In episode 104, Mike and James blow out a lot of hot air about the use of medications for acute asthma and they come to the quick realization that the concepts they have been evangelising for the past 2 years (low dose and shared-informed decision making) have no role in acute asthma. James, in an act of defiance gets a cat to sit on top of Mike’s head until becomes acutely short of breath and then gives Mike a 1/4 puff of salbutamol. Shockingly, the outcome was less than optimal.

Show notes

1) Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma

Cochrane review

2) Continuous versus intermittent beta-agonists for acute asthma

Cochrane review

3) Combined inhaled anticholinergics and beta2-agonists for initial treatment of acute asthma in children

Cochrane review

4) Early emergency department treatment of acute asthma with systemic corticosteroids

Cochrane review

5) Magnesium for acute asthma

Cochrane review

6) Aminophylline for acute asthma

Cochrane review

In episode 103, James and Mike discuss the whole concept of discussion of side effects with patients. They rarely disagree but commonly get confused and at the end they both develop all the side effects discussed, which goes completely against the available literature.

Show notes

1) Important elements of outpatient care

Ann Intern Med 1996;125:640-5

2) The consent form that caused side effects

Clin Pharmacol Ther 1987;42:250-3

3) The evidence that telling patients about side effects doesn’t cause side effects

Br J Psych 1973;122:461-4

Br J Psych 1978;132:526-7

J Behav Med 1982;5:263-73

Br J Clin Pharmac 1984;17:21-5

Br J Clin Pharmac 1989;27:723-39

J Fam Pract 1990;31:62-4

Arch Int Med 1994;154:2753-6

4) If you are allergic you are allergic

N Engl J Med 2003;349:1628-35

5) Why you shouldn’t use words to describe the magnitude of side effects

Lancet 2002;359:853–54

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