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In episode 122, James and Mike welcome to the podcast a good friend and colleague Mark McConnell, an internist from Lacrosse, Wisconsin. We discuss how Mark became interested in evidence and how his practice has evolved, for the better, by incorporating the concepts of evidence and shared-informed decision making. At the end we get a very special message from Reverend Lovejoy’s identical twin who really provides us with the most insightful comment of the whole podcast.

In episode 121, Mike, James and Tina tackle the issue of who needs a bone density measurement and describe a simple tool that will help you with that decision.

However, at the end, Mike threatens to jump out of his building and James and Tina talk him down by promising not to measure his BMD more than once.

Show notes

1) Tools for Practice

Screening for Osteoporosis – Who Should Receive Bone Mineral Density Testing?

2) Osteoporosis Self Assessment Tool (OST)

Simple application of OST:

Age – Weight (kg)

If greater than minus 5, increased risk of osteoporosis and BMD is warranted

A cut-off of greater than positive 5 should be used for Asian patients.

In Episode 120, Mike and James, in an attempt to truly make this a PREMIUM podcast, elicit Tina Korownyk to yet again help us unravel the mysteries of medicines. In this podcast, we report on two new studies that look at two old therapies for cough and cold symptoms (Vapor Rub and Zinc). We learn that despite coughs and colds being a very common condition, effective therapies are definitely not common.

Show notes

1) Vapor Rub for children with nocturnal cough and cold symptoms

Pediatrics 2010;126:1092-9 

2) Zinc systematic review

Cochrane Library

HI Everyone – sorry for the hit and miss approach to podcasts over the last month or so. Over the last few weeks we had some technological challenges and Mike and I have also needed to spend time getting ready for our Annual Drug Therapy Course here in Vancouver – April 1 and 2. We have had a great response and a couple of weeks we had to put a stop to registration because we can’t fit any more people in the ballroom at the hotel – a great problem to have. Nonetheless, their should be a premium podcast posted either Wednesday or Thursday this week (and what a perfect time to become a Premium Subscriber) but we may need to take another week or so off after the course. I also have not had time to personally respond to a number of questions and comments that have been left on the website but we will get to the questions in a future podcast. For those of you who are coming to Vancouver, I very much looking forward to meeting you and while we will be busy, please try to catch up with us and say hello. THANKS.

In episode 119, Mike and James tackle a few final issues of atrial fibrillation – rate vs rhythm control, anticoagulation in the elderly, what do with high INR numbers, and short-term warfarin interruption. They outline the details in such a clear and succint manner that they decide all you have to do is follow their guidelines but as they really don’t like guidelines it really is unclear what you should do.

Show notes

1) Rate vs rhythm meta-analyses

Arch Intern Med. 2005;165:258-62

European Heart Journal 2005;26:2000–6

Br J Clin Pham 2005;60:347-54

2) Strict versus lenient rate control

N Engl J Med 2010;362:1363-73

3) Other info on atrial fibrillation

N Engl J Med 2008;358:2667-77

Circulation 2006;114;e257-e354

4) Anticoagulation of the elderly

Circulation 2007;115:2689-96

Lancet 2007;370:493–503

5) High INR and Vitamin K

Ann Intern Med. 2009;150:293-300

Chest 2008;133:160–98S

6) Short-term warfarin interruption

Arch Intern Med 2008;168:63-69

Circulation 2006;114;e257-e354

Chest 2008;133;299S-339S

In episode 118, James and Mike continue their discussion of atrial fibrillation by going into details about the evidence for treating patients with atrial fibrillation and how to make decisions between ASA/warfarin/dabigatran and also what it means to be in or out of the INR therapeutic range. At the end James gives Mike a well deserved, but late, Christmas present, and both their hearts skip a beat – but not enough to require anticoagulation.

Show notes

1) Canadian Cardiovascular Society 2010 Atrial Fibrillation Guidelines

2) Warfarin vs ASA in afib

Ann Intern Med 2007;146:857-67

Heart 2008;94:1607-1613

2) Time in therapeutic range

Can Fam Phys 2005; 51:384-5

Can Fam Phys 2003; 49:181-4

Family Practice 2004; 21:612–6

J Manag Care Pharm 2009:15:244-52

3) Event rates by INR range

CMAJ 2008;179(3):235-44

4) Clopidogrel and ASA in atrial fibrillation 

Lancet 2006;367:1903-12

NEJM 2009;360:2066-78  

NEJM 2009;360:2127-9

In episode 117, Mike and James delve into the first of a few podcasts on options for atrial fibrillation. In this first podcast they look at ways to assess risks and talk at length about a web-based tool that makes the process as easy as possible. The process is so easy that the hearts of both Mike and James start to flutter yet only one of them decides to take warfarin. You decide whom that is.

Show notes

1) Risk calculators for atrial fibrillation

The best/easiest way to present information about the risks associated with atrial fibrillation and the benefits and harms of therapy – from peterloewen.com

SPARC – Stroke Prevention in Atrial Fibrillation Risk Calculator

Other Afib calculators

md+calc

QxMD

2) Some useful Afib numbers

In episode 116, James and Mike take a re-look, with some new evidence, at the use of antibiotics for acute otitis media in children and come to the conclusion that antibiotics do have an effect and produce side effects. They both agree that if the child is really sick you may as well give antibiotics and if they aren’t really sick then you can wait. At the end of the podcast Mike agrees that this information doesn’t in anyway change what he already was doing. But at least he is now supported by 2 articles in the New England Journal of Medicine – which makes everything feel so much better.

Show notes

1) Two new otitis media trials

N Engl J Med 2011;364:116-26

N Engl J Med 2011;364:105-15

2) Systematic review of otitis media treatment

JAMA 2010;304:2161-9

In episode 115, Mike and James, in yet another stellar PREMIUM performance, provide the listening audience with the definitive answer on the cardiovascular risks associated with the NSAIDs. They then bring in a guest (Winnie-the-Pooh) to discuss in a sweet fashion whether or not there are any benefits from using honey for cough in children. At the end we are unable to recommend or not recommend honey, and so uncharacteristically Winnie-the Pooh bites both James and Mike and they end up on NSAIDs for the pain. 

Show notes

1) Cardiovascular safety of NSAIDs – or lack thereof

BMJ 2011; 342:c7086 doi: 10.1136/bmj.c7086

2) Acetaminophen/paracetamol

Causes liver damage and is “bad”

BMJ 2010; 341:c6764 doi: 10.1136/bmj.c6764

Hang-on, is it really bad or is it really safe? – and just how do you define narrow therapeutic ratio?

BMJ 2011; 2011; 342:d625 doi: 10.1136/bmj.d625 

“Other than citing a narrow therapeutic index, defined by the FDA as exceeding the daily 4,000 mg recommended maximum dose, between the therapeutic and toxic doses of acetaminophen, the FDA did not present any evidence upon which to validate their recommendation to reduce the daily dose from 4,000 to 3,250 mg”

Clin Toxicol 2009;47:784-9

2) Honey and cough in children 

J Alt Compl  Med 2010;16:787-93

In episode 114, James and Mike finally bring some topical information to the TEC podcast listeners by reviewing the available evidence for topical NSAIDs. We find out that they do work and that they should be considered a useful tool in your “how should I treat pain” armamentarium. Mike and James at the end of the podcast make a resolution to send all our PREMIUM podcast subscribers – if you aren’t one yet get on with it – a vat of a generic topical NSAID to help them with the intermittent pain associated with listening to the podcasts.

Show notes 

1) Tools for Practice – Topical NSAIDs: Do they top Placebo or Oral NSAIDs?

2) Evidence for topical NSAIDs

Cochrane Library Review – CD007402

BMJ 2004;329:324.doi:10.1136/bmj.38159.639028.7C 

BMC Musculoskeletal Disorders 2004 5:28 doi:10.1186/1471-2474-5-28.

J Rheumatol 2006;33:1841–4

Bandolier, 2003 April

Pain Medicine 2010;11:535–49

BMJ 2008;336:502-3. doi:10.1136/bmj.39490.608009.

NICE OA Guideline