Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Far more interesting is that there are now 2 studies showing clearly that good estimates of cardiovascular risk can be made without knowing lab values like cholesterol and CRP. All you have to basically do is look at the patient. Mike looks at James and declares that James is at very high risk of annoying Mike – so he does, just to show the evidence is solid.

Show Notes

1) Reynolds Risk Score

www.reynoldsriskscore.org

2) CRP goes up as weight goes up

Diabetes Metab 2003;29:133-8

JAMA 1999;282:2131-5

3) Estimating cardiovascular risk estimates without knowing cholesterol or CRP

Lancet 2008;371:923–31

Eur J Card Prev RehabMay 2009

Episode 52 goes back in time to look in more detail at what we talked about in episode 30; the whole issue of CRP measurement. Mike and James start at the “large” issue of intra-subject variability, then focus on the “small” impact CRP has on absolute risk assessment, and briefly discuss how “accurate” risk assessments are in the first place. Finally they come to the conclusion that, as with most of the podcasts, they are very accurately vague and there is huge intra-podcaster variability.

Show Notes

1) Issues of intra-subject CRP measurement variability

Clinical Chemistry 2001;47:444–50

2) Need for repeat and multiple values

Clinical Chemistry 1997;43:52–8

Ann Clin Biochem 2002;39:85-8

3) Impact on risk assessment of adding CRP to other risk factors

“Our findings suggest that routine measurement of these novel markers [CRP] is not warranted for risk assessment”

Arch Intern Med 2006;166:1368-73

“the addition of multimarker scores [CRP] to conventional risk factors resulted in only small increases in the ability to classify risk” 

NEJM 2006;355;2631-9

“CRP does not perform better than the Framingham risk equation for discrimination. The improvement in risk stratification or reclassification …is small and inconsistent”

Int J Epidem 2009;38:217–31

4) Reclassification in risk level when using CRP

Women

Ann Int Med 2006;145:21-9

Men

Circulation 2008;118:2243-51

Net reclassification less than that seen in the above studies

Circ Cardiovasc Qual Outcomes 2008;1:92-7

5) Issue of confidence intervals around risk assessments

J Cardiovasc Risk 2002;9:183-90

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In episode 51, we again bring in the charming Dr. Tina Korownyk to help us work through 4 more recent studies that hopefully will have relevance to your practice. We find out that Vitamin B12 works for apthous ulcers, inhaled corticosteroids should be continued in pregnancy, that NSAID risks can be reduced – but not to zero, and an ARB (telmisartan) provides no benefit when given to stroke patients. Finally, it is revealed that Mike and James have very limited absolute charm.

Show Notes
1) Apthous ulcers – sublingual Vitamin B12

J Am Board Fam Med 2009;22:9 –16

2) GI protection for NSAIDs

Am J Gastroenterol  2009; 104:728-38

3) Asthma control in pregnancy – OK to use inhaled corticosteroids

Ann Allergy Asthma Immunol 2008;101:137–43

4) Telmisartan for stroke – no benefit

N Engl J Med 2008;359:1225-37

In episode 50, we talk about 4 more clinical trials that might help you in your practice. We cover topics ranging from fever control with acetaminophen or ibuprofen, injections for rotator cuff injuries, diabetes, and osteoarthritis. Mike and James finally bring in a much needed female flavour to the show, by asking Dr. Tina Korownyk to help out with the evaluation of these studies. Unfortunately we quickly realise that the past 49 shows have, much to our chagrin, lacked any significant sex appeal.

Show Notes

1) Treatment of fever with acetaminophen, ibuprofen or both

BMJ 2008;337:a1302

Arch Pediatr Adolesc Med 2004;158:521-6

Lancet 1997;350:704-9

J Pediatr 1989;114:1045-8

2) Rotator cuff injections – do they need to go in the shoulder

BMJ 2009;338;a3112

3) Diabetes is NOT a CHD risk equivalent

Diabet Med 2009;26,142–8

4) Resistance/strength training for osteoarthritis

Arthritis Care Res 2008;59:1488–94

In episode 49, we continue on from the previous anxiety ladened podcast, and cautiously delve into the whole area of treatment options for anxiety disorders. Mike and James do this by once again cautiously delving into the complex mind of our psychiatry colleague, Dr. Adil Virani. We end up with great advice but get no further insight into how men’s brains work – if in fact they do.

In episode 48, we again invite our psychiatry colleague Adi Virani to talk about the important area of anxiety disorders. Mike and Adil talk about the 6 most common conditions and we find out 25% of the population have some sort of an anxiety disorder. Fortunately, there were only three of us on the podcast so James decides the one who must have an anxiety disorder is our good friend Bob Rangno.

Mike and James celebrate their first anniversary by inviting a good friend and colleague Bob Rangno back to the podcast. We talk about things in medicine that drive us crazy and at the end we come to the conclusion laughter is the best medicine. We then write a Laughter Guideline and outline exactly how patients should laugh, when they should laugh and how often they should laugh.

Show Notes

1) The prostate specific antigen era in the United States is over for prostate cancer: what happened in the last 20 years?

J Urology 2004;172:1297-1301

2) Do you need sterile gloves when suturing a wound?

Ann Emerg Med 2004;43:362-70

3) Using tap water to irrigate a wound

Cochrane Library 2008

4) Lubricating a speculum is OK

Obstet Gynecol 2002;100:889-92

5) Reassessment of Clinical Practice Guidelines – Go Gently Into That Good Night

JAMA 2009;301:868-9

6) The evidence behind the guidelines

JAMA 2009;301:831-41

In episode 46 we speak with one of the gurus of drug safety, Dr. Bruce Psaty, to get some insight on the whole issue of identifying the good and bad things that drugs can do. We come to the conclusion that high quality information is ultimately what is needed if we are to understand what drugs can and cannot do. Both Mike and James lament on their ability to produce high quality information.

In our 45th episode, we review a few more practice changing studies with Dr Mike Kolber. We go through the renal outcomes of a large trial of ACE or ARB or together, the benefits of medical therapy to pass of renal stones and then we journey into another evidence void to review the most recent antibiotic prophylactic guidelines from NICE (UK) and the US. At the end James tries to sort out which Mike is the expert and which one is just opinion, and he can’t so he enrolls them both in an RCT without their consent.

Show Notes

1) Renal outcomes with ACE & ARB (alone or combined).

Lancet 2008;372:547-53.

Canadian Hypertension Education Program (CHEP) urges physicians NOT to combine ACE & ARB

2) Medical therapy for renal stone passage.

Ann Emerg Med 2007;50:552-63

Lancet 2006;368:1171-9

3) Antibiotic Prophylaxis for Infective Endocarditis

J Am Coll Cardio 2008;52:676-85

Heart 2008;94;930-1

Who gets prophylaxis

• US: dental procedures with manipulation of either gingival tissue, the periapical region of teeth or perforation of the oral mucosa
  1. Prosthetic cardiac valves or prosthetic material used for cardiac valve repair
  2. Previous infective endocarditis.
  3. Congenital heart disease (CHD – see below for clarity)
  4. Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve.
• “Patients with CHD. (Level of Evidence: B)
• Unrepaired cyanotic CHD, including palliative shunts and conduits. (Level of Evidence: B)
• Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure. (Level of Evidence: B)
• Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization). (Level of Evidence: B)”