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

In this pseudopodcast, James let's you know what is likely going to be happening with the podcasts and Bob and James, with limited success, make pharmacokinetics and drug levels interesting.
Show Notes

In episode 71, James starts off with a plea for a pledge and then the “Two Mikes” discuss the whole issue of what to do with the new evidence around PSA screening. We find out that if you believed in it before you’ll likely continue believing and if you didn’t believe in it you will still think that way – isn’t evidence wonderful? At the end James hopes you will continue to believe the podcast should continue.

Show Notes

1) Drop James an email at jmccorma@interchange.ubc.ca

2) The two latest studies on PSA screening

NEJM 2009;360:1310-19

NEJM 2009;360:1320-8

3) A useful PSA screening document

ICES 2002 – PSA physician reference document – a pdf

In episode 70, we continue with the “Two Mikes” and discuss a number of issues surrounding asthma treatment. We debate back and forth on the use of LABAs and their use alone or in combination and then come to complete agreement on the duration of prednisone for acute exacerbations. During the podcast James tries to steal the mic away and gets into trouble with Mike because Mike thought James was trying to steal Mike away from Mike.

Show Notes

1) LABAs in patients with asthma – risks and benefits

Cochrane 2008;4:CD006923

Cochrane 2008;3:CD006363

Cochrane 2009;2:CD006924

Cochrane 2009;3:CD006922

NEJM 2009;360:1592-95

2) Short course (3 days) of oral steroids for asthma exacerbations

Medical Journal of Australia 2008;189:306–10

3) Doubling the dose of inhaled corticosteroids provides no benefit but what about quadrupling the dose?

Lancet 2004;363:271-5

Thorax 2004;59:550–6

Am J Respir Crit Care Med 2009;180:598-602

In episode 69, the “Two Mikes” are back at it and they use their mics to dispense some really great prescriptive advice for patients with asthma and no heart burn pain and backs and knees which do have pain. James sits back and goes along for the ride but develops back and knee pain by the end, and the Mikes recommend a full body CT scan.

Show Notes

1) In patients with uncontrolled asthma and no GERD, the use of a PPI does not improve asthma symptoms

N Engl J Med 2009;360:1487-99

2) The use of PPIs and other GERD treatment in patients with asthma and acid-reflux symptoms shows no benefit in asthma symptoms

Chest 2005;128:1128–35

Cochrane Review 2003, No.: CD001496

2) Lumbar imaging for low-back pain without indications of serious underlying conditions does not improve clinical outcomes

Lancet 2009;373:463–72

3) Incidental meniscal findings on MRI of the knee are common in the general population and increase with increasing age

N Engl J Med 2008;359:1108-15

4) Arthroscopic surgery for osteoarthritis of the knee – no benefit

N Engl J Med 2002;347:81-8

In episode 68, we get to the “heart of the matter” of stroke prevention for atrial fibrillation. We find out from Peter Loewen, that it is all a numbers game, and he gives us the tools to deal with this issue. We talk about warfarin and ASA and clopidogrel with respect to their benefits and harms. At the end of the podcast Peter tells us about dabigatran, which obviates all the messages we provide in this podcast. Mike develops an intracranial bleed during the podcast, Peter and James act concerned but continue on because that is what Mike would have wanted.

Show Notes

1) Estimating the risk of strokes in a patient with atrial fibrillation

CHADS2 score

JAMA 2001;285:2864-70

A useful electronic resource from peterloewen.com

Web-based calculator

2) Warfarin versus ASA in atrial fibrillation patients > 75 yrs old

Lancet 2007;370:493–503

3) Clopidogrel and atrial fibrillation

ACTIVE W

Clopidogrel plus ASA versus warfarin (in patients suitable for warfarin)

Lancet 2006;367:1903-12

ACTIVE A

ASA plus clopidogrel vs ASA (in patients not suitable for warfarin)

NEJM 2009;360:2066-78

4) Vitamin K supplementation for labile INRs

Blood 2007;109:2419-23

5) Brief stops in warfarin – what do you do?

Cohort studies (no RCT yet, will get when BRIDGE finished)

Arch Intern Med 2008;168:63-9

Mayo Clin Proc 2008;83:639-45

6) Dabigatran versus warfarin for stroke prevention in atrial fibrillation

RE-LY

N Engl J Med 2009;361:1139-51