More of the Most Important Primary Care Studies of 2021

Part 2 of 4... your votes requested.

Welcome to the 2nd of 4 posts on this subject! Here is the first in case you missed it.

Much energy was spent in 2021 studying Covid. The explosion of knowledge about this novel pathogen sucked up most of the oxygen in the room. But primary care is still a kaleidoscope of problems large and small, and there were a lot of studies from last year with the potential to change or clarify what we recommend to patients. It’s not all about Covid, all the time, so this second post is based on that article from American Family Physician. Basically, a panel of experts combed through 20,000 journal articles, selected 260 that would really matter to primary docs practicing on the front lines, and then boiled each one down to the take-home points. I’m going to give you my take on the 20 studies that were rated by other physicians as the most likely to be relevant, valid, and potentially practice-changing for good patient care.

These study conclusions are best presented as answers to clinical questions I’m going to present all 5, but which question interests you the most?

• Is it a good practice to give written prescriptions for antibiotics when in doubt, but then tell patients to hold off on filling them unless symptoms persist?

• Which vague abdominal symptoms should be taken the most seriously, and referred for additional work up?

• Does eating eggs increase the risk of cardiovascular disease?

• Do muscle relaxers actually help lower back pain?

• Which non-drug therapies actually work for chronic pain?

I realize that not all of these questions apply to each reader, but I think the answers are still instructive, interesting, and in some cases surprising. Think of this series as mini-med school… without all the debt, and very different.

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~ Is it a good practice to give written prescriptions for antibiotics when in doubt, but then tell patients to hold off filling them unless symptoms persist?

This situation is well known to most people who have ever seen a doctor when feeling sick - especially in the old days before Covid when I used to see hundreds (thousands?) of people a year with their coughs, sneezes, mucous, and fevers while not even wearing a mask. There can be an unspoken tension between the sick patient who feels they need antibiotics, and the reluctant physician who feels they do not. Good antibiotic stewardship is important to reduce resistant organisms, and to avoid the potential harms of taking too many antibiotics. So sometimes we print out a script for a Zpack and state: I don’t think you need this antibiotic right now because your illness seems viral… but if it gets worse over the next couple days, or fails to improve, then go ahead and take the Zpack.

In adults this approach has been shown to reduce actual antibiotic usage. A study last year confirmed this in children as well. Only 1 out of 4 children whose parents were given a written script (with instructions to fill it if symptoms worsened/persisted over a certain time frame) went ahead and took the antibiotics. 75% did not! Symptom severity, time to resolution of illness, complications, and follow up appointments were similar in treated and untreated groups. Parents who did not go ahead and give the antibiotic did buy more OTC meds to “do something” for their child. Predictably, those kids who ended up taking the antibiotics of dubious value, for likely viral infections, did go on to have more gastrointestinal side effects like diarrhea.

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~ Which vague abdominal symptoms should be taken the most seriously, and referred for additional work up?

Abdominal and digestive complaints are very common. Think bloating, gas, heartburn, cramping, etc. While all such concerns should be discussed with your doctor, the following 3 symptoms have the most predictive value that something is really going on, and diagnoses like inflammatory bowel disease (IBD) and cancer need to be carefully ruled out:

• trouble or pain with swallowing

• changes in usual bowel habits

• rectal bleeding

These symptoms carry a small but significant risk (>3% of the time IBD or cancer might be detected, depending on the age group), and should not be blown off.

Interestingly, the symptoms of dyspepsia are not particularly helpful in predicting whether someone has a more serious problem. Dyspepsia can be defined as “a pain or an uncomfortable feeling in the upper middle part of your stomach area.” I always take this symptom seriously as well, but it is common enough that usually a benign cause is found.

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~ Does eating eggs increase the risk of cardiovascular disease?

Restricting eggs, shrimp, and other tasty sources of dietary cholesterol used to be the fashionable advice doctors and nutritionists would give. Newer evidence has consistently pointed away from dietary cholesterol as a major cardiovascular risk factor, and more towards saturated fats, trans fats, sugar and other junk. A systematic review of 23 studies, comprising data from 1.4 million people, found that eating more eggs did not increase risk of cardiovascular events. This was over an average observational period of 12 years.

In fact, those people who reported eating on average more than 1 egg per day actually had an 11% decreased likelihood of coronary artery disease. Some caution with interpretation is advised, as the authors point out that people who eat more eggs may be more likely to engage in other healthy behaviors. Maybe cooking their own food, avoiding sugary cereals, exercising more and eating more protein perhaps?

You know about shakshuka, right? If not, google SHAKSHUKA. Premade shakshuka sauce can be bought like spaghetti sauce at Whole Foods/Wegmans. Or make it from scratch if you are retired!

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~ Do muscle relaxers actually help lower back pain?

I know a lot of people swear by them, and I oblige to prescribe these when requested. But I try to give the disclaimer that most studies have shown muscle relaxers don’t really work much better than placebo, so this study is just more confirmation.

Doctors have prescribed muscle relaxers for over 50 years.

NSAIDs like naproxen work best, but can have side effects like gastrointestinal irritation, blood pressure elevation, and other problems with longer term use.

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~ Which non-drug therapies actually work for chronic pain?

It is too easy to write (or type) a prescription for a pill - easy for the patient, and even easier for the doctor. But pills have potential side effects, and often do not achieve sustainable results. Chronic pain is very challenging to cure, especially as we get older and degenerative changes accumulate. But in terms of what the evidence shows might help, these non-pill based strategies usually work to varying degrees if we put in the time:

• exercise

• yoga

• massage

• mindfulness-based stress reduction programs

These interventions do not require interaction with the health care system, and so that might be a bonus, too!

More specifically:

For chronic low back pain, exercise, massage, yoga, cognitive behavior therapy, mindfulness-based stress reduction, acupuncture, spinal manipulation, low-level
laser therapy, and rehabilitation all reduced pain and/or improved function.

There was evidence for the use of exercise, massage, low-level laser therapy, acupuncture, and Pilates in the treatment of chronic neck pain.

Only exercise and cognitive behavior therapy were helpful for knee osteoarthritis.

There is evidence only for the use of exercise and manual therapies for the treatment of hip osteoarthritis.

Patients with fibromyalgia benefited from cognitive behavioral therapy, myofascial release massage, tai chi, qi gong, acupuncture, rehabilitation, and exercise.

This might as well be a self-portrait. Future post on the importance of good posture coming!

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And now for a post test, assuming you have read this far :)

Hopefully this post will give you some antibiotic strategies to review with your doctor the next time there is a divide in terms of expectations. I hope your abdominal symptoms end up being nothing serious (the odds are in your favor, just don’t blow them off). May you enjoy eggs a bit more freely. Pause when asking for muscle relaxers, as your doctor should not really be recommending these unless you’ve had prior success and request them perhaps. And invest some time, when you can, on non-pill strategies for chronic pain. I’m going to do a little walk out the door now, fold myself into a Toyota, hurtle across space and time, and maybe get a little stretching in before bed.

Take good care,

Ryan