In episode 150, the last for 2011, Mike and James elicit the help of Laurie Mallery and Paige Moorhouse from Halifax. Laurie and Paige guide us through a step-by step approach to deal with frailty and end of life care. We also discuss their PATH (Palliative and Therapeutic Harmonization) clinic developed for older people in Nova Scotia with chronic health conditions.

Show notes

1) Respecting frailty

J Med Ethics 2010. doi:10.1136/jme.2010.040147

2) PATH – Palliative and Therapeutic Harmonization Clinic

pathclinic.ca

In episode 149, Mike and James finally get to the last of the questions and discuss the use of vinegar for weight loss, surrogate markers and what to do about them, steroids for migraine, niacinamide for acne, statins for women, and what is the meaning of life. We discuss, all of these issues in depth and believe it or not at the end of the podcast we actually figure out the meaning of life but accidentally erase that part. We’ll bring that issue up at a later date in a PREMIUM podcast.

Show notes

1) Vinegar for weight loss

Bioscience, Biotechnology, and Biochemistry 2010:73:1837–43

2) Steroids for acute migraines

Academic Emergency Medicine 2008;15:1223–33
BMJ 2008;336:1359–61

3) Statins in women

Circulation 2010;121:1069-77

In episode 148, Mike and James return to the town of Questionville and attempt to answer riddles from near and far. Despite Mike having a cold, we tackle long acting insulins, exercise, multivitamins and varenecline with near Herculean-like abilities but provide answers that are much more on the mere-mortal side.

Show notes

1) Long acting insulins

CADTH report  Long-Acting Insulin Analogues for the Treatment of Diabetes Mellitus

Diabetes Care 2009;32:32-37

Adv Ther 2009;26:535-51

Tools for Practice – The long and short of long acting insulin analogues (versus NPH)

Tools For Practice – Strategies for initiating insulin in Type 2 Diabetics:  What is the optimal regimen for initiating insulin in type 2 diabetes?

2) Activity

QoL stuff

Arch Intern Med 2009;169:269-278

Pedometers

Can Fam Physician 2010;56:887

Exercise Improves: Sleep, osteoarthritis pain, depression, obesity, glucose, lipids, BP

Cochrane 2002;CD003404

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

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

Cochrane 2008:CD004366

Cochrane 2008:CD004376

Inactivity a bigger risk than weight

J Am Geriatr Soc 2010;58:234–241

Activity and mortality

Arch Intern Med 2007;167:2453-2460

JAMA 2003;289:2379-2386

NEJM 2002;347:716-25

JAMA 1995;273:1093-8

Circulation 2008;117: 614-622

PLOS 2008;5: e12.

More activity, better

Br J Sports Med 2008;42:238–243

NEJM 1999;341:650-8

Eur J Epidemiol 2009;24:181–192

RCT of activity vs angioplasty

Circulation 2004;109:1371-8

3) Multivitamin Evidence

A & E harmful

Can Fam Physician 2005;51:1471-2

Tools for practice #10 

Multivitamins unnecessary(among first to be stopped in polypharmacy)

JAMA 2010;304:1592-1601

Vitamin B increases mortality

BMJ 2010;341:c6273

4) Vitamin D

Vitamin D problems

JAMA 2010;303:1815-1822

Rheumatology 2007;46:1852–1857

Regular dose reduces mortality

Cochrane:CD007470

Reduces falls

BMJ 2009;339:b3692 doi:10.1136/bmj.b3692

Cochrane:CD007146

For fractures (yes with Ca+, unsure otherwise)

Cochrane:CD000227

Re-evaluating the whole reference range

J Clin Endocrinol Metab 2011;96:53–58

5) Calcium evidence

Can Fam Physician 2011;57:798

6) Varenicline for smoking cessation

Cardiovascular events

CMAJ 2011;183:1359-66

Pharmacotherapy for smoking cessation

CFP 2011;57:47

In episode 147, Mike and James cover the issue of humor in teaching, put drugectomies in LTC facilities into perspective, discuss the use of antibiotics in COPD, and finally contextualize bisphophonates and estrogen for fracture reduction. At the end they agree that the 30 minutes of podcast excellence should leave the audience laughing and crying but not for the right reasons.

Show notes

1) Chronic antibiotics in COPD

Am J Respir Crit Care Med 2008;178:1139-47

N Engl J Med 2011;365:689-98

2) Bisphosphonates/zoledronic acid

BMC Musculoskeletal Disorders 2011,12:209

N Engl J Med 2007; 356:1809-1822

3) Lower doses of estrogen

Fertil Steril 2001;75:1065-79

In episode 146, a PREMIUM podcast, Mike and James talk about some timely studies. Mike discusses some interesting results from a study that looked at the simple intervention of taking antihypertensives at bedtime and we find out that this intervention not only has an impact on blood pressure but also produces a further reduction in cardiovascular events. James then discusses the latest atrial fibrillation study which looked at what happens to cardiovascular events when you compare warfarin to apixaban. 

Shownotes

1) Taking antihypertensives at bedtime

Chronobiology International 2010;27:1629–51

2) Apixaban versus warfarin in patients with atrial fibrillation

N Engl J Med 2011;365:981-92

In episode 145, Mike and James bring you, live on-tape from down-under, our presentation at the 2011 Conference for General Practice in New Zealand. We talk about why most new things aren’t much if any better and then discuss the issue of things like surrogate markers, physiological mechanisms, meta-analyses, selective publication/reporting, measurement/scales and “Risky” superlatives.

In episode 144, Mike and James finish up their discussion about headache prevention with a poignant yet stirring discussion of the use of antihypertensive and antiepileptic agents for migraine prevention. We show these drugs work and decide that they work not as antihypertensives or antiepileptics but have something to do with their ability to induce fairies to sprinkle magical dust on the brain. At the end we realise that even when it comes to fairy dust, low dose is the way to go. 

Show notes

1) Propranolol for migraines

Cochrane Library CD003225

2) Lisinopril for migraine

BMJ 2001;322:1-5

3) Candesartan for migraine

JAMA 2003;289:65-69

4) Verapamil for headache

Am J Med 1991;90:S48-S53

Headache 1989;29:425-7

5) Hypertension treatment and headaches

Circulation 2005;112:2301-6

6) Overview of pharmacological management

BMJ 2011;342:d583doi:10.1136/bmj.d583

CMAJ 2010;182:E269-E276.DOI:10.1503/cmaj.081657

In episode 143, Mike and James quickly create headaches among their listeners but fortunately just as quickly get to a discussion about the prevention of headaches with antidepressants. We find out that tricyclics work but SSRIs don’t. To prove that point we both take high doses of fluoxetine during the podcast with no effect, except the clear effect it has on the quality of the podcast. 

Show notes

Tricyclics for preventing headaches

BMJ 2010;341:c5222doi:10.1136/bmj.c5222.2

SSRIs for preventing headaches

Cochrane Library CD002919

Prophylaxis of migraine review

CMAJ 2010;182:E269-76

In episode 142, Mike and James finish off the elderly, but hopefully not literally, by discussing some key RCTs that help inform us as to a few medications that likely should be part of your discussion/armamentarium with your elderly patients. At the end Mike extols the virtues of low doses and James tells him I told you so.

Show notes

1) “Optimal” managaement of elderly patients with vascular disease

Am Heart J 2006;152:585-92

2) Drug withdrawal in the elderly

IMAJ 2007;9:430–434.

3) Withdrawing antipsychotics

JAMA 2005;294:1934-43

NEJM 2005:353:2335-41

Lancet Neurol 2009;8:151–57

PLoS Med 5(4): e76.doi:10.1371/journal.pmed.0050076

4) Testosterone

NEJM 2010; 363:109-22

5) BP in the elderly

Lancet 2000;355:865–872

Cochrane CD000028

N Engl J Med 2008;358:1887-98

Cardiol J 2009;16:379–385

Hypertens Res 2008;31:1595-601

Hypertension 2010;56:196-202

Circulation 2001;104:1923-6

6) Anticoagulation in the elderly

Lancet 2007;370:493–503

7) Rate control in the elderly with A fib

N Engl J Med 2010;362:1363-73

8) Low-dose iron

Am J Med 2005;118:1142-7

In episode 141, Mike and James whine about the Beers criteria that is used to evaluate drug use but in the end they realise that all drug use criteria are quite arbitrary and that individual drug use issues need to be dealt with individually. To that end we discuss general concepts as to how to review patients on polypharmacy.

Shownotes

1) Different drug use in the elderly criteria

Arch Intern Med 2003;163:2716-24

Pharmacother 2010;44:1968-75

Arch Intern Med 2007;167:781-7

Dtsch Arztebl Int 2010;107:543–51

2) Association of drug use criteria and bad outcomes

Ann Pharmacother 2007;41:438-8

Am J Med 2009;122,1142-9

J Am Geriatr Soc 2011;59:875-80

Ann Pharmacother 2010;44:1725-32

Age & Ageing 2008;37:673–9

Arch Intern Med 2011;171:1013-9

3) Studies of unsafe prescribing

Arch Intern Med 2009;169:1952-60

Drugs Aging 2008;25:61-70

J Gerontol A Biol Sci Med Sci 2007;62:1172-81

Arch Intern Med 2009;169:1952-1960

Drug Safety 2007;30:171-184

Drug Safety 2009;32:489-98