other issue for another time. Show Notes 1) Diabetes is NOT a CHD risk equivalent Diabet Med 2009;26:142–8 2) Calculating cardiovascular risk for type 2 diabetics UKPDS risk engine 3) The risks associated with diabetes Diabetes Care 2003;26:2353-8 (http://care.diabetesjournals.org/content/26/8/2353.abstract) Dr James McCormack and Dr Michael Allan no 25:02 http://therapeuticseducation.org/2009/06/17/episode-55-diabetes-how-sweet-it-isnt/ http://therapeuticseducation.org/2009/06/17/episode-55-diabetes-how-sweet-it-isnt/#comments Wed, 17 Jun 2009 20:00:34 +0000 TEC http://therapeuticseducation.org/?p=801 http://therapeuticseducation.org/2009/06/17/episode-55-diabetes-how-sweet-it-isnt/feed/ 4 diabetes,glucose,HbA1c,Jillian Popel,risk,UKPDS Episode 55 starts off a "sweet" new topic - type 2 diabetes. In the first podcast on this topic we talk about the whole issue of the diagnosis of diabetes, how to make the diagnosis and to some degree what the diagnosis means. Episode 55 starts off a "sweet" new topic - type 2 diabetes. In the first podcast on this topic we talk about the whole issue of the diagnosis of diabetes, how to make the diagnosis and to some degree what the diagnosis means. To do this we get some great help from a 1st year medical student, Jillian Popel. In addition, we talk about how the way we presently diagnose type 2 diabetes may change in the not too distant future. At the end of the podcast both Mike and James decide Jillian is far sweeter than either of them and send her off to get her glucose tested - at least Mike does, James just gets her to measure her HbA1c. Show Notes 1) International committee suggests A1C in the diagnosis of diabetes for the diagnosis of diabetes Diabetes Care 2009;32;1-8 (http://care.diabetesjournals.org/site/misc/DC09-9033.pdf) 2) Calculating cardiovascular risk for type 2 diabetics UKPDS risk engine (http://www.dtu.ox.ac.uk/index.php?maindoc=/riskengine) 3) How does HbA1c relate to average daily glucose Simple formula 1.5 x HbA1c - 2 = Average daily glucose (mmoles/L) Actual formula 1.583 × HbA1c – 2.52  - from the Annual meeting of the European Association for the Study of Diabetes - Oct 16, 2007 Examples HbA1c of 6% means an average daily glucose of around 7 mmoles/L 1.5 x 6 - 2 = 7 HbA1c of 8% means an average daily glucose of around 10 mmoles/L 1.5 x 8 - 2 = 10 Dr James McCormack and Dr Michael Allan no 27:16 http://therapeuticseducation.org/2009/06/10/episode-5-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice-part-iii/ http://therapeuticseducation.org/2009/06/10/episode-5-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice-part-iii/#comments Wed, 10 Jun 2009 20:00:54 +0000 TEC http://therapeuticseducation.org/?p=662 http://therapeuticseducation.org/2009/06/10/episode-5-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice-part-iii/feed/ 2 c-reactive protein,CRP,risk,risk assessment,rosuvastatin Episode 54 finishes off the whole issue of CRP measurement by looking at the evidence we have about what happens to patients when they take drugs that lower CRP - glitazones, COX-2s, fibrates, vitamin E, niacin, ezetimibe, and statins. Episode 54 finishes off the whole issue of CRP measurement by looking at the evidence we have about what happens to patients when they take drugs that lower CRP - glitazones, COX-2s, fibrates, vitamin E, niacin, ezetimibe, and statins. Other than statins and maybe niacin, it doesn't look good - in contrast to Mike and James of course that is. Show Notes 1) Drugs that lower CRP Cardiovasc Drug Rev 2006;24:33-50 (http://www3.interscience.wiley.com/journal/118604038/abstract) Chest 2004;125:1610-5 (http://www.chestjournal.org/content/125/5/1610.abstract) Atherosclerosis 2005;179:361-7 (http://www.atherosclerosis-journal.com/article/S0021-9150(04)00560-X/abstract) 2)Drugs that lower CRP and their effect on outcome Glitazones JAMA 2007;298:1189-95 (http://jama.ama-assn.org/cgi/content/abstract/298/10/1189) COX-2s CMAJ 2002;166:1649-50 (http://www.cmaj.ca/cgi/content/full/166/13/1649) Fenofibrate Lancet 2005;366;1849-61 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)67667-2/abstract) Bezafibrate Circulation 2000;102:21-7 (http://circ.ahajournals.org/cgi/content/abstract/102/1/21) Vitamin E Lancet 2003;361:2017-23 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13637-9/abstract) JAMA 2007;297:842-57 (http://jama.ama-assn.org/cgi/content/abstract/297/8/842) Niacin JAMA 1975;231:360-81 (http://jama.ama-assn.org/cgi/content/summary/231/4/360) Ezetimibe N Engl J Med 2008;358:1431-43 (http://content.nejm.org/cgi/content/abstract/358/14/1431) Statins Lancet 2008;371:117-25 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60104-X/abstract) High dose statins - not treating to target CMAJ2008;178(5):576-84 ( http://www.cmaj.ca/cgi/content/abstract/178/5/576?ct) Dr James McCormack and Dr Michael Allan no 25:35 http://therapeuticseducation.org/2009/06/03/659/ http://therapeuticseducation.org/2009/06/03/659/#comments Wed, 03 Jun 2009 20:00:11 +0000 TEC http://therapeuticseducation.org/2009/05/26/659/ http://therapeuticseducation.org/2009/06/03/659/feed/ 6 c-reactive protein,CRP,obesity,risk,risk assessment Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Far more interesting is that there are now 2 studies showing clearly that good estimates of cardiovascular risk can be made without knowing lab values like cholesterol and CRP. All you have to basically do is look at the patient. Mike looks at James and declares that James is at very high risk of annoying Mike - so he does, just to show the evidence is solid. Show Notes 1) Reynolds Risk Score www.reynoldsriskscore.org (http://www.reynoldsriskscore.org/) 2) CRP goes up as weight goes up Diabetes Metab 2003;29:133-8 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B8CX1-4N3P936-5&_user=1022551&_coverDate=04%2F30%2F2003&_rdoc=5&_fmt=high&_orig=browse&_srch=doc-info(%23toc%2340073%232003%23999709997%23644816%23FLP%23display%23Volume)&_cdi=40073&_sort=d&_docanchor=&_ct=13&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=3caa7dcf8245270cad1f7782892a91cc) JAMA 1999;282:2131-5 (http://jama.ama-assn.org/cgi/content/abstract/282/22/2131) 3) Estimating cardiovascular risk estimates without knowing cholesterol or CRP Lancet 2008;371:923–31 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60418-3/abstract) Eur J Card Prev RehabMay 2009 (http://www.ncbi.nlm.nih.gov/pubmed/19357517?dopt=Abstract) (http://therapeuticseducation.org/wp-content/uploads/2009/05/obese-lancet-150x150.jpg) Dr James McCormack and Dr Michael Allan no 16:47 http://therapeuticseducation.org/2009/05/28/episode-52-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice/ http://therapeuticseducation.org/2009/05/28/episode-52-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice/#comments Thu, 28 May 2009 20:44:40 +0000 TEC http://therapeuticseducation.org/?p=693 http://therapeuticseducation.org/2009/05/28/episode-52-crp-an-important-part-of-a-comprehensive-risk-profile-or-a-completely-ridiculous-practice/feed/ 2 c-reactive protein,CRP,risk,risk assessment - Episode 52 goes back in time to look in more detail at what we talked about in episode 30; the whole issue of CRP measurement. Mike and James start at the "large" issue of intra-subject variability, then focus on the "small" impact CRP has on absolu... Episode 52 goes back in time to look in more detail at what we talked about in episode 30; the whole issue of CRP measurement. Mike and James start at the "large" issue of intra-subject variability, then focus on the "small" impact CRP has on absolute risk assessment, and briefly discuss how "accurate" risk assessments are in the first place. Finally they come to the conclusion that, as with most of the podcasts, they are very accurately vague and there is huge intra-podcaster variability. Show Notes 1) Issues of intra-subject CRP measurement variability Clinical Chemistry 2001;47:444–50 (http://www.clinchem.org/cgi/content/abstract/47/3/444) 2) Need for repeat and multiple values Clinical Chemistry 1997;43:52–8 (http://www.clinchem.org/cgi/content/abstract/43/1/52) Ann Clin Biochem 2002;39:85-8 (http://acb.rsmjournals.com/cgi/content/abstract/39/2/85) 3) Impact on risk assessment of adding CRP to other risk factors “Our findings suggest that routine measurement of these novel markers [CRP] is not warranted for risk assessment” Arch Intern Med 2006;166:1368-73 (http://archinte.ama-assn.org/cgi/content/abstract/166/13/1368) “the addition of multimarker scores [CRP] to conventional risk factors resulted in only small increases in the ability to classify risk” NEJM 2006;355;2631-9 (http://content.nejm.org/cgi/content/abstract/355/25/2631) “CRP does not perform better than the Framingham risk equation for discrimination. The improvement in risk stratification or reclassification ...is small and inconsistent” Int J Epidem 2009;38:217–31 (http://ije.oxfordjournals.org/cgi/content/abstract/38/1/217) 4) Reclassification in risk level when using CRP Women Ann Int Med 2006;145:21-9 (http://www.annals.org/cgi/content/abstract/145/1/21) Men Circulation 2008;118:2243-51 (http://circ.ahajournals.org/cgi/content/abstract/118/22/2243) Net reclassification less than that seen in the above studies Circ Cardiovasc Qual Outcomes 2008;1:92-7 (http://circoutcomes.ahajournals.org/cgi/content/abstract/1/2/92) 5) Issue of confidence intervals around risk assessments J Cardiovasc Risk 2002;9:183-90 (http://www.jcardiovascularrisk.com/pt/re/ejcpr/abstract.00043798-200208000-00002.htm;jsessionid=KclVJCtnptYbLNqqtn2cvQr1QH2KQldlkVfbvnDfhnkbRph8vc77!-1775402713!181195628!8091!-1) Dr James McCormack and Dr Michael Allan no 21:16 http://therapeuticseducation.org/2009/05/28/what-is-happening-with-the-podcast/ http://therapeuticseducation.org/2009/05/28/what-is-happening-with-the-podcast/#comments Thu, 28 May 2009 17:48:19 +0000 TEC http://therapeuticseducation.org/?p=701 http://therapeuticseducation.org/2009/05/28/what-is-happening-with-the-podcast/feed/ 0 Dear Listener, - Some changes have been made to where the podcast resides. Please listen to this brief blurb to hear what is going on. If you have any questions or comments please leave us a note below. You will have to register to make a comment but t... Dear Listener, Some changes have been made to where the podcast resides. Please listen to this brief blurb to hear what is going on. If you have any questions or comments please leave us a note below. You will have to register to make a comment but that only takes a second and will allow you to receive regular updates on our activities. Thanks. Register here!. Dr James McCormack and Dr Michael Allan no 5:03 http://therapeuticseducation.org/2009/05/13/episode-51-more-useful-clinical-trials-with-a-gentler-touch-part-ii/ http://therapeuticseducation.org/2009/05/13/episode-51-more-useful-clinical-trials-with-a-gentler-touch-part-ii/#comments Wed, 13 May 2009 18:38:43 +0000 TEC http://therapeuticseducation.org/?p=589 http://therapeuticseducation.org/2009/05/13/episode-51-more-useful-clinical-trials-with-a-gentler-touch-part-ii/feed/ 2 apthous ulcers,ARB,inhaled corticosteroids,NSAIDs,Tina Korownyk In episode 51, we again bring in the charming Dr. Tina Korownyk to help us work through 4 more recent studies that hopefully will have relevance to your practice. We find out that Vitamin B12 works for apthous ulcers, In episode 51, we again bring in the charming Dr. Tina Korownyk to help us work through 4 more recent studies that hopefully will have relevance to your practice. We find out that Vitamin B12 works for apthous ulcers, inhaled corticosteroids should be continued in pregnancy, that NSAID risks can be reduced - but not to zero, and an ARB (telmisartan) provides no benefit when given to stroke patients. Finally, it is revealed that Mike and James have very limited absolute charm. Show Notes 1) Apthous ulcers - sublingual Vitamin B12 J Am Board Fam Med 2009;22:9 –16 (http://www.jabfm.org/cgi/content/abstract/22/1/9) 2) GI protection for NSAIDs Am J Gastroenterol  2009; 104:728-38 (http://www.nature.com/ajg/journal/v104/n3/abs/ajg2009115a.html) 3) Asthma control in pregnancy - OK to use inhaled corticosteroids Ann Allergy Asthma Immunol 2008;101:137–43 (http://www.ncbi.nlm.nih.gov/pubmed/18727468)4) Telmisartan for stroke - no benefitN Engl J Med 2008;359:1225-37 (http://content.nejm.org/cgi/content/abstract/359/12/1225) Dr James McCormack and Dr Michael Allan no 32:58 http://therapeuticseducation.org/2009/05/06/episode-50-more-useful-clinical-trials-with-a-gentler-touch-part-i/ http://therapeuticseducation.org/2009/05/06/episode-50-more-useful-clinical-trials-with-a-gentler-touch-part-i/#comments Wed, 06 May 2009 18:37:24 +0000 TEC http://therapeuticseducation.org/?p=587 http://therapeuticseducation.org/2009/05/06/episode-50-more-useful-clinical-trials-with-a-gentler-touch-part-i/feed/ 0 diabetes,fever,osteoarthritis,rotator cuff,Tina Korownyk In episode 50, we talk about 4 more clinical trials that might help you in your practice. We cover topics ranging from fever control with acetaminophen or ibuprofen, injections for rotator cuff injuries, diabetes, and osteoarthritis. In episode 50, we talk about 4 more clinical trials that might help you in your practice. We cover topics ranging from fever control with acetaminophen or ibuprofen, injections for rotator cuff injuries, diabetes, and osteoarthritis. Mike and James finally bring in a much needed female flavour to the show, by asking Dr. Tina Korownyk to help out with the evaluation of these studies. Unfortunately we quickly realise that the past 49 shows have, much to our chagrin, lacked any significant sex appeal. Show Notes 1) Treatment of fever with acetaminophen, ibuprofen or both BMJ 2008;337:a1302 (http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302) Arch Pediatr Adolesc Med 2004;158:521-6 (http://archpedi.ama-assn.org/cgi/content/abstract/158/6/521) Lancet 1997;350:704-9 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)02255-1/abstract) J Pediatr 1989;114:1045-8 (http://www.jpeds.com/article/S0022-3476(89)80461-5/abstract) 2) Rotator cuff injections - do they need to go in the shoulder BMJ 2009;338;a3112 (http://www.bmj.com/cgi/content/full/338/jan23_1/a3112) 3) Diabetes is NOT a CHD risk equivalent Diabet Med 2009;26,142–8 (http://www3.interscience.wiley.com/journal/121567674/abstract) 4) Resistance/strength training for osteoarthritis Arthritis Care Res 2008;59:1488–94 (http://www3.interscience.wiley.com/journal/121425836/abstract) Dr James McCormack and Dr Michael Allan no 30:42 http://therapeuticseducation.org/2009/04/30/episode-49-becoming-less-anxious-about-anxiety-disorders-part-ii/ http://therapeuticseducation.org/2009/04/30/episode-49-becoming-less-anxious-about-anxiety-disorders-part-ii/#comments Thu, 30 Apr 2009 18:36:30 +0000 TEC http://therapeuticseducation.org/?p=585 http://therapeuticseducation.org/2009/04/30/episode-49-becoming-less-anxious-about-anxiety-disorders-part-ii/feed/ 0 Adil Virani,anxiety In episode 49, we continue on from the previous anxiety ladened podcast, and cautiously delve into the whole area of treatment options for anxiety disorders. Mike and James do this by once again cautiously delving into the complex mind of our psychiatr... In episode 49, we continue on from the previous anxiety ladened podcast, and cautiously delve into the whole area of treatment options for anxiety disorders. Mike and James do this by once again cautiously delving into the complex mind of our psychiatry colleague, Dr. Adil Virani. We end up with great advice but get no further insight into how men's brains work - if in fact they do. Dr James McCormack and Dr Michael Allan no 49:20 http://therapeuticseducation.org/2009/04/22/episode-48-becoming-less-anxious-about-anxiety-disorders/ http://therapeuticseducation.org/2009/04/22/episode-48-becoming-less-anxious-about-anxiety-disorders/#comments Wed, 22 Apr 2009 18:29:44 +0000 TEC http://therapeuticseducation.org/?p=583 http://therapeuticseducation.org/2009/04/22/episode-48-becoming-less-anxious-about-anxiety-disorders/feed/ 0 Adil Virani,anxiety In episode 48, we again invite our psychiatry colleague Adi Virani to talk about the important area of anxiety disorders. Mike and Adil talk about the 6 most common conditions and we find out 25% of the population have some sort of an anxiety disorder. (http://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?i=54032808&id=279020839) (http://itunes.apple.com/WebObjects/MZStore.woa/wa/viewPodcast?i=54032808&id=279020839)In episode 48, we again invite our psychiatry colleague Adi Virani to talk about the important area of anxiety disorders. Mike and Adil talk about the 6 most common conditions and we find out 25% of the population have some sort of an anxiety disorder. Fortunately, there were only three of us on the podcast so James decides the one who must have an anxiety disorder is our good friend Bob Rangno. Dr James McCormack and Dr Michael Allan no 29:07 http://therapeuticseducation.org/2009/04/01/2nd-post/ http://therapeuticseducation.org/2009/04/01/2nd-post/#comments Wed, 01 Apr 2009 08:00:57 +0000 TEC http://ti.ubc.ca/edutest/?p=15 http://therapeuticseducation.org/2009/04/01/2nd-post/feed/ 0 Bob Rangno,guidelines Mike and James celebrate their first anniversary by inviting a good friend and colleague Bob Rangno back to the podcast. We talk about things in medicine that drive us crazy and at the end we come to the conclusion laughter is the best medicine. Mike and James celebrate their first anniversary by inviting a good friend and colleague Bob Rangno back to the podcast. We talk about things in medicine that drive us crazy and at the end we come to the conclusion laughter is the best medicine. We then write a Laughter Guideline and outline exactly how patients should laugh, when they should laugh and how often they should laugh. Show Notes 1) The prostate specific antigen era in the United States is over for prostate cancer: what happened in the last 20 years? J Urology 2004;172:1297-1301 (http://www.jurology.com/article/S0022-5347(05)61155-X/abstract) 2) Do you need sterile gloves when suturing a wound? Ann Emerg Med 2004;43:362-70 (http://www.annemergmed.com/article/S0196-0644(03)00969-7/abstract) 3) Using tap water to irrigate a wound Cochrane Library 2008 (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003861/frame.html) 4) Lubricating a speculum is OK Obstet Gynecol 2002;100:889-92 (http://journals.lww.com/greenjournal/Abstract/2002/11000/The_Effect_of_Vaginal_Speculum_Lubrication_on_the.11.aspx) 5) Reassessment of Clinical Practice Guidelines - Go Gently Into That Good Night JAMA 2009;301:868-9 (http://jama.ama-assn.org/cgi/content/extract/301/8/868) 6) The evidence behind the guidelines JAMA 2009;301:831-41 (http://jama.ama-assn.org/cgi/content/abstract/301/8/831) Dr James McCormack and Dr Michael Allan no 44:19 http://therapeuticseducation.org/2009/03/25/episode-46-high-quality-information-on-drug-safety-special-guest-dr-bruce-psaty/ http://therapeuticseducation.org/2009/03/25/episode-46-high-quality-information-on-drug-safety-special-guest-dr-bruce-psaty/#comments Thu, 26 Mar 2009 02:19:31 +0000 TEC http://therapeuticseducation.org/?p=371 http://therapeuticseducation.org/2009/03/25/episode-46-high-quality-information-on-drug-safety-special-guest-dr-bruce-psaty/feed/ 0 Bruce Psaty In episode 46 we speak with one of the gurus of drug safety, Dr. Bruce Psaty, to get some insight on the whole issue of identifying the good and bad things that drugs can do. We come to the conclusion that high quality information is ultimately what is... In episode 46 we speak with one of the gurus of drug safety, Dr. Bruce Psaty, to get some insight on the whole issue of identifying the good and bad things that drugs can do. We come to the conclusion that high quality information is ultimately what is needed if we are to understand what drugs can and cannot do. Both Mike and James lament on their ability to produce high quality information. Dr James McCormack and Dr Michael Allan no 36:32 http://therapeuticseducation.org/2009/03/18/episode-45-practice-changing-articles-with-double-the-mikes-part-ii/ http://therapeuticseducation.org/2009/03/18/episode-45-practice-changing-articles-with-double-the-mikes-part-ii/#comments Thu, 19 Mar 2009 02:18:16 +0000 TEC http://therapeuticseducation.org/?p=369 http://therapeuticseducation.org/2009/03/18/episode-45-practice-changing-articles-with-double-the-mikes-part-ii/feed/ 0 ACEI,ARB,endocarditis,Mike Kolber,renal stones In our 45th episode, we review a few more practice changing studies with Dr Mike Kolber. We go through the renal outcomes of a large trial of ACE or ARB or together, the benefits of medical therapy to pass of renal stones and then we journey into anot... In our 45th episode, we review a few more practice changing studies with Dr Mike Kolber. We go through the renal outcomes of a large trial of ACE or ARB or together, the benefits of medical therapy to pass of renal stones and then we journey into another evidence void to review the most recent antibiotic prophylactic guidelines from NICE (UK) and the US. At the end James tries to sort out which Mike is the expert and which one is just opinion, and he can’t so he enrolls them both in an RCT without their consent. Show Notes 1) Renal outcomes with ACE & ARB (alone or combined). Lancet 2008;372:547-53. (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61236-2/abstract) Canadian Hypertension Education Program (CHEP) urges physicians NOT to combine ACE & ARB (http://www.theheart.org/article/938703.do) 2) Medical therapy for renal stone passage. Ann Emerg Med 2007;50:552-63 (http://www.annemergmed.com/article/S0196-0644(07)00612-9/abstract) Lancet 2006;368:1171-9 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69474-9/abstract) 3) Antibiotic Prophylaxis for Infective Endocarditis J Am Coll Cardio 2008;52:676-85 (http://content.onlinejacc.org/cgi/reprint/52/8/676.pdf) Heart 2008;94;930-1 (http://heart.bmj.com/cgi/content/extract/94/7/930) Who gets prophylaxis * US: dental procedures with manipulation of either gingival tissue, the periapical region of teeth or perforation of the oral mucosa * Prosthetic cardiac valves or prosthetic material used for cardiac valve repair * Previous infective endocarditis. * Congenital heart disease (CHD – see below for clarity) * Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve. * “Patients with CHD. (Level of Evidence: B) * Unrepaired cyanotic CHD, including palliative shunts and conduits. (Level of Evidence: B) * Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure. (Level of Evidence: B) * Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization). (Level of Evidence: B)” Dr James McCormack and Dr Michael Allan no 34:20 http://therapeuticseducation.org/2009/03/11/episode-44-practice-changing-articles-with-double-the-mikes/ http://therapeuticseducation.org/2009/03/11/episode-44-practice-changing-articles-with-double-the-mikes/#comments Thu, 12 Mar 2009 02:17:17 +0000 TEC http://therapeuticseducation.org/?p=367 http://therapeuticseducation.org/2009/03/11/episode-44-practice-changing-articles-with-double-the-mikes/feed/ 0 depression,gestational diabetes,Mike Kolber,pregnancy,vomiting In Episode 44, we review another collection of practice changing articles and are joined by Dr. Mike Kolber. The first case and study considers the use of metformin in gestational diabetes and the trial leads to a longer discussion of the challenges o... In Episode 44, we review another collection of practice changing articles and are joined by Dr. Mike Kolber. The first case and study considers the use of metformin in gestational diabetes and the trial leads to a longer discussion of the challenges of prescribing in pregnancy. The second case and study concerns the use of ondansetron for vomiting in pediatric patients. James interrupts the two Mikes frequently but never knows which one. Show Notes 1) Metformin for gestational diabetes NEJM 2008;358:2003-15 (http://content.nejm.org/cgi/content/abstract/358/19/2003) 2) Glyburide for gestational diabetes NEJM 2000;343:1134-8 (http://content.nejm.org/cgi/content/abstract/343/16/1134) 3) Persistent pulmonary hypertension of the newborn NEJM 2006;354:579-87 (http://content.nejm.org/cgi/content/abstract/354/6/579) 4) Risk of depression relapse in pregnancy JAMA 2006;295:499-507 (http://jama.ama-assn.org/cgi/content/abstract/295/5/499) Lancet 2003;361:653–51 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)12599-8/abstract) 5) Vomiting in kids and ondansetron Arch Pediatr Adolesc Med 2008;162: 858-65 (http://archpedi.ama-assn.org/cgi/content/abstract/162/9/858) Dosing: Ondansetron usually 1 dose: IV 0.15-0.3 mg/kg or oral 2-8 mg (range based on weight) or 1.6-4 mg (range based on age) Dr James McCormack and Dr Michael Allan no 27:09 http://therapeuticseducation.org/2009/03/04/episode-43-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-iii/ http://therapeuticseducation.org/2009/03/04/episode-43-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-iii/#comments Thu, 05 Mar 2009 02:16:18 +0000 TEC http://therapeuticseducation.org/?p=365 http://therapeuticseducation.org/2009/03/04/episode-43-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-iii/feed/ 0 activity,diets,exercise,obesity,pedometers In episode 43, we take our last run/jog at the problem of obesity by exercising our right to talk about the benefits of increasing activity. James tells the listening audience that Mike is 5’ 6” and weighs 250 lbs and Mike demonstrates to James how to ... In episode 43, we take our last run/jog at the problem of obesity by exercising our right to talk about the benefits of increasing activity. James tells the listening audience that Mike is 5’ 6” and weighs 250 lbs and Mike demonstrates to James how to become more active by chasing him around the studio with a hockey stick – but only metaphorically speaking, as Mike lives in Edmonton and James lives in Vancouver. Show Notes 1) Latest NEJM paper on different “diets” NEJM 2009;369:859-73 (http://content.nejm.org/cgi/content/abstract/360/9/859) 2) Activity-related benefits – morbidity and mortality Arch Intern Med 2007;167:2453-60 (http://archinte.ama-assn.org/cgi/content/abstract/167/22/2453) JAMA 1995; 273:1093-8 (http://jama.ama-assn.org/cgi/content/abstract/273/14/1093) Circulation 2008;117:614-22 (http://circ.ahajournals.org/cgi/content/abstract/117/5/614) JAMA 2003;289:2379-86 (http://jama.ama-assn.org/cgi/content/abstract/289/18/2379) NEJM 2002;347:716-25 3) Other activity benefits Cochrane Database SystRev 2002:CD003404 (http://www.ncbi.nlm.nih.gov/pubmed/12519595) J Gerontol A Biol Sci Med Sci 2008;63:997-1004 (http://biomed.gerontologyjournals.org/cgi/content/abstract/63/9/997) J Sports Med Phys Fitness 2007;47:462-7 (http://www.minervamedica.it/index2.t) Cochrane Database SystRev. 2008;CD004366 (http://www.ncbi.nlm.nih.gov/pubmed/18843656) Cochrane Database SystRev. 2008;CD004376 (http://www.ncbi.nlm.nih.gov/pubmed/18843657) 4) Impact of exercise on weight JAMA 2003;290:1323-30 (http://jama.ama-assn.org/cgi/content/abstract/290/10/1323) JAMA 2003;289:323-30 (http://jama.ama-assn.org/cgi/content/abstract/289/3/323) 5) Exercise versus angioplasty Circulation 2004;109:1371-8 (http://circ.ahajournals.org/cgi/content/abstract/109/11/1371) 6) Do patients adhere? NEJM 2002;346:393-403 (http://content.nejm.org/cgi/content/abstract/346/6/393) 7) Write a prescription for lifestyle – reminders etc J Fam Pract 2000;49:158-68 (http://www.jfponline.com/Pages.asp?AID=2448&issue=February%202000&UID=) Am J Public Health 1998;88:288-91 (http://www.ajph.org/cgi/content/abstract/88/2/288) 8) Pedometers JAMA 2007;298:2296-2304 (http://jama.ama-assn.org/cgi/content/abstract/298/19/2296) Dr James McCormack and Dr Michael Allan no 29:05 http://therapeuticseducation.org/2009/02/25/episode-42-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-ii/ http://therapeuticseducation.org/2009/02/25/episode-42-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-ii/#comments Thu, 26 Feb 2009 02:15:09 +0000 TEC http://therapeuticseducation.org/?p=363 http://therapeuticseducation.org/2009/02/25/episode-42-obesity-%e2%80%93-what%e2%80%99s-the-big-deal-part-ii/feed/ 0 diet,diet drugs,lifestyle,obesity,small plates In episode 42, we continue to take a bite out of the big problem of obesity by getting down and dirty with “diets” and drugs. As usual, lifestyle issues win out and James and Mike celebrate this news by pigging out - but it’s OK because we used small p... In episode 42, we continue to take a bite out of the big problem of obesity by getting down and dirty with “diets” and drugs. As usual, lifestyle issues win out and James and Mike celebrate this news by pigging out - but it’s OK because we used small plates. Show Notes 1) Lifestyle beats out drugs Stopping patients with IGT going to DM Metformin, acarbose, rosiglitazone: NNT = 7-14 (?)1-4 Lifestyle NNT= 4-9 1,5,6 (#1) Developing the metabolic syndrome 7 (#7) Metformin vs Lifestyle NNT: Resolve = 20 vs 5 IGT to DM long-term 7 years 8 (#7) (3 yrs without intervention): NNT = 32/yr 20 years 9 (#7) (14 yrs without intervention): NNT 7 (or 140/yr) with 93% vs 80% DM References for the above 1. NEJM 2002;346:393-403 (http://content.nejm.org/cgi/content/abstract/346/6/393) 2. Lancet 2002;359:2072-7 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)08905-5/abstract) 3. Diabetes Care 2006;29:2095-101 (http://care.diabetesjournals.org/cgi/content/abstract/29/9/2095) 4. Lancet 2006;368:1096-105 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69420-8/abstract) 5. Diabetes Care 1997;20:537-44 (http://care.diabetesjournals.org/cgi/content/abstract/20/4/537) 6. NEJM 2001;344:1343-50 (http://content.nejm.org/cgi/content/abstract/344/18/1343) 7. Ann Intern Med 2005;142:611-19 (http://www.annals.org/cgi/content/abstract/142/8/611) 8. Lancet 2006;368:1673-79 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69701-8/abstract) 9. Lancet 2008;371:1783–89 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60766-7/abstract) 2) Little evidence for any one commercial diet over another Ann Intern Med 2005;142:56-66 (http://www.annals.org/cgi/content/abstract/142/1/56) Am J Med 2005;118:991-7 (http://www.amjmed.com/article/S0002-9343(05)00279-2/abstract) Obesity 2007;15:421-9 (http://www.nature.com/oby/journal/v15/n2/abs/oby2007531a.html) JAMA 2004;292:2482-90 (http://jama.ama-assn.org/cgi/content/abstract/292/20/2482) Int J Obes 2004;28:1349-52 (http://www.nature.com/ijo/journal/v28/n10/abs/0802765a.html) 3) No difference if you eat fat or protein or carbs Int J Obes 2006;30:552-60 (http://www.nature.com/ijo/journal/v30/n3/abs/0803186a.html) Arch Intern Med 2006;166:1466-75 (http://archinte.ama-assn.org/cgi/content/abstract/166/14/1466) Am J Clin Nutr 2005;81:1298-306 (http://www.ajcn.org/cgi/content/abstract/81/6/1298) Arch Intern Med 2004;164:210-7 (http://archinte.ama-assn.org/cgi/content/abstract/164/2/210) J Int Med 2007;261:366-74 (http://www3.interscience.wiley.com/journal/117966544/abstract) Am J Clin Nutr 2006;84:813-21 (http://www.ajcn.org/cgi/content/abstract/84/4/813) JAMA 2003; 289:1837-50 (http://jama.ama-assn.org/cgi/content/abstract/289/14/1837) Cochrane 2002;2:CD003640 (http://www.ncbi.nlm.nih.gov/pubmed/12076496?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus) JAMA 2007;297:969-77 (http://jama.ama-assn.org/cgi/content/abstract/297/9/969) Int J Obes 2004;28:1283-90 (http://www.nature.com/ijo/journal/v28/n10/abs/0802767a.html) Ann Intern Med 2004;140:778-85 (http://www.annals.org/cgi/content/abstract/140/10/778) N Engl J Med 2008;359:229-41 (http://content.nejm.org/cgi/content/abstract/359/3/229) 4) Top 10 tips for weight loss Int J Obesity 2008;32:700–7 (http://www.nature.com/ijo/journal/v32/n4/abs/0803771a.html) 5) Smaller plates Arch Intern Med 2007;167:1277-83 (http://archinte.ama-assn.org/cgi/content/abstract/167/12/1277) 6) Drugs for weight loss Sibutramine and orlistat Diabetes Care 2007;30:27-32 (http://care.diabetesjournals.org/cgi/content/abstract/30/1/27) JAMA 2001;286:1331-9 (http://jama.ama-assn.org/cgi/content/abstract/286/11/1331) J Intern Med 2000;248:245-54 (http://www3.interscience.wiley.com/journal/119187863/abstract) Dr James McCormack and Dr Michael Allan no 35:36 http://therapeuticseducation.org/2009/02/18/episode-41-obesity-%e2%80%93-what%e2%80%99s-the-big-deal/ http://therapeuticseducation.org/2009/02/18/episode-41-obesity-%e2%80%93-what%e2%80%99s-the-big-deal/#comments Thu, 19 Feb 2009 02:13:48 +0000 TEC http://therapeuticseducation.org/?p=361 http://therapeuticseducation.org/2009/02/18/episode-41-obesity-%e2%80%93-what%e2%80%99s-the-big-deal/feed/ 0 metabolic syndrome,obesity In episode 41, we start to tackle the big problem of obesity by getting the advice of 2 Mikes for the price of one. We discuss how classification is more useful from an epidemiologic perspective than it is from an individual patient perspective – which... In episode 41, we start to tackle the big problem of obesity by getting the advice of 2 Mikes for the price of one. We discuss how classification is more useful from an epidemiologic perspective than it is from an individual patient perspective – which is often the case in medicine. In the end, the team heads to a local fast food restaurant to verify the evidence for caloric binging. Show Notes 1) Depression and obesity Synopsis of the 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children. CMAJ 2007;176(8 suppl):S1-13 (http://www.cmaj.ca/cgi/reprint/176/8/1103.pdf) 2) Obesity and increased mortality Ann Intern Med 2003;138:24-32 (http://www.annals.org/cgi/content/abstract/138/1/24) 3) Being a little bit overweight is OK JAMA 2007;298:2028-2037 (http://jama.ama-assn.org/cgi/content/abstract/298/17/2028) Lancet 2006;368:666-78 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)69251-9/abstract) J Am Geriatr Soc 2005;53:2112-8 (http://www3.interscience.wiley.com/journal/118681049/abstract) 4) Metabolic syndrome – who cares? Metabolic syndrome classification predicts CVD risk no better than just using the regular CVD factors like age, sex, cholesterol, blood pressure, diabetes etc. Diabetes Care 2006;29:1693 (http://care.diabetesjournals.org/cgi/content/full/29/7/1693) Framingham risk score was a better predictor of CHD and stroke than the metabolic syndrome Arch Intern Med 2005;165:2644-50 (http://archinte.ama-assn.org/cgi/content/abstract/165/22/2644) Dr James McCormack and Dr Michael Allan no 29:50 http://therapeuticseducation.org/2009/02/11/episode-40-keeping-up-with-the-medical-literature-101/ http://therapeuticseducation.org/2009/02/11/episode-40-keeping-up-with-the-medical-literature-101/#comments Thu, 12 Feb 2009 02:12:54 +0000 TEC http://therapeuticseducation.org/?p=359 http://therapeuticseducation.org/2009/02/11/episode-40-keeping-up-with-the-medical-literature-101/feed/ 0 keeping up,medical literature In episode 40 we discuss 4-5 different and fairly simple ways to keep up with the medical literature and we both come to the conclusion that the best way to keep up is to listen to these podcasts. Unfortunately we were unable to find any evidence to su... In episode 40 we discuss 4-5 different and fairly simple ways to keep up with the medical literature and we both come to the conclusion that the best way to keep up is to listen to these podcasts. Unfortunately we were unable to find any evidence to support such a belief. Mike critically appraises James and finds a number of fatal flaws in his design. Show Notes 1) InfoPOEMS http://www.essentialevidenceplus.com/product/features_dailyip.cfm (http://www.essentialevidenceplus.com/product/features_dailyip.cfm) 2) ACP journal club http://www.acpjc.org (http://www.acpjc.org) 3) Evidence-based medicine http://ebm.bmj.com (http://ebm.bmj.com) 4) Quickscan reviews http://www.cmeonly.com/QSR/qsrdemo.html (http://www.cmeonly.com/QSR/qsrdemo.html) 5) NetNewsWire - RSS reader for Mac users http://www.newsgator.com/INDIVIDUALS/NETNEWSWIRE (http://www.newsgator.com/INDIVIDUALS/NETNEWSWIRE) 6) Amedeo http://www.amedeo.com (http://www.amedeo.com) Dr James McCormack and Dr Michael Allan no 26:20 http://therapeuticseducation.org/2009/02/04/episode-39-new-trials-you-need-to-know-about-part-2-2/ http://therapeuticseducation.org/2009/02/04/episode-39-new-trials-you-need-to-know-about-part-2-2/#comments Thu, 05 Feb 2009 02:11:47 +0000 TEC http://therapeuticseducation.org/?p=357 http://therapeuticseducation.org/2009/02/04/episode-39-new-trials-you-need-to-know-about-part-2-2/feed/ 0 ACCOMPLISH,BMI,COPD In episode 39 we get to the 4 studies we didn’t get to in the previous podcast. We discuss evidence that BMI is as useful as cholesterol when it comes to estimating cardiovascular risk, inhaled corticosteroids increase risk of pneumonia in patients wit... In episode 39 we get to the 4 studies we didn’t get to in the previous podcast. We discuss evidence that BMI is as useful as cholesterol when it comes to estimating cardiovascular risk, inhaled corticosteroids increase risk of pneumonia in patients with COPD – but don’t worry just put them on daily erythromycin – and finally we discuss yet another antihypertensive trial. Mike demonstrates some sensitivity approaches to medicine in general and James ignores him. Show Notes 1) BMI predicts risk as well as knowing a patient’s cholesterol Lancet 2008;371:923-31 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60418-3/abstract) 2) Meta-analysis of inhaled corticosteroids in COPD – no difference in mortality, reduction in exacerbations but pneumonia was increased by 4% (absolute) over a period of a year JAMA 2008;300:2407-16 (http://jama.ama-assn.org/cgi/content/abstract/300/20/2407) 3) Erythromycin 250 mg BID for one year compared to placebo – exacerbations reduced to a similar degree as to that seen with inhalers Am J Respir Crit Care Med 2008;178:1139–47 (http://ajrccm.atsjournals.org/cgi/content/abstract/178/11/1139) 4) ACCOMPLISH - Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients N Engl J Med 2008;359:2417-28 (http://content.nejm.org/cgi/content/abstract/359/23/2417) Dr James McCormack and Dr Michael Allan no 29:24 http://therapeuticseducation.org/2009/01/28/episode-38-new-trials-you-need-to-know-about/ http://therapeuticseducation.org/2009/01/28/episode-38-new-trials-you-need-to-know-about/#comments Thu, 29 Jan 2009 02:08:43 +0000 TEC http://therapeuticseducation.org/?p=353 http://therapeuticseducation.org/2009/01/28/episode-38-new-trials-you-need-to-know-about/feed/ 0 anticholinergics,COPD,smoking cessation,VADT,varenicline In episode 38 we try to go over 8 new studies in one podcast but only get half-way there. We cover 2 inhaled anticholinergic studies, one new glucose lowering trial and the latest smoking cessation RCT. Mike and James wax poetically about a variety o... In episode 38 we try to go over 8 new studies in one podcast but only get half-way there. We cover 2 inhaled anticholinergic studies, one new glucose lowering trial and the latest smoking cessation RCT. Mike and James wax poetically about a variety of issues and demonstrate clearly their well-honed technique of how not to stay foccussed, succint and to-the-point which explains why we only got to half the studies. Show Notes 1) Inhaled anticholinergics – for better or worse? Tiotropium given for 4 years on-top of existing therapy – no increase in mortality and fewer myocardial infarctions N Engl J Med 2008;359:1543-54 (http://content.nejm.org/cgi/content/abstract/359/15/1543) Inhaled anticholinergics increases risk of cardiovascular death – but not total mortality JAMA 2008;300:1439-1450 (http://jama.ama-assn.org/cgi/content/abstract/300/12/1439) 2) VADT – trial - the third study showing either no benefit or harm from aggressively lowering blood glucose - glycated hemoglobin level reduced from 8.4% to 6.9% N Engl J Med 2009;360:129-39 (http://content.nejm.org/cgi/content/abstract/360/2/129) 3) Varenicline for smoking cessation Varenicline verus transdermal nicotine Thorax 2008;63:717-24 (http://thorax.bmj.com/cgi/content/abstract/63/8/717) Evidence showing 0.5 mg BID of varenicline is as effective as 1 mg BID FDA document (http://www.fda.gov/cder/foi/nda/2006/021928_s000_Chantix_PharmR.pdf) Dr James McCormack and Dr Michael Allan no 29:54 http://therapeuticseducation.org/2009/01/22/episode-37-diverse-listener-questions-and-comments-q-a-with-no-qa/ http://therapeuticseducation.org/2009/01/22/episode-37-diverse-listener-questions-and-comments-q-a-with-no-qa/#comments Fri, 23 Jan 2009 02:07:46 +0000 TEC http://therapeuticseducation.org/?p=351 http://therapeuticseducation.org/2009/01/22/episode-37-diverse-listener-questions-and-comments-q-a-with-no-qa/feed/ 0 COPD,diabetes,listener questions In Episode 37, we again review listener questions and comments around such diverse topics as Bell's Palsy, viruses that break bones, glucose monitoring, glitazones and COPD. Both James and Mike give diverse answers with diverse meanings that even they ... In Episode 37, we again review listener questions and comments around such diverse topics as Bell's Palsy, viruses that break bones, glucose monitoring, glitazones and COPD. Both James and Mike give diverse answers with diverse meanings that even they don't really understand. Show Notes 1) The third study showing either no benefit or harm from aggressively lowering blood glucose - glycated hemoglobin level reduced from 8.4% to 6.9% NEJM 2009;360:129-39 (http://content.nejm.org/cgi/content/abstract/360/2/129) 2) Studies of monitoring blood sugar in type 2 diabetics showing no benefit and increased depression scores BMJ 2007;335:132 (http://www.bmj.com/cgi/content/abstract/335/7611/132) BMJ 2008;336:1177-80 (http://www.bmj.com/cgi/content/abstract/336/7654/1177) 3) Beta-blockers and thiazides do appear to increase the chance of developing diabetes Am J Cardiol 2007;100:1254–62 (http://www.ajconline.org/article/S0002-9149(07)01332-X/abstract) 4) 10-year follow-up of intensive glucose control in Type 2 diabetes NEJM 2008;359:1577-89 (http://content.nejm.org/cgi/content/abstract/359/15/1577) 5) COPD guidelines recommending inhaled steroids as one of the first line inhalers Ann Int Med 2007;147:639-53 (http://www.annals.org/cgi/content/abstract/147/9/639) Dr James McCormack and Dr Michael Allan no 34:04 http://therapeuticseducation.org/2009/01/14/episode-36-information-on-older-drugs-from-an-even-older-doctor-%e2%80%93-part-2/ http://therapeuticseducation.org/2009/01/14/episode-36-information-on-older-drugs-from-an-even-older-doctor-%e2%80%93-part-2/#comments Thu, 15 Jan 2009 02:05:56 +0000 TEC http://therapeuticseducation.org/?p=349 http://therapeuticseducation.org/2009/01/14/episode-36-information-on-older-drugs-from-an-even-older-doctor-%e2%80%93-part-2/feed/ 0 Bob Rangno,colchicine,diabetes,iron,metformin,nitroglycerin,nortriptyline,smoking cessation,vitamin B12 In episode 36, we take up where we left off in episode 35 by reviewing eight more (not ten) old drugs that hopefully you are still using – if not, get with the progam – in your day-to-day practice. Dr Bob joins us yet again for this episode and provide... In episode 36, we take up where we left off in episode 35 by reviewing eight more (not ten) old drugs that hopefully you are still using – if not, get with the progam – in your day-to-day practice. Dr Bob joins us yet again for this episode and provides us with some great clinical experience and finally some reasonable humour. Mike tries to deliver some useful clinical pearls and James tries to keep things flowing smoothly – neither have tremendous success. Show Notes Nortriptyline 1) Chronic headache JAMA. 2001;285:2208-2215 (http://jama.ama-assn.org/cgi/content/abstract/285/17/2208?ck=nck) 2) Smoking cessation Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1 (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000031/frame.html) Fluoxetine 1) Weight loss in diabetics Arch Intern Med 2004;164:1395-1404 (http://archinte.ama-assn.org/cgi/content/abstract/164/13/1395) Metformin 1) Metformin’s contraindications should be contraindicated CMAJ 2005;173:502-504 (http://www.cmaj.ca/cgi/content/full/173/5/502) Colchicine 1) Gout – uptake of colchicine into leukocytes Clin Pharmacol Ther 1993;54:360-7 (http://www.nature.com/clpt/journal/v54/n4/abs/clpt1993161a.html) 2) Does colchicine work? The results of the first controlled study in acute gout Aust NZ J Med 1987;17:301-4 (http://www3.interscience.wiley.com/journal/120024024/abstract) Br J Clin Pharmacol 1988;26:488-9 (http://www.ncbi.nlm.nih.gov/pubmed/3263878?ordinalpos=42&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum) 3) Pericarditis Arch Intern Med 2005;165:1987-91 (http://archinte.ama-assn.org/cgi/content/abstract/165/17/1987) 4) Osteoarthritis Arth Care Res 2002;47:280-4 (http://www3.interscience.wiley.com/journal/94516612/abstract) Osteoarthritis Cartilage 2002; 10:247-52 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP3-45KND4H-1&_user=1022551&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=8f946a633969d2345fa8ba903a492ede) 5) Cirrhosis NEJM 1988;318:1709-13 (http://content.nejm.org/cgi/content/abstract/318/26/1709) Vitamin B12 1) Oral vs IM Vitamin B 12 Fam Pract 2006;23:279-85 (http://fampra.oxfordjournals.org/cgi/content/abstract/23/3/279) Iron 1) Low dose (15 and/or 50 mg) is as good as high doses (150mg) Am J Med 2005; 118: 1142-7 (http://www.amjmed.com/article/S0002-9343(05)00210-X/abstract) Nitroglycerin 1) Tennis elbow Am J Sports Med 2003;31:915-20 (http://ajs.sagepub.com/cgi/content/abstract/31/6/915) 2) Acute pulmonary edema Amer J Emerg Med 1999;1716:571-4 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W9K-4D0Y9BV-80&_user=10&_coverDate=10%2F31%2F1999&_rdoc=15&_fmt=high&_orig=browse&_srch=doc-info(%23toc%236685%231999%23999829993%23513482%23FLA%23display%23Volume)&_cdi=6685&_sort=d&_docanchor=&_ct=35&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=16a5c840b2b72cb924b132776f97f982) 3) Anal/bum fissures Lancet 1997;349:11-4 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)06090-4/abstract) 4) Raynaud’s Lancet 1982;1:76-7 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=LANCET%5BJour%5D%20AND%2076%5Bpage%5D%20AND%201982%5Bpdat%5D) Dr James McCormack and Dr Michael Allan no 37:39 http://therapeuticseducation.org/2009/01/07/episode-35-information-on-older-drugs-from-an-even-older-doctor/ http://therapeuticseducation.org/2009/01/07/episode-35-information-on-older-drugs-from-an-even-older-doctor/#comments Thu, 08 Jan 2009 02:04:26 +0000 TEC http://therapeuticseducation.org/?p=347 http://therapeuticseducation.org/2009/01/07/episode-35-information-on-older-drugs-from-an-even-older-doctor/feed/ 0 ALLHAT,amoxicillin,Bob Rangno,chlorpheniramine,doxycycline,nitofurantion,reserpine,spironolactone,sulfa drug,thiazides In this first episode of the New Year (Episode #35) we review nine (not ten) old drugs that should, in most circumstances, still likely play an important role in your day-to-day prescribing and recommendations. In this first episode of the New Year (Episode #35) we review nine (not ten) old drugs that should, in most circumstances, still likely play an important role in your day-to-day prescribing and recommendations. Dr Robert Rangno again joins us for this episode and provides us with some great clinical experience and some mediocre humour. Mike and James, as usual laugh about a variety of things that in hindsight really aren’t all that funny. Show Notes Chlorpheniramine 1) Editorial on antihistamines CMAJ 1997;157:37-8 (http://www.cmaj.ca/cgi/reprint/157/1/37?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=rangno&andorexactfulltext=and&searchid=1&FIRSTINDEX=10&sortspec=date&resourcetype=HWCIT) 2) Tolerance to the sedative effects of 100 mg of diphenhydramine occurs within 3 days J Clin Psychopharmacol 2002:22:511–15 (http://www.psychopharmacology.com/pt/re/jclnpsychopharm/abstract.00004714-200210000-00012.htm;jsessionid=JjTKh4WBHQW5yxHk0sDpfF1n7mLFZfphphxFL79Xw1ms9nKD8g5K!1329102805!181195628!8091!-1) Thiazides 1) ALLHAT JAMA 2002;288:2981-97 (http://jama.ama-assn.org/cgi/content/abstract/288/23/2981) 2) ACE inhibitors no better than thiazides in diabetics Arch Intern Med 2005;165:1401-9 (http://archinte.ama-assn.org/cgi/content/abstract/165/12/1401) (http://ti.ubc.ca/podcasting/iTS/image/e35-1.png) (http://ti.ubc.ca/podcasting/iTS/image/e35-2.png) Spironolactone 1) RALES/CHF study New Engl J Med 1999;341:709-17 (http://content.nejm.org/cgi/content/abstract/341/10/709) (http://ti.ubc.ca/podcasting/iTS/image/e35-3.png) 2) Spironolactone for resistant hypertension AJH 2003;16:925–30 (http://www.nature.com/ajh/journal/v16/n11/abs/ajh2003173a.html) Journal of Hypertension 2007;25:891-4 (http://www.jhypertension.com/pt/re/jhypertension/abstract.00004872-200704000-00023.htm;jsessionid=JjVXR372Pf6GzVNfyWvCbjmmLn2RWRCfpxrBw0Y6W2QpcrKj39FH!-482373940!181195629!8091!-1) 3) Polycystic ovarian disease J Clin Endocrinol Metab 2004;89:2756-62 (http://jcem.endojournals.org/cgi/content/abstract/89/6/2756) Reserpine 1) Potentially useful agent Clin Pharmacol Therap 1996;60:368–73 (http://www.nature.com/clpt/journal/v60/n4/abs/clpt1996496a.html) 2) Treatment of diastolics of 115-129 mmHg – VA Study JAMA 1967;202:1028-34 (NO LINK - Archived) Amoxicillin 1) Once daily amoxicillin for Strep throat Arch Disease Childhood 2008;93:474-8 (http://adc.bmj.com/cgi/content/abstract/93/6/474) Pediatrics 1999;103:47-51 (http://pediatrics.aappublications.org/cgi/content/abstract/103/1/47) Doxycycline 1) No appreciable resistance to doxycycline, including pneumococcus Chest 2004;125:1913 (http://www.chestjournal.org/cgi/content/full/125/5/1913) Arch Int Med 1999;159:266-70 (http://archinte.ama-assn.org/cgi/content/abstract/159/3/266) 2) Community acquired MRSA Antimicrob Agents Chemother 2007;51:2628-30 (http://aac.asm.org/cgi/content/abstract/51/7/2628) Clin Infect Dis 2005;40:1429-34 (http://www.journals.uchicago.edu/doi/abs/10.1086/429628) 3) Low dose (20 mg twice daily) for acne Arch Dermatol 2003;139:459-64 (http://archderm.ama-assn.org/cgi/content/abstract/139/4/459) Sulfa drugs Allergy to penicillin increases your risk of reacting to sulfa drugs N Engl J Med 2003;349:1628-35 (http://content.nejm.org/cgi/content/abstract/349/17/1628) Nitrofurantoin Still good for bladder infections British Journal of General Practice 2002;52:729-34 (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1314413) Dr James McCormack and Dr Michael Allan no 34:13 http://therapeuticseducation.org/2008/12/17/episode-34-holiday-extravaganza-confirming-or-dispelling-myths-and-beliefs/ http://therapeuticseducation.org/2008/12/17/episode-34-holiday-extravaganza-confirming-or-dispelling-myths-and-beliefs/#comments Thu, 18 Dec 2008 02:02:58 +0000 TEC http://therapeuticseducation.org/?p=345 http://therapeuticseducation.org/2008/12/17/episode-34-holiday-extravaganza-confirming-or-dispelling-myths-and-beliefs/feed/ 0 In Episode 34, we review some of the myths and beliefs common in many cultures. A renowned and profound guest joins us (Dr Robert Rangno). We start with a study of Santa Claus and then move on to a variety of myths like the need for bed rest, In Episode 34, we review some of the myths and beliefs common in many cultures. A renowned and profound guest joins us (Dr Robert Rangno). We start with a study of Santa Claus and then move on to a variety of myths like the need for bed rest, cold exposure causing infective illness, swimming after eating, etc. It is light-hearted and lacks intellectual content (even more than usual). We end with the Christmas Poem “A Sick Night before Christmas.” Dr James McCormack and Dr Michael Allan no 40:09 http://therapeuticseducation.org/2008/12/10/episode-33-nsaids-considering-the-risks-and-benefits/ http://therapeuticseducation.org/2008/12/10/episode-33-nsaids-considering-the-risks-and-benefits/#comments Thu, 11 Dec 2008 02:01:52 +0000 TEC http://therapeuticseducation.org/?p=343 http://therapeuticseducation.org/2008/12/10/episode-33-nsaids-considering-the-risks-and-benefits/feed/ 0 H pylori,misoprostol,NSAIDs In our 33rd episode we follow-up our discussion of osteoarthritis by examining the risks and benefits of oral anti-inflammatories including Cox-2 inhibitors. We review the effects on pain relief and the theory of anti-inflammation. In our 33rd episode we follow-up our discussion of osteoarthritis by examining the risks and benefits of oral anti-inflammatories including Cox-2 inhibitors. We review the effects on pain relief and the theory of anti-inflammation. We discuss the possible gastrointestinal effects and possible approaches to reduce the risk. We consider the cardiovascular risks and debate the choices in prescribing. We finish by struggling to get in the last word. Show Notes 1) Eradication of H. Pylori decreases the chance of a GI bleed in patients about to receive NSAIDs Lancet 2002;359:9-13 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)07272-0/abstract) 2) Misoprostol decreases the chance of bleeds but increases the number of GI side effects Ann Int Med 1995;123:241-9 (http://www.annals.org/cgi/content/abstract/123/4/241) 3) PPI added to ASA (in patients with previous ulcer on ASA) NEJM 2005;352:238-44 (http://content.nejm.org/cgi/content/abstract/352/3/238) 4) Naprosyn possibly protective for cardiac events Lancet. 2004;364:2021-9 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17514-4/abstract) 5) Possible impaired fracture healing with NSAIDs Injury 2008;39:384-94 (http://www.injuryjournal.com/article/S0020-1383(07)00445-7/abstract) J Bone Joint Surg (Br) 2007;89:1553-60 (http://www.jbjs.org.uk/cgi/content/abstract/89-B/12/1553) Emerg Med J 2005;22:652-3 (http://emj.bmj.com/cgi/content/abstract/22/9/652-a) Dr James McCormack and Dr Michael Allan no 33:08 http://therapeuticseducation.org/2008/12/03/episode-32-aches-and-pains-an-overview-of-osteoarthritis-treatment/ http://therapeuticseducation.org/2008/12/03/episode-32-aches-and-pains-an-overview-of-osteoarthritis-treatment/#comments Thu, 04 Dec 2008 01:56:43 +0000 TEC http://therapeuticseducation.org/?p=341 http://therapeuticseducation.org/2008/12/03/episode-32-aches-and-pains-an-overview-of-osteoarthritis-treatment/feed/ 0 exercise,glucosamine,NSAIDs,opioids,osteoarthritis,surgery,topical NSAIDs In our 32nd episode we review the therapeutic options for the treatment of osteoarthritis. We first deal with lifestyle interventions for osteoarthritis. We consider the pain pharmaceuticals like acetaminophen, topical or oral NSAIDs, In our 32nd episode we review the therapeutic options for the treatment of osteoarthritis. We first deal with lifestyle interventions for osteoarthritis. We consider the pain pharmaceuticals like acetaminophen, topical or oral NSAIDs, and opiates as well as some of the other osteoarthritis therapies such as glucosamine or steroid injections. We also summarize a number of other interventions (cold compresses to surgical debridement). Show Notes 1) Obesity and hip OA Rheumatology 2002;41:1155-62 (http://rheumatology.oxfordjournals.org/cgi/content/abstract/41/10/1155) 2) Exercise for OA of the knee Cochrane Library (http://www.cochrane.org/reviews/en/ab004376.html) 3) Aquatic exercise for knee and hip OA Cochrane Library (http://www.cochrane.org/reviews/en/ab005523.html) 4) Glucosamine for OA Cochrane Library (http://www.cochrane.org/reviews/en/ab002946.html) 5) Topical NSAIDs for OA Longterm efficacy of topical nonsteroidal antiinflammatory drugs in knee OA J Rheumatol 2006;33:1841-4 (http://www.jrheum.com/abstracts/abstracts06/1841.html) Topical diclofenac for OA of the knee J Rheumatol 2004;31:2002-12 (http://jrheum.com/abstracts/abstracts04/2002.html) Meta-analysis of topical NSAIDs for OA BMJ 2004;329:324 (http://www.bmj.com/cgi/content/abstract/329/7461/324) Meta-analysis of topical NSAIDs for OA BMC Musculoskeletal Disorders 2004;5:28 (http://www.biomedcentral.com/1471-2474/5/28) Bandolier on topical NSAIDs (http://www.medicine.ox.ac.uk/bandolier/booth/painpag/Chronrev/Analges/CP071.html) 6) Oral NSAIDs including COX-2s for OA BMJ 2004;329:1317 (http://www.bmj.com/cgi/content/abstract/329/7478/1317) 7) Oral NSAIDs vs Acetaminophen A meta-analysis Ann Rheum Dis 2004;63:901-7 (http://ard.bmj.com/cgi/content/abstract/63/8/901) A systematic review J Rheumatol 2004;31:344-54 (http://www.jrheum.com/abstracts/abstracts04/344.html) Versus diclofenac/misoprostol Arthritis Rheum 2001;44:1587-98 (http://www3.interscience.wiley.com/journal/84504274/abstract) 8) Steroid injections for OA of the knee BMJ 2004;328:869 (http://www.bmj.com/cgi/content/abstract/328/7444/869) Can Fam Physician 2004;50:241-8 (http://www.cfp.ca/cgi/content/abstract/50/2/241) Cochrane Library (http://www.cochrane.org/reviews/en/ab005328.html) 9) Opioids for OA Oxycodone Arch Intern Med 2000;160:853-60 (http://archinte.ama-assn.org/cgi/content/abstract/160/6/853) Codeine J Rheumatol 2000;27:764-71 (http://www.jrheum.com/abstracts/abstracts00/764.html) Morphine J Pain Symptom Manage 2002;23:278-91 (http://www.jpsmjournal.com/article/S0885-3924(02)00383-4/abstract) Tramadol J Rheumatol 2007;34:543-55 (http://www.jrheum.com/abstracts/abstracts07/543.html) 10) Hyaluronic acid injections Meta-analysis showing no effect CMAJ 2005;172:1039-43 (http://www.cmaj.ca/cgi/content/abstract/172/8/1039) Cochrane review showing an effect Cochrane Library (http://www.cochrane.org/reviews/en/ab005321.html) 11) Surgical debridement Cochrane review showing no benefit Cochrane Library (http://www.cochrane.org/reviews/en/ab005118.html) 12) Other TENS Cochrane review Cochrane Library (http://www.cochrane.org/reviews/en/ab002823.html) Thermotherapy Cochrane review Cochrane Library (http://www.cochrane.org/reviews/en/ab004522.html) Ultrasound Cochrane review Cochrane Library (http://www.cochrane.org/reviews/en/ab003132.html) Balneotherapy for OA (Mineral Baths) Cochrane review Cochrane Library (http://www.cochrane.org/reviews/en/ab006864.html) Acupuncture Meta-analysis Rheumatology 2006;45:1331-7 (http://rheumatology.oxfordjournals.org/cgi/content/abstract/45/11/1331) Dr James McCormack and Dr Michael Allan no 33:39 http://therapeuticseducation.org/2008/11/26/episode-31-old-ideas-for-coping-with-new-drugs/ http://therapeuticseducation.org/2008/11/26/episode-31-old-ideas-for-coping-with-new-drugs/#comments Thu, 27 Nov 2008 01:55:16 +0000 TEC http://therapeuticseducation.org/?p=339 http://therapeuticseducation.org/2008/11/26/episode-31-old-ideas-for-coping-with-new-drugs/feed/ 0 new drugs In our 31st episode we offer an approach to new drugs. We look at the last five years of new product introduction and consider the frequency of new drugs being truly novel and a substantial addition. We examine how medicines termed “new” are frequent... In our 31st episode we offer an approach to new drugs. We look at the last five years of new product introduction and consider the frequency of new drugs being truly novel and a substantial addition. We examine how medicines termed “new” are frequently modifications that make no measurable change in the product. Finally, we consider a basic approach to new products. James gets militant on the theme (but not the message) while Mike runs for cover. Show Notes 1) Number of drugs considered to be a “substantial” improvement – 2001 to 2007 – category 2 is considered substantial improvement (14 out of 147) PMPRB 2007 Annual report (http://www.pmprb-cepmb.gc.ca/english/view.asp?x=1068&all=true) (http://www.ti.ubc.ca/podcasting/iTS/image/e31-1.png) 2) Prescrire review of new drugs Can J Clin Pharmacol 2005;12:e10-e21 (http://www.cjcp.ca/pdf/CJCP04-041_e22.pdf) 3) Drugs withdrawn from the Canadian market for safety reasons CMAJ 2005;172:765–7 (http://www.cmaj.ca/cgi/content/full/172/6/765) 4) Guideline recommendations are not necessarily based on “solid” evidence and are often opinion-based Example – Canadian Cardiovascular Society position statement – Recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease Can J Cardiol 2006;22:913-927 (http://www.pulsus.com/journals/abstract.jsp?sCurrPg=abstract&jnlKy=1&atlKy=6670&isuKy=147&isArt=t&fromfold=) Of the 15 specific recommendations in this document: 4 were considered Level A - Data derived from multiple randomized controlled trials or meta-analyses 0 were considered Level B - Data derived from a single randomized controlled trial or large, nonrandomized studies 11 were considered Level C - Consensus of opinion by experts and/or small studies, retrospective studies or registries Dr James McCormack and Dr Michael Allan no 25:58 http://therapeuticseducation.org/2008/11/19/episode-30-a-new-far-out-trial-welcome-to-jupiter/ http://therapeuticseducation.org/2008/11/19/episode-30-a-new-far-out-trial-welcome-to-jupiter/#comments Thu, 20 Nov 2008 01:54:09 +0000 TEC http://therapeuticseducation.org/?p=337 http://therapeuticseducation.org/2008/11/19/episode-30-a-new-far-out-trial-welcome-to-jupiter/feed/ 0 CRP,JUPITER,rosuvastatin The topic for our 30th episode is stolen from the headlines. We look at the much publicized Jupiter trial of C-Reactive Protein (CRP) and the use of a statin. We review the details, strengths and weakness of the trial. The topic for our 30th episode is stolen from the headlines. We look at the much publicized Jupiter trial of C-Reactive Protein (CRP) and the use of a statin. We review the details, strengths and weakness of the trial. From there we look at related questions of risk assessment with CRP, reducing CRP and the uncertainty in the lipid hypothesis. We end by concluding that although trust in mechanisms and theories can lead to poor decisions they are generally less confusing than our podcasts. Show Notes 1) Jupiter – statins, lipids and CRP NEJM 2008;359:2195-207 (http://content.nejm.org/cgi/content/abstract/NEJMoa0807646) (http://content.nejm.org/cgi/content/abstract/NEJMoa0807646) (http://www.ti.ubc.ca/podcasting/iTS/image/e30-1.png) (http://www.ti.ubc.ca/podcasting/iTS/image/e30-2.png) 2) Knowing CRP doesn’t change estimation of cardiovascular risk NEJM 2006;355:2631-9 (http://content.nejm.org/cgi/content/abstract/355/25/2631) Arch Intern Med 2006;166:1368-73 (http://archinte.ama-assn.org/cgi/content/abstract/166/13/1368) 3) Web site calculator that uses CRP Reynolds Risk Score (http://www.reynoldsriskscore.org) 4) Ezetrol Study (reduces CRP but no other change) N Engl J Med 2008;358:1431-43. (http://content.nejm.org/cgi/content/abstract/358/14/1431) 5) Mechanistic mistaken thinking Beta-blockers in CHF Arch Intern Med 2002;162:641-8 (http://archinte.ama-assn.org/cgi/content/abstract/162/6/641) Anti-oxidant studies Lancet 2002;360:23-33 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(02)09328-5/abstract) Lancet 2003;361:2017-23. (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)13637-9/abstract) Atenolol for BP but not for outcomes Lancet 2004;364:1684-9 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17355-8/abstract) Dr James McCormack and Dr Michael Allan no 24:19 http://therapeuticseducation.org/2008/11/11/episode-29-creating-confusion-or-clarity-qa-of-listener-mail-2/ http://therapeuticseducation.org/2008/11/11/episode-29-creating-confusion-or-clarity-qa-of-listener-mail-2/#comments Wed, 12 Nov 2008 02:22:03 +0000 TEC http://therapeuticseducation.org/?p=336 http://therapeuticseducation.org/2008/11/11/episode-29-creating-confusion-or-clarity-qa-of-listener-mail-2/feed/ 0 ACCORD,ADVANCE,high blood pressure,listener questions,Mediterranean diet,statins,UKPDS In Episode 29, we review questions around informed decision-making, risk-benefits of statins across different populations (women, chronic kidney disease, etc), and comparisons of calculated risks and trial results. In Episode 29, we review questions around informed decision-making, risk-benefits of statins across different populations (women, chronic kidney disease, etc), and comparisons of calculated risks and trial results. We also talk about prescribing of new antimicrobials, differentiating typical from atypical pneumonias and then attempt to clarify a few trials including HOPE. James desperately searches for pearls among Mike’s explanations of the uncertainty and gaps in the research. Show Notes 1) The HOPE trial NEJM 2000;342:145–53 (http://content.nejm.org/cgi/content/full/342/3/145) (http://www.ti.ubc.ca/podcasting/iTS/image/e29-1.png) (http://www.ti.ubc.ca/podcasting/iTS/image/e29-2.png) 2) HOPE was actually more like a blood pressure trial than originally thought – 24 hour blood pressure differences between the 2 groups were 10/4 mmHg Hypertension 2001;38;e28-e32 (http://hyper.ahajournals.org/cgi/content/abstract/38/6/e28) 4) Meta-analysis of statins in patients with chronic kidney disease BMJ 2008;336:645-51 (http://www.bmj.com/cgi/content/abstract/336/7645/645) 5) Meta-analysis CMAJ on high vs low dose statin in secondary prevention CMAJ 2008;178:576-84 (http://www.cmaj.ca/cgi/content/full/178/5/576) 6) Mediterranean diet – no difference between the groups in weight, cholesterol or blood pressure at the end of the study but cardiovascular events were reduced Lancet 1994;343:1454-9 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=%22Lancet%22%5BJour%5D%20AND%20343%5Bvolume%5D%20AND%201454%5Bpage%5D%20AND%201994%5Bpdat%5D) 7) ACCORD and ADVANCE trials Podcast #9 (http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/) (http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/)8)UKPDS (recent results) NEJM 2008;359:1577-89 (http://content.nejm.org/cgi/content/abstract/359/15/1577) (http://www.ti.ubc.ca/podcasting/iTS/image/e29-3.png) 9) BP trial for patients over age 80 NEJM 2008;358:1887-98 (http://content.nejm.org/cgi/content/abstract/358/18/1887) Dr James McCormack and Dr Michael Allan no 35:51 http://therapeuticseducation.org/2008/11/05/episode-28-creating-confusion-or-clarity-qa-of-listener-mail/ http://therapeuticseducation.org/2008/11/05/episode-28-creating-confusion-or-clarity-qa-of-listener-mail/#comments Thu, 06 Nov 2008 01:48:47 +0000 TEC http://therapeuticseducation.org/?p=333 http://therapeuticseducation.org/2008/11/05/episode-28-creating-confusion-or-clarity-qa-of-listener-mail/feed/ 0 calcium,listener questions. PPIs,STENO In Episode 28, we review questions around osteoporosis including: bone density testing and the limits of medical tests in general; the risks (including osteoporosis) and benefits of proton pump inhibitors for heartburn; and assessing calcium intake and... In Episode 28, we review questions around osteoporosis including: bone density testing and the limits of medical tests in general; the risks (including osteoporosis) and benefits of proton pump inhibitors for heartburn; and assessing calcium intake and the possible risks of calcium. We also briefly discuss topics of risk assessors of CVD, an approach to patients using complementary alternative therapies, and make a few random, but obviously brilliant suggestions. Show Notes 1) Comparison of H2 Blocker vs PPI CADTH report on the Evidence for PPI Use in GERD (http://www.cadth.ca/media/compus/reports/compus_Scientific_Report_final.pdf) 2) Studies suggesting risk from PPI for osteoporosis/fracture and C. difficile CMAJ 2008;179:319-26 (http://www.cmaj.ca/cgi/content/abstract/179/4/319) JAMA 2005;294:2989-95. (http://jama.ama-assn.org/cgi/content/abstract/294/23/2989) 3) Calcium and vascular events BMJ 2008;336:262-6 (http://www.bmj.com/cgi/content/abstract/336/7638/262) Circulation 2007;115:846-54 (http://circ.ahajournals.org/cgi/content/abstract/115/7/846) 4) STENO – multifactorial intervention for type 2 diabetes N Engl J Med 2008;358:580-91 (http://content.nejm.org/cgi/content/abstract/358/6/580) 5) The book The Bedford Murder: An Evidence-Based Clinical Mystery (Paperback) by Marshall Godwin & Geoffrey Hodgetts (http://www.elsevier.com/wps/find/bookaudience.cws_home/697720/description) Dr James McCormack and Dr Michael Allan no 33:33 http://therapeuticseducation.org/2008/10/29/episode-27-copd-breathing-life-into-effective-some-not-copd-treatments/ http://therapeuticseducation.org/2008/10/29/episode-27-copd-breathing-life-into-effective-some-not-copd-treatments/#comments Thu, 30 Oct 2008 01:47:46 +0000 TEC http://therapeuticseducation.org/?p=331 http://therapeuticseducation.org/2008/10/29/episode-27-copd-breathing-life-into-effective-some-not-copd-treatments/feed/ 2 COPD,theophylline,vaccines In episode 27, we examine the management of COPD Exacerbation and adjunctive treatments. We review the relatively good evidence for antibiotics and steroids in Exacerbations including the options in choice, dosing, and mode of administration. In episode 27, we examine the management of COPD Exacerbation and adjunctive treatments. We review the relatively good evidence for antibiotics and steroids in Exacerbations including the options in choice, dosing, and mode of administration. We briefly examination some of the other treatment options in chronic COPD with combination puffers, immunizations, theophyline, and home oxygen. We close by discussing the general use of methylxanthines (like chocolate) for overall well-being. Show Notes 1) Vaccinations “An annual influenza vaccination reduces morbidity and mortality from the disease by as much as 50% in the elderly and reduces the incidence of hospitalization by as much as 39% in patients with chronic respiratory conditions. The benefit of pneumococcal vaccine in COPD is less well established” Can Respir J 2007;Vol 14 Suppl 5b-32b (http://www.pulsus.com:80/journals/JnlSupToc.jsp?sCurrPg=journal&jnlKy=4&supKy=418) Influenza vaccine “It appears, from the limited number of studies performed, that inactivated vaccine reduces exacerbations in COPD patients” Cochrane Library 2008 (http://www.cochrane.org/reviews/en/ab002733.html) Pneumococcal vaccine “There is no evidence from randomised controlled trials that injectable pneumococcal vaccination in persons with COPD has a significant impact on morbidity or mortality Cochrane Library 2008 (http://www.cochrane.org/reviews/en/ab001390.html) 2) Work-up for Exacerbation Can Respir J 2003;10 Suppl A:11A-65A (http://www.pulsus.com:80/journals/JnlSupToc.jsp?sCurrPg=journal&jnlKy=4&supKy=387) Ann Intern Med. 2001;134:600-620. (http://www.annals.org/cgi/content/abstract/134/7/600) 3) Acute Exacerbation “Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment” Cochrane Library 2008 (http://www.cochrane.org/reviews/en/ab001288.html) “This review shows that in COPD exacerbations with increased cough and sputum purulence antibiotics, regardless of choice, reduce the risk of short-term mortality by 77%, decrease the risk of treatment failure by 53% and the risk of sputum purulence by 44%; with a small increase in the risk of diarrhoea” Cochrane Library2008 (http://www.cochrane.org/reviews/en/ab004403.html) Can Respir J 2007;Vol 14 Suppl 5b-32b (http://www.pulsus.com:80/journals/JnlSupToc.jsp?sCurrPg=journal&jnlKy=4&supKy=418) 4) Home Oxygen Ann Intern Med. 2007;147:633-638 (http://www.annals.org/cgi/content/abstract/147/9/633) Ann Intern Med. 2007;147:639-653. (http://www.annals.org/cgi/content/abstract/147/9/639) 5) Theophylline “This systematic review shows that orally administered theophylline improves lung function and levels of oxygen and carbon dioxide in the blood. However, there is limited data on its effect on symptoms, exercise capacity or quality of life. Despite being associated with increased side effects, particularly nausea, subjects preferred theophylline over placebo.” Cochrane Library 2008 (http://www.cochrane.org/reviews/en/ab003902.html) Dr James McCormack and Dr Michael Allan no 24:10 http://therapeuticseducation.org/2008/10/22/episode-26-copd-confusing-overwhelming-puffer-data-leaving-us-breathless/ http://therapeuticseducation.org/2008/10/22/episode-26-copd-confusing-overwhelming-puffer-data-leaving-us-breathless/#comments Thu, 23 Oct 2008 01:46:35 +0000 TEC http://therapeuticseducation.org/?p=329 http://therapeuticseducation.org/2008/10/22/episode-26-copd-confusing-overwhelming-puffer-data-leaving-us-breathless/feed/ 0 COPD,inhaled corticosteroids,tiotropium In episode 26, we examine the initial management of COPD. We first discuss the diagnosis of COPD and if screening is recommended. We encourage an initial focus on smoking cessation and then episodic, symptom control. In episode 26, we examine the initial management of COPD. We first discuss the diagnosis of COPD and if screening is recommended. We encourage an initial focus on smoking cessation and then episodic, symptom control. We then review long acting puffers and the large body of confusing research with underwhelming and at times conflicting results. Unfortunately, the data available for long acting puffers serves as a good example of how more information can exacerbate confusion. Show Notes 1) Diagnosis data JAMA 2000;283:1853-7 (http://jama.ama-assn.org/cgi/content/abstract/283/14/1853) Ann Intern Med. 2007;147:633-638. (http://www.annals.org/cgi/content/abstract/147/9/633) 2) Lung decline and smoking JAMA 2003;290:2301-2312. (http://jama.ama-assn.org/cgi/content/abstract/290/17/2301) 3) Evidence only for symptomatic and FEV<60% Ann Intern Med 2007;147:639-653 (http://www.annals.org/cgi/content/abstract/147/9/639) 4) Outcomes for puffers in COPD Overall Ann Intern Med 2007;147:639-653 (http://www.annals.org/cgi/content/abstract/147/9/639) Tiotropium JGIM 2006;21:1011-9 (http://www3.interscience.wiley.com/journal/118582574/abstract) LABA/Steroid NEJM 2007;356:775-89 LABA/steroid (http://content.nejm.org/cgi/content/abstract/356/8/775) (http://www.ti.ubc.ca/podcasting/iTS/image/e26-1.png) (http://www.ti.ubc.ca/podcasting/iTS/image/e26-2.png) 5) Latest tiotropium data JAMA 2008;300:1439-50 (http://jama.ama-assn.org/cgi/content/abstract/300/12/1439) NEJM 2008;359:1543-54 (http://content.nejm.org/cgi/content/abstract/359/15/1543) (http://www.ti.ubc.ca/podcasting/iTS/image/e26-3.png) (http://www.ti.ubc.ca/podcasting/iTS/image/e26-4.png) 6) Inhaled steroid adverse events Chest. 2005;127:89-97 (http://www.chestjournal.org/cgi/content/abstract/127/1/89) NEJM 2000;343:1902-9 (http://content.nejm.org/cgi/content/abstract/343/26/1902) Cochrane 2007;4: CD 006829 (http://www.cochrane.org/reviews/en/ab006829.html) NEJM 2007;356:775-89 (http://content.nejm.org/cgi/content/abstract/356/8/775) Dr James McCormack and Dr Michael Allan no 31:29 http://therapeuticseducation.org/2008/10/15/episode-25-de-bugging-the-approaches-to-sinusitis-and-bronchitis/ http://therapeuticseducation.org/2008/10/15/episode-25-de-bugging-the-approaches-to-sinusitis-and-bronchitis/#comments Thu, 16 Oct 2008 01:45:18 +0000 TEC http://therapeuticseducation.org/?p=327 http://therapeuticseducation.org/2008/10/15/episode-25-de-bugging-the-approaches-to-sinusitis-and-bronchitis/feed/ 0 bronchitis,sinusitis,suppositories In episode 25, we finish (for now) the discussion of in-office infectious disease management. We first review a case of sinusitis including the challenges of diagnosis and the benefit of antibiotics and/or nasal steroids. In episode 25, we finish (for now) the discussion of in-office infectious disease management. We first review a case of sinusitis including the challenges of diagnosis and the benefit of antibiotics and/or nasal steroids. We then discuss a case of bronchitis with the concerns of diagnosis and the benefits of antibiotics. We wrap up our discussion of upper respiratory tract infections with a summary and tangent that will leave most listeners questioning our role as educators. Show Notes 1) Antibiotics for sinusitis Cochrane Review (http://www.cochrane.org/reviews/en/ab000243.html) 2) Steroids for sinusitis Cochrane Review (http://www.cochrane.org/reviews/en/ab000243.html) 3) Macrolides created resistance within 4 days and it lasted for at least 3 months Lancet 2007; 369:482-90 (http://www.thelancet.com/journals/lancet/article/PIIS0140673607602359/abstract) 4) Antibiotics for Bronchitis – Cochrane Library (http://www.ti.ubc.ca/podcasting/iTS/image/e25.png) 5) Suppositories – where do they fit in? Journal of Clinical Nursing 2006;16:98–103 (http://www3.interscience.wiley.com/journal/118513621/abstract) Dr James McCormack and Dr Michael Allan no 22:47 http://therapeuticseducation.org/2008/10/08/episode-24-de-bugging-the-approaches-to-ear-infections-and-strep-throat/ http://therapeuticseducation.org/2008/10/08/episode-24-de-bugging-the-approaches-to-ear-infections-and-strep-throat/#comments Thu, 09 Oct 2008 01:43:50 +0000 TEC http://therapeuticseducation.org/?p=325 http://therapeuticseducation.org/2008/10/08/episode-24-de-bugging-the-approaches-to-ear-infections-and-strep-throat/feed/ 1 fever,ibuprofen,otitis media,Strep throat In episode 24, we continue the discussion of in-office infectious disease management. We discuss a case of AOM in an 8 year old child including the signs/symptoms important in making the diagnosis, pain control and the utility of antibiotics. In episode 24, we continue the discussion of in-office infectious disease management. We discuss a case of AOM in an 8 year old child including the signs/symptoms important in making the diagnosis, pain control and the utility of antibiotics. We then discuss a case of sore throat in a 17 year old woman including a validated scoring system for diagnosis, pain control, and the utility of antibiotics. We don’t complete all upper respiratory infections but make a mess of those we do discuss. Show Notes 1) Diagnosis of AOM – does this child have acute otitis media JAMA. 2003;290:1633-1640 (http://jama.ama-assn.org/cgi/content/abstract/290/12/1633) 2) Ibuprofen vs acetaminophen for pain control and fever In musculoskeletal pain in children for every 10 children treated with ibuprofen instead of acetaminophen 1 more will have “adequate” pain relief Pediatrics 2007;119:460-7 (http://pediatrics.aappublications.org/cgi/content/abstract/119/3/460) In children with migraine, acetaminophen and ibuprofen produced similar pain relief at all endpoints (6 major endpoints) except ibuprofen treated subjects had a 20% absolute increase in the number of children who were completely pain free at 2 hours Neurology 1997;48:103-7 (http://www.neurology.org/cgi/content/abstract/48/1/103) Ibuprofen faster (by 26 minutes) for time to fever clearance and a greater time (39 minutes) without fever in the first 4 hours (39 minutes) compared to acetaminophen. No difference in symptoms of discomfort. BMJ 2008;337;a1302 (http://www.bmj.com/cgi/content/abstract/337/sep02_2/a1302) Meta-analysis of ibuprofen versus acetaminophen for pain or fever. In children, single doses of ibuprofen and acetaminophen have similar efficacy for relieving moderate to severe pain, and similar safety as analgesics or antipyretics. Ibuprofen was a more effective antipyretic than acetaminophen at 2, 4, and 6 hours post-treatment. Arch Pediatr Adolesc Med 2004;158:521-6 (http://archpedi.ama-assn.org/cgi/content/abstract/158/6/521) 3) Compared “love” of parent vs television Arch Dis Child 2006;91:1015-7 (http://adc.bmj.com/cgi/content/abstract/91/12/1015) 4) Antibiotic treatment of AOM – Cochrane Library (http://www.ti.ubc.ca/podcasting/iTS/image/e24-1.png) 5) Scoring system for Strep Throat. CMAJ. 1998;158:75-83 (http://www.cmaj.ca/cgi/content/abstract/158/1/75) CMAJ. 2000; 163:811-815 (http://www.cmaj.ca/cgi/content/abstract/163/7/811) 6) Antibiotic treatment of Strep throat – Cochrane Library (http://www.ti.ubc.ca/podcasting/iTS/image/e24-2.png) 7) Meta-analysis of short course antibiotic treatment for Group A Streptococcal tonsillopharyngitis Pediatr Infect Dis J 2005;24:909–17 (http://www.pidj.com/pt/re/pidj/abstract.00006454-200510000-00012.htm;jsessionid=LsXbj9CJckRPvQk7JTK9whNKVbvqrLLrmJzZGQPC6H7G0zsxD8Th!-2060166207!181195629!8091!-1) Dr James McCormack and Dr Michael Allan no 33:55 http://therapeuticseducation.org/2008/10/01/episode-23-de-bugging-the-approach-to-pneumonia/ http://therapeuticseducation.org/2008/10/01/episode-23-de-bugging-the-approach-to-pneumonia/#comments Thu, 02 Oct 2008 01:42:22 +0000 TEC http://therapeuticseducation.org/?p=323 http://therapeuticseducation.org/2008/10/01/episode-23-de-bugging-the-approach-to-pneumonia/feed/ 0 amoxicillin,pneumonia In episode 23, we begin the discussion of antibiotic prescribing in common respiratory tract infections with a focus on pneumonia. We talk about the limited evidence for the clinical exam in diagnosing pneumonia. In episode 23, we begin the discussion of antibiotic prescribing in common respiratory tract infections with a focus on pneumonia. We talk about the limited evidence for the clinical exam in diagnosing pneumonia. We review the variability in antibiotics suggested in guidelines and evidence for coverage of atypical pneumonia. We also discuss the research on dosing and duration of antibiotics. We find out what antibiotic James and Mike would take (and some infections they have had)! Show Notes 1) Contributions of symptoms, signs, and other things to the diagnosis of pneumonia. Br J Gen Pract 2003;53:358–64 (http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1314594) 2) Do you cover for atypical organisms or not when you are treating pneumonia? Community acquired BMJ 2005;330:456-9 (http://www.bmj.com/cgi/content/abstract/330/7489/456) Hospitalized patients Cochrane Review (http://www.cochrane.org/reviews/en/ab004418.html) 3) Amoxicillin for community acquired pneumonia – use 500 to 1000 mg TID Thorax 2001;56(Suppl 4):iv1-iv64 (http://thorax.bmj.com/cgi/content/full/56/suppl_4/iv1) 4) Shorter duration and treating until “feeling better” for 72hours “Until further data are available, it seems reasonable to treat bacterial infections such as those caused by S. pneumoniae until a patient is afebrile for 72 h” Lancet 2003;362:1991–2001 (http://www.thelancet.com/journals/lancet/article/PIIS0140673603150210/abstract) Three days of antibiotics for hospitalized patients with community acquired pneumonia BMJ 2006;332:1355 (http://www.bmj.com/cgi/content/abstract/332/7554/1355) Dr James McCormack and Dr Michael Allan no 26:12 http://therapeuticseducation.org/2008/09/24/episode-22-the-down-low-on-low-dose-the-how-to/ http://therapeuticseducation.org/2008/09/24/episode-22-the-down-low-on-low-dose-the-how-to/#comments Thu, 25 Sep 2008 01:41:17 +0000 TEC http://therapeuticseducation.org/?p=321 http://therapeuticseducation.org/2008/09/24/episode-22-the-down-low-on-low-dose-the-how-to/feed/ 0 low dose,placebo In our 22nd episode we continue our low dose discussion. We talk about the concept of n-of-1 trials and allowing patients to determine their dose. We review some of the benefits of low-dose prescribing, such as low side-effect risk and reduced costs, In our 22nd episode we continue our low dose discussion. We talk about the concept of n-of-1 trials and allowing patients to determine their dose. We review some of the benefits of low-dose prescribing, such as low side-effect risk and reduced costs, but emphasize the medical conditions in which low doses are inappropriate. We end by offering some practical suggestions to assist patients with very low doses (in which James forces Mike to acknowledge the superior power of pharmacists). Show Notes 1) Placebo what it is and should you use it - go with low dose instead? BMJ 2008;336;1020 (http://www.bmj.com/cgi/content/extract/336/7651/1020) BMJ 1995; 311:551-3 (http://www.bmj.com/cgi/content/extract/311/7004/551) 2) Cost has an effect on adherence Med Care 2001 39: 296–301 (http://www.lww-medicalcare.com/pt/re/medcare/abstract.00005650-200103000-00009.htm;jsessionid=LZTDQhpyVW5W5kyTTZG27LcmvV47cHr0qphRcc8Pcs5xz3dtHKlp!1177656273!181195629!8091!-1) J Manag Care Pharm 2006 12: 377–382 (http://www.amcp.org/data/jmcp/research_377-382.pdf) Dr James McCormack and Dr Michael Allan no 19:26 http://therapeuticseducation.org/2008/09/17/episode-21-the-down-low-on-low-dose-the-logic/ http://therapeuticseducation.org/2008/09/17/episode-21-the-down-low-on-low-dose-the-logic/#comments Thu, 18 Sep 2008 01:40:15 +0000 TEC http://therapeuticseducation.org/?p=319 http://therapeuticseducation.org/2008/09/17/episode-21-the-down-low-on-low-dose-the-logic/feed/ 0 bupropion,captopril,fluoxetine,HCTZ,iron,low dose,sildenafil,TCAs In our 21st episode we jump into our ongoing debate about low and very low dose of medication. We present the reason why initial doses of new drugs are often too high and the logic for trialing lower doses in patients. In our 21st episode we jump into our ongoing debate about low and very low dose of medication. We present the reason why initial doses of new drugs are often too high and the logic for trialing lower doses in patients. We also review over 10 examples of medications proven in randomized control trials to be equally effective (or more) at lower doses. Although promoting low dose, the size of the podcast is moderate dose (while the quality is high dose with minimal side-effects). Show Notes 1) Examples of evidence for effective lower doses – these examples typically show lower doses were as effective as higher doses, but in some of the examples higher doses were somewhat more effective but lower doses nonetheless produced clinically important results 6.25 mg of hydrochlorothiazide is effective at lowering blood pressure, and comes in a number of combination products - initially 50 to 200 mg was the recommended starting dose Arch Int Med 1994;154:1461-8 (http://archinte.ama-assn.org/cgi/content/abstract/154/13/1461) 6.25 mg of captopril has been shown to be effective for blood pressure yet captopril 25 mg PO TID is still a commonly recommended initial starting dose for hypertension. Circulation 1983;67:1340-6 (http://www.ncbi.nlm.nih.gov/pubmed/6342835) 25 mg of sildenafil (Viagra) has been shown to be an effective dose for erectile dysfunction Bandolier (http://www.medicine.ox.ac.uk/bandolier/booth/SexHlth/Viag.html) 25 mg of sumatriptan (Imitrex) works almost as well as100 mg and in fact for most drugs in this class there is a flat dose-response curve seen at the doses studied. Cephalalgia 2002;22:633-58. (http://www3.interscience.wiley.com/journal/118953152/abstract) 5 mg daily of fluoxetine (Prozac) has been shown to have an effect similar to 20 mg daily. N Engl J Med 1994;331:1354-61 (http://content.nejm.org/cgi/content/extract/331/20/1354) 0.25 mg (1/40th of the recommended initial starting dose of 10 mg) of ezetimibe (Ezetrol) provides 50% of the LDL lowering effect seen with 10 mg Clin Ther 2001;23:1209-30 (http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6VRS-446636M-M&_user=1022551&_coverDate=08%2F31%2F2001&_rdoc=7&_fmt=high&_orig=browse&_srch=doc-info(%23toc%236242%232001%23999769991%23267945%23FLP%23display%23Volume)&_cdi=6242&_sort=d&_docanchor=&_ct=15&_acct=C000050484&_version=1&_urlVersion=0&_userid=1022551&md5=88339d76e7ace189519b50fbf756093e) 15 mg of elemental iron daily has been shown to be as effective for anemia as 50 mg and 150 mg, with a lower incidence of side effects. Am J Med 2005;118:1142-7 (http://www.amjmed.com/article/S0002-9343(05)00210-X/abstract) 150 mg daily of bupropion (Zyban) produces the same rate of smoking cessation at one year as 300 mg daily. N Engl J Med 1997;337:1195-202 (http://content.nejm.org/cgi/content/abstract/337/17/1195) 200 mg of ibuprofen (Motrin) is as effective as 400 mg for migraine headache. Headache 2001;41:665-79 (http://www3.interscience.wiley.com/journal/119014621/abstract) 25 mg of ranitidine (Zantac) has been shown to be as effective as 125 mg for heartburn relief. Aliment Pharmacol Ther 1999;13:475-81 (http://www3.interscience.wiley.com/journal/119090070/abstract) Compared to standard-dose treatment, low-doses of depot antipsychotics improve psychosocial function and reduce the frequency of side effects. Schizophrenia bulletin 1993;19:155-64 (http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/19/1/155) Tricyclic antidepressant doses of 75-100mg are as effective for depression as doses greater than100mg. BMJ 2002;325:991-5 (http://www.bmj.com/cgi/content/abstract/325/7371/991) 500 and 1000 µg of oral B12 was more effective than 2.5, 100 or 250 µg at improving the surrogate marker of B12 deficiency (methylmalonic acid). Arch Intern Med. 2005;165:1167-1172 (http://archinte.ama-assn.org/cgi/content/abstract/165/10/1167) Meta-analysis showing higher doses of statins produced greater reductions in cardiovascular events – as an aside, Dr James McCormack and Dr Michael Allan no 26:53 http://therapeuticseducation.org/2008/09/10/episode-20-mysteries-within-enigmas-answering-listener-mail/ http://therapeuticseducation.org/2008/09/10/episode-20-mysteries-within-enigmas-answering-listener-mail/#comments Thu, 11 Sep 2008 01:39:08 +0000 TEC http://therapeuticseducation.org/?p=317 http://therapeuticseducation.org/2008/09/10/episode-20-mysteries-within-enigmas-answering-listener-mail/feed/ 0 antidepressants,bisphosphonates,listener questions,statins In our 20th episode we try to answer our accumulating listener mail. We review questions around cardiovascular disease risk-benefits and try to demystify the calculators. Listeners question antidepressants: when they should start to work, In our 20th episode we try to answer our accumulating listener mail. We review questions around cardiovascular disease risk-benefits and try to demystify the calculators. Listeners question antidepressants: when they should start to work, when to change dose/type and their use for chronic pain. Other issues include stopping bisphosphonates, addressing the placebo effect and uncertainties with industry funded trials. In the end, Mike talks about Giraffes and James becomes spastic. Show Notes 1) Meta-analysis data for mortality benefit with statins in primary prevention TI meta-analysis on statins in women for primary prevention. (http://www.ti.ubc.ca/letter48) "For women without cardiovascular disease, lipid lowering does not affect total or CHD mortality. Lipid lowering may reduce CHD events, but current evidence is insufficient to determine this conclusively.” JAMA 2004;291:2243-52 (http://www.ncbi.nlm.nih.gov/pubmed/15138247?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum) 2) Don’t change the doses of antidepressants too quickly Br J Psyc 2006;189:309–16 (http://bjp.rcpsych.org/cgi/content/abstract/189/4/309) 3) How quickly do antidepressants work? Arch Gen Psyc 2006; 63: 1217-23. (for how fast anti-depressants work) (http://archpsyc.ama-assn.org/cgi/content/abstract/63/11/1217) 4) How long do we use bisphosphonates? N Engl J Med 2004;350:1189–1199 (http://content.nejm.org/cgi/content/abstract/350/12/1189) JAMA 2006;296:2927-38 (http://jama.ama-assn.org/cgi/content/abstract/296/24/2927) Dr James McCormack and Dr Michael Allan no 42:51 http://therapeuticseducation.org/2008/09/03/episode-19-osteoporosis-treating-for-fracture-reduction/ http://therapeuticseducation.org/2008/09/03/episode-19-osteoporosis-treating-for-fracture-reduction/#comments Thu, 04 Sep 2008 01:37:18 +0000 TEC http://therapeuticseducation.org/?p=315 http://therapeuticseducation.org/2008/09/03/episode-19-osteoporosis-treating-for-fracture-reduction/feed/ 0 bisphosphonates,osteoporosis ptions in treatment, which ones have evidence of non-vertebral fracture and the absolute benefits of those treatments. We discuss reliability of monitoring bone density of patients on therapy and the duration of therapy. ptions in treatment, which ones have evidence of non-vertebral fracture and the absolute benefits of those treatments. We discuss reliability of monitoring bone density of patients on therapy and the duration of therapy. Show Notes 1) Evidence for fracture reduction There is good evidence from randomized controlled trials (RCTs) that alendronate, etidronate, ibandronate, risedronate, calcitonin, 1-34 PTH, and raloxifene prevent vertebral fractures compared with placebo. There is good evidence from RCTs that risedronate and alendronate prevent both nonvertebral and hip fractures compared with placebo. There is good evidence that zoledronic acid prevents vertebral and nonvertebral fractures, and fair evidence that it prevents hip fractures. Agency for healthcare research and quality - report (http://effectivehealthcare.ahrq.gov/healthInfo.cfm?infotype=rr&DocID=73&ProcessID=8) 2) Calcitonin appears to be effective in the management of acute pain associated with acute osteoporotic vertebral compression fractures by shortening time to mobilization Osteoporosis Int 2005;16:1281-90 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term="Osteoporosis international %3A a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA"[Jour] AND 1281[page] AND 2005[pdat]) 3) Relative and absolute benefits from using alendronate for 2-3 years Approximately 45% reduction in vertebral fractures – 2% absolute reduction for primary and 6% for secondary 20% reduction in non-vertebral - just secondary prevention – 2% absolute reduction 50% reduction in hip fractures - just secondary prevention – 1% absolute reduction Cochrane Library (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001155/frame.html) Dr James McCormack and Dr Michael Allan no 21:18 http://therapeuticseducation.org/2008/08/27/episode-18-osteoporosis-the-initial-approach-to-bone-density/ http://therapeuticseducation.org/2008/08/27/episode-18-osteoporosis-the-initial-approach-to-bone-density/#comments Thu, 28 Aug 2008 01:35:44 +0000 TEC http://therapeuticseducation.org/?p=313 http://therapeuticseducation.org/2008/08/27/episode-18-osteoporosis-the-initial-approach-to-bone-density/feed/ 0 bone density,osteoporosis,vitamin D In episode 18 we consider the approach to questions of bone density and fracture risk. We use a series of cases to work through the risk of osteoporosis (using a simple tool) and help us decide on bone mineral density testing. In episode 18 we consider the approach to questions of bone density and fracture risk. We use a series of cases to work through the risk of osteoporosis (using a simple tool) and help us decide on bone mineral density testing. We discuss initial options in the prevention of fractures including weight-bearing exercise, Calcium and Vitamin D (and its additional advantages). Show Notes 1) Osteoporosis self-assessment tool – estimating risk of osteoporosis (http://www.ti.ubc.ca/podcasting/iTS/image/e18-1.jpg) 2) Vitamin D and Calcium (for fracture) (http://www.ti.ubc.ca/podcasting/iTS/image/e18-2.jpg) (http://www.ti.ubc.ca/podcasting/iTS/image/e18-3.jpg) 3) Vitamin D and falling risk JAMA 2004;291:1999-2006 (http://jama.ama-assn.org/cgi/content/abstract/291/16/1999) 4) Meta-analysis of Vit D on Mortality Arch Intern Med 2007;167:1730-1737 (http://archinte.ama-assn.org/cgi/content/abstract/167/16/1730) Dr James McCormack and Dr Michael Allan no 21:02 http://therapeuticseducation.org/2008/08/20/episode-17-anti-depressants-some-issues-in-managing-depression/ http://therapeuticseducation.org/2008/08/20/episode-17-anti-depressants-some-issues-in-managing-depression/#comments Thu, 21 Aug 2008 01:34:32 +0000 TEC http://therapeuticseducation.org/?p=311 http://therapeuticseducation.org/2008/08/20/episode-17-anti-depressants-some-issues-in-managing-depression/feed/ 0 Adil Virani,antidepressants,fluoxetine In episode 17 we look at managing the treatment of depression once we’ve started a medication. We discuss the patient conversations necessary for initiating treatment including the patient perception of the illness, In episode 17 we look at managing the treatment of depression once we’ve started a medication. We discuss the patient conversations necessary for initiating treatment including the patient perception of the illness, expectations and potential side-effects. We debate the quandaries around starting doses, when or if to increase, duration of therapy and relapse prevention. Although we use available evidence, we acknowledge some of our advice is Best-Guess based medicine. Show Notes 1) Monitoring form for using antidepressants in children and adolescents (http://www.bcmhas.ca/NR/rdonlyres/1A00C3FA-D970-4687-BB17-7991F8CECF95/20240/AntidepressantMonitoringFormSept06v4.pdf  ) 2) Clinical tool to monitor antidepressant treatment (http://www.atypon-link.com/GPI/doi/pdf/10.1521/capn.2005.10.8.4) 3) Scales, doctors finding benefit (when there isn’t any) Lancet 2004;363:1341-5 (http://www.thelancet.com/journals/lancet/article/PIIS0140673604160431/abstract) 4) Investigators' conclusions on the efficacy of newer antidepressants in childhood depression have exaggerated their benefits BMJ 2004;328:879-83 (http://www.bmj.com/cgi/content/extract/328/7444/879) 5) Benefit seen in 1 week with antidepressants Arch Gen Psychiatry 2006;63:1217-23 (http://archpsyc.ama-assn.org/cgi/content/abstract/63/11/1217) 6) The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases Am J Psychiatry 2000;157:229–233) (http://ajp.psychiatryonline.org/cgi/content/abstract/157/2/229) 7) Relapse due to stopping meds - relapse at 12 months – 18% on drugs 41% on placebo Lancet 2003;361:653–51 (http://www.thelancet.com/journals/lancet/article/PIIS0140673603125998/abstract) 8) 5mg of fluoxetine works Psychopharmacology Bulletin 1988;24:183-8 Click here to download article (http://www.ti.ubc.ca/podcasting/iTS/resource/Low-dose-fluoxetine.pdf) Dr James McCormack and Dr Michael Allan no 20:02 http://therapeuticseducation.org/2008/08/13/episode-16-anti-depressants-is-there-a-drug-of-choice/ http://therapeuticseducation.org/2008/08/13/episode-16-anti-depressants-is-there-a-drug-of-choice/#comments Thu, 14 Aug 2008 01:33:09 +0000 TEC http://therapeuticseducation.org/?p=309 http://therapeuticseducation.org/2008/08/13/episode-16-anti-depressants-is-there-a-drug-of-choice/feed/ 0 Adil Virani,amitriptyline,antidepressants,depression,fluoxetine In episode 16 we look at initiating treatment for depression. We briefly review screening and the diagnosis of depression before discussing the non-drug treatment options (therapy, exercise, sleep hygiene). In episode 16 we look at initiating treatment for depression. We briefly review screening and the diagnosis of depression before discussing the non-drug treatment options (therapy, exercise, sleep hygiene). We search for the anti-depressant of choice (being any) and end up deciding to tailor the choice based on factors such as side-effect profile, targeted symptoms, and cost. Although we stress the importance of regular follow-up, James refuses to come to see Mike or Adil. Show Notes 1) Two screening questions for depression - do you feel depressed, do you have little interest in doing things BMJ 2003; 327:1144-46 (http://www.bmj.com/cgi/content/abstract/327/7424/1144) J Gen Intern Med. 1997;12:439-45 (http://www3.interscience.wiley.com/journal/120836280/abstract) 2) Benefit seen in 1 week with antidepressants Arch Gen Psychiatry 2006;63:1217-23 (http://archpsyc.ama-assn.org/cgi/content/abstract/63/11/1217) 3) No difference between the second generation antidepressants in effect Ann Intern Med. 2005;143 :415-26 (http://www.annals.org/cgi/content/abstract/143/6/415) 4) Weight benefit with fluoxetine. Arch Intern Med 2004;164:1395-1404 (http://archinte.ama-assn.org/cgi/content/abstract/164/13/1395) 5) Amitriptyline is as effective as other tricyclics or newer agents Cochrane Library (http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004186/frame.html) 6) Monitoring form for using antidepressants in children and adolescents (http://www.bcmhas.ca/NR/rdonlyres/1A00C3FA-D970-4687-BB17-7991F8CECF95/20240/AntidepressantMonitoringFormSept06v4.pdf  ) 7) Clinical tool to monitor antidepressant treatment (http://www.atypon-link.com/GPI/doi/pdf/10.1521/capn.2005.10.8.4) Dr James McCormack and Dr Michael Allan no 22:25 http://therapeuticseducation.org/2008/08/06/episode-15-treating-depression-the-recent-sad-news-about-anti-depressants/ http://therapeuticseducation.org/2008/08/06/episode-15-treating-depression-the-recent-sad-news-about-anti-depressants/#comments Thu, 07 Aug 2008 01:31:23 +0000 TEC http://therapeuticseducation.org/?p=307 http://therapeuticseducation.org/2008/08/06/episode-15-treating-depression-the-recent-sad-news-about-anti-depressants/feed/ 0 Adil Virani,depression,fluoxetine,SSRIs In episode 15 a guest assists us in addressing the evidence suggesting anti-depressants are not as effective as believed. We review some biases in the anti-depressant research including publication bias (how good studies are published more than bad stu... In episode 15 a guest assists us in addressing the evidence suggesting anti-depressants are not as effective as believed. We review some biases in the anti-depressant research including publication bias (how good studies are published more than bad studies). We discuss how the benefits of anti-depressants over placebo increase as the severity of depression worsens. James prompts us to explain the effectiveness of the medications; although we dodge, some vague commitments do manage to escape. Show Notes 1) Selective publication of selective serotonin reuptake inhibitors data BMJ 2003;326:1171-73 (http://www.bmj.com/cgi/content/abstract/326/7400/1171) 2) Another select report on the selective publication of selective serotonin reuptake inhibitors NEJM 2008; 358: 252 (http://content.nejm.org/cgi/content/abstract/358/3/252) 3) Antidepressants have a clinically important effect above placebo only in patients with severe depression PLOS 2008:5(2):0260-8 (http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050045) 4) Fluoxetine – evidence for benefit in children – others maybe not? Lancet 2004;363:1341-5 (http://www.thelancet.com/journals/lancet/article/PIIS0140673604160431/abstract) 5) In children, with antidepressants, the magnitude of benefit is unlikely sufficient to justify the harms http://www.bmj.com/cgi/content/full/328/7444/879 (http://www.bmj.com/cgi/content/full/328/7444/879) Dr James McCormack and Dr Michael Allan no 16:07 http://therapeuticseducation.org/2008/07/30/episode-14-listener-mail-addressing-the-questions-and-confusion/ http://therapeuticseducation.org/2008/07/30/episode-14-listener-mail-addressing-the-questions-and-confusion/#comments Thu, 31 Jul 2008 01:29:00 +0000 TEC http://therapeuticseducation.org/?p=305 http://therapeuticseducation.org/2008/07/30/episode-14-listener-mail-addressing-the-questions-and-confusion/feed/ 0 cholesterol,high blood pressure,listener questions In episode 14 we attempt to answer some of the mail received from listeners. We talk about using the evidence to promote shared decision-making. We review calculating risk, the limitations of risk calculators and presenting the data in the positive (... In episode 14 we attempt to answer some of the mail received from listeners. We talk about using the evidence to promote shared decision-making. We review calculating risk, the limitations of risk calculators and presenting the data in the positive (chance of not having an event). We address heart disease as the leading cause of mortality (despite advancement in treatment) and emerging discussions of statin use in children (age ?8). We unwrap these enigmas to create more confusion. Show Notes 1) Some references showing high cholesterol in patients over age 75-80 is not necessarily associated with increased mortality or sometimes not even increased cardiovascular disease. Ann Epidemiol 2004;14:705–21 (http://www.annalsofepidemiology.org/article/S1047-2797(03)00358-2/abstract) JAMA 1994;272:1335-40 (http://jama.ama-assn.org/cgi/content/abstract/272/17/1335) Ann Int Med 1997;126:753-60 (http://www.annals.org/cgi/content/abstract/126/10/753) J Am Geriatr Soc 2004;52:1639-47 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=%22Journal%20of%20the%20American%20Geriatrics%20Society%22%5BJour%5D%20AND%201639%5Bpage%5D%20AND%202004%5Bpdat%5D) Arch Int Med 2003;163:1549-54 (http://archinte.ama-assn.org/cgi/content/abstract/163/13/1549) J Am Geriatr Soc 2005;53:2159-64 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=%22Journal%20of%20the%20American%20Geriatrics%20Society%22%5BJour%5D%20AND%202159%5Bpage%5D%20AND%202005%5Bpdat%5D) J Am Geriatr Soc 2005;53:219-26 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=%22Journal%20of%20the%20American%20Geriatrics%20Society%22%5BJour%5D%20AND%20219%5Bpage%5D%20AND%202005%5Bpdat%5D) 2) Treatment of hypertension in patients 80 years of age or older reduces the chance of a cardiovascular event by 3% over 2 years NEJM 2008;358:1887-98 (http://content.nejm.org/cgi/content/abstract/358/18/1887) Dr James McCormack and Dr Michael Allan no 20:22 http://therapeuticseducation.org/2008/07/23/episode-13-butt-outsilencing-%e2%80%9cthe-smoking-gun%e2%80%9d-in-health/ http://therapeuticseducation.org/2008/07/23/episode-13-butt-outsilencing-%e2%80%9cthe-smoking-gun%e2%80%9d-in-health/#comments Thu, 24 Jul 2008 01:25:06 +0000 TEC http://therapeuticseducation.org/?p=303 http://therapeuticseducation.org/2008/07/23/episode-13-butt-outsilencing-%e2%80%9cthe-smoking-gun%e2%80%9d-in-health/feed/ 0 bupropion,nortriptyline,smoking cessation,varenecline In our 13th episode, we discuss smoking cessation. We present the impressive benefits in hard outcomes when people stop smoking. We then go through the list of interventions, from brief advice to the pharmaceutical options of nicotine replacement, In our 13th episode, we discuss smoking cessation. We present the impressive benefits in hard outcomes when people stop smoking. We then go through the list of interventions, from brief advice to the pharmaceutical options of nicotine replacement, two anti-depressants (Buproprion or Nortiriptyline) and the newest agent, Varenicline. Dosing, cessation rates and adverse events are reviewed (for medications, not cigarettes: that dose is zero). Show Notes 1) Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease Chest 2007; 131: 446–52. (http://www.chestjournal.org/cgi/content/abstract/131/2/446) 2) Listening empathetically and asking if they are ready to quit smoking Silagy C, Ketteridge S. The effectiveness of physician advice to aid smoking cessation. Cochrane Database of Systematic Reviews 1998. Issue 2 (http://www.ti.ubc.ca/letter21) 3) Bupropion at a dose of 150 mg daily works as well as 300 mg daily New Engl J Med 1997; 337:1195-202 (http://content.nejm.org/cgi/content/abstract/337/17/1195) 4) Nortriptyline and bupropion for smoking cessation Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1 (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000031/frame.html) 5) Varenicline for smoking cessation Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2008. Issue 3 (http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD006103/frame.html) Dr James McCormack and Dr Michael Allan no 18:38 http://therapeuticseducation.org/2008/07/16/episode-12-getting-hyper-tense-about-monitoring/ http://therapeuticseducation.org/2008/07/16/episode-12-getting-hyper-tense-about-monitoring/#comments Thu, 17 Jul 2008 01:23:33 +0000 TEC http://therapeuticseducation.org/?p=301 http://therapeuticseducation.org/2008/07/16/episode-12-getting-hyper-tense-about-monitoring/feed/ 0 beta-blockers,COPD,HCTZ,high blood pressure In our 12th episode, we divide and conquer the remaining points around hypertension. In section A, we talk about monitoring blood pressure: frequency, reliability and home monitoring are all discussed. In section B, In our 12th episode, we divide and conquer the remaining points around hypertension. In section A, we talk about monitoring blood pressure: frequency, reliability and home monitoring are all discussed. In section B, we talk about the potential side-effects of different hypertension therapies and the need to monitor for biochemical-metabolic effects. In the end, Mike is hyper and James is tense but both need therapy. Show Notes 1) Effect of home blood pressure monitoring on blood pressure BMJ 2004;329:145 (http://www.bmj.com/cgi/content/abstract/329/7458/145) 2) Hypokalemia and metabolic effects of thiazides are dose related BMJ 1990;300:975 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=BMJ[Jour] AND 975[page] AND 1990[pdat]) 3) Cardioselective beta-blockers in mild-moderate asthma and COPD Cardioselective beta-blockers in asthma Ann Intern Med. 2002;137:715-725 (http://www.annals.org/cgi/content/abstract/137/9/715) Cardioselective beta-blockers in COPD Cochrane library (http://www.cochrane.org/reviews/en/ab003566.html) Other resources * Beta-Blockers in Asthma (Ann-Intern-Med, 2003) (http://www.ti.ubc.ca/podcasting/iTS/resource/Beta-Blockers_in_Asthma.pdf) * Beta-Blockers in COPD (cochrane, 2005) (http://www.ti.ubc.ca/podcasting/iTS/resource/Beta-Blockers_in_COPD.pdf) * Meta-analysis of home BP monitoring (BMJ, 2004) (http://www.ti.ubc.ca/podcasting/iTS/resource/meta-analysis_of_home_BP_monitoring.pdf) (http://www.ti.ubc.ca/podcasting/iTS/image/e12-thiazids.gif) Dr James McCormack and Dr Michael Allan no 26:27 http://therapeuticseducation.org/2008/07/09/episode-11-taking-the-pressure-off-other-drugs/ http://therapeuticseducation.org/2008/07/09/episode-11-taking-the-pressure-off-other-drugs/#comments Thu, 10 Jul 2008 01:21:37 +0000 TEC http://therapeuticseducation.org/?p=299 http://therapeuticseducation.org/2008/07/09/episode-11-taking-the-pressure-off-other-drugs/feed/ 0 ALLHAT,atenolol,beta-blockers,high blood pressure,spironolactone In our 11th episode, we discuss the laundry list of the remaining hypertensive medications and their evidence. The issue of blood pressure as a surrogate marker is discussed and we encourage clinicians to focus on hypertensive agents that effect patie... In our 11th episode, we discuss the laundry list of the remaining hypertensive medications and their evidence. The issue of blood pressure as a surrogate marker is discussed and we encourage clinicians to focus on hypertensive agents that effect patient oriented outcomes. While the evidence is reasonable for Ca+ Blocker, we put Beta-blockers low down (and Atenolol off) the list with Alpha-blockers and a few others.We have few laughs along the way, primarily at our lack of humor. Show Notes 1) Atenolol no better than placebo and other drugs are better than atenolol in reducing cardiovascular outcomes in patents with high blood pressure Lancet 2004;364:1684–9 (http://www.thelancet.com/journals/lancet/article/PIIS0140673604173558/abstract) 2) Beta-blockers do appear to increase the chance of developing diabetes Am J Cardiol 2007;100:1254–62 (http://www.ajconline.org/article/S0002-9149(07)01332-X/abstract) 3) A debate on using or not using betablockers for high blood pressure Can Fam Physician 2007;53:614-7 (http://www.cfp.ca/cgi/content/full/53/4/614-a) 4) ALLHAT – the problem with alpha-blockers JAMA 2000;283:1967-75 (http://jama.ama-assn.org/cgi/content/abstract/283/15/1967) 5) Data for felodipine and cardiovascular events in patients with high blood pressure Lancet 1998;351:1755-62 (http://www.thelancet.com/journals/lancet/article/PIIS0140673698043116/abstract) 6) Use of low-dose spironolactone in “resistant” hypertension Amer J Hyper 2003;16:925–30 (http://www.nature.com/ajh/journal/v16/n11/abs/ajh2003173a.html) 7) Effect of spironolactone on albuminuria Diabetes Care 2005;28:2106–12 (http://care.diabetesjournals.org/cgi/content/abstract/28/9/2106) Dr James McCormack and Dr Michael Allan no 19:27 http://therapeuticseducation.org/2008/07/02/episode-10-taking-the-pressure-off-ace-inhibitors/ http://therapeuticseducation.org/2008/07/02/episode-10-taking-the-pressure-off-ace-inhibitors/#comments Thu, 03 Jul 2008 01:19:40 +0000 TEC http://therapeuticseducation.org/?p=297 http://therapeuticseducation.org/2008/07/02/episode-10-taking-the-pressure-off-ace-inhibitors/feed/ 0 ACEI,ARB,high blood pressure In our tenth episode, we discuss our second choice of hyperåtensive medication agent, the ACE inhibitor. We review dosing and renal protection (briefly) before agreeing our choice is based mostly on once a day adminstration and costs. In our tenth episode, we discuss our second choice of hyperåtensive medication agent, the ACE inhibitor. We review dosing and renal protection (briefly) before agreeing our choice is based mostly on once a day adminstration and costs. We look at substituting with ARBs but not combining with ARBs (with possible exception of co-morbid CHF). Throughout the podcast, James disagrees with Mike on a variety of issues, more on principle than fact. Show Notes 1) A meta-analysis of ACE inhibitors/ARBs versus other antihypertensive drugs on renal outcomes - in diabetics, no difference in end-stage renal disease or doubling of creatinine - albuminuria was reduced but remember this is a surrogate endpoint Lancet 2005;366:2026-33 (http://www.thelancet.com/journals/lancet/article/PIIS0140673605678142/abstract) 2) Telmisartan produced the same outcome as ramipril in diabetics – the combination did not add benefit but increased adverse events N Engl J Med 2008;358:1547-59 (http://content.nejm.org/cgi/content/abstract/358/15/1547) 3) Combining ACEs and ARBs in heart failure did produce a benefit Lancet. 2003;362:767-71 (http://www.thelancet.com/journals/lancet/article/PIIS0140673603142833/abstract) Dr James McCormack and Dr Michael Allan no 17:38 http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/ http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/#comments Thu, 26 Jun 2008 01:17:32 +0000 TEC http://therapeuticseducation.org/?p=294 http://therapeuticseducation.org/2008/06/25/episode-9-news-flash-aggressive-blood-sugar-control-not-all-sweet/feed/ 0 ACCORD,ADVANCE,diabetes,glucose monitoring In our ninth episode, we interrupt our regularly scheduled podcast to talk about the recently released ACCORD and ADVANCE trials which focus on intensive glucose control (reduction) in diabetes. We discuss the patient-oriented outcomes and harms, In our ninth episode, we interrupt our regularly scheduled podcast to talk about the recently released ACCORD and ADVANCE trials which focus on intensive glucose control (reduction) in diabetes. We discuss the patient-oriented outcomes and harms, ranging from mortality to hypoglycemia, as well as the potential benefits such as preventing microalbuminuria. Evidence regarding patient blood sugar monitoring is reviewed while reminding listeners how much fun monitoring is for our patients. Show Notes 1) A synopsis of what was reported in the ACCORD and ADVANCE studies. Download PDF (http://www.ti.ubc.ca/podcasting/iTS/image/accord-advance.pdf) N Engl J Med 2008 358:2545-2559 (http://content.nejm.org/cgi/content/abstract/358/24/2545) N Engl J Med 2008 358:2560-2572 (http://content.nejm.org/cgi/content/abstract/358/24/2560) 2) Studies of monitoring blood sugar in type 2 diabetics showing no benefit and increased depression scores BMJ. 2007 Jul 21;335(7611):105-6 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=BMJ[Jour] AND 132[page] AND 2007[pdat]) BMJ. 2008 May 24;336(7654):1174-7 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=BMJ[Jour] AND 1174[page] AND 2008[pdat]) Dr James McCormack and Dr Michael Allan no 18:36 http://therapeuticseducation.org/2008/06/18/episode-8-taking-the-pressure-off-hypertension-drugs/ http://therapeuticseducation.org/2008/06/18/episode-8-taking-the-pressure-off-hypertension-drugs/#comments Thu, 19 Jun 2008 01:14:32 +0000 TEC http://therapeuticseducation.org/?p=291 http://therapeuticseducation.org/2008/06/18/episode-8-taking-the-pressure-off-hypertension-drugs/feed/ 2 ACEI,ALLHAT,ARB,CCB,HCTZ,high blood pressure In our eighth installment, we discuss the initiation of hypertensive drug therapy. In recommending thiazide diuretics, we outline the evidence (e.g. ALLHAT trial) showing equivalence and the significantly lower yearly cost. In our eighth installment, we discuss the initiation of hypertensive drug therapy. In recommending thiazide diuretics, we outline the evidence (e.g. ALLHAT trial) showing equivalence and the significantly lower yearly cost. We debate (politely this time) dosing and attempt to dispel the smokescreen of thiazide metabolic issues (e.g. blood glucose). The usual banter ensues around the challenges of monitoring therapeutic effect and the pseudo-logic of initiating combination drugs. Show Notes 1) ALLHAT (http://jama.ama-assn.org/cgi/content/full/288/23/2981?ijkey=6e2515ec93dbb738d6061a90a8ee21cabccfd091) – no difference in CVD outcomes between thiazides, ACEI or CCBs in hypertensive patients treated for 4.9 years 2) Additional benefits of ACEIs/ARBs on renal outcomes in diabetic patients is unproven Lancet 2005;366:2026-33 (http://www.ncbi.nlm.nih.gov/pubmed/16338452?dopt=Abstract) 3) No evidence of superiority of CCBs or ACEs over thiazides for hypertenison in type 2 diabetics Arch Intern Med 2005;165:1401-9 (http://archinte.ama-assn.org/cgi/content/abstract/165/12/1401?ijkey=bb24aa70a953808ab88c542f5227688f52621665&keytype2=tf_ipsecsha) Dr James McCormack and Dr Michael Allan no 18:28 http://therapeuticseducation.org/2008/06/11/episode-7-hypertension-taking-the-pressure-off-stage-1/ http://therapeuticseducation.org/2008/06/11/episode-7-hypertension-taking-the-pressure-off-stage-1/#comments Thu, 12 Jun 2008 01:11:08 +0000 TEC http://therapeuticseducation.org/?p=287 http://therapeuticseducation.org/2008/06/11/episode-7-hypertension-taking-the-pressure-off-stage-1/feed/ 0 high blood pressure,pedometer,salt - In our seventh installment, we discuss the options for blood pressure reduction before adding medications. We first talk about medicines, drug use and dietary factors that may increase blood pressure. We review the approach and potential benefits ... In our seventh installment, we discuss the options for blood pressure reduction before adding medications. We first talk about medicines, drug use and dietary factors that may increase blood pressure. We review the approach and potential benefits of varying lifestyle interventions like Exercise (e.g. pedometers), Diet (e.g. DASH) and Salt Reduction. The ever elusive balance between nagging and encouragement is debated (James and Mike pick sides). Show Notes 1) Using a Pedometer * Ask the patient to wear the pedometer for one week * Have them calculate their “steps/day” * Next add 1000 steps to the day average and that will be their daily goal for each day next week. * They repeat this every week. * Once at 10,000 steps/day. They can stay stable (and come to see you to brag about their success) NOTE: This is only one way. There are many and you should feel free to use any safe approach to help you patients increase their activity. 2) Approximately 35% of patients who reduced their salt intake either had no change in blood pressure (20%) or an increase in blood pressure (15%) Hypertension 2003;42:459-67 (http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term="Hypertension"[Jour] AND 459[page] AND 2003[pdat]) Dr James McCormack and Dr Michael Allan no 19:08 http://therapeuticseducation.org/2008/06/04/episode-6-hypertension-coping-with-the-pressure/ http://therapeuticseducation.org/2008/06/04/episode-6-hypertension-coping-with-the-pressure/#comments Wed, 04 Jun 2008 23:07:23 +0000 TEC http://therapeuticseducation.org/?p=283 http://therapeuticseducation.org/2008/06/04/episode-6-hypertension-coping-with-the-pressure/feed/ 0 high blood pressure In our sixth installment, we begin to discuss hypertension. We review the principles of making the diagnosis of hypertension and confounders in the office. Although the identification of an elevated blood pressure for a certain patient may be new, In our sixth installment, we begin to discuss hypertension. We review the principles of making the diagnosis of hypertension and confounders in the office. Although the identification of an elevated blood pressure for a certain patient may be new, the hypertension itself is likely not and rarely an emergency. The risks of hypertension are put in context of global cardiovascular risk while we wax poetically around evolving hypertension guidelines. Show Notes 1) Our 45 y/o 10-year risk Framnigham 10 year change of CVD Overall CVD 14.1% CHD 12.3% MI 6.4% Stroke 1.2% Death of CVD 2.0% Death for CHD 2.0% 2) Treating a Blood Pressure of 160 /100 mmHg for 5 years - CVD ? 1% (4% to 3%) * TI Letter # 62 (http://www.ti.ubc.ca/letter62). * Episode 2: Evidence does not equal decision-making (http://therapeuticseducation.org/2008/04/16/episode-2-evidence-does-not-equal-decision-making/) 3) Diagnosis of high blood pressure * CMAJ 2005,173: 480-83 (http://www.cmaj.ca/cgi/content/full/173/5/480) (http://www.ti.ubc.ca/podcasting/iTS/image/E6Monogram.gif) Dr James McCormack and Dr Michael Allan no 17:18 http://therapeuticseducation.org/2008/05/28/episode-5-swiss-cheese-the-evidence-holes-in-the-lipid-hypothesis/ http://therapeuticseducation.org/2008/05/28/episode-5-swiss-cheese-the-evidence-holes-in-the-lipid-hypothesis/#comments Wed, 28 May 2008 22:58:45 +0000 TEC http://therapeuticseducation.org/?p=279 http://therapeuticseducation.org/2008/05/28/episode-5-swiss-cheese-the-evidence-holes-in-the-lipid-hypothesis/feed/ 0 cholesterol,ezetimibe,fibrates,statins,torcetrapib - In our fifth installment, we end our discussion of cholesterol outlining some of the remaining evidence gaps. Areas discussed are primary prevention for women, the use of other cholesterol reducing medicines, In our fifth installment, we end our discussion of cholesterol outlining some of the remaining evidence gaps. Areas discussed are primary prevention for women, the use of other cholesterol reducing medicines, and the need for follow-up cholesterol... Dr James McCormack and Dr Michael Allan no 20:47 http://therapeuticseducation.org/2008/05/14/episode-4-de-constructing-risk-or-benefit/ http://therapeuticseducation.org/2008/05/14/episode-4-de-constructing-risk-or-benefit/#comments Wed, 14 May 2008 22:52:36 +0000 TEC http://therapeuticseducation.org/?p=275 http://therapeuticseducation.org/2008/05/14/episode-4-de-constructing-risk-or-benefit/feed/ 0 risk - In our fourth installment, we apply the absolute benefit for statin therapy to our patient. We discuss the absolute benefits in context of the individual risk and acknowledge that when translating pooled literature numbers to individual patients an... In our fourth installment, we apply the absolute benefit for statin therapy to our patient. We discuss the absolute benefits in context of the individual risk and acknowledge that when translating pooled literature numbers to individual patients an element of mysterious uncertainty always remains (except for James who knows but won’t tell and Mike who doesn’t know but tells us he does). Show Notes Definitions CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease - fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes - and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease) Calculating benefit * Change the factor and recalculate the chance of CVD * Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient * Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials A synopsis of the relative benefit of drugs * Statins ? 30%? in CHD (0%? in women)? 5 years * BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years * Metformin ? 35%? in CHD and stroke ? 8-10 years A synopsis of the absolute benefit of drugs Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%) Absolute benefit of statins over approx 5 years Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%) Primary 1-1.5* - - 8-9 to 7 Diabetes 2 - 1-1.5 10 to 7 Secondary 4 2 1 20 to 15 * just in males and NO difference in overall serious adverse events Dr James McCormack and Dr Michael Allan no 14:32 http://therapeuticseducation.org/2008/04/30/episode-3-the-risky-business-of-cvd-risk-assessment/ http://therapeuticseducation.org/2008/04/30/episode-3-the-risky-business-of-cvd-risk-assessment/#comments Wed, 30 Apr 2008 22:40:22 +0000 TEC http://therapeuticseducation.org/?p=271 http://therapeuticseducation.org/2008/04/30/episode-3-the-risky-business-of-cvd-risk-assessment/feed/ 0 risk - In the third session, we discuss the advantages and disadvantages of three methods to present “benefit”: changes in risk calculators, using relative risk, or the absolute benefit. We review the challenges of absolute vs relative risk (or relative v... In the third session, we discuss the advantages and disadvantages of three methods to present “benefit”: changes in risk calculators, using relative risk, or the absolute benefit. We review the challenges of absolute vs relative risk (or relative vs absolute truth) and discuss patient expectations in regards to the medical miracle of prevention. The duration of therapy is put in context of the epoch time frames of risk calculators and studies. Show Notes Definitions CVD is cardiovascular disease and typically refers to the combination of CHD (coronary heart disease - fatal and non-fatal MIs and sometimes angina) PLUS cerebrovascular disease (fatal and non-fatal strokes - and sometimes TIAs) PLUS (sometimes) other conditions (heart failure, peripheral vascular disease) Calculating benefit * Change the factor and recalculate the chance of CVD * Use the relative benefits seen in clinical trials (typically 5 years in duration) and apply them to the chance calculated for your patient * Avoid the use of CDV calculators and just use the absolute benefits seen in clinical trials A synopsis of the relative benefit of drugs * Statins ? 30%? in CHD (0%? in women)? 5 years * BP ? 40 %? in strokes and ? 20%? in CHD ? 5 years * Metformin ? 35%? in CHD and stroke ? 8-10 years A synopsis of the absolute benefit of drugs Statins over 5 years in a post MI patient Coronary events ?4% (15% to 11%) Death ?2% (12% to 10%) Strokes ?1% (5% to 4%) Treating a Blood Pressure of 160 /100 mmHg for 5 years CVD ? 1% (4% to 3%) * Therapeutics Letter #62 (http://www.ti.ubc.ca/letter62). Absolute benefit of statins over approx 5 years Major coronary events (%)* Death (%) Strokes (%) FROM WHAT CVD TO WHAT CVD (%) Primary 1-1.5* - - 8-9 to 7 Diabetes 2 - 1-1.5 10 to 7 Secondary 4 2 1 20 to 15 * just in males and NO difference in overall serious adverse events Dr James McCormack and Dr Michael Allan no 14:37 http://therapeuticseducation.org/2008/04/16/episode-2-evidence-does-not-equal-decision-making/ http://therapeuticseducation.org/2008/04/16/episode-2-evidence-does-not-equal-decision-making/#comments Wed, 16 Apr 2008 22:35:26 +0000 TEC http://therapeuticseducation.org/?p=267 http://therapeuticseducation.org/2008/04/16/episode-2-evidence-does-not-equal-decision-making/feed/ 0 evidence,risk In our second session we discuss the philosophy of calculating risk and the many factors that influence the application of these numbers. We each calculate risk using our personal preference for risk estimators and discuss the mystery of why these num... In our second session we discuss the philosophy of calculating risk and the many factors that influence the application of these numbers. We each calculate risk using our personal preference for risk estimators and discuss the mystery of why these numbers are not the same. “Treating” asymptomatic patients and instituting preventive interventions taken for a life time does not require great haste. Show Notes Canadian Cardiovascular Society Risk Calculator 12 points =10% risk in 10 years (of non-fatal MI or coronary death) Risk factors Points Age 3 Total cholesterol 6 HDL 2 BP 1 Smoke 0 TOTAL 12 Can J Cardiol 2006;22(11):913-27 Our 45 y/o 10-year risk Framingham 10 year chance of CVD Overall CVD 14.1% CHD 12.3% MI 6.4% Stroke 1.2% Death of CVD 2.0% Death for CHD 2.0% Dr James McCormack and Dr Michael Allan no 14:08 http://therapeuticseducation.org/2008/04/02/episode-1-philosophy-guidelines-and-the-truth/ http://therapeuticseducation.org/2008/04/02/episode-1-philosophy-guidelines-and-the-truth/#comments Wed, 02 Apr 2008 17:44:15 +0000 TEC http://therapeuticseducation.org/?p=253 http://therapeuticseducation.org/2008/04/02/episode-1-philosophy-guidelines-and-the-truth/feed/ 0 evidence,philosophy,risk In this first session we offer a slightly long introduction (but not long enough to reach REM sleep). We present Mr. Guy Lines, a 45 year old male with a number of risks for cardiovascular, who we will consider over the next number of sessions on prima... In this first session we offer a slightly long introduction (but not long enough to reach REM sleep). We present Mr. Guy Lines, a 45 year old male with a number of risks for cardiovascular, who we will consider over the next number of sessions on primary prevention. We lay the rocky groundwork of future podcasts; touching on patient values, the arbitrary nature of guidelines, discussing risks, the asymptomatic ‘sick’ patient, and the art (or enigma) of applying the evidence. Show Notes Hippocrates would be proud? Mr G. Lines is a 45 year old male in for his “periodic” health exam. He describes himself as happy and healthy Aside from reminding him to wear a seatbelt, floss regularly, etc, you find… * He is relieved to hear routine rectal exams don't start until age 50 * His BP is 146/85 today (you took it twice hoping it would be below 140) * His BMI=29 and his WC=98 cm * His Lipids: Total Cholesterol = 6.8/265, HDL = 1.0/39, LDL = 4.9/191, Trig = 2/312 * His Blood Sugar = 6.4/115 * He is not a smoker Dr James McCormack and Dr Michael Allan no 12:39