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.
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.
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?
2) Do you need sterile gloves when suturing a wound?
3) Using tap water to irrigate a wound
4) Lubricating a speculum is OK
Obstet Gynecol 2002;100:889-92
5) Reassessment of Clinical Practice Guidelines – Go Gently Into That Good Night
6) The evidence behind the guidelines
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.
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).
Canadian Hypertension Education Program (CHEP) urges physicians NOT to combine ACE & ARB
2) Medical therapy for renal stone passage.
3) Antibiotic Prophylaxis for Infective Endocarditis
J Am Coll Cardio 2008;52:676-85
Who gets prophylaxis
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
2) Glyburide for gestational diabetes
3) Persistent pulmonary hypertension of the newborn
4) Risk of depression relapse in pregnancy
5) Vomiting in kids and ondansetron
Arch Pediatr Adolesc Med 2008;162: 858-65
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)
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”
2) Activity-related benefits – morbidity and mortality
Arch Intern Med 2007;167:2453-60
NEJM 2002;347:716-25
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
6) Do patients adhere?
7) Write a prescription for lifestyle – reminders etc
Am J Public Health 1998;88:288-91
8) Pedometers
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
3. Diabetes Care 2006;29:2095-101
5. Diabetes Care 1997;20:537-44
7. Ann Intern Med 2005;142:611-19
2) Little evidence for any one commercial diet over another
3) No difference if you eat fat or protein or carbs
Arch Intern Med 2006;166:1466-75
Am J Clin Nutr 2005;81:1298-306
Arch Intern Med 2004;164:210-7
Ann Intern Med 2004;140:778-85
4) Top 10 tips for weight loss
Arch Intern Med 2007;167:1277-83
6) Drugs for weight loss Sibutramine and orlistat
Fluoxetine vs sibutramine or orlistat
Arch Intern Med 2004;164:1395-404
Ann Intern Med 2005;142:532-46
Ann Intern Med 2005;142:547-59
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.
2) Obesity and increased mortality
3) Being a little bit overweight is OK
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.
Framingham risk score was a better predictor of CHD and stroke than the metabolic syndrome
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
THE NUTRITION PROPOSITION BOOK
Check it out at nutritionproposition.com and think about picking up a copy on Amazon. All the evidence you ever wanted about nutrition and the only nutrition book that won’t tell you what to eat.
This pragmatic trial is now recruiting in BC. Make a difference and get involved with pragmatic trials (www.pragmatictrials.ca)
