Recent comments

  • Episode 250: New Studies – two podcasts for the price of one   6 days 2 hours ago

    Discussing the new recommendations from AMerican College of Physicians against routine screening pelvic examinations in adult, asymptomatic, average risk, non-pregnant women. THis has causd quite an uproar by gynecologists. Don't know if Canadian docs can participate in Sermo.com but the discussion is quite ugly with talk of missed ovarian cancers, missed fibroids, missed PID, etc. For example: 

    As an ob/gyn, I don't go around telling internists to not bother to listen to hearts and lungs because most of the time, you don't find anything wrong. I mean, the patient's breathing normally right?

    All this is going to do is keep my field busy in the next 15 years. Because in general, women don't know if they're asymptomatic because they aren't educated on what is normal or abnormal...

     

    There will be a small lull, then we are going to start seeing the horendiomas that I used to see when I was a young pup. You know,, fibroid uteri as big as a 20 week uterus, Ovarian "cysts" that weigh 40 pounds. 

    We had a patient when I was a resident who hadn't seen anyone for years. She had vague abdominal symptoms. Work-up finally got her to one of my attendings. Her ovarian tumor (fortunately benigh) weighed in the 20 pound range. When she was walking around the nursing station on post op day 4 (!) someone said to her that she looked like she had lost weight. Her reply? "I've been jogging>

     

    Ovarian cancer is a silent disease. Without either exam or ultrasound it can't be detected usually until it is too late. So if an ovary becomes cancerous how long does it take to spread and be fatal? Exam frequency my take this into account and prevent deaths from ovarian cancer.

    Of course there are all the other diseases and problems.

    Anything short of year visits (meaning pelvic exam and/or US) I feel is inadequate care.

     

    Without that annual exam and a little getting used to the exam and talking about all that "embarrassing stuff", us women probably wouldn't be ready to bring up the weird stuff that really IS a problem. 
    Internists don't know everything!

     

    I wonder how valid is it. Patient of mine, had some changes in her menstrual cycle and some intense cramping ith it too, by the way, she is on BCPs. In December goes to her OB for her yearly but doesn't mention anything. 
    Normal exam. In April, goes and tells him evrything. He does vaginal ultrasound which is painful. The end result is fibroid(s) and they need to be removed.

    Thanks for considering it.

  • Episode 238: PREMIUM – two new cardiovascular studies and a bit about cough   3 weeks 10 hours ago

    URTI duration is something that isn't taught at all in residency. I think most residents like myself just based our estimates on personal experience and what we think sounds right. This definitely gives me a more solid foundation to stand on and say to patients, "This is still probably a virus and the week-long cough is totally normal".  Thanks!

  • Episode 210: An explosive look at probiotics for the prevention of C.difficile associated diarrhea   14 weeks 5 days ago

    No , that is cool, I have been supporting my patients who are offered probiotics by the local chemist recently, I can now back to me default position of encouraging them not to buy anything in a chemist's shop apart from combs and perfume. My patients need combs and perfume.

  • Episode 234: PREMIUM – Fatty acids and should you eat acetaminophen during pregnancy   22 weeks 1 day ago

    Hi there,

    nice podcast as usual!

    Please give some notes/links for your comments about specialist and their approach to studies of their field. Thanks!

    And I'd still like to hear more about medical problems in hospital, e.g. anticoagulation for venous thromboembolism (just look at this one: http://www.thennt.com/nnt/anticoagulation-for-venous-thromboembolism/ - amazing, but true?)

    Greetings from Germany

    Fabian

  • Episode 234: PREMIUM – Fatty acids and should you eat acetaminophen during pregnancy   22 weeks 2 days ago

    Thanks - the link is fixed!!

  • Episode 234: PREMIUM – Fatty acids and should you eat acetaminophen during pregnancy   22 weeks 5 days ago

    takes to annals article

  • Episode 228: PREMIUM – The new JNC8 high blood pressure guidelines dissected and exposed   30 weeks 4 days ago

    I do inform my patients of the 160 cutoff being real, but I also tell them that I don't mind that the recommendations are lower because as a parent, if I wanted my kids home at midnight I told them to be home at 11:30. 

  • Episode 228: PREMIUM – The new JNC8 high blood pressure guidelines dissected and exposed   31 weeks 1 day ago

    I was disappointed that the updated guidelines had no comment on taking blood pressure medications at bedtime.

  • Episode 227: Vaccines - how many pricks do you really need? Part III   32 weeks 20 hours ago

    Hi James and Mike, (proper order of salutation): my wife recently "won" a new line of work at our hospital that involves working days, evenings and nights. She is a poor sleeper at the best of times and is worried about recovering/living through the evening shifts, any new material, pharmaceutical and non-pharmaceutical, on treating insomnia or sleep deprivation.... especially in shift workers?

    Cheers,

    Ian

  • Episode 227: Vaccines - how many pricks do you really need? Part III   32 weeks 20 hours ago

     I hope that other health practioners in British Columbia don't think, from this article, that pharmacists in B.C. get this kind of reimbursement for prescritions.... Oh!, to be allowed to have mark-ups and sliding scale dispensing fees on prescriptions!! Also, be aware that the "BC" used in this article refers to (Alberta) Blue Cross, and not to Brithish Columbia.

  • Episode 195: PREMIUM – The Mediterranean cuisine cruises to another win   33 weeks 4 days ago

    Hi folks!

    I've listened to the podcast episode but am puzzled by skepticism of the combined niacin study results.

    407 subjects were culled from 4 studies with established vascular disease who had no diabetesmellitus diagnosis; had baseline fasting glucose of less than 100 mg/dL; 90% were male; mean age 58.7; BMI 27.4; 197 received ~2 g niacin daily, 210 received no niacin. Some niacin subjects received time release; some received immediate release. The onset of impaired fasting gluvose, diabetes mellitus, changes in mean proximal coronary stenosis and major cardiovascular events (including death, MI, stroke and revascularization) were measured after three years.

    While the niacin group had a higher increase in IFG vs non-niacin (9.9 vs 4.1 mg/dL), there was no statistical difference in insulin levels or progression to DM between the groups. In other words, a marker change but no harm outcome change.

    For changes in coronary stenosis, the niacin group showed no change in 3 yrs whereas the non-niacin group worsened (0.1% vs 2%). This is a positive health outcome for the niacin group.

    For major coronary events, the niacin group experienced 8% vs 21% for the non-niacin. This again is a postivie health outcome for the niacin group.

    Doesn't this suggest that, for patients not wishing to use a statin, that niacin should, in fact, be encouraged? And that further studies would be worth pursuing?

    Thanks,
    Alexander Inglis
    In Toronto 

  • Episode 220: Confusing confidence intervals   34 weeks 3 days ago

    After listening to you discuss results that fall very close to significance or not, and how do we interpret this, I thought this recent comment in Nature's Spinal Cord might be of interest:

    http://www.nature.com/sc/journal/v52/n1/full/sc2013117a.html?WT.ec_id=SC...

    Cheers,

    James Telfer

  • Episode 217: Shining a bright light on the Vitamin D evidence   37 weeks 6 days ago

    Any comments on Vit D levels and supplementation in pts with MS? Specifically reducing exacerbations and slowing dz progression?

  • Episode 221: Finally getting the cholesterol guidelines right – almost   40 weeks 1 day ago

    Hi guys,

    Thanks for the nice update of the new American guidelines. Glad to hear that evidence is starting to prevail. I do want to take slight issue with your discussion of one of the subgroups recommended for statin therapy by the guidelines, i.e. those with high LDL levels. Mike made the point of using global risk stratification as opposed to just the LDL level (which James rightly pointed out isn't part of our standard calculators), however my impression is that the guidelines are targeting those with familial hypercholesterolemia, who may have isolated high LDL without any other obvious risk factors, and for whom the risk calculators are probably underestimating their lifetime risk. (According to the 2006 CMAJ review of FH linked below, risk of CAD by age 60 is 30-60%.) That said, without a positive family history or tendon xanthomas (or other weird and wonderful clinical signs), I agree that it's tough to justify treatment based on LDL level alone. 

     

    Also, thanks for pointing out the variability in the outcomes being predicted by various CV risk calculators. When I started using my EMR and its built-in "Framingham calculator," I was surprised at how high the predicted 10 year risk was for some of my patients. After a little digging, it turned out the calculator included a lot more than just the usual "hard" outcomes. I'd urge everyone using a similar EMR-based calculator to either look into what you're actually calculating, or use a specific calculator that you trust. 

     

    Ed

     

    1. Yuan et al. CMAJ - 2006 - http://www.cmaj.ca/content/174/8/1124.full.pdf.

  • Episode 221: Finally getting the cholesterol guidelines right – almost   41 weeks 2 days ago

    ESC guidelines on hypertension 2013: <140/90 is the new goal for all subgroups! And treatment isn't always necessary betwenn 140 and 160 systolic RR..... unfortunately, they are promoting sartans as first line opton, and even aliskiren as a second line agent.... you can't have it all....

    link: http://eurheartj.oxfordjournals.org/content/34/28/2159.full.pdf+html?sid=5dbe9b90-8a6d-4969-b3e0-76d1d905ed05

    still love your podcast.... what's the reason you don't talk more about in-hospital-care? I would like to hear that....

    greetings form germany

    fabian

  • Episode 26: COPD: Confusing Overwhelming Puffer Data leaving us Breathless   50 weeks 3 days ago

    Very helpful

  • Episode 210: An explosive look at probiotics for the prevention of C.difficile associated diarrhea   1 year 1 week ago
  • Episode 208: PREMIUM – COPD, gout and NSAIDs oh my   1 year 10 weeks ago

    I nearly had a gout attack, or heart attack, after hearing of this allopurinol study protocol including colchicine, for everyone,  twice daily for 90 days. For NINETY days?(!)

    For one thing, you & Mike have I think discussed the option of using colchicine as once daily dosing, because of its favourable half-life. But how about using colchicine only until the toe pain is gone...maybe 5 or 6 days. Even without specific treatment, podagra attacks tend to resolve over 7 - 10 days. Of course anti-inflammatory treatments (NSAID +/- colchicine) should drop that down to fewer than that.

  • Episode 208: PREMIUM – COPD, gout and NSAIDs oh my   1 year 10 weeks ago

    Have you ever done a podcast where you've looked at the evidence around NSAID use prior to athletic events (e.g. long distance running, endurance cycling, etc)  especially among those of use who are middle-aged?  I seem to recall that there was some media attention a few months ago about a study that came out, and if there is sufficient interest and data, it would be interesting to hear your views.

    Phil Emberley, Director, Pharmacy Innovation, CPhA

  • Episode 203: PREMIUM – Vitamin D, chelation therapy, and obesity studies you need to know about   1 year 15 weeks ago

    It seems to me that all Vitamin D is, is a surrogate marker for sunshine. It is certain that we have but a vague knowledge of the effects os sunshine. More basic research is needed.
    Regards,
    Peter Catt NZ GP

  • Episode 194: The evidence for Vitamin D and folic acid for depression is not all that depressing   1 year 19 weeks ago

    hi Mike, hi James

    I love your website, podcasts, and course - they are very helpful in sorting out the research and, ultimately, guiding practice.

    Several times, I have heard discussion regarding information about the cost of medication.  I am sure you are also aware of RxFiles [www.RxFiles.ca], an exceptionally compact and 'robust' drug information source that includes [canadian] pricing information.

  • Episode 187: A spine-tingling look at neuropathic pain – PART III   1 year 20 weeks ago

    Hi James (and Mike, although this question is probably just for James)

    At the end of episode 187 (Part III of the neuropathic pain segments) you mentioned a book I can access on my iPad that talks about evaluating studies. What is the title of that book? Thanks!

    Stacy Jardine BSc.Pharm R.Ph

    Peace River, AB

  • SPECIAL Episode – Bad Science, Bad Pharma, Good Podcast with Ben Goldacre   1 year 24 weeks ago

    This was an outstanding podcast.
    I do not agree with everything thing that Ben Goldacre says but as he himself stated it is always great to get another perspective.
    The conversation between John and Ben held my attention for the full hour. It is a pity that Mike was not available too.
    Great work.
    Thanks,
    Pol Morton

  • How to Critically Appraise an RCT in 10 Minutes   1 year 25 weeks ago

    Hi guys- I don't have an ipad- but would love access to this book...is there a PC version available?? thankyou

  • Episode 188: PREMIUM – Taking a bite out of fasting for cholesterol measurements and more bad news about low A1cs   1 year 26 weeks ago

    In the same journal issue of JAGS, there was this item:http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2012.04099.x/abstract stating that a HIGHER A1C (8%) versus 5.5% led to more fuctional decline.

    Comments?