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

2) Activity-related benefits – morbidity and mortality

Arch Intern Med 2007;167:2453-60

JAMA 1995; 273:1093-8

Circulation 2008;117:614-22

JAMA 2003;289:2379-86

NEJM 2002;347:716-25

3) Other activity benefits

Cochrane Database SystRev 2002:CD003404

J Gerontol A Biol Sci Med Sci 2008;63:997-1004

J Sports Med Phys Fitness 2007;47:462-7

Cochrane Database SystRev. 2008;CD004366

Cochrane Database SystRev. 2008;CD004376

4) Impact of exercise on weight

JAMA 2003;290:1323-30 JAMA 2003;289:323-30

5) Exercise versus angioplasty

Circulation 2004;109:1371-8

6) Do patients adhere?

NEJM 2002;346:393-403

7) Write a prescription for lifestyle – reminders etc

J Fam Pract 2000;49:158-68

Am J Public Health 1998;88:288-91

8) Pedometers

JAMA 2007;298:2296-2304

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

Developing the metabolic syndrome 7

Metformin vs Lifestyle NNT: Resolve = 20 vs 5

IGT to DM long-term

7 years 8 (3 yrs without intervention): NNT = 32/yr

20 years 9 (14 yrs without intervention): NNT 7 (or 140/yr) with 93% vs 80% DM

References for the above

1. NEJM 2002;346:393-403

2. Lancet 2002;359:2072-7

3. Diabetes Care 2006;29:2095-101

4. Lancet 2006;368:1096-105

5. Diabetes Care 1997;20:537-44

6. NEJM 2001;344:1343-50

7. Ann Intern Med 2005;142:611-19

8. Lancet 2006;368:1673-79

9. Lancet 2008;371:1783–89

2) Little evidence for any one commercial diet over another

Ann Intern Med 2005;142:56-66

Am J Med 2005;118:991-7

Obesity 2007;15:421-9

JAMA 2004;292:2482-90

Int J Obes 2004;28:1349-52

3) No difference if you eat fat or protein or carbs

Int J Obes 2006;30:552-60

Arch Intern Med 2006;166:1466-75

Am J Clin Nutr 2005;81:1298-306

Arch Intern Med 2004;164:210-7

J Int Med 2007;261:366-74

Am J Clin Nutr 2006;84:813-21

JAMA 2003; 289:1837-50

Cochrane 2002;2:CD003640

JAMA 2007;297:969-77

Int J Obes 2004;28:1283-90

Ann Intern Med 2004;140:778-85

N Engl J Med 2008;359:229-41

4) Top 10 tips for weight loss

Int J Obesity 2008;32:700–7

5) Smaller plates

Arch Intern Med 2007;167:1277-83

6) Drugs for weight loss Sibutramine and orlistat

Diabetes Care 2007;30:27-32

JAMA 2001;286:1331-9

J Intern Med 2000;248:245-54

Fluoxetine vs sibutramine or orlistat

Arch Intern Med 2004;164:1395-404

Cochrane 2004;3:CD004094

Ann Intern Med 2005;142:532-46

7) Surgery for weight loss

Ann Intern Med 2005;142:547-59

Int J Obes 2006;30:129-33

Ann Intern Med 2006;144:625-33

Cochrane 2003;2:CD003641

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

2) Obesity and increased mortality

Ann Intern Med 2003;138:24-32

3) Being a little bit overweight is OK

JAMA 2007;298:2028-2037

Lancet 2006;368:666-78

J Am Geriatr Soc 2005;53:2112-8

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

Framingham risk score was a better predictor of CHD and stroke than the metabolic syndrome

Arch Intern Med 2005;165:2644-50

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

2) ACP journal club http://www.acpjc.org

3) Evidence-based medicine http://ebm.bmj.com

4) Quickscan reviews http://www.cmeonly.com/QSR/qsrdemo.html

5) NetNewsWire – RSS reader for Mac users http://www.newsgator.com/INDIVIDUALS/NETNEWSWIRE

6) Amedeo http://www.amedeo.com

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

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

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

4) ACCOMPLISH – Benazepril plus Amlodipine or Hydrochlorothiazide for Hypertension in High-Risk Patients

N Engl J Med 2008;359:2417-28

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

Inhaled anticholinergics increases risk of cardiovascular death – but not total mortality

JAMA 2008;300:1439-1450

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

3) Varenicline for smoking cessation Varenicline verus transdermal nicotine

Thorax 2008;63:717-24

Evidence showing 0.5 mg BID of varenicline is as effective as 1 mg BID

FDA document

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

2) Studies of monitoring blood sugar in type 2 diabetics showing no benefit and increased depression scores

BMJ 2007;335:132

BMJ 2008;336:1177-80

3) Beta-blockers and thiazides do appear to increase the chance of developing diabetes

Am J Cardiol 2007;100:1254–62

4) 10-year follow-up of intensive glucose control in Type 2 diabetes

NEJM 2008;359:1577-89

5) COPD guidelines recommending inhaled steroids as one of the first line inhalers

Ann Int Med 2007;147:639-53

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

2) Smoking cessation Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1

Fluoxetine

1) Weight loss in diabetics Arch Intern Med 2004;164:1395-1404

Metformin

1) Metformin’s contraindications should be contraindicated CMAJ 2005;173:502-504

Colchicine

1) Gout – uptake of colchicine into leukocytes Clin Pharmacol Ther 1993;54:360-7

2) Does colchicine work? The results of the first controlled study in acute gout Aust NZ J Med 1987;17:301-4 Br J Clin Pharmacol 1988;26:488-9

3) Pericarditis Arch Intern Med 2005;165:1987-91

4) Osteoarthritis Arth Care Res 2002;47:280-4 Osteoarthritis Cartilage 2002; 10:247-52

5) Cirrhosis NEJM 1988;318:1709-13

Vitamin B12

1) Oral vs IM Vitamin B 12 Fam Pract 2006;23:279-85

Iron

1) Low dose (15 and/or 50 mg) is as good as high doses (150mg) Am J Med 2005; 118: 1142-7

Nitroglycerin

1) Tennis elbow Am J Sports Med 2003;31:915-20

2) Acute pulmonary edema Amer J Emerg Med 1999;1716:571-4

3) Anal/bum fissures Lancet 1997;349:11-4

4) Raynaud’s Lancet 1982;1:76-7

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

2) Tolerance to the sedative effects of 100 mg of diphenhydramine occurs within 3 days

J Clin Psychopharmacol 2002:22:511–15

Thiazides

1) ALLHAT JAMA 2002;288:2981-97

2) ACE inhibitors no better than thiazides in diabetics

Arch Intern Med 2005;165:1401-9

Spironolactone

1) RALES/CHF study New Engl J Med 1999;341:709-17

2) Spironolactone for resistant hypertension

AJH 2003;16:925–30 Journal of Hypertension 2007;25:891-4

3) Polycystic ovarian disease

J Clin Endocrinol Metab 2004;89:2756-62

Reserpine

1) Potentially useful agent

Clin Pharmacol Therap 1996;60:368–73

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

Pediatrics 1999;103:47-51

Doxycycline

1) No appreciable resistance to doxycycline, including pneumococcus

Chest 2004;125:1913

Arch Int Med 1999;159:266-70

2) Community acquired MRSA

Antimicrob Agents Chemother 2007;51:2628-30

Clin Infect Dis 2005;40:1429-34

3) Low dose (20 mg twice daily) for acne

Arch Dermatol 2003;139:459-64

Sulfa drugs

Allergy to penicillin increases your risk of reacting to sulfa drugs

N Engl J Med 2003;349:1628-35

Nitrofurantoin

Still good for bladder infections

British Journal of General Practice 2002;52:729-34

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.”