Top 20 Research Studies of 2021, Part III
Relevant, evidence-based knowledge for primary care.
I’m going to almost wrap up this series with today’s 3rd installment. You can read the first here, and the second here. Using an article from American Family Physician, I’m distilling the take home points from a panel of experts who combed through 20,000 journal articles, and found those with potentially practice-changing results for good patient care. Most of them are meta-analyses that pool the results of many other small studies to get the highest quality answers. I’ll try to do a wrap up podcast providing commentary on this whole series soon.
But before we begin, let’s take a moment of silence for the 2022 Philadelphia Phillies who lost the World Series, and for the Philadelphia Union who lost the MLS soccer championship on the same day about 5 hours earlier. Our silence solemnly recognizes that no city had ever lost 2 championships on the same day before. Well, at least the Eagles are still undefeated. Aren’t they? I missed the end of the game.
When you live in South Philly, there are many ways to cope with legendary sports disappointments. Friendly neighborhoods despite the media drumbeat of violence. A foodie’s paradise. And people who are genuine and talented abound. For example, take this painting from one of our more artistic neighbors. He painted a tribute to Bryce Harper - on the exterior of his actual house.
And now back to the medical realm.
How close are the blood pressures obtained in your doctor’s office to the real thing?
An interesting study compared blood pressures obtained from patients in a strict research study with those obtained by their regular primary care physicians. They found that BP readings at your doctor’s office tend to be at least 5-8 points higher than the true readings when measured with perfect techniques. Some people varied to even greater degrees. The implications are that we should back off trying to push everyone’s BP below 120/80 in the office:
The recommendations to lower systolic blood pressure to less than 120 need to be interpreted accordingly—in the real world, achieving a level of 130 is probably similar to 120 in the trial setting.
This further validates the slack I usually give when interpreting BP readings at check ups. We need to assume a few extra points from rushing in, not being able to relax for a couple minutes, and the simple anticipation that creates anxiety, while the inflatable cuff starts to tighten like an anaconda. Home BP monitors are great, and I recommend them for these reasons, too.
Should I take a statin medication based on the risk calculator my doctor is using?
This is an oversimplification, but primary care docs and cardiologists are taught to assess a person’s risk of having a heart attack or stroke in the next 10 years, and then use that percentage chance to guide whether a statin med like Lipitor or Crestor should be started. We use one of two calculators, the Framingham Risk Score and the Pooled Cohort Equation, both of which factor in variables like total cholesterol, HDL, blood pressure, and a bunch of other data points. For adults age 40-75 years of age, with at least one cardiovascular risk factor, statins are recommended if the calculators compute a 10 year risk of heart attack/stroke >10%.
But a Canadian study this year compared this computed risk to that actually seen in real life among 80,000 patients. They found that the calculators really overestimated people’s risk:
For example, a person with a 10-year risk of 10% probably has a true risk closer to 5%, leading to very different guideline recommendations for a statin.
There is certainly a lot of haggling, negotiating, and bargaining made around the primary care table as docs and patients go back and forth. But I will say that in appropriately selected people, multiple clinical trials with statins have consistently shown that statins reduce heart disease and stroke by 30-50% in those at higher risk.
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Are short courses of antibiotics as effective as longer courses for common infections?
Most of the time, yes. I’ll let the evidence-based guidelines speak for themselves. You might be surprised at how short some of these intervals are when compared to what your doctor actually prescribes. There are a lot of reasons I’ll try to expand upon in the upcoming podcast:
American College of Physicians guidelines recommend 5 days of antibiotics for community-acquired pneumonia, 5 days for COPD exacerbation, 5 to 7 days for uncomplicated pyelonephritis (kidney infection) if using a quinolone, and 5 to 6 days for cellulitis. Longer courses may be necessary if there is no clinical improvement.
Overuse and unnecessary prolonged use of antibiotics are the norm.
Which medication should be first line for musculoskeletal injuries?
Not including back pain, most musculoskeletal injuries are best treated first with topical diclofenac. This is better known as the branded Voltaren Gel.
I was kind of surprised by this one, but I understand that when balancing the risk of side effects from oral meds and the efficacy of topical versus oral anti-inflammatories, The American College of Physicians and American Academy of Family Physicians collaborated to give first dibs to Voltaren gel. I suppose I need to recommend that more than I have been. Here’s how they phrase it:
Based on a large systematic review and network meta-analysis, they give a strong recommendation for topical diclofenac as first-line therapy and a conditional recommendation for oral NSAIDs, acetaminophen, acupressure, or TENS. Opioids are not recommended because of greater adverse effects and risk of prolonged use.
There are a couple more studies to review that round out the most popular 20 from last year… but I’ll save them for the podcast wrap up. Some answers about diabetes care, overtreatment with diabetic medications, whether meds actually prevent bad outcomes, whether patients with back pain do better just by knowing their MRI results, and which combination of OTC meds is most effective for pain.
And why the story of Gritty, the at-first-scorned-but-now-loved mascot of the Philadelphia Flyers, can help all of us cultivate a sense of resilience after defeat.
But for now, don’t obsess about “perfect” blood pressures in the office. Statin recommendations are somewhat malleable and always negotiable with your doctor. Antibiotics should be used judiciously, and perhaps for shorter durations than most doctors prescribe. And maybe give Voltaren gel a try if your doc says it’s ok for you - as it works better than most of us might guess, and with fewer potential adverse effects.
Take good care,
Like the comment about BP and offer this personal anecdote. My former doctor would have my BP rechecked at the end of the visit. She knew that I have a bit of "clinical anxiety" and BP would settle down 10-15 points. As for home BP monitor, I would suggest checking for a FDA approved and avoid cheap models. Good ones also have bluetooth capabilities and you can down load your data. If your first reading is high, relax and wait a while and retest. This is a nice guideline from Harvard. https://www.health.harvard.edu/heart-health/reading-the-new-blood-pressure-guidelines
Statin medicines has been the subject of much debate. However, think that, considering the average "American" diet of fast food and junk, think this is a no brainer. One thing though, some statins can cause drug/drug interaction. Should not be a big deal to discontinue for a week???
Antibiotic misuse/abuse is a pet peeve of mine. I was rather astonished to find Amoxicillin being prescribed for viral diseases.
One more thing, as usual with me :), the generic for Voltaren is Diclofenac Sodium Gel 1%. Save few bucks and its OTC. I am on board with this recommendation. Trust me, it doesn't small anything like Bengay.