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

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

J Neurol Sci 2009;282:21–7

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

BMJ 2009;338:b2266

Osteopor Int 2005;16:842-8

3) Only measure BMD once

Arch Intern Med 2007;167:155-60

4) An RCT of vertebroplasty for vertebral fractures

In episode 90, Mike and James solicit the mainly brilliant, but always delightful help of Mike Kolber and Tina Korownyk. We talk about what to do for the chronic pain that can be associated with Herpes zoster and we have a quick look at the old and new data surrounding the area of PPIs and platelet inhibitors. Mike and James cap off the podcast by deciding that Mike and Tina do a way better job than they do so they sell the podcast to the new duo for a brand name PPI and a generic cup of coffee.

Show notes

1) Chronic pain – dual therapy gabapentin plus nortriptyline

Lancet 2009;374:1252-61

2) Clopidogrel and PPIs

JAMA 2009;301:937-44

CMAJ 2009;180:713-8

Lancet 2009; 374: 989–97

Circulation 2009;120:2322-9

Circulation 2009;120;2310-2

COGENT

3) Duration of clopidogrel

N Engl J Med 2010;362:1374-82

In episode 89, Mike and James finish the Bruce Arroll trilogy, but, as with Star Wars we hope there will be more at a later date. We talk about herpes zoster, depression, anxiety, corns, warts and the benefits of making making house calls, phone calls and drugectomies. At the end of the podcast both Mike and James decide to make a house call to Bruces’s house when they go to New Zealand and hope they will get prescribed high doses of very decent wine.

Show notes

None as we really just talked about concepts and approaches and avoided evidence as much as possible.

In episode 88, James and Mike continue their conversation with Bruce Arroll from down under and cover a broad range of topics from smoking to antibiotics for acute bronchitis, warfarin, and spironolactone. At the end of the podcast Bruce and Mike decide that much of what James has to say is up and over the top.

Show notes

1) Stopping smoking benefit

Chest 2007;131:446–52

2) Low-dose aspirin in patients with stable cardiovascular disease

Am J Med 2008;121:43-9

3) Losartan – 50 vs 150 mg

Lancet 2009;374:1840-8

4) Antibiotics for COPD Acute Exacerbation

Cochrane 2006;2:CD004403

5) Many patients unaware of GI risk from NSAIDs

J Rheumatol 2005;32:2218-24

6) Spironolactone for resistant hypertension

AJH 2003;16:925–30

Journal of Hypertension 2007;25:891-4

In episode 87, Mike and James bring up the unlikely issue of likelihood ratios. As they knew they would likely have difficulty discussing this, they bring in the expert help of Bruce Arroll from New Zealand who really likes our podcast. We also like what he does as he has published so many useful articles in the area of rational therapeutics. However, at the end, the likelihood that any of this made sense is about 1.01, which is likely similar to the end result for most of the podcasts.

1) Simplifying Likelihood Ratios

For pre-test probabilities between 10% and 90% a positive test with an:

LR of 2 – increases the probability by 15% (absolute increases)
LR of 5 – increases the probability by 30%
LR of 10 – increases the probability by 45%

LR of 0.5 – decreases the probability by 15% (absolute decreases)
LR of 0.2 – decreases the probability by 30%
LR of 0.1 – decreases the probability by 45%
J Gen Intern Med 2002;17:647-50

2) Likelihood Ratio of a Positive Test Result
1-2 – “Poor”
2-5 “Small – Moderate”
5-10 “Good”
>10 “Excellent (Rule in)”

3) Likelihood Ratio of a Negative Test Result
1 – 0.5 “Poor”
0.5 – 0.2 “Small -Moderate”
0.2 – 0.1 “Good”
< 0.1 “Excellent (Rule out)”

4) Examples of some useful LRs
Phalen Test positive (Carpal Tunnel):
LR = 1.3
Shifting Dullness present (Ascites):
LR = 2.3
Patient Reporting Fever (>38 Temp):
LR = 4.9
Interstitial Edema on Chest X-Ray (CHF):
LR = 12.7
Ottawa Ankle Rules (Ankle #) negative:
LR = 0.08
Canadian C-Spine Rules (C-spine #) negative
LR = 0.013
(vs NEXUS LR = 0.25)
For children age 3-15 – throat swab for GABHS
LR +ve test = 2.9
LR -ve test = 0.04

JAMA 2000;283:3110-7
J Gen Intern Med 1988:423-8
Ann Emerg Med 1996:27:693-5
Am J Med 2004; 116: 363-8
BMJ 2003;326:417
NEJM 2003; 349: 2510-8

5) A clinical score to reduce unnecessary antibiotic use in patients with sore throat
CMAJ 1998;158:75-83

This week we have something slightly different for you. This pseudopodcast is a recording from our most recent drug therapy course held here in Vancouver in April 2010.
Typically on the last afternoon of the course we get a panel together to discuss issues that are of importance to health care professionals who “use’”drugs.