In episode 81, Mike and James talk about new studies. They run the gamut from Vitamin K, sequential therapy for peptic ulcer disease, single dose steroids for Strep throat and yet another meta-analysis of statin therapy. At the end we clearly demonstrate our skill at critical appraisal by recommending Vitamin K for ulcers, sequential antibiotic therapy for primary prevention, steroids for INR problems, statins for Strep throat (come on, you knew statins would work for this) and a kick in the ass for Chris our producer. Show notes 1) Vitamin K and warfarin Ann Intern Med 2009;150:293-300 2) Sequential therapy for PUD – 10 days Amer J Gastro 2009;104:3069-79 3) Single dose steroids for sore throat BMJ 2009;339:b2976

Circulation 2010;121:1069-77 BMJ 2009;338:b2376

In episode 80, Mike and James continue getting back to listener questions. We discuss such topics as glucose monitoring, ezetimibe, niacin, nebulised salbutamol and niacin with uncanny intuitive insight coupled with a degree of emotional sensitivity rarely encountered in podcasts. We then wake up and get Peter Loewen to help answer a difficult question on oral anticoagulants. Show notes 1) Self-monitoring of blood glucose ESMON BMJ 2008;336:1174-7 DiGEM BMJ 2008;336:1177-80 CADTH – thorough review of the  issue of glucose monitoring 2) Ezetimibe ENHANCE N Engl J Med 2008;358:1431-43 SEAS N Engl J Med 2008;359:1343-56 Cancer data N Engl J Med 2008;359:1357-66 3) Ezetimibe vs niacin – niacin better? ARBITER 6–HALTS N Engl J Med 2009;361:2113-22 4) Torcetrapib – worsens outcomes N Engl J Med 2007;357:2109-22 5) Niacin Coronary drug project Eur J Clin Pharmacol 1991;40 [Suppl 1]: S49-S51 6) Anticoagulation issues SARS (ASA, ASA+warf, ASA+ticlopidine) post ACS+stent NEJM 1998;339:1665-71 Registry of AF patients on OAC at time of PCI+stent JACC 2008;51:818–25 Registry of OAC patients (various indications) post PCI+DES J Intern Med 2008;264:472-80 Registry of OAC patients (various indications) post PCI+stent J Invasive Cardiol 2006;18:162-4

In episode 79, Mike and James get back to trying to answer questions posed by our wonderful listeners. We both, in our own minds, give wonderful, thoughtful and sensitive answers to issues associated with diabetes, statins, metformin, strep throat etc. Unfortunately, our producer Chris edited all these out and you are left with a lot of ranting and raving from the duo. At the end of the podcast, James and Mike realise Chris has been editing all the podcasts this way and they go searching for a new producer.

Show notes

Tools for practice

Statins overall benefit chart

University of Edinburgh Cardiovascular Risk Calculator

1) UKPDS 34 metformin Lancet 1998;352:854-65

2) ATLAS 3164 patients with class II to IV heart failure randomised to receive either 2.5 to 5.0 mg daily or 32.5 to 35 mg daily of lisinopril for approx 4 years Circ 1999;100:2312-8

3) Statin dose meta-analysis response CMAJ 2008;178:576-84

4) Metformin Vit B12 deficiency Arch Intern Med 2006;166:1975-79

5) Strep test Ped Emerg Care 2001;17:272-8 10% prevalence – PPV of 53% and a NPV of 97% 40% prevalence – PPV of 87% and a NPV of 82%

6) Scoring system for strep throat CMAJ 1998;158:75-83 CMAJ 2000; 163:811-15

In episode 78, the final one on the frail elderly, Mike and James, with John Sloan, deal with what is really important to the frail elderly, and that is symptom control. We discuss pain and opioids, sleep and benzos, and combativeness and whatever seems to work – but all in very low doses. To cap of this final episode on the frail elderly, Mike and James forget to plug John’s book and he experiences great pain, he can’t sleep and becomes quite combative, but fortunately Mike and James have listened to this podcast and know what to do.

Show notes

1) Selective reporting of gabapentin NEJM 2009, 361:1963-71

A Bitter Pill – By John Sloan

In episode 77, Mike and James stop waxing philosophically and get specific about therapeutics and the frail elderly. Once again we get our friend and colleague John Sloan to help us navigate through this evidence-free zone. We specifically talk about how to deal with the patient on 47 drugs and what to do about blood pressure, cholesterol, osteoporosis, and type 2 diabetes. To wrap it all up Mike, James and John do a no-analgesia drugectomy on each other and, other than a bit of whining, seem to do OK.

Show notes

1) HYVET – Treatment of Hypertension in Patients 80 Years of Age or Older NEJM 2008;358:1887-98

A Bitter Pill – By John Sloan

In episode 76, Mike and James explore the topic of the treatment of the frail elderly. To do this properly, we bring in an “expert”, Dr John Sloan, who has spent the majority of his practice driving to the homes of the frail elderly and taking care of them. In the first of three episodes on this topic, we philosophize on the general issues of how to deal, or not deal, with the frail elderly – symptoms first, and then if you have any left over time deal with the other issues. At the end, Mike tells James he is closer to being a frail elderly person than he is and decides it’s important to get all of James’ lab values to what he had when he was age 19.

Show notes

Not many notes this week because there isn’t much evidence surrounding the frail elderly

A Bitter Pill – By John Sloan

In episode 75, Mike and James get together with Tina one more time to talk about two topics that have nothing to do with each other (starting insulin in type II diabetics and treating acute musculoskeletal pain in children). However, through the magic of podcasts we transition seamlessly from one topic to the other without any pain and without having to start insulin. Be amazed.  At the end, Mike and James are thrilled they got through yet another podcast, but it was painful and at the end we were both hypoglycemic.

Show notes

1) Tools for Practice

2) Using insulin in a type 2 diabetic – complicated versus less complicated regimens

4-T study

N Engl J Med 2009;361:1736-47

APOLLO

Lancet 2008;371:1073–84

INITIATE

Diabetes Care 2005;28:260-5

JDDM

Diabetes Res Clin Pract 2008;79:171-6

3) Pain control for musculoskeletal injuries in children

Single dose – ibuprofen vs acetaminophen vs codeine

Pediatrics 2007;119:460-7

Ibuprofen vs acetaminophen plus codeine

Acad Emerg Med 2009;16:711-16

Ann Emerg Med 2009;54:553-60

In episode 74, Mike (Bert) and James (Ernie), along with Tina (Betty Lou) continue their stroll down medical Sesame Street and take a look at the evidence behind Vitamins (Letters) A,B,C, and E. Lo and behold, they find that not all letters are created equal and some are even quite bad. At the end, both Mike and James join the Cookie Monster for some Vitamin enriched (just D that is) treats and, they get Tina to pay.

Show notes

1) Tools for Practice

2) Two systematic reviews shows increased mortality for beta-carotene, Vitamin A, Vitamin E, but not for selenium and Vitamin C

JAMA 2007;297:842-57

Cochrane Database Syst Rev 2008;(2):CD007176

3) BMI – not too fat and not too skinny

Lancet 2006;368:666–78

J Am Geriatr Soc 2010;58:234–41

4) Vitamin B (folic acid) and homocysteine – 1 positive trial, 3 negative trials

JAMA 2002; 288:973-9

N Engl J Med 2004;350:2673-81

JAMA 2004;291:565-75

J Am Coll Cardiol 2003;41:2105-13

4) Measuring hsCRP—An Important Part of a Comprehensive Risk Profile or a Clinically Redundant Practice?
PLoS Med 2010;7:e1000196

In episode 73, we try to put Vitamin D levels into context and Tina Korownyk once again is here to help us decipher the evidence for Vitamin D supplementation when it comes to fractures, falls and overall mortality. At the end of the podcast Mike, James and Tina don their swim gear and go outside without sunscreen on to make some Vitamin D, although Mike and Tina quickly realise they live in Edmonton and it’s wintertime.

Show notes

1) CRP paper by Mike and James

PloS article – Measuring hsCRP—An Important Part of a Comprehensive Risk Profile or a Clinically Redundant Practice?

2) Meta-analyses of Vitamin D and impact on fractures, falls and mortality

Arch Intern Med 2009;169:551-6

JAMA 2004;291:1999-2006

Arch Intern Med 2007;167:1730-7

BMJ 2010;340:b5463

3) Toxicity of Vitamin D

Am J Clin Nutr 2007;85:6-18

4) Sun and Vitamin D3

J Clin Endo Metab 2009;94:1092–3

In episode 72, we find out what Mike has really been doing for the last 3 months by testing his Vitamin D level and finding it to be abnormally high. This leads us, along with our always charming guest Dr. Tina Korownyk, to a discussion of the proper use of Vitamin D levels and what they really mean. At the end of the podcast James and Mike both agree to do podcasts more often than every three months.

Show notes

1) Different reference Vitamin D levels

BC  Biomedical Labs

The Vitamin D Society

2) “the most-ordered hormone assay in the United States”

J Clin Endocrinol Metab 2009;94:1092–3

3) Vitamin D levels

Calgary

CMAJ 2002;166(12):1517-24

Average levels

Am J Clin Nutr 2008;88:558S-564s

4) Multiple health outcomes and Vitamin D levels – nonvertebral fractures, hip fractures, periodontal disease, balance, colon cancer, falls

Am J Clin Nutr 2006;84:18–28

BMJ 2009;339:b3692

Arch Intern Med 2009;169:551-61

JAMA 2005;293:2257-2264

“whether an individual is found to have low or normal vitamin D status is a function of the laboratory used”

J Clin Endocrin Metab 2004;89:3152-7

5) Variability Differences between the mean values of labs was 38%

Ost Int 1999;9:394-7

Mean relative uncertainties between labs were 19.4%, 16.0%, and 11.3%

Ost Int 2009 – 9 September 2009 –Online

Within patient variability – 15-20%

Ost Int 1998 8:222–30