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 2) Sequential therapy for PUD – 10 days Amer J Gastro 2009;104:3069-79 3) Single dose steroids for sore throat BMJ 2009;339:b2976

Circulation 2010;121:1069-77 BMJ 2009;338:b2376

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 DiGEM BMJ 2008;336:1177-80 CADTH – thorough review of the  issue of glucose monitoring 2) Ezetimibe ENHANCE N Engl J Med 2008;358:1431-43 SEAS N Engl J Med 2008;359:1343-56 Cancer data N Engl J Med 2008;359:1357-66 3) Ezetimibe vs niacin – niacin better? ARBITER 6–HALTS N Engl J Med 2009;361:2113-22 4) Torcetrapib – worsens outcomes N Engl J Med 2007;357:2109-22 5) Niacin Coronary drug project Eur J Clin Pharmacol 1991;40 [Suppl 1]: S49-S51 6) Anticoagulation issues SARS (ASA, ASA+warf, ASA+ticlopidine) post ACS+stent NEJM 1998;339:1665-71 Registry of AF patients on OAC at time of PCI+stent JACC 2008;51:818–25 Registry of OAC patients (various indications) post PCI+DES J Intern Med 2008;264:472-80 Registry of OAC patients (various indications) post PCI+stent J Invasive Cardiol 2006;18:162-4

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

Statins overall benefit chart

University of Edinburgh Cardiovascular Risk Calculator

1) UKPDS 34 metformin Lancet 1998;352:854-65

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

3) Statin dose meta-analysis response CMAJ 2008;178:576-84

4) Metformin Vit B12 deficiency Arch Intern Med 2006;166:1975-79

5) Strep test Ped Emerg Care 2001;17:272-8 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 CMAJ 2000; 163:811-15

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

A Bitter Pill – By 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. 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

A Bitter Pill – By John Sloan