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?
2) LABAs with or without inhaled corticosteroids
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
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
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
3) Diabetes cohort
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
| Condition | Positive Likelihood ratio | Negative Likelihood ratio |
| Herniated Disc | 1.1 – 33 | 0 – 0.93 |
| Stenosis | 3.2 – ? | 0.1 – 0.14 |
| Cancer | 8.3 – 31 | 0.07 – 0.19 |
| Infection | 12 | 0.04 |
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
2) Effect of Propranolol in Mild Hypertension
3) Clopidogrel
In episode 93, we once again get back to listener questions. We explore everything from haloperidol for nausea and vomiting, to statin dosing, ASA in diabetics, and finally Alzheimer's drugs. Towards the end, James and Mike realise that listener questions are too hard and they make up some easy ones of their own yet still struggle.
Show notes
In episode 92, we do a final session with our two family physician friends and colleagues, Mike K and Tina K. We start off with Tina discussing some satisfying evidence for the use of bupropion in women with low sexual desire which causes sexually related personal distress. In the second part Mike K in a slightly less satisfying way looks at the recent evidence surrounding vascular surgery for a treatment of multiple sclerosis. To conclude this 3-part series we all stop talking, to the satisfaction of all our listeners.
Show notes
1) Bupropion for sex
BJU Int 2010 Feb 11. [Epub ahead of print]
2) Surgery for multiple sclerosis
In episode 91, yet again we bring in Mike K and Tina K to help us out with some very useful clinical information surrounding the issue of bone density and osteoporosis. We look at studies from the BMJ (Bowel Medical Journal), one of Mike A’s favourite journal, and we all agree that simple models should be used and repeat BMDs are basically not needed. Unfortunately we also come to the realisation that in a similar fashion, Mike A and James are basically not needed for the podcast as they are too simple.
Show notes
1) Simple models vs more complex models – simple is just as good
Arch Intern Med 2009;169:2087-94
2) Repeat bone density – is it needed – likely not
3) Only measure BMD once
Arch Intern Med 2007;167:155-60
4) An RCT of vertebroplasty for vertebral fractures
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This pragmatic trial is now recruiting in BC. Make a difference and get involved with pragmatic trials (www.pragmatictrials.ca)
