In episode 102, Mike and James, with laser precision, look at the evidence around blood pressure targets. We cover data in non-diabetics, diabetics, chronic kidney disease and the elderly. At the end they agree that the BP target we used 30 years ago (140/90) is still pretty good. To prove the point James gives Mike some sublingual nifedipine and Mike demonstrates the J-curve by falling on the floor and ‘pretending’ to be unable to get up (faker!).

Show notes
1) Systematic review of intensive BP treatment

Cochrane review CD004349

2) ACCORD blood pressure study
N Engl J Med 2010;362:1575-8

3) CARDIO-Sis
Lancet 2009;374:525–33

4) AASK – chronic kidney disease
N Engl J Med 2010;363:918-29

5) INVEST – retrospective data
JAMA 2010;304:61-68

6) BP guidelines
US
Curr Hypertens Rep 2010; 12:290–295
The Seventh Report of the Joint National Committee on: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. August 2004
Canadian
2009 Canadian Hypertension Education Program Recommendations: The Scientific Summary
European
J Hypertension 2009, 27:2121–2158

7) BP in the elderly
N Engl J Med 2008;358:1887-98
Hypertens Res 2008;31:1595-601
Hypertension 2010;56:196-202

In episode 101, your friendly centurions, James and Mike, take a shot at the evidence around target doses for drugs in CHF and find the data is not as compelling as one might think. They discuss the approach of making sure we don’t cause side effects trying to get patients to these targets.  To prove the point, we both took high doses of ACE inhibitors, ARBs, and beta-blockers at the beginning of the podcast and the recording results clearly demonstrate the harm  that can occur from arbitrary use of high doses of medications.

Show notes

1) Getting to carvedilol doses

QJM 2004;97: 133-9

2) Network – ACE doses

Eur Heart J 1998;19:481-9

3) ATLAS – ACE doses

Circ 1999;100:2312-8

4) Carvedilol doses

Circulation 1996;94:2807-16

4) Beta-blocker doses

Ann Intern Med 2009;150:784-94

5) HEAAL – losartan

Lancet 2009;374;1840-8

Mike and James ‘celebrate’ their 100th episode by scouring the world for insightful commentary and therapeutic gems and bring them to you in a hodgepodge of a podcast. The bottom line – we wish to thank you for listening, we hope our rantings have improved your practice in some way and that you stick with us as we enter the next century of TEC podcasts.

In episode 99, Mike and James shed light on two useful new trials. We breath air into what to do with patients with asthma who don't respond completely to inhaled corticosteroids and we take a close look with improved visual acuity at the microvascular data from ACCORD.

Mike and James were down in New Zealand the first week of September, Christchurch in particular, to give a presentation at the Royal New Zealand College of General Practitioners Annual Scientific Conference – “Doing the Right Thing'.

In episode 98, James and Mike delve into the world of asthma and leave the audience breathless with anticipation. We discuss what you do if inhaled corticosteroids don’t work completely and the risk of using LABAs on their own. Close to the end of the podcast James develops an acute asthmatic attack and Mike ‘accidentally’ gives James the wrong direction to the emergency room.

Show notes

1) Children with asthma – after inhaled steroids – then what?

N Engl J Med 2010;362:975-85

2) LABAs with or without inhaled corticosteroids

Am J Med 2010;123:322-8

3) Tools for Practice – Long-Acting Beta-Agonist Inhalers in Asthma: Breathing Evidence into the Debate?

http://www.acfp.ca/docs09/ToolsforPracticeInfoforWebsiteDec142009.pdf

4) Short-acting beta-agonists and harm

N Engl J Med 1992;326:501-6

Lancet 1990;336:1391-6

In Episode 97, Mike and James present listeners with 4 ‘diamonds in the rough’ which should have an impact on practice, or at least get you trending towards a change. Information on MMR and autism, metformin and Vit B12, HbA1C not being zero, and low dose colchicine are presented with the usual clarity and profoundness listeners have come to expect from the podcast. At the end we refer people to the show notes to clear up all the misinformation presented.

Show notes

1) Autism

Tools for practice synopsis

Lancet 1998; 351: 637–41

Clin Pharmacol Ther 2007;82:756-9

PLoS ONE 2008;3: e3140

N Engl J Med 2002;347:1477-82

Lancet 1998;351:1327-8

Lancet 1999; 353: 2026–9

BMJ 2002;324:393–6

JAMA 2001;285:1183-5

BMJ 2001;322:460–3

Lancet 2004; 364: 963–9

JAMA 2003;290:1763-6

Pediatrics 2004;114;584-91

Pediatrics 2003;112;1039-48

CMAJ 2010;182:e199-200

BMJ 2010;340:c593

Lancet 2004;363:750

BMJ 2006;333:890–5

Pediatrics 2010;125;654-9

2) Metformin and viamin B12 deficiency

BMJ 2010;340:c2181

3) Diabetes cohort

Lancet 2010; 375: 481–89

Arth Rheu 2010;62;1060–8

In episode 96, Mike and James continue on with the discussion around evidence for low back pain treatment. They discuss things like traction, heat, exercise and bedrest and then finally get into drugs – not personally of course, at least not much, but into the discussion  of which ones work and by how much. We conclude with an expert discussion of experts and suggest that experts are not necessarily experts when it comes to evidence.

Show notes

1) Traction

Cochrane 2007;2:CD003010

2) Heat and ice

Cochrane 2006;1:CD004750

3) Lumbar support

Cochrane 2008;2:CD001823

4) Transcutaneous electrical nerve stimulation

Cochrane 2008;4:CD003008

5) Exercise

Cochrane 2005;3:CD000335

6) Bedrest

Cochrane 2004;4:CD001254

7) Yoga and transcutaneous electrical stimulation

Ann Intern Med 2007;147:492-504

8) Acetaminophen

Eur Spine J 2008;17:1423-30

9) NSAIDs

Cochrane 2008;1:CD000396

10) Opioids

Cochrane 2007; 3:CD004959

Ann Intern Med 2007;146:116-27

11) Muscle relaxants

Ann Intern Med 2007;147:505-14

12) Benzodiazepines

Ann Intern Med 2007;147:505-14

13) Gabapentin

N Engl J Med 2009;361:1963-71

14) GPs with special interest in back pain tend to not know the evidence

Spine 2009;34:1218–26

In episode 95, Mike and James look at the issue of non-specific low back pain and deal with concepts around diagnosis and we find out that x-rays aren’t that useful but MRI’s in the right patient population can play a role. We then start to look at the available evidence for treatment (massage, acupuncture, spinal manipulation) and at the end Mike tries to give James a two-handed neck massage and in retaliation James does acupuncture on Mike with a harpoon.

Show notes

1) Guidelines on back pain

TOP Back Guideline

American College Guideline

Ann Intern Med 2007; 147:478-91

Ann Intern Med 2007;147:505-14 (meds)

Ann Intern Med 2007;147:492-504 (non-meds)

Summary of guidelines

BMJ 2006; 332:1430-4

Evidence-based Series (non-medication) on Back Pain

Spine 2009, 34:1066-77 and 1078-93 and 1094-1109

2) Imaging – x-ray, CT and MRI

BMJ 2001;322:400-5

Lancet 2009;373:463-72

JAMA 2003;289:2810–8

MRI likelihood ratios

Ann Intern Med 2002;137:586-97

BMJ 2006;332:1430-4

Ann Intern Med 2007;147:478-91

4) Massage

Cochrane 2008; 4: CD001929

5) Acupuncture

Ann Intern Med. 2005 Apr 19;142(8):651-63

Cochrane 2005; 1:CD001351

6) Spinal manipulation

Cochrane 2004; 1: CD000447

In episode 94, we get to yet more listener questions and provide vague, yet deep and thoughtful answers. We talk about the use of benzodiazepines, serotonin syndrome, buspirone, ‘urgent’ hypertension and pontificate even more on low doses. Mike and James realise that while low is often a good way to start, all their podcasts to date start of with high expectations yet end with not much more of an effect than placebo.

Show notes

1) Effects of Treatment on Morbidity in Hypertension – Results in Patients With Diastolic Blood Pressures Averaging 115 Through 129 mm Hg

JAMA 1967;202:1028-34

2) Effect of Propranolol in Mild Hypertension

Lancet 1966;288:1148-50

3) Clopidogrel

See episode 90