Transcript: Twitter Journal Club Sixth Meeting 8pm, Sunday 10th July 2011

Short et al. (2011) Effect of blockers in treatment of chronic obstructive pulmonary disease: a retrospective cohort study, BMJ - Available at http://bit.ly/pfylWe Hosted by Fi Douglas

twitjournalclub Good evening, and welcome to this week's #TwitJC on beta blockers in COPD. 8:00 PM amcunningham @milesmack join in #twitjc just starting now on this paper http://www.bmj.com/content/342/bmj.d2549.full -8:00 PM northern_doctor Looking forward to the discussion tonight. Recent paper, topical subject, relevant to many specialties. #TwitJC -8:00 PM alasdairforrest @northern_doctor And the research was done in Dundee @DundeeUniv. What more could you ask for? #twitjc -8:00 PM twitjournalclub It's Fi (@fidouglas) here, hosting this evening. The link to the paper is: http://www.bmj.com/content/342/bmj.d2549.full #TwitJC -8:01 PM PaedsSHO Evening all. Dave, paediatrics. This paper's not really my area, but interested nonetheless. #twitjc -8:01 PM northern_doctor @alasdairforrest @DundeeUniv Almost as prestigious as Newcastle ;-) #TwitJC 8:01 PM twitjournalclub An introduction to the paper is here: http://t.co/yjuC0Tp and the discussion points can be found here: http://t.co/3a2CnTU #TwitJC -8:02 PM amcunningham @kevinmd @drmikesevilla @medicallessons @LindaP_MD @hrana like to join #twitjc discussion of this paper just now? http://is.gd/nU6WzS -8:02 PM medicallessons RT @amcunningham: Twitter journal club( on beta blockers and COPD) join in, #twitjc just starting now on this paper http://bit.ly/mBqMgx -8:02 PM amcunningham @twitjournalclub #TwitJC I'm Anne Marie- Gp in Cardiff- nice to see paper very relevant to #1care:) -8:03 PM twitjournalclub As usual, if we can begin with introductions... #TwitJC -8:03 PM alasdairforrest #TwitJC Alasdair Forrest, just graduated from @DundeeUniv, about to start work in Aberdeen. -8:03 PM welsh_gas_doc My dinner's nearly ready, so won't be partaking in tonight's #TwitJC. Sorry x -8:03 PM northern_doctor I'm Mark - teaching fellow & geris SpR in North East #x #TwitJC -8:04 PM mgtmccartney margaret, gp in glasgow, #twitjc @twitjournalclub -8:04 PM silv24 Good evening all, Natalie F1 in gastroenterology and partner in crime to @fidouglas in running the journal club #twitjc -8:04 PM mtvpaul #TwitJC Paul - 3rd year medical student at Brighton & Sussex; evening everyone. #twitjc 8:04 PM

hrana @amcunningham I'll be dipping in and out as I'm on holiday until Wednesday morning. :) #twitjc -8:05 PM StuartBerry1 #twitjc this is something that I have been saying to patients for >1yr? When was the paper that 1st suggested bblickers not harmful in copd? -8:05 PM fidouglas Fi here, chairing this evening, but may also contribute any other thoughts from this account. Pre-clinical med student at Cambridge. #twitjc -8:06 PM drgandalf52 Dr Gandalf academic teaching fellow at university of Leeds, first5 GP and general techy and mystical medic #twitjc -8:06 PM welsh_gas_doc Before I go, could somebody explain to @Phillippajones how #TwitJC works? Thanks. -8:06 PM a_singledrop Medical student in Chicago, mostly lurking on #twitjc due to poor internet, but glad to be around to at least follow the conversation! -8:06 PM northern_doctor Before the serious discussion gets going, I'd like to applaud the creation of a database using the acronym TARDIS. Good work! #TwitJC -8:06 PM amcunningham RT @northern_doctor: Before the serious discussion gets going, I'd like to applaud the creation of a database using the acronym TARDIS. Good work! #TwitJC -8:07 PM amcunningham @Phillippajones hi- what do you need to know? search twitter for #twitjc and you will see the discussion- ad (cont) http://deck.ly/~FuInl -8:08 PM twitjournalclub @welsh_gas_doc @Phillippajones This may help: http://twitjc.wordpress.com/wp-admin/post.php?post=26&;action=edit #TwitJC -8:08 PM marcela RT @twitjournalclub: An introduction to the paper is here: http://t.co/yjuC0Tp and the discussion points can be found here: http://t.co/3a2CnTU #TwitJC -8:08 PM yazman89 LOL --> RT @northern_doctor: I'd like to applaud the creation of a database using the acronym TARDIS. Good work! #TwitJC -8:08 PM drgandalf52 But it not really a TARDIS more TRDIS lol #twitjc -8:08 PM StuartBerry1 RT @medicallessons: RT @amcunningham: Twitter journal club( on beta blockers and COPD) join in, #twitjc just starting now on this paper http://bit.ly/mBqMgx -8:09 PM amcunningham @hrana #twitjc great:) although you know who we had tweeting from his holiday last week? :) http://is.gd/P46wF9 #twitjc -8:10 PM twitjournalclub If we can begin with the first discussion point, which concerns the nature of the study... #TwitJC -8:10 PM hrana @amcunningham I know! I'm no Atul but I shall put my best foot forward. :) #twitjc -8:10 PM colleen_young @Doctor_V We were reading @amcunningham's Storify of @atul_gawande joining #TwitJC at the same time. -8:10 PM StuartBerry1 #twitjc sorry. Thus is my first one. Hi all i am a gp in Pendle Lancashire uk. -8:11 PM twitjournalclub This is a retrospective cohort study: What is the place of observational studies in influencing/changing clinical practice? #TwitJC -8:11 PM northern_doctor Wow - tough to summarise pros & cons of observational studies in 140 characters...! #TwitJC -8:11 PM northern_doctor Observational studies definitely have their place and can be v useful, but need to be aware of limitations #TwitJC -8:12 PM

fidouglas @northern_doctor You do have to be succinct, yes! ;-) #twitjc -8:12 PM alasdairforrest @twitjournalclub The Regional Ethics Committee may have preferred a retrospective study to a therapeutic trial. Or 1/5 paperwork? #twitjc -8:12 PM GabrielScally #TwitJC They are amazingly cheaper to do are they not? -8:12 PM northern_doctor Difficult to be as 'controlled' as prospective studies, but can allow for greater patient numbers to be studied #TwitJC -8:13 PM amcunningham @northern_doctor #TwitJC agree it is a hard question- but I suggested it! Ivery interested in the perspective of others:) -8:14 PM silv24 Often far far simpler to carry out, cheaper to carry out and requires less time but limitations have to be acknowledged #twitjc -8:14 PM alasdairforrest Do you think a therapeutic trial would have easy to justify, if intervention is known to decrease FEV1? #twitjc -8:14 PM northern_doctor RT @GabrielScally: #TwitJC They are amazingly cheaper to do are they not? <--Very true! Also faster (usually). #TwitJC -8:14 PM yazman89 The obvious con of such studies being the 'non-randomised' nature of the results. #TwitJC #twitjc -8:14 PM colleen_young Here's the link to @amcunningham's Storify of @atul_gawande joining #TwitJC http://is.gd/P46wF9 -8:14 PM mgtmccartney #twitjc @GabrielScally can also lead to more definitive questions and enable better rcts in future -8:14 PM drgandalf52 A mentioned @norther_doctor the main issues are limitations ie the population u are observing #twitjc -8:14 PM fidouglas @silv24 Less time, as in overall timescale from start to finish, or in terms of man-hours put into the study...? #twitjc -8:15 PM northern_doctor @alasdairforrest: Might be easier to justify now, after this paper! #TwitJC -8:15 PM silv24 Need to interpret the results of observational studies very carefully with regards to confounding factors etc #twitjc -8:15 PM teachingofsci hmm... is quite cool that I'm finding refs for #twitjc for my blog post, while i'm seeing tweets from @silv24 about in in timeline... -8:15 PM alasdairforrest @silv24 Any obvious confounding factors here? #twitjc -8:16 PM amcunningham In the case of this paper-what biases might have been avoided if it had been an RCT? Do we think those on bblocker were healthier? #twitjc -8:16 PM northern_doctor @amcunningham Not knocking the question - definitely valid for this forum. I just have too much to say for a single tweet! #TwitJC -8:16 PM StuartBerry1 #twitjc and you have decided to try and find out why they aren't on a bblocker .it's easier to say ; well done people did a study with peopl -8:16 PM silv24 @fidouglas both actually, generally take less time and man hours than prospective studies #twitjc -8:16 PM GabrielScally #twitjc I also noted in the subsequent correspondence the problem of "immortal time bias"! I'll have to study the concept. -8:17 PM

alasdairforrest @amcunningham But Carstairs index not greatly different between cohorts. Would imagine socioec is biggest confounding variable. #twitjc -8:17 PM silv24 @alasdairforrest we don't actually know why any of these patients were on beta blockers for one thing! #twitjc -8:17 PM amcunningham @GabrielScally #twitjc yes, I saw that... I'm guessing it means that the delay in entering trial may mean they are healthier -8:17 PM alasdairforrest Mean to say, except socioec is similar in both groups due to Carstairs being similar. #twitjc -8:18 PM amcunningham @GabrielScally #twitjc but I guess you could pick two time points for other side as well... -8:18 PM StuartBerry1 #twitjc the doc interaction with patient in thus scenario is interesting. You are having to say medicine previously got it wrong. Now takebb -8:19 PM northern_doctor Although database sounds comprehensive, past history of patients is unknown and no record of indication for starting BBs #TwitJC -8:19 PM amcunningham @alasdairforrest #twitjc the biggest bias might have been that bblocker were only prescribed to less seriously ill in first place -8:19 PM JDMoffatt #twitjc Are we all aware of the relatively new idea that beta-blockers might be *good* for inflammatory lung diseases? <-basic sci talking. -8:19 PM silv24 RT @northern_doctor: Although database sounds comprehensive, past hx of patients unknown & no record of indication for starting BBs #twitjc -8:19 PM amcunningham @JDMoffatt #twitjc yes, that is mentioned in the paper ... http://is.gd/K9QgwE ,_ betablockers and asthma -8:20 PM GabrielScally #twitjc Nice definition of "immortal time bias" in this paper:- http://bit.ly/nCLwES 8:20 PM drgandalf52 @StuartBerry1 true but we do that all the time, rosiglitazone par example #twitjc -8:21 PM silv24 RT @JDMoffatt: #twitjc Are we all aware of the relatively new idea that beta-blockers might be *good* for inflammatory lung diseases? <-basic sci talking. -8:21 PM drgandalf52 @JDMoffatt it news to me till I read this paper #twitjc -8:21 PM StuartBerry1 @JDMoffatt yes it's new ish but was written about in the med journals. Possibly variable uptake of new info amongst clinicians ? #twitjc -8:22 PM jonthehen @donotcallmemike do you take part in #TwitJC how do u find this weeks paper? -8:22 PM northern_doctor @JDMoffatt Slowly filtering through, but taking a while to overcome traditional perception that they are contraindicated #TwitJC -8:23 PM yazman89 @JDMoffatt But was the paper arguing that BBs are good for inflammatory diseases directly? Or was it cuz they helped with co-morbid? #TwitJC -8:23 PM twitjournalclub Can observational studies be used to change clinical practice, or do we need further studies to confirm findings? #TwitJC -8:23 PM StuartBerry1 #twitjc big element of dependency on what knowledge the clinician has and their faith in the stuff they have read. -8:24 PM

GabrielScally #twitjc Depends on the strength of evidence on which the current practice is based. 8:24 PM amcunningham Another paper that mentions 'immortal time' bias http://is.gd/5lpmZR #twitjc it's about survival of Oscar winners- found via wikipedia -8:24 PM northern_doctor Observational studies alone usually not strong enough to lead to change in practice, but contribute to body of evidence #TwitJC -8:24 PM alasdairforrest @twitjournalclub I think, as @northern_doctor said, this makes a prospective study more acceptable. But that's a slow way to work #twitjc -8:25 PM silv24 It's down to the grade of evidence - if there is better evidence avaliable it will always trump an observational study #twitjc -8:25 PM drgandalf52 @twitjournalclub to convince the bulk GPs need to convince NICE #twitjc -8:25 PM amcunningham Earlier I linker to Rawlins' presentation on place of observation studies... something he wrote at the same time http://is.gd/5lpmZR #twitjc -8:25 PM PaedsSHO RT @silv24: It's down to the grade of evidence - if there is better evidence avaliable it will always trump an observational study #twitjc -8:25 PM JDMoffatt @amcunningham I saw that too. Not a great choice for a ref IMHO. Most "beta-blockers" are *inverse* agonists... See RA Bond's work. #twitjc -8:25 PM fidouglas @silv24 But are observational studies alone ever enough? #twitjc -8:25 PM mgtmccartney #twitjc depends on strength and meaning of findings. just looking at pubmed to see strength of clinical evidence against bblockers/asthma -8:25 PM amcunningham @drgandalf52 #twitjc I think that slowness to change diabetes management in light of ACCORD is evidence of lag -8:26 PM GabrielScally @amcunningham #twitjc That's a very neat explanation using the Oscar Winners. Yeah! I've learnt something! -8:26 PM silv24 @fidouglas in my limited experience...difficult one. Probably not but sometimes they are all we have & are a good starting point #twitjc -8:26 PM alasdairforrest @fidouglas @silv24 I think the subgroup analysis of serial FEV1 stands apart, though. #twitjc -8:27 PM yazman89 Observational studies that showed beta agonists increased mortality due to cardiovascular events didnt change practice much #TwitJC -8:27 PM citylivindundee hi everyone, saw tweet about #twitjc through thorax. I'm phil short Resp spr and first author of paper. happy to answer questions. -8:27 PM StuartBerry1 #twitjc it's also experiential. The 1st time you px bblockers in copd you are more cautious about the effect it will have. Experience v imp -8:27 PM alasdairforrest @citylivindundee Welcome, from the other side of the city. #twitjc -8:28 PM amcunningham @citylivindundee #twitjc that's brilliant- thanks for joining! -8:28 PM amcunningham RT @citylivindundee: hi everyone, saw tweet about #twitjc through thorax. I'm phil short Resp spr and first author of paper. happy to answer questions. -8:28 PM twitjournalclub Second topic: were the end points robust enough to show that beta blockers are safe in COPD in this patient population? #TwitJC -8:29 PM

northern_doctor @citylivindundee Glad you could make it. Great to have your perspective on everyone's thoughts! #TwitJC -8:29 PM silv24 @citylivindundee really thrilled you could join in the discussion tonight - Natalie (I run the journal club with @fidouglas) #twitjc -8:29 PM twitjournalclub @citylivindundee Hi Phil - welcome! Glad you could join us. :-) #TwitJC -8:30 PM northern_doctor I think the end points were robust enough to say that BBs were safe for this particular population #TwitJC -8:30 PM northern_doctor Not just saying that because the author's here...! #TwitJC -8:31 PM amcunningham @citylivindundee #twitjc not to distract things... but I'm wondering if you think this research should influence practice now? -8:31 PM alasdairforrest @twitjournalclub Hazard ratio for emergency steroids is a good endpoint. #twitjc 8:31 PM yazman89 At one point the paper mentioned that the FEV1 although not sig reduced as a group, was affected in certain individuals. #TwitJC -8:32 PM drgandalf52 Is there a breakdown of effects on cardiac and non cardiac patients? Couldn't see it #twitjc -8:33 PM mgtmccartney #twitjc in reality all research should be taken into context with what already known. rare for one paper to be only work on subject -8:33 PM JDMoffatt #twitjc For those interested in the beta-agonist/antagonist controversy: PMID:19887938 <-Prob not comorbid effect (I'm having dinner.) -8:33 PM silv24 Found the data on reductions in hospital admissions and emergency oral corticosteroid use very interesting #twitjc -8:34 PM amcunningham #twitjc RT @citylivindundee: @amcunningham in those patients with copd and IHD, definitely should use beta-blo (cont) http://deck.ly/~aPCCm -8:34 PM northern_doctor RT @alasdairforrest: Hazard ratio for emergency steroids is a good endpoint. <-- Yes! Helps show no adverse effect of BBs on airway #TwitJC -8:34 PM StuartBerry1 #twitjc in the real world you would try this and review. Give the patient a name / think yourself into the gp chair -8:35 PM alasdairforrest @silv24 Agree. Always suspicious of all-cause mortality, but was impressed by the admissions and emergency steroid endpoints. #twitjc -8:35 PM amcunningham @mgtmccartney #twitjc indeed... observational studies like this http://is.gd/iEJ0it ... in addition to ACCOR (cont) http://deck.ly/~inoTB -8:36 PM citylivindundee @amcunningham #twitjc thanks for RT, not very good with twitter, but will try to keep up -8:36 PM northern_doctor @StuartBerry1 Agreed. Helps to allay fears that rx could be harmful though, which makes you more likely to offer it. #TwitJC -8:36 PM alasdairforrest @northern_doctor Exactly! Don't think this paper intends to change international practice. But good at showing BB don't constrict #twitjc -8:36 PM fidouglas @alasdairforrest @silv24 Why the suspicion? Takes into account adverse as well as positive effects of intervention. #twitjc -8:37 PM amcunningham @citylivindundee you're OK- we had an author join #twitjc last week too... and he made the odd slip up;) http://is.gd/P46wF9 -8:37 PM

alasdairforrest @northern_doctor Also, I am impressed by the serial FEV1 and FVC, even if in subgroup of unknown provenance. #twitjc -8:37 PM StuartBerry1 #twitjc bob 48yearold. Asked you why his mate, who also has angina is on a bblocker but he isn't. What would you have said in 2007?2011? -8:37 PM amcunningham @alasdairforrest @northern_doctor #twitjc - as @citylivindundee point out- at least ensure that all those with CV disease have bblocker? -8:38 PM amcunningham RT @StuartBerry1: #twitjc bob 48yearold. Asked you why his mate, who also has angina is on a bblocker but he isn't. What would you have said in 2007?2011? -8:39 PM yazman89 @amcunningham I think so. At least give a BB to antagonize the adverse effects a beta agonist has on risk of cardiac disease #TwitJC -8:40 PM northern_doctor I think authors were very thorough with statistical and subgroup analysis to anticipate possible limitations. #TwitJC -8:40 PM northern_doctor Couldn't have done more with data that was available #TwitJC -8:40 PM mgtmccartney #twitjc @StuartBerry1 Bob might like to know why we hadn't been paying attention to cochrane in 2002. -8:40 PM twitjournalclub The next topic concerns the fact this paper looks at a specific geographical area. #TwitJC -8:40 PM amcunningham @citylivindundee did u see Richard Lehman's comments on the paper? could right-sided heart disease be a factor in bblocker benefit? #twitjc -8:40 PM silv24 @StuartBerry1 risks & benefits for that individual patient, if risk factors or CV disease would you be able not to prescribe? #twitjc -8:41 PM twitjournalclub Should we be trying to build up the links needed to produce this kind of data across the UK more generally? #TwitJC -8:41 PM LindaP_MD @amcunningham thanks for asking. Can't today. What's the best way to find out the next article being discussed ahead of time? #twitjc -8:41 PM StuartBerry1 #twitjc sorry my Internet speed is so poor. This is like a 1990s call to Australia ! Superfast broadband Yorkshire now please -8:41 PM amcunningham @LindaP_MD #twitjc I guess have to set up a tweetdeck column for the tag and subscribe to RSS feed from blog? -8:42 PM alasdairforrest @northern_doctor I like the hypothesis, which looks like neuropharmacology, of receptor up-grading. #twitjc -8:42 PM silv24 And as this database is just for specific geographical area does this also add caution to the results? #twitjc -8:42 PM citylivindundee @alasdairforrest @northern_doctor tiotropium has been shown to prevent BB induced constriction (Ind 1980s). most copd pts. get tio #twitjc -8:42 PM northern_doctor RT @twitjournalclub: Should we build up links to produce this kind of data across the UK? <--- Ideally yes, but challenging #TwitJC -8:43 PM fidouglas @LindaP_MD @amcunningham If you follow @TwitJournalClub, then we tweet about the paper in advance. #twitjc -8:43 PM amcunningham @citylivindundee #twitjc I know that Dundee has always been leader in informatics... could these links be rolled out more widely easily? -8:43 PM

alasdairforrest @silv24 This is a normal-ish town, Dundee. We're still human. Socioeconomic factors slightly confound things, though. Pretty poor. #twitjc -8:43 PM northern_doctor @alasdairforrest Yep - interesting stuff. Would love to know if it's true! #TwitJC 8:43 PM citylivindundee @silv24 #twitjc database covers tayside, population >200,000. we believe it to be typical of general pop -8:44 PM alasdairforrest @northern_doctor If it is - shock horror! - it looks ever so slightly like enlightened homeopathy (gasp). #twitjc -8:44 PM LindaP_MD @amcunningham I just signed up for the RSS feed. Will set up tweetdeck column. Thanks! #twitjc -8:44 PM twitjournalclub RT @silv24: And as this database is just for specific geographical area does this also add caution to the results? #TwitJC -8:44 PM StuartBerry1 #twitjc also would a gp who knows that bblockers ok also be more proactive at promoting pulmonary rehab/exercise& more likely to promote it? -8:44 PM northern_doctor National/international database is possible - just look at the SITS-MOST data for stroke thrombolysis #TwitJC -8:44 PM silv24 @citylivindundee thank you. It is an impressive sounding database, that struck me when I was reading the paper. Great resource! #twitjc -8:45 PM silv24 RT @citylivindundee: @silv24 #twitjc database covers tayside, population >200,000. we believe it to be typical of general pop #twitjc -8:45 PM fidouglas @StuartBerry1 Don't BBs reduce capacity to do aerobic exercise quite a bit? #twitjc -8:45 PM northern_doctor @alasdairforrest Shudder! I hope not! #TwitJC -8:46 PM drgandalf52 Is this not devisable by GP records done via a system wide hub.....#twitjc -8:46 PM citylivindundee @amcunningham #twitjc bio-informatics possible through unique patient identifier (CHI) used in scot, dont know if used in england -8:46 PM amcunningham @StuartBerry1 #twitjc hmm was there any evidence that gp practice determined likelihood of being on bblocker? @citylivindundee -8:46 PM fidouglas @drgandalf52 ...begin debate about feasibility of a national NHS database... #twitjc -8:47 PM mgtmccartney hate to say the gp contract but wasn't that in it then? @StuartBerry1 #twitjc -8:47 PM northern_doctor Problem is you have to have a specific reason for database to justify time & expense. #TwitJC -8:47 PM alasdairforrest @fidouglas There is no national NHS. Never has been. All nations have one. #twitjc -8:47 PM amcunningham @mgtmccartney #twitjc you mean pulm rehab for COPD? not use of bblockers in COPD? -8:48 PM fidouglas @alasdairforrest Oh you know what I mean tho, centralised records and all that? Debate pops up in the media every so often. #twitjc -8:48 PM northern_doctor Theoretical solution is to have single database about every patient in NHS - but that's a pandora's box that I don't want to open! #TwitJC -8:48 PM

silv24 @northern_doctor as pointed out disease specific databases are a fantastic resource, this paper highlights! I think worth the effort #twitjc -8:49 PM northern_doctor RT @silv24: And as this database is just for specific geographical area does this also add caution to the results? <--- Absolutely #TwitJC -8:49 PM mgtmccartney yes, sorry; am sure we've been referring patients for years and ticking box like everyone else #twitjc @amcunningham -8:49 PM fidouglas @northern_doctor Exactly. I'm hopelessly uninformed about how it works in other countries. Would be worth finding out. #twitjc -8:49 PM citylivindundee @amcunningham #twitjc interesting point. definite possibility. -8:50 PM amcunningham @mgtmccartney #twitjc I think @StuartBerry1 meant that someone who was up to speed with cochrane review might be more proactive in care? -8:50 PM northern_doctor @silv24 I agree, but (playing devil's advocate) you then end up with time & expense of multiple databases for each condition #TwitJC -8:50 PM drgandalf52 @fidouglas feasible but bet there some IT man who would make the computer say no #twitjc -8:51 PM mgtmccartney sorry - yes but haven't we all being doing pul rehab as contract requirement whatever else we are doing? @amcunningham @StuartBerry1 #twitjc -8:51 PM northern_doctor RT @drgandalf52: @fidouglas feasible but bet there some IT man who would make the computer say no <--- Count on it! #TwitJC -8:51 PM StuartBerry1 #twitjc there is likely to be variation between docs in same practice, also spectrum of coping within practice population. -8:52 PM twitjournalclub Final point this evening: Is there a need for prospective research into whether beta blockers are safe in patients with COPD? #TwitJC -8:52 PM amcunningham @mgtmccartney #twitjc is contract not about offering referral... uptake might be different depending on how sold -8:52 PM citylivindundee @northern_doctor #twitjc, absolutely! RCTs needed to assess benefit further -8:53 PM alasdairforrest @twitjournalclub Into whether it is advisable to reduce mortality etc, yes. But this does show it is safe? #twitjc -8:53 PM amcunningham @citylivindundee #twitjc have you any plans for an RCT? who would fund it? 8:53 PM northern_doctor I think there's a lot of research already suggesting BBs are safe in COPD. Prospective research now needed to assess actual benefit #TwitJC -8:54 PM mgtmccartney @amcunningham #twitjc absolutely -8:54 PM northern_doctor What we need to know is whether pts with COPD would benefit from BB rx independent of CV disease #TwitJC -8:54 PM amcunningham @citylivindundee #twitjc I'm guessing that numbers are too small in any one practice to be able to see if true variation #twitjc -8:55 PM northern_doctor For now, I think message is that we shouldn't be afraid of giving them in COPD when indicated for other reasons #TwitJC -8:55 PM StuartBerry1 You could have used exception report@mgtmccartney: hate to say the gp contract but wasn't that in it then? @StuartBerry1 #twitjc. -8:55 PM

citylivindundee @amcunningham #twitjc ideally would want to do RCT but ethically challenging. doing RCT in benefits of BB in asthma just now.. -8:55 PM drgandalf52 So bb safe in copd and may even improve outcomes, just stick with atenolol, which just found out is cardioselective #twitjc -8:56 PM amcunningham @northern_doctor #TwitJC as @mgtmccartney pointed out- we've known safe in copd since 2005 http://is.gd/H6UodQ -8:56 PM northern_doctor Might also be that particular subgroups (rather than all COPD patients) benefit if so, need to be identified for targeted rx #TwitJC -8:56 PM fidouglas "@JDMoffatt: @twitjournalclub Yes, using a *single* 'blocker'. Most have mixed properties, and it's too messy otherwise." #TwitJC -8:56 PM amcunningham RT @citylivindundee: @amcunningham #twitjc ideally would want to do RCT but ethically challenging. doing RCT in benefits of BB in asthma just now.. -8:56 PM mgtmccartney #twitjc @StuartBerry1 agree -8:57 PM alasdairforrest @citylivindundee & I like the neuropharmacology-like receptor up-regulation hypothesis. Any basic science on that you know of? #twitjc -8:57 PM StuartBerry1 @amcunningham: @mgtmccartney #twitjc is contract not about offering referral... uptake might be different depending on how sold ! Exactly -8:57 PM drgandalf52 @northern_doctor but doesnt this paper state it does....I just don't get how they got to that idea #twitjc -8:57 PM amcunningham @citylivindundee #twitjc yes... since we know bblocker does no harm, and probably benefits we are hardly in equipoise about situation! -8:57 PM StuartBerry1 RT @northern_doctor: For now, I think message is that we shouldn't be afraid of giving them in COPD when indicated for other reasons #TwitJC -8:57 PM northern_doctor @amcunningham Yes. Study adds to evidence & helps message to filter down to practice. Thanks for link. #twitjc -8:58 PM silv24 Think always need to strive for more and better evidence, just easier said than done at times. This paper has its place #twitjc -8:59 PM yazman89 @StuartBerry1 @northern_doctor Especially when beta agonists themselves been shown to increase risk of heart disease in COPD pts #TwitJC -8:59 PM amcunningham @silv24 #twitjc what are your concerns about this paper? why might an rct be better? would it even be ethical? #twitjc -8:59 PM citylivindundee @alasdairforrest #twitjc Prof Lipworth has written a lot about - paper in lancet wrt asthma might interest you. it,http://t.co/lTjGl7m -9:00 PM alasdairforrest @amcunningham Good question about the ethics. Surely we cannot expect RCT before any change in therapeutics. #twitjc -9:00 PM silv24 @amcunningham was more a general point. I think this is a very good paper (have read it several times now) #twitjc -9:00 PM northern_doctor Got to sign off now folks - thanks for an interesting chat, as always! #TwitJC 9:00 PM StuartBerry1 #twitjc or research into variations in uptake and quality of pulm rehab between gps/practices/regions what works/ what doesn't.&smoking cess -9:00 PM

alasdairforrest @StuartBerry1 That's a key point, too. What research like that isn't getting done. Answer: none like that is ever done. #twitjc -9:01 PM amcunningham @citylivindundee #twitjc when should we start giving bblocker (or stop giving bagonist) to all COPD pts? -9:01 PM Chestcracker One of the lessons of this paper is that people with COPD & with an appropriate indication should not be denied a trial of beta bls #twitjc -9:02 PM amcunningham @Chestcracker @citylivindundee #twitjc should we be thinking more about rightsided failure? investigating? treating? -9:03 PM alasdairforrest RT @amcunningham: @Chestcracker @citylivindundee #twitjc should we be thinking more about right-sided failure? investigating? treating? -9:03 PM amcunningham @Chestcracker #twitjc is COPD an indication in itself for a bblocker? @citylivindundee -9:04 PM drgandalf52 RT @amcunningham: @Chestcracker @citylivindundee #twitjc should we be thinking more about right-sided failure? investigating? treating? -9:04 PM silv24 @amcunningham I think if there is a body of evidence from papers like this than an RCT may not be ethical - therapeutic uncertainty? #twitjc -9:05 PM citylivindundee @amcunningham @Chestcracker #twitjc COPD patients need a more extensive assessment of cardiovascular risk. -9:05 PM citylivindundee @amcunningham @Chestcracker #twitjc think further work is need before that could ever be applied, need to establish pulmonary benefits -9:06 PM amcunningham @citylivindundee #twitjc by CVrisk do you mean echo? pretty sure that most will be screened for hypertensionand high cholesterol... -9:06 PM amcunningham @silv24 #twitjc absolutely- it's a murky old world:) -9:07 PM drgandalf52 Enjoyed today's #twitjc learnt something too, looking forward to next week if can make it -9:07 PM twitjournalclub I think we'll formally draw things to a close now, but as ever feel free to keep discussing things. #TwitJC -9:07 PM Chestcracker @amcunningham @citylivindundee Good question. beta blockers have prognostic benefit in L heart failure - not sure about right #twitjc -9:08 PM amcunningham @citylivindundee #twitjc your conclusion "Our study supports the use of blockers in COPD patients." didn't specify pts with CV indication -9:08 PM citylivindundee @amcunningham #twitjc baseline echo would be beneficial. -9:08 PM twitjournalclub Thanks to everyone who participated, especially @citylivindundee. #TwitJC -9:08 PM silv24 Thank you all yet again for joining in tonight #twitjc -9:08 PM alasdairforrest Thank you to @fidouglas for being @twitjournalclub chair for a good #twitjc tonight. -9:09 PM amcunningham @twitjournalclub #TwitJC thank you- I really enjoyed this! and thanks to @citylivindundee especially:) and @Chestcracker -9:09 PM twitjournalclub We'll get a transcript and summary up when we can, and will announce next week's paper in a few days. #TwitJC -9:09 PM

mgtmccartney thankyou again #twitjc @amcunningham @twitjournalclub @citylivindundee @Chestcracker -9:10 PM PaedsSHO Apologies for my complete lack of #twitjc contribution tonight. Vettel was on Top Gear. 9:10 PM citylivindundee @amcunningham #twitjc. we believe our paper showed that there were benefits in addition to addressing CV risk, hence conclusion -9:10 PM alasdairforrest RT @citylivindundee: @amcunningham #twitjc. we believe our paper showed that there were benefits in addition to addressing CV risk, hence conclusion -9:11 PM citylivindundee #twitjc thanks for the discussion, found it really interesting to hear other peoples' opinions @amcunningham @alasdairforrest @silv24 -9:12 PM StuartBerry1 RT @amcunningham: @twitjournalclub #TwitJC thank you- I really enjoyed this! and thanks to @citylivindundee especially:) and @Chestcracker -9:12 PM amcunningham @citylivindundee #twitjc Yes! Just thought you were being more cautious in what you said tonight and wantd o clarify:) -9:13 PM silv24 @citylivindundee thank you so much for joining in. This is our 6th week now of #TwitJC & have really enjoyed it. Learnt so much -9:14 PM alasdairforrest Let's see which author #TwitJC holds to account next week! Good discussion. Thanks @silv24 @fidouglas @amcunningham and all the rest. -9:16 PM amcunningham @citylivindundee #twitjc it is all a bit chaotic and crazy- you did really well to keep up! and you heard through Thorax? that's great -9:16 PM amcunningham RT @alasdairforrest: Let's see which author #TwitJC holds to account next week! Good discussion. Thanks @silv24 @fidouglas @amcunningham and all the rest. -9:16 PM citylivindundee @silv24 no worries, enjoyed it. #twitjc -9:16 PM