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Medication Mythbusters – Home of the Best Science (BS) Medicine Podcast

Episode 89: Warts and all – part three of the New Zealand experience

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.

Episode 88: A hodgepodge from down under – smoking, ASA, antibiotics, NSAIDs, warfarin, 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 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

2) Low-dose aspirin in patients with stable cardiovascular disease

Am J Med 2008;121:43-9

3) Losartan – 50 vs 150 mg

Lancet 2009;374:1840-8

4) Antibiotics for COPD Acute Exacerbation

Cochrane 2006;2:CD004403

5) Many patients unaware of GI risk from NSAIDs

J Rheumatol 2005;32:2218-24

6) Spironolactone for resistant hypertension

AJH 2003;16:925–30

Journal of Hypertension 2007;25:891-4

Episode 87: Increasing the likelihood you will use likelihood ratios?

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

Episode 83: Gabapentin and bioidentical hormones – a look at ALL the data

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

2) CIHR trials

CMAJ 2004;171:735-40

3) Gabapentin for pain

Therapeutics Initiative Letter 2009 (July – Dec)

4) Pregabalin

First CEDAC report

Final recommendation

5) Systematic review of bioidentical hormones

Episode 82: Lost faith in surrogates yet? ACCORD challenges beliefs again

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

2) ACCORD – blood pressure lowering

NEJM 2010:10.1056/NEJMoa1001286

3) ACCORD – cholesterol lowering with fenofibrate

NEJM 2010:10.1056/NEJMoa1001282

3) FIELD – fenofibrate

Lancet 2005;366:1849-61

3) Studies, systematic reviews and meta-analyses of fibrates

Am Heart J 2007;154:943-53

Am J Med 2009; 122: 962.e1-962.e8

J Am Coll Cardiol 2005;45:185–97

Arch Intern Med. 2005;165:725-730

Int J Cardiol 2009; doi:10.1016/j.ijcard.2008.11.211

Episode 81: New studies about Vit K/INR, PUD, GABHS and statins

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

4) More meta-analyses for statins

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

Episode 80: Listener comments and questions with an attempt at answers – Part II

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

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