In episode 441, James and Mike revisit the problem with guidelines. We talk about recent writings on the issues around guidelines. We discuss the main problems and believe it or not we give advice and suggestions for how to make them better.

Show notes

1) Health Affair

Fixing Clinical Practice Guidelines

2) Evidence vs Consensus in Clinical Practice Guidelines

JAMA 2019 Jul 19. doi: 10.1001/jama.2019.9751

3) The future of guidelines: Primary care focused, patient oriented, evidence based and simplified

Maturitas 2017;95:61-62

In episode 440, Mike and James yet again invite Adrienne to go over all the evidence for treating toenail onychomycosis.  We find that ~ 40% more people get better on oral treatments than on placebo. For topicals the number is closer to 10%. Topicals should likely only be used if there is <40% nail involvement.

Show notes

Tools For Practice

Putting the FUN in Fungi: Toenail onychomycosis treatments

RxFiles

In episode 439, Mike and James invite Adrienne to take us through the impressively large amount of evidence for the PDE5 inhibitors for erectile dysfunction. We find that the NNTs are 2-3 for the not clearly defined endpoint of successful intercourse. There is a 20% absolute increase in adverse effects but almost no one stops using these medications because of these effects. Go figure.

Show notes

Tools For Practice

Taking a hard look at the evidence: Phosphodiesterase-5- inhibitors in erectile dysfunction

In episode 438, Mike and James discuss 4 studies that likely could change what you are doing, or saying to your patients in your practice. Hip replacements – they last longer than you may think, vitamin D – bigger isn’t better, actinic keratosis – 5-FU is best, and weight loss really does treat T2DM. Check it out.

Show notes

Handout

In episode 437, Mike and James invite Joey Ton to help us work through all the evidence around Platelet-Rich Plasma (PRP) injections for tendinopathies. The best evidence for Achilles tendinopathy, lateral epicondylitis, and rotator cuff tendinopathy shows no difference in pain, function or return to sport when PRP is compared to dry needling or saline.

Show notes

Tools for Practice

Injecting Evidence into Platelet-Rich Plasma Injections

In episode 436, Mike and James invite Samantha Moe to help us work through the recent evidence suggesting that hydrocholorothiazide is associated with squamous cell skin cancer. We go over all the numbers and talk about how we use cohort data to figure out if an association needs to influence our clinical practice. As always it is tricky.

Show notes

Tools for Practice

Hydrochlorothiazide and Squamous Cell Skin Cancer: Remember when hypertension was easy?

In episode 435, Mike and James unravel the evidence around thyroid testing. We talk about an approach to deal with the lack of research and the variation in the measurement of TSH and many other things. At the end we both complain of fatigue, dry skin, puffy eyes, anxiety and depression – and immediately get a TSH test.

Show notes

1) Tools for Practice

Helping physicians fatigued by TSH Screening and Subclinical Hypothyroidism

2) Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

BMJ. 2019 May 14;365:l2006. doi: 10.1136/bmj.l2006

In episode 434, James and Mike discuss the Treat Stroke to Target trial where subjects were randomized to attain different LDL levels in patients experiencing a stroke or TIA. We talk about whether the results of this trial mean you need to measure LDL levels or just give more statin. Listen to find out.

Show notes

A Comparison of Two LDL Cholesterol Targets after Ischemic Stroke

N Engl J Med. 2019 Nov 18. doi: 10.1056/NEJMoa1910355

In episode 433, Mike and James get all sweet on the latest diabetic trials from 2019. We provide the results, the critique and the context and we do it all with our usual level of charm and wit – which is by all accounts at a level similar to the size of the effect that many diabetes medications have on CVD events. 

Show notes

Diabetes trials synopsis

In episode 432, James and Mike finish their review of the evidence around medications for systolic heart failure. In this episode our goal was to try to make sense of the process by adding as much art as possible to the evidence and also use a modicum of common sense. Let us know if we achieved our goal.

Show notes

Podcast handout