Clinical Inquiries

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

Evidence summary

Bell’s palsy is a lower motor neuron disease of the facial nerve characterized by a transient paralysis. Healing is occasionally incomplete, resulting in residual nerve dysfunction, including partial palsy and motor synkinesis (involuntary movement accompanying a voluntary one) and autonomic synkinesis (involuntary lacrimation after a voluntary muscle movement). Bell’s palsy is associated with significant edema and ischemia of the facial nerve as it passes through its bony canal.

Herpes simplex reactivation has been shown to be associated with a large proportion of cases.

Corticosteroids are the most studied form of therapy for Bell’s palsy (Table). Early work in England culminated in 1971 with a well-performed study demonstrating lower rates of incomplete recovery with prednisolone compared with corticotrophin.¹ A potentially definitive randomized controlled trial in 1970 was stopped prematurely because of investigators’ subjective impression that prednisone markedly reduced postauricular pain.² Subsequently, the highest-quality study had few patients (n=51) and reported no difference in outcomes between patients receiving 10 days of oral prednisone plus vitamins and those receiving vitamins alone.³

One open randomized controlled trial demonstrated shorter mean recovery times with intramuscular methylcobalamin (1.95 weeks) and methylcobalamin plus prednisone (2.0 weeks) compared with prednisone alone (9.6 weeks).⁴ Another trial of 239 patients showed improved rates of autonomic synkinesis after treatment with 16 days of prednisone compared with placebo.⁵

A randomized, controlled trial of children 2 to 6 years of age found no significant differences in short-term recovery after treatment with methylprednisolone compared with untreated controls.⁶ Eventually, all these children recovered normal facial nerve function within 12 months.

Two randomized controlled trials have assessed the efficacy of acyclovir for treatment of Bell’s palsy. One trial compared prednisone with acyclovir and found patients treated with prednisone had better complete recovery rates, 93.6% versus 77.7% (absolute risk reduction [ARR]=15.9%, 95% confidence interval [CI]=2.8%–29%], number needed to treat [NNT]=7).⁷

Another study demonstrated that the combination of prednisone and acyclovir had greater complete recovery rates compared with prednisone alone (92% vs. 76%, ARR=16%, 95% CI=1.7%–30.3%, NNT=7).⁸

Overall, the data suggest corticosteroid therapy may provide a small clinical benefit in adult patients with Bell’s palsy. In many of these studies, patients who had contraindications to steroid therapy (peptic ulcer disease, uncontrolled diabetes, hypertension, or immunosuppression) were excluded.

If no contraindications to steroids exist, it is resonable to initiate treatment with corticosteroids for an adult patient with new-onset Bell’s palsy. Most studies have started patients on steroids within 10 days of onset of symptoms.

TABLE
Therapies for Bell’s palsy

Recommendations from others

A practice parameter from the American Academy of Neurology states that steroids are safe and probably effective (SOR: B), whereas acyclovir is safe and possibly effective (SOR: C).⁹ Systematic reviews from the Cochrane Database report that available evidence from randomized controlled trials does not show significant benefit from treating Bell’s palsy with corticosteroids and that clinical trials on acyclovir are inconclusive and therefore cannot be used to make recommendations regarding its use.^10,11

PATIENT INFORMATION

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

Evidence summary

Bell’s palsy is a lower motor neuron disease of the facial nerve characterized by a transient paralysis. Healing is occasionally incomplete, resulting in residual nerve dysfunction, including partial palsy and motor synkinesis (involuntary movement accompanying a voluntary one) and autonomic synkinesis (involuntary lacrimation after a voluntary muscle movement). Bell’s palsy is associated with significant edema and ischemia of the facial nerve as it passes through its bony canal.

Herpes simplex reactivation has been shown to be associated with a large proportion of cases.

Corticosteroids are the most studied form of therapy for Bell’s palsy (Table). Early work in England culminated in 1971 with a well-performed study demonstrating lower rates of incomplete recovery with prednisolone compared with corticotrophin.¹ A potentially definitive randomized controlled trial in 1970 was stopped prematurely because of investigators’ subjective impression that prednisone markedly reduced postauricular pain.² Subsequently, the highest-quality study had few patients (n=51) and reported no difference in outcomes between patients receiving 10 days of oral prednisone plus vitamins and those receiving vitamins alone.³

One open randomized controlled trial demonstrated shorter mean recovery times with intramuscular methylcobalamin (1.95 weeks) and methylcobalamin plus prednisone (2.0 weeks) compared with prednisone alone (9.6 weeks).⁴ Another trial of 239 patients showed improved rates of autonomic synkinesis after treatment with 16 days of prednisone compared with placebo.⁵

A randomized, controlled trial of children 2 to 6 years of age found no significant differences in short-term recovery after treatment with methylprednisolone compared with untreated controls.⁶ Eventually, all these children recovered normal facial nerve function within 12 months.

Two randomized controlled trials have assessed the efficacy of acyclovir for treatment of Bell’s palsy. One trial compared prednisone with acyclovir and found patients treated with prednisone had better complete recovery rates, 93.6% versus 77.7% (absolute risk reduction [ARR]=15.9%, 95% confidence interval [CI]=2.8%–29%], number needed to treat [NNT]=7).⁷

Another study demonstrated that the combination of prednisone and acyclovir had greater complete recovery rates compared with prednisone alone (92% vs. 76%, ARR=16%, 95% CI=1.7%–30.3%, NNT=7).⁸

Overall, the data suggest corticosteroid therapy may provide a small clinical benefit in adult patients with Bell’s palsy. In many of these studies, patients who had contraindications to steroid therapy (peptic ulcer disease, uncontrolled diabetes, hypertension, or immunosuppression) were excluded.

If no contraindications to steroids exist, it is resonable to initiate treatment with corticosteroids for an adult patient with new-onset Bell’s palsy. Most studies have started patients on steroids within 10 days of onset of symptoms.

TABLE
Therapies for Bell’s palsy

Recommendations from others

A practice parameter from the American Academy of Neurology states that steroids are safe and probably effective (SOR: B), whereas acyclovir is safe and possibly effective (SOR: C).⁹ Systematic reviews from the Cochrane Database report that available evidence from randomized controlled trials does not show significant benefit from treating Bell’s palsy with corticosteroids and that clinical trials on acyclovir are inconclusive and therefore cannot be used to make recommendations regarding its use.^10,11

PATIENT INFORMATION

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

Evidence summary

Bell’s palsy is a lower motor neuron disease of the facial nerve characterized by a transient paralysis. Healing is occasionally incomplete, resulting in residual nerve dysfunction, including partial palsy and motor synkinesis (involuntary movement accompanying a voluntary one) and autonomic synkinesis (involuntary lacrimation after a voluntary muscle movement). Bell’s palsy is associated with significant edema and ischemia of the facial nerve as it passes through its bony canal.

Herpes simplex reactivation has been shown to be associated with a large proportion of cases.

Corticosteroids are the most studied form of therapy for Bell’s palsy (Table). Early work in England culminated in 1971 with a well-performed study demonstrating lower rates of incomplete recovery with prednisolone compared with corticotrophin.¹ A potentially definitive randomized controlled trial in 1970 was stopped prematurely because of investigators’ subjective impression that prednisone markedly reduced postauricular pain.² Subsequently, the highest-quality study had few patients (n=51) and reported no difference in outcomes between patients receiving 10 days of oral prednisone plus vitamins and those receiving vitamins alone.³

One open randomized controlled trial demonstrated shorter mean recovery times with intramuscular methylcobalamin (1.95 weeks) and methylcobalamin plus prednisone (2.0 weeks) compared with prednisone alone (9.6 weeks).⁴ Another trial of 239 patients showed improved rates of autonomic synkinesis after treatment with 16 days of prednisone compared with placebo.⁵

A randomized, controlled trial of children 2 to 6 years of age found no significant differences in short-term recovery after treatment with methylprednisolone compared with untreated controls.⁶ Eventually, all these children recovered normal facial nerve function within 12 months.

Two randomized controlled trials have assessed the efficacy of acyclovir for treatment of Bell’s palsy. One trial compared prednisone with acyclovir and found patients treated with prednisone had better complete recovery rates, 93.6% versus 77.7% (absolute risk reduction [ARR]=15.9%, 95% confidence interval [CI]=2.8%–29%], number needed to treat [NNT]=7).⁷

Another study demonstrated that the combination of prednisone and acyclovir had greater complete recovery rates compared with prednisone alone (92% vs. 76%, ARR=16%, 95% CI=1.7%–30.3%, NNT=7).⁸

Overall, the data suggest corticosteroid therapy may provide a small clinical benefit in adult patients with Bell’s palsy. In many of these studies, patients who had contraindications to steroid therapy (peptic ulcer disease, uncontrolled diabetes, hypertension, or immunosuppression) were excluded.

If no contraindications to steroids exist, it is resonable to initiate treatment with corticosteroids for an adult patient with new-onset Bell’s palsy. Most studies have started patients on steroids within 10 days of onset of symptoms.

TABLE
Therapies for Bell’s palsy

Recommendations from others

A practice parameter from the American Academy of Neurology states that steroids are safe and probably effective (SOR: B), whereas acyclovir is safe and possibly effective (SOR: C).⁹ Systematic reviews from the Cochrane Database report that available evidence from randomized controlled trials does not show significant benefit from treating Bell’s palsy with corticosteroids and that clinical trials on acyclovir are inconclusive and therefore cannot be used to make recommendations regarding its use.^10,11

PATIENT INFORMATION

What is Bell’s palsy?

Weakness and slumping on one side of the face are common features of this condition in which the nerve controlling the face has been injured. Other symptoms are:

• Inability to move affected side of the face
• Drooping mouth, unblinking eye
• Numbness
• Twitching of facial muscles
• Taste disturbance
• Increased sensitivity to sound.

Symptoms usually start suddenly. Pain behind the ear may be felt hours to days before other symptoms appear. People between ages 30 and 60 years are most likely to be affected, but this disorder can happen at any age.

Any sudden weakness of the face also suggests the possibility of stroke—a serious emergency. You should contact your physician immediately.

Possible causes

The most common cause of Bell’s palsy is an infection of the facial nerve by the herpes simplex virus. Your doctor will also ask about possible recent trauma to the face and will check for swelling of facial tissues or a mass pressing on the facial nerve.

What to expect

In many cases, the symptoms of Bell’s palsy go away in about 3 weeks without treatment, and the face regains its normal appearance. A good sign that this will happen is if the weakness or other symptoms begin to resolve after 1 week.

In other cases, symptoms may take several months to disappear. Lasting effects are possible, though rare.

Treatments your doctor may prescribe

If a viral infection is the likely cause of your symptoms, your doctor may have you take acyclovir (Zovirax), famciclovir (Famvir), or another antiviral medication to speed your recovery. These antiviral medications are taken as pills, usually a few times a day for 10 days.

A steroid (prednisone, for example) may also help to reduce swelling that could be pressing on the facial nerve. This medication is also administered as a pill over 1 to 2 weeks.

If you cannot blink, and dryness of the eye is one of your symptoms, your doctor will ask you to use moisturizing eye drops to protect the eye from damage while you recover.

Evidence summary

A Cochrane review found only a small number of poor-quality trials, providing insufficient support to recommend cranberry juice to prevent UTI.¹ However, 2 recent randomized studies, not included in the Cochrane review, found that women taking cranberry juice have fewer symptomatic UTIs.

In women with prior Escherichia coli UTI, 50 mL of cranberry-lingonberry juice concentrate daily for 6 months reduced the recurrence of symptomatic UTI from 36% in the control group to 16% in the treated group (NNT=5).²

In a placebo-controlled randomized trial, women with prior UTI who took 1 tablet of concentrated cranberry juice (at least 1:30 parts concentrated juice) twice daily (n=50) or drank 250 mL of pure unsweetened cranberry juice 3 times a day for 12 months (n=50) reduced their incidence of symptomatic UTI.3 Women who drank the juice had an ARR of 12% (32% symptomatic UTI on placebo group, 20% in cranberry juice group, NNT=8.3) over 1 year. Use of cranberry juice tablets produced an ARR of 14% (32% symptomatic UTI in placebo group; 18% in cranberry tablet group, NNT=7.1). Self-reported compliance was 75% to 90% in the juice group and 90% in the tablet group.

No dose-response studies have been done to determine the optimal volume of juice or number of tablets needed to prevent infection. Studies have used between 200 mL once a day to 250 mL 3 times a day of the juice or 1 cranberry tablet taken twice daily. The subject dropout rate was as high as 34% in one study using juice,⁴ implying that cranberry juice—which is acidic and astringent at full strength—may not be acceptable to many patients as a prophylactic therapy over a long period. The 1-month compliance rate of patients taking cranberry tablets was between 88% and 100%, suggesting that this form of cranberry may improve compliance.

The cost of cranberry juice and cranberry tablets was estimated at $1400 and $624 per year, respectively.³ This must be balanced against the cost of treating symptomatic UTIs. No randomized trials have tested the more readily available and palatable cranberry juice cocktail—which is mixed with water, a sweetener, and vitamin C—to prevent recurrent UTI.

Cranberry juice does not inhibit bacterial growth and will not sterilize the urinary tract. Also, cranberry juice does not prevent or treat UTI by changing the pH of the urine. Rather, the suspected mechanism of action is that proanthocyanidins contained in cranberry juice prevent bacterial adherence to uroepithelial cells, thus reducing the development of UTI.⁵ Cranberry juice has been shown to reduce uroepithelial cell adherence by bacteria resistant to trimethoprim-sulfamethoxazole.⁶

Recommendations from others

No national practice guidelines have recommended cranberry juice as a preventive strategy for recurrent UTI but, anecdotally, patients are often advised to try cranberry juice to prevent UTI.

Evidence summary

A Cochrane review found only a small number of poor-quality trials, providing insufficient support to recommend cranberry juice to prevent UTI.¹ However, 2 recent randomized studies, not included in the Cochrane review, found that women taking cranberry juice have fewer symptomatic UTIs.

In women with prior Escherichia coli UTI, 50 mL of cranberry-lingonberry juice concentrate daily for 6 months reduced the recurrence of symptomatic UTI from 36% in the control group to 16% in the treated group (NNT=5).²

In a placebo-controlled randomized trial, women with prior UTI who took 1 tablet of concentrated cranberry juice (at least 1:30 parts concentrated juice) twice daily (n=50) or drank 250 mL of pure unsweetened cranberry juice 3 times a day for 12 months (n=50) reduced their incidence of symptomatic UTI.3 Women who drank the juice had an ARR of 12% (32% symptomatic UTI on placebo group, 20% in cranberry juice group, NNT=8.3) over 1 year. Use of cranberry juice tablets produced an ARR of 14% (32% symptomatic UTI in placebo group; 18% in cranberry tablet group, NNT=7.1). Self-reported compliance was 75% to 90% in the juice group and 90% in the tablet group.

No dose-response studies have been done to determine the optimal volume of juice or number of tablets needed to prevent infection. Studies have used between 200 mL once a day to 250 mL 3 times a day of the juice or 1 cranberry tablet taken twice daily. The subject dropout rate was as high as 34% in one study using juice,⁴ implying that cranberry juice—which is acidic and astringent at full strength—may not be acceptable to many patients as a prophylactic therapy over a long period. The 1-month compliance rate of patients taking cranberry tablets was between 88% and 100%, suggesting that this form of cranberry may improve compliance.

The cost of cranberry juice and cranberry tablets was estimated at $1400 and $624 per year, respectively.³ This must be balanced against the cost of treating symptomatic UTIs. No randomized trials have tested the more readily available and palatable cranberry juice cocktail—which is mixed with water, a sweetener, and vitamin C—to prevent recurrent UTI.

Cranberry juice does not inhibit bacterial growth and will not sterilize the urinary tract. Also, cranberry juice does not prevent or treat UTI by changing the pH of the urine. Rather, the suspected mechanism of action is that proanthocyanidins contained in cranberry juice prevent bacterial adherence to uroepithelial cells, thus reducing the development of UTI.⁵ Cranberry juice has been shown to reduce uroepithelial cell adherence by bacteria resistant to trimethoprim-sulfamethoxazole.⁶

Recommendations from others

No national practice guidelines have recommended cranberry juice as a preventive strategy for recurrent UTI but, anecdotally, patients are often advised to try cranberry juice to prevent UTI.

Evidence summary

A Cochrane review found only a small number of poor-quality trials, providing insufficient support to recommend cranberry juice to prevent UTI.¹ However, 2 recent randomized studies, not included in the Cochrane review, found that women taking cranberry juice have fewer symptomatic UTIs.

In women with prior Escherichia coli UTI, 50 mL of cranberry-lingonberry juice concentrate daily for 6 months reduced the recurrence of symptomatic UTI from 36% in the control group to 16% in the treated group (NNT=5).²

In a placebo-controlled randomized trial, women with prior UTI who took 1 tablet of concentrated cranberry juice (at least 1:30 parts concentrated juice) twice daily (n=50) or drank 250 mL of pure unsweetened cranberry juice 3 times a day for 12 months (n=50) reduced their incidence of symptomatic UTI.3 Women who drank the juice had an ARR of 12% (32% symptomatic UTI on placebo group, 20% in cranberry juice group, NNT=8.3) over 1 year. Use of cranberry juice tablets produced an ARR of 14% (32% symptomatic UTI in placebo group; 18% in cranberry tablet group, NNT=7.1). Self-reported compliance was 75% to 90% in the juice group and 90% in the tablet group.

No dose-response studies have been done to determine the optimal volume of juice or number of tablets needed to prevent infection. Studies have used between 200 mL once a day to 250 mL 3 times a day of the juice or 1 cranberry tablet taken twice daily. The subject dropout rate was as high as 34% in one study using juice,⁴ implying that cranberry juice—which is acidic and astringent at full strength—may not be acceptable to many patients as a prophylactic therapy over a long period. The 1-month compliance rate of patients taking cranberry tablets was between 88% and 100%, suggesting that this form of cranberry may improve compliance.

The cost of cranberry juice and cranberry tablets was estimated at $1400 and $624 per year, respectively.³ This must be balanced against the cost of treating symptomatic UTIs. No randomized trials have tested the more readily available and palatable cranberry juice cocktail—which is mixed with water, a sweetener, and vitamin C—to prevent recurrent UTI.

Cranberry juice does not inhibit bacterial growth and will not sterilize the urinary tract. Also, cranberry juice does not prevent or treat UTI by changing the pH of the urine. Rather, the suspected mechanism of action is that proanthocyanidins contained in cranberry juice prevent bacterial adherence to uroepithelial cells, thus reducing the development of UTI.⁵ Cranberry juice has been shown to reduce uroepithelial cell adherence by bacteria resistant to trimethoprim-sulfamethoxazole.⁶

Recommendations from others

No national practice guidelines have recommended cranberry juice as a preventive strategy for recurrent UTI but, anecdotally, patients are often advised to try cranberry juice to prevent UTI.

Evidence summary

Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.¹ This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.

A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.² While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).

Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.³ Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.

Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.⁴ A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.⁵

Recommendations from others

The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).⁶

The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).

The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).⁷

ACKNOWLEDGMENTS

The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.

Evidence summary

Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.¹ This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.

A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.² While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).

Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.³ Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.

Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.⁴ A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.⁵

Recommendations from others

The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).⁶

The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).

The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).⁷

ACKNOWLEDGMENTS

The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.

Evidence summary

Two clinical trials directly addressed the prevention of pneumonia in nursing home patients. A prospective, risk-stratified, randomized study of the 14-valent pneumococcal vaccine in 1686 patients living in hospices and nursing homes in France showed an absolute risk reduction (ARR) of 2.9% in the incidence of all-cause pneumonia, corresponding to a number needed to treat (NNT) of 35.¹ This study has 2 major limitations: the authors did not comment on whether the study was blinded, and 31% of patients were lost to follow-up.

A 6-year randomized clinical trial that studied the trivalent pneumococcal vaccine in preventing pneumonia in New York City Home (a nursing home) subjects showed an ARR=2.7% and NNT=37.² While this report also did not specify whether there was blinding, any bias introduced by absence of blinding is unlikely to account for the large effect size (relative risk reduction=0.56).

Nursing home residents may be especially vulnerable to acquiring pneumococcal infection due to advanced age, chronic illnesses, and their communal setting. The Centers for Disease Control and Prevention (CDC) has reported outbreaks of invasive pneumococcal disease in nursing homes where vaccination rates are low.³ Pneumococcal bacteremia is seen in only 10%–20% of patients with pneumococcal pneumonia but confers a significant risk of death. Therefore, pneumococcal vaccination is indicated for patients ≥ 65 years or those with chronic medical conditions.

Case-control studies have consistently shown efficacy in preventing invasive pneumococcal disease. Farr and colleagues found efficacy of 70% (95% confidence interval [CI], 37%–86%) among 2 groups of patients: those ≥ 2 years of age with chronic disease or those ≥ 65 years.⁴ A case-control study by Sims and colleagues also found the vaccine to have efficacy of 70% (95% CI, 37%– 86%) in preventing invasive pneumococcal disease in immunocompetent patients aged ≥ 55 years.⁵

Recommendations from others

The CDC Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal vaccination of persons aged ≥65 years and those aged 2 to 64 who have chronic cardiovascular disease, chronic pulmonary disease, or diabetes mellitus (SOR: A).⁶

The ACIP also recommends the pneumococcal vaccine for persons aged 2 to 64 years who have alcoholism, chronic liver disease, or cerebrospinal fluid leaks (SOR: B).

The Canadian Task Force on Preventive Health Care endorses vaccination for immunocompetent patients 55 years residing in institutions (SOR: A).⁷

ACKNOWLEDGMENTS

The authors wish to thank Yves LeBlanc, MD, and Khalil Nasrallah, MD, for assistance with translation.

Evidence summary

The Women’s Health Initiative (WHI),¹ the largest randomized trial of HRT, showed that long-term use of HRT poses more risks than benefits for healthy postmenopausal women. WHI studied the use of estrogen plus progestin for prevention of coronary heart disease in 16,608 postmenopausal women age 50–79 years. After 5 years of follow-up, this arm of the study was stopped because of the adverse effects of the intervention. The researchers found that HRT increases the risk of several events:

• coronary heart disease events (number needed to harm [NNH]=1428)
• invasive breast cancer (NNH=1250)
• stroke (NNH=1250)
• venous thromboembolic events (NNH=555)
• pulmonary embolism (NNH=1250).

An ongoing arm of WHI is studying estrogen alone in postmenopausal women who have had a hysterectomy.

The Heart and Estrogen/progestin Replacement Study (HERS)² examined the effects of HRT in postmenopausal women with coronary artery disease. HERS was a large randomized controlled trial of 2763 women with an average follow-up time of 4.1 years. It showed no statistically significant difference between the HRT (estrogen plus medroxyprog-esterone) group compared with the placebo group in either the primary outcomes (nonfatal myocardial infarction or coronary heart disease death) or in the secondary outcomes (coronary revascularization, unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke or transient ischemic attack, and peripheral arterial disease). The findings of the WHI and HERS trials have been summarized in a recent meta-analysis done for the United States Preventive Services Task Force.³

Both the WHI and HERS trials demonstrated some benefits for HRT. WHI found a reduced risk of colorectal cancer (number needed to treat [NNT]=1667) and a decreased risk of any osteoporotic fracture (NNT=228). The HERS group found that HRT improved the quality of life of women with postmenopausal symptoms, particularly flushing.

Evidence indicates that women who take HRT for 3 years and then stop achieve as much protection from osteoporotic fractures as women who continue their HRT beyond 3 years.⁴

Continuing HRT beyond 5 years dramatically increases the risk of coronary heart disease, stroke, thromboembolic events, breast cancer, and cholecystitis.³

Recommendations from others

The American College of Obstetricians and Gynecologists has convened a multispecialty panel of experts to draft new recommendations for HRT in light of the WHI findings.

Evidence summary

The Women’s Health Initiative (WHI),¹ the largest randomized trial of HRT, showed that long-term use of HRT poses more risks than benefits for healthy postmenopausal women. WHI studied the use of estrogen plus progestin for prevention of coronary heart disease in 16,608 postmenopausal women age 50–79 years. After 5 years of follow-up, this arm of the study was stopped because of the adverse effects of the intervention. The researchers found that HRT increases the risk of several events:

• coronary heart disease events (number needed to harm [NNH]=1428)
• invasive breast cancer (NNH=1250)
• stroke (NNH=1250)
• venous thromboembolic events (NNH=555)
• pulmonary embolism (NNH=1250).

An ongoing arm of WHI is studying estrogen alone in postmenopausal women who have had a hysterectomy.

The Heart and Estrogen/progestin Replacement Study (HERS)² examined the effects of HRT in postmenopausal women with coronary artery disease. HERS was a large randomized controlled trial of 2763 women with an average follow-up time of 4.1 years. It showed no statistically significant difference between the HRT (estrogen plus medroxyprog-esterone) group compared with the placebo group in either the primary outcomes (nonfatal myocardial infarction or coronary heart disease death) or in the secondary outcomes (coronary revascularization, unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke or transient ischemic attack, and peripheral arterial disease). The findings of the WHI and HERS trials have been summarized in a recent meta-analysis done for the United States Preventive Services Task Force.³

Both the WHI and HERS trials demonstrated some benefits for HRT. WHI found a reduced risk of colorectal cancer (number needed to treat [NNT]=1667) and a decreased risk of any osteoporotic fracture (NNT=228). The HERS group found that HRT improved the quality of life of women with postmenopausal symptoms, particularly flushing.

Evidence indicates that women who take HRT for 3 years and then stop achieve as much protection from osteoporotic fractures as women who continue their HRT beyond 3 years.⁴

Continuing HRT beyond 5 years dramatically increases the risk of coronary heart disease, stroke, thromboembolic events, breast cancer, and cholecystitis.³

Recommendations from others

The American College of Obstetricians and Gynecologists has convened a multispecialty panel of experts to draft new recommendations for HRT in light of the WHI findings.

Evidence summary

The Women’s Health Initiative (WHI),¹ the largest randomized trial of HRT, showed that long-term use of HRT poses more risks than benefits for healthy postmenopausal women. WHI studied the use of estrogen plus progestin for prevention of coronary heart disease in 16,608 postmenopausal women age 50–79 years. After 5 years of follow-up, this arm of the study was stopped because of the adverse effects of the intervention. The researchers found that HRT increases the risk of several events:

• coronary heart disease events (number needed to harm [NNH]=1428)
• invasive breast cancer (NNH=1250)
• stroke (NNH=1250)
• venous thromboembolic events (NNH=555)
• pulmonary embolism (NNH=1250).

An ongoing arm of WHI is studying estrogen alone in postmenopausal women who have had a hysterectomy.

The Heart and Estrogen/progestin Replacement Study (HERS)² examined the effects of HRT in postmenopausal women with coronary artery disease. HERS was a large randomized controlled trial of 2763 women with an average follow-up time of 4.1 years. It showed no statistically significant difference between the HRT (estrogen plus medroxyprog-esterone) group compared with the placebo group in either the primary outcomes (nonfatal myocardial infarction or coronary heart disease death) or in the secondary outcomes (coronary revascularization, unstable angina, congestive heart failure, resuscitated cardiac arrest, stroke or transient ischemic attack, and peripheral arterial disease). The findings of the WHI and HERS trials have been summarized in a recent meta-analysis done for the United States Preventive Services Task Force.³

Both the WHI and HERS trials demonstrated some benefits for HRT. WHI found a reduced risk of colorectal cancer (number needed to treat [NNT]=1667) and a decreased risk of any osteoporotic fracture (NNT=228). The HERS group found that HRT improved the quality of life of women with postmenopausal symptoms, particularly flushing.

Evidence indicates that women who take HRT for 3 years and then stop achieve as much protection from osteoporotic fractures as women who continue their HRT beyond 3 years.⁴

Continuing HRT beyond 5 years dramatically increases the risk of coronary heart disease, stroke, thromboembolic events, breast cancer, and cholecystitis.³

Recommendations from others

The American College of Obstetricians and Gynecologists has convened a multispecialty panel of experts to draft new recommendations for HRT in light of the WHI findings.

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

Evidence summary

A recent Cochrane review based on only 1 RCT of 22 patients published in 1964 concluded that surgical treatment of carpal tunnel syndrome appears to be more effective than wrist splinting.¹ A well-designed RCT of 176 patients published since that Cochrane review stated that with regard to overall improvement of symptoms and function status, surgical treatment of carpal tunnel syndrome was more effective than wrist splinting 18 months posttreatment.² The investigators found that surgery resulted in worse short-term outcomes at 1 month follow-up (29% vs 42% success), but by 3 months the improvement in all outcomes was greater in the surgery group (80% vs 54% success). The number needed to treat (NNT) over 18 months was only 2 patients in the treatment-received (per protocol) analysis (92% vs 37% success) and 7 in the intention-to-treat analysis (90% vs 75% success). Patients in the conservative treatment group who underwent surgery after splinting had failed had a higher success rate after 18 months follow-up than patients who did not have surgery (94% vs 62% success rate; NNT = 3).

One cohort study of 90 patients concluded that with respect to symptom control and return to function, open release surgery was as effective as local steroid injection at 1 month follow-up.³ However, at 4 to 6 months after the operation, surgery patients were found to have significantly improved symptom and function scores, with continued improvement compared with patients who received the steroid injection. One other cohort study of 429 patients found that surgery (open or closed endoscopic) was more effective with respect to symptom relief and functional status than various nonsurgical therapies (NSAIDs, splints, physical or occupational therapy, local steroid injections, work modification, or vitamin B₆) at 30 months follow-up.⁴ In both cohort studies, the patients’ pretreatment symptom and functioning scores were worse in the surgery group than in the nonsurgical group. The investigators in the first study³ did not report controlling for these scores. In the second study,⁴ the authors controlled for functional status scores, but not for symptom severity.

One recent systematic review of 14 RCTs comparing types of surgical therapies for carpal tunnel syndrome concluded that none of the alternative surgical procedures, including closed endoscopic release, appeared to give better symptom relief than open release; and that the evidence is conflicting as to whether endoscopic release results in earlier return to work or improved level of function.⁵

Recommendations from others

The American Society of Plastic and Reconstructive Surgeons recommends surgical release in the following situations⁶: (1) failed or incomplete conservative therapy; (2) motor weakness or thenar atrophy; (3) lumbrical pattern symptoms (occur when the metacarpophalangeal joints are held at 90 degrees, eg, driving, letter writing, holding a magazine, pinching, using a small tool); (4) severe pattern on electrical studies (not defined); (5) space-occupying lesions requiring excision; (6) acute carpal tunnel syndrome with symptoms lasting longer than 6 to 8 hours; and (7) progressive or severe symptoms lasting longer than 12 months. The Society did not recommend one surgical procedure over another.

Patient Information

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

Evidence summary

A recent Cochrane review based on only 1 RCT of 22 patients published in 1964 concluded that surgical treatment of carpal tunnel syndrome appears to be more effective than wrist splinting.¹ A well-designed RCT of 176 patients published since that Cochrane review stated that with regard to overall improvement of symptoms and function status, surgical treatment of carpal tunnel syndrome was more effective than wrist splinting 18 months posttreatment.² The investigators found that surgery resulted in worse short-term outcomes at 1 month follow-up (29% vs 42% success), but by 3 months the improvement in all outcomes was greater in the surgery group (80% vs 54% success). The number needed to treat (NNT) over 18 months was only 2 patients in the treatment-received (per protocol) analysis (92% vs 37% success) and 7 in the intention-to-treat analysis (90% vs 75% success). Patients in the conservative treatment group who underwent surgery after splinting had failed had a higher success rate after 18 months follow-up than patients who did not have surgery (94% vs 62% success rate; NNT = 3).

One cohort study of 90 patients concluded that with respect to symptom control and return to function, open release surgery was as effective as local steroid injection at 1 month follow-up.³ However, at 4 to 6 months after the operation, surgery patients were found to have significantly improved symptom and function scores, with continued improvement compared with patients who received the steroid injection. One other cohort study of 429 patients found that surgery (open or closed endoscopic) was more effective with respect to symptom relief and functional status than various nonsurgical therapies (NSAIDs, splints, physical or occupational therapy, local steroid injections, work modification, or vitamin B₆) at 30 months follow-up.⁴ In both cohort studies, the patients’ pretreatment symptom and functioning scores were worse in the surgery group than in the nonsurgical group. The investigators in the first study³ did not report controlling for these scores. In the second study,⁴ the authors controlled for functional status scores, but not for symptom severity.

One recent systematic review of 14 RCTs comparing types of surgical therapies for carpal tunnel syndrome concluded that none of the alternative surgical procedures, including closed endoscopic release, appeared to give better symptom relief than open release; and that the evidence is conflicting as to whether endoscopic release results in earlier return to work or improved level of function.⁵

Recommendations from others

The American Society of Plastic and Reconstructive Surgeons recommends surgical release in the following situations⁶: (1) failed or incomplete conservative therapy; (2) motor weakness or thenar atrophy; (3) lumbrical pattern symptoms (occur when the metacarpophalangeal joints are held at 90 degrees, eg, driving, letter writing, holding a magazine, pinching, using a small tool); (4) severe pattern on electrical studies (not defined); (5) space-occupying lesions requiring excision; (6) acute carpal tunnel syndrome with symptoms lasting longer than 6 to 8 hours; and (7) progressive or severe symptoms lasting longer than 12 months. The Society did not recommend one surgical procedure over another.

Patient Information

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

Evidence summary

A recent Cochrane review based on only 1 RCT of 22 patients published in 1964 concluded that surgical treatment of carpal tunnel syndrome appears to be more effective than wrist splinting.¹ A well-designed RCT of 176 patients published since that Cochrane review stated that with regard to overall improvement of symptoms and function status, surgical treatment of carpal tunnel syndrome was more effective than wrist splinting 18 months posttreatment.² The investigators found that surgery resulted in worse short-term outcomes at 1 month follow-up (29% vs 42% success), but by 3 months the improvement in all outcomes was greater in the surgery group (80% vs 54% success). The number needed to treat (NNT) over 18 months was only 2 patients in the treatment-received (per protocol) analysis (92% vs 37% success) and 7 in the intention-to-treat analysis (90% vs 75% success). Patients in the conservative treatment group who underwent surgery after splinting had failed had a higher success rate after 18 months follow-up than patients who did not have surgery (94% vs 62% success rate; NNT = 3).

One cohort study of 90 patients concluded that with respect to symptom control and return to function, open release surgery was as effective as local steroid injection at 1 month follow-up.³ However, at 4 to 6 months after the operation, surgery patients were found to have significantly improved symptom and function scores, with continued improvement compared with patients who received the steroid injection. One other cohort study of 429 patients found that surgery (open or closed endoscopic) was more effective with respect to symptom relief and functional status than various nonsurgical therapies (NSAIDs, splints, physical or occupational therapy, local steroid injections, work modification, or vitamin B₆) at 30 months follow-up.⁴ In both cohort studies, the patients’ pretreatment symptom and functioning scores were worse in the surgery group than in the nonsurgical group. The investigators in the first study³ did not report controlling for these scores. In the second study,⁴ the authors controlled for functional status scores, but not for symptom severity.

One recent systematic review of 14 RCTs comparing types of surgical therapies for carpal tunnel syndrome concluded that none of the alternative surgical procedures, including closed endoscopic release, appeared to give better symptom relief than open release; and that the evidence is conflicting as to whether endoscopic release results in earlier return to work or improved level of function.⁵

Recommendations from others

The American Society of Plastic and Reconstructive Surgeons recommends surgical release in the following situations⁶: (1) failed or incomplete conservative therapy; (2) motor weakness or thenar atrophy; (3) lumbrical pattern symptoms (occur when the metacarpophalangeal joints are held at 90 degrees, eg, driving, letter writing, holding a magazine, pinching, using a small tool); (4) severe pattern on electrical studies (not defined); (5) space-occupying lesions requiring excision; (6) acute carpal tunnel syndrome with symptoms lasting longer than 6 to 8 hours; and (7) progressive or severe symptoms lasting longer than 12 months. The Society did not recommend one surgical procedure over another.

Patient Information

What is carpal tunnel syndrome?

Carpal tunnel syndrome is felt as pain, tingling, a burning sensation, or loss of sensation that occurs throughout all or part of the hand. These symptoms may be worse at night and can wake you from sleep. You may feel the pain in just the hand, or it may travel up the arm.

How it’s diagnosed

Carpal tunnel syndrome can be challenging to diagnose.

Your doctor will ask you to describe your symptoms and may ask you to perform specific motions with your hand or wrist to see how they affect your symptoms.

Your doctor may arrange for a nerve conduction study—a test to determine how well the nerves in your hand are working. The test can detect if the pressure on the nerve is enough to affect how well it works.

How it’s treated

Your doctor may ask you to wear wrist splints at night or during work, and may advise you to reduce those activities that make the problem worse. Steroid injections into the carpal tunnel may also help. If such conservative treatment does not help, your doctor may talk to you about a simple surgical procedure to relieve pressure on the nerve. The surgeon cuts the ligament over the carpal tunnel, which releases the pressure on the nerve. This surgery works well to relieve the symptoms of carpal tunnel syndrome.

The carpal “tunnel” is the space in which nerves, tendons, and blood vessels pass through the bones of the wrist. Anything that narrows the tunnel, such as swelling of tendons, can compress the nerve and cause carpal tunnel syndrome.

Evidence summary

Most trials of bronchiolitis treatment suffer from 2 constraints: possible inclusion of patients with asthma and inconsistent outcome measures. Five trials of nebulized epinephrine, involving 225 children, have been published in the last decade. All have shown clinical improvement in measures such as respiratory rate, wheezing, retractions, hospital admission rates, and length of stay.¹

Data from other clinical trials, meta-analyses, and a comprehensive Cochrane systematic review do not support the routine use of selective beta-2 agonists. Studies with unselected patients noted some benefit, which may reflect the inclusion of asthmatic children, or the effects of suctioning in combination with inhalational therapy. Large proportions of patients admitted to hospital with bronchiolitis receive bronchodilators, and many physicians continue to advocate their use.² The cost of routine bronchodilators for children with bronchiolitis may be as high as $37.5 million per year.²

One systematic review and 8 RCTs found conflicting evidence on the effects of corticosteroids.³ Steroid therapy, given as inhalations, intravenously, orally, or intramuscularly, does not have a consistent effect on clinical status or on length of stay.⁴

A 1997 systematic review showed that ribavirin had no significant effect on mortality or the risk of respiratory deterioration in children admitted to hospital with respiratory syncytial virus (RSV) bronchiolitis.³ In fact, cohort studies and randomized trials have shown that ribavirin use is associated with an increase in the number of days of mechanical ventilation, intensive care unit stay, and hospitalizations.⁴

Passive immunotherapy with pooled immunoglobulins remains controversial and is undergoing intense study.⁴ Three RCTs failed to show any effect on length of hospital stay, and subsequent studies of an RSV-specific humanized monoclonal antibody (palivizumab) have not shown improvements in outcome.

The evidence supporting the use of supplemental oxygen and suctioning of respiratory secretions is limited to expert opinion.⁵

Recommendations from others

Most pediatric infectious diseases specialists surveyed in Europe recommend bronchodilators. However, bronchodilators are seldom used to treat bronchiolitis in the United Kingdom.² The present consensus from the American Academy of Pediatrics⁶ states that ribavirin should be considered in infants with underlying congenital heart disease, lung disease, or immunosuppression, or for infants requiring mechanical ventilation.

Evidence summary

Most trials of bronchiolitis treatment suffer from 2 constraints: possible inclusion of patients with asthma and inconsistent outcome measures. Five trials of nebulized epinephrine, involving 225 children, have been published in the last decade. All have shown clinical improvement in measures such as respiratory rate, wheezing, retractions, hospital admission rates, and length of stay.¹

Data from other clinical trials, meta-analyses, and a comprehensive Cochrane systematic review do not support the routine use of selective beta-2 agonists. Studies with unselected patients noted some benefit, which may reflect the inclusion of asthmatic children, or the effects of suctioning in combination with inhalational therapy. Large proportions of patients admitted to hospital with bronchiolitis receive bronchodilators, and many physicians continue to advocate their use.² The cost of routine bronchodilators for children with bronchiolitis may be as high as $37.5 million per year.²

One systematic review and 8 RCTs found conflicting evidence on the effects of corticosteroids.³ Steroid therapy, given as inhalations, intravenously, orally, or intramuscularly, does not have a consistent effect on clinical status or on length of stay.⁴

A 1997 systematic review showed that ribavirin had no significant effect on mortality or the risk of respiratory deterioration in children admitted to hospital with respiratory syncytial virus (RSV) bronchiolitis.³ In fact, cohort studies and randomized trials have shown that ribavirin use is associated with an increase in the number of days of mechanical ventilation, intensive care unit stay, and hospitalizations.⁴

Passive immunotherapy with pooled immunoglobulins remains controversial and is undergoing intense study.⁴ Three RCTs failed to show any effect on length of hospital stay, and subsequent studies of an RSV-specific humanized monoclonal antibody (palivizumab) have not shown improvements in outcome.

The evidence supporting the use of supplemental oxygen and suctioning of respiratory secretions is limited to expert opinion.⁵

Recommendations from others

Most pediatric infectious diseases specialists surveyed in Europe recommend bronchodilators. However, bronchodilators are seldom used to treat bronchiolitis in the United Kingdom.² The present consensus from the American Academy of Pediatrics⁶ states that ribavirin should be considered in infants with underlying congenital heart disease, lung disease, or immunosuppression, or for infants requiring mechanical ventilation.

Evidence summary

Most trials of bronchiolitis treatment suffer from 2 constraints: possible inclusion of patients with asthma and inconsistent outcome measures. Five trials of nebulized epinephrine, involving 225 children, have been published in the last decade. All have shown clinical improvement in measures such as respiratory rate, wheezing, retractions, hospital admission rates, and length of stay.¹

Data from other clinical trials, meta-analyses, and a comprehensive Cochrane systematic review do not support the routine use of selective beta-2 agonists. Studies with unselected patients noted some benefit, which may reflect the inclusion of asthmatic children, or the effects of suctioning in combination with inhalational therapy. Large proportions of patients admitted to hospital with bronchiolitis receive bronchodilators, and many physicians continue to advocate their use.² The cost of routine bronchodilators for children with bronchiolitis may be as high as $37.5 million per year.²

One systematic review and 8 RCTs found conflicting evidence on the effects of corticosteroids.³ Steroid therapy, given as inhalations, intravenously, orally, or intramuscularly, does not have a consistent effect on clinical status or on length of stay.⁴

A 1997 systematic review showed that ribavirin had no significant effect on mortality or the risk of respiratory deterioration in children admitted to hospital with respiratory syncytial virus (RSV) bronchiolitis.³ In fact, cohort studies and randomized trials have shown that ribavirin use is associated with an increase in the number of days of mechanical ventilation, intensive care unit stay, and hospitalizations.⁴

Passive immunotherapy with pooled immunoglobulins remains controversial and is undergoing intense study.⁴ Three RCTs failed to show any effect on length of hospital stay, and subsequent studies of an RSV-specific humanized monoclonal antibody (palivizumab) have not shown improvements in outcome.

The evidence supporting the use of supplemental oxygen and suctioning of respiratory secretions is limited to expert opinion.⁵

Recommendations from others

Most pediatric infectious diseases specialists surveyed in Europe recommend bronchodilators. However, bronchodilators are seldom used to treat bronchiolitis in the United Kingdom.² The present consensus from the American Academy of Pediatrics⁶ states that ribavirin should be considered in infants with underlying congenital heart disease, lung disease, or immunosuppression, or for infants requiring mechanical ventilation.

Evidence summary

The primary role of colposcopy is to identify cervical lesions, allowing directed biopsies to identify invasive cancer or its precursors. Although colposcopy has been studied as a primary screening technique, issues of cost, accessibility, invasiveness, and low specificity severely limit its usefulness in this role.¹ Using histology as the gold standard, the sensitivity of colposcopy for cervical abnormalities is high (96%; 95% confidence interval [CI], 95%–97%), but the specificity is much lower (48%; 95% CI, 47%–49%).² This low specificity means that more than half of women with no cervical pathology will have an abnormal colposcopy result. The corresponding positive and negative likelihood ratios are 2 and 0.1, respectively. Consequently, a normal colposcopy result can effectively rule out cervical pathology, thus supporting its role as a diagnostic rather than a screening tool.

While most lesions are found by abnormal cytology, the sensitivity of the Papanicolaou smear ranges from 30% to 89%.³ Therefore, colposcopy is also indicated for patients with symptoms suggestive of cervical dysplasia or cancer (abnormal appearance of the cervix, or persistent and undiagnosed vaginal discharge or bleeding), even in the setting of normal cytology.⁴

Colposcopy is also indicated for follow-up after treatment of cervical dysplasia. One study⁵ identified 3 risk factors for recurrence of dysplasia after a loop electrocautery excision procedure (LEEP): residual disease at either the endocervical or ectocervical margins, and involvement of endocervical glands. The presence of these risk factors predicted a recurrence rate of almost 70%.⁵ Because 8% of the recurrences were missed on cytology, the authors recommended colposcopy 6 months after LEEP for patients with these risk factors.

Recommendations from others

The place of colposcopy in the work-up of patients with abnormal cytology is well supported. With the recent revision of the Bethesda System by the National Cancer Institute,⁶ the American Society for Colposcopy and Cervical Pathology (ASCCP) held a consensus conference to review the literature and provide evidence-based guidelines for management of abnormal cervical cytology.⁷ Its recommendations on colposcopy are summarized in the Table.

The U.S. Preventive Services Task Force’s 1996 recommendations found insufficient evidence to recommend either for or against the use of colposcopy as a screening tool for cervical cancer. Based on high cost and low specificity, it recommends against screening colposcopy.⁸

TABLE
Recommendations for colposcopy, American Society for Colposcopy and Cervical Pathology⁷

Evidence summary

The primary role of colposcopy is to identify cervical lesions, allowing directed biopsies to identify invasive cancer or its precursors. Although colposcopy has been studied as a primary screening technique, issues of cost, accessibility, invasiveness, and low specificity severely limit its usefulness in this role.¹ Using histology as the gold standard, the sensitivity of colposcopy for cervical abnormalities is high (96%; 95% confidence interval [CI], 95%–97%), but the specificity is much lower (48%; 95% CI, 47%–49%).² This low specificity means that more than half of women with no cervical pathology will have an abnormal colposcopy result. The corresponding positive and negative likelihood ratios are 2 and 0.1, respectively. Consequently, a normal colposcopy result can effectively rule out cervical pathology, thus supporting its role as a diagnostic rather than a screening tool.

While most lesions are found by abnormal cytology, the sensitivity of the Papanicolaou smear ranges from 30% to 89%.³ Therefore, colposcopy is also indicated for patients with symptoms suggestive of cervical dysplasia or cancer (abnormal appearance of the cervix, or persistent and undiagnosed vaginal discharge or bleeding), even in the setting of normal cytology.⁴

Colposcopy is also indicated for follow-up after treatment of cervical dysplasia. One study⁵ identified 3 risk factors for recurrence of dysplasia after a loop electrocautery excision procedure (LEEP): residual disease at either the endocervical or ectocervical margins, and involvement of endocervical glands. The presence of these risk factors predicted a recurrence rate of almost 70%.⁵ Because 8% of the recurrences were missed on cytology, the authors recommended colposcopy 6 months after LEEP for patients with these risk factors.

Recommendations from others

The place of colposcopy in the work-up of patients with abnormal cytology is well supported. With the recent revision of the Bethesda System by the National Cancer Institute,⁶ the American Society for Colposcopy and Cervical Pathology (ASCCP) held a consensus conference to review the literature and provide evidence-based guidelines for management of abnormal cervical cytology.⁷ Its recommendations on colposcopy are summarized in the Table.

The U.S. Preventive Services Task Force’s 1996 recommendations found insufficient evidence to recommend either for or against the use of colposcopy as a screening tool for cervical cancer. Based on high cost and low specificity, it recommends against screening colposcopy.⁸

TABLE
Recommendations for colposcopy, American Society for Colposcopy and Cervical Pathology⁷

Evidence summary

The primary role of colposcopy is to identify cervical lesions, allowing directed biopsies to identify invasive cancer or its precursors. Although colposcopy has been studied as a primary screening technique, issues of cost, accessibility, invasiveness, and low specificity severely limit its usefulness in this role.¹ Using histology as the gold standard, the sensitivity of colposcopy for cervical abnormalities is high (96%; 95% confidence interval [CI], 95%–97%), but the specificity is much lower (48%; 95% CI, 47%–49%).² This low specificity means that more than half of women with no cervical pathology will have an abnormal colposcopy result. The corresponding positive and negative likelihood ratios are 2 and 0.1, respectively. Consequently, a normal colposcopy result can effectively rule out cervical pathology, thus supporting its role as a diagnostic rather than a screening tool.

While most lesions are found by abnormal cytology, the sensitivity of the Papanicolaou smear ranges from 30% to 89%.³ Therefore, colposcopy is also indicated for patients with symptoms suggestive of cervical dysplasia or cancer (abnormal appearance of the cervix, or persistent and undiagnosed vaginal discharge or bleeding), even in the setting of normal cytology.⁴

Colposcopy is also indicated for follow-up after treatment of cervical dysplasia. One study⁵ identified 3 risk factors for recurrence of dysplasia after a loop electrocautery excision procedure (LEEP): residual disease at either the endocervical or ectocervical margins, and involvement of endocervical glands. The presence of these risk factors predicted a recurrence rate of almost 70%.⁵ Because 8% of the recurrences were missed on cytology, the authors recommended colposcopy 6 months after LEEP for patients with these risk factors.

Recommendations from others

The place of colposcopy in the work-up of patients with abnormal cytology is well supported. With the recent revision of the Bethesda System by the National Cancer Institute,⁶ the American Society for Colposcopy and Cervical Pathology (ASCCP) held a consensus conference to review the literature and provide evidence-based guidelines for management of abnormal cervical cytology.⁷ Its recommendations on colposcopy are summarized in the Table.

The U.S. Preventive Services Task Force’s 1996 recommendations found insufficient evidence to recommend either for or against the use of colposcopy as a screening tool for cervical cancer. Based on high cost and low specificity, it recommends against screening colposcopy.⁸

TABLE
Recommendations for colposcopy, American Society for Colposcopy and Cervical Pathology⁷

Evidence summary

Metlay and colleagues¹ found only 4 high-quality, prospective cohort trials evaluating the sensitivity and specificity of the clinical history and physical examination in pneumonia. In each of the 4 studies, the reference standard for the diagnosis of pneumonia was a new infiltrate on chest radiograph. Subjects were community-dwelling adults with acute cough who were seen in ambulatory settings, and who had an average pneumonia prevalence of 7% (range, 3%–38%).¹ Although no study specifically addressed the interobserver reliability of the history and physical examination findings in pneumonia, other studies of chest findings typically found variable reproducibility. In a study by Spiteri and associates,² 24 physicians examined 24 patients with a variety of respiratory conditions: only 4 had pneumonia on chest x-ray. The most reliable findings (dullness to percussion and wheezing) had only fair agreement among examiners (kappa approximately 0.5).

Nine symptoms (cough, dyspnea, sputum production, subjective fever, chills, night sweats, myalgias, sore throat, and rhinorrhea) and 3 items in the past medical history (asthma, immunosuppression, and dementia) were associated with pneumonia. For most elements of history, both the positive and negative likelihood ratios (LR+, LR−) were in the indeterminate range of 0.5 to 2.0. No single feature was sufficient to either rule in or rule out the diagnosis.¹

Regarding the physical examination, tachypnea, tachycardia, and fever had LR+s between 1.5 and 2.4 in an ambulatory setting. In one study, the absence of any vital sign abnormalities reduced the likelihood of pneumonia substantially (LR− = 0.18), but did not rule out the diagnosis completely.¹ Egophony had an LR+ of 5.3. Other physical findings (rhonchi, crackles, decreased breath sounds, dullness to percussion, and bronchial breath sounds) yielded LR+s from 1.5 to 3.5, respectively. Most individual findings were insufficient to diagnose pneumonia. For example, if the baseline prevalence of pneumonia was 5%, the presence of crackles raised the probability to 10% and their absence decreased the probability to 3%.

The sensitivity and specificity of clinical diagnosis varied with the prevalence of pneumonia. In a general practice setting, 20 of 402 patients with cough were diagnosed with pneumonia by chest x-ray.³ Physicians correctly diagnosed 7 patients clinically, and incorrectly diagnosed pneumonia in 22 additional patients.³ At a Veterans Administration hospital, a prospective cohort of 52 men with acute cough and change in sputum production underwent sequential blinded examination by 3 physicians. Rales and bronchial breath sounds were common, and chest x-ray confirmed pneumonia in 28 patients. Sensitivity of clinical diagnosis ranged from 47% to 69%, and specificity from 58% to 75%.⁴

Several researchers improved diagnostic accuracy by combining multiple elements from the history and physical examination. For example, according to Metlay and colleagues,¹ Heckerling et al calculated the probability of pneumonia if up to 5 predictors were present. However, if the prevalence of pneumonia in a primary care population is 5%, the presence of all 5 predictors raises the probability of pneumonia only to 53%.¹ The absence of 4 of the 5 findings (fever >37.8°C, heart rate >100 beats per minute, decreased breath sounds, crackles) reduces the risk of pneumonia to 1%, thus eliminating the need for radiography or antibiotics in most situations. If the patient also has asthma, the risk drops even further.

Recommendations from others

The Infectious Diseases Society of North America states that a chest x-ray is necessary for accurate diagnosis. In otherwise healthy adults with acute cough illness, antibiotic therapy is indicated only for pneumonia. A normal chest x-ray obviates the need for antibiotics.^5,6

Evidence summary

Metlay and colleagues¹ found only 4 high-quality, prospective cohort trials evaluating the sensitivity and specificity of the clinical history and physical examination in pneumonia. In each of the 4 studies, the reference standard for the diagnosis of pneumonia was a new infiltrate on chest radiograph. Subjects were community-dwelling adults with acute cough who were seen in ambulatory settings, and who had an average pneumonia prevalence of 7% (range, 3%–38%).¹ Although no study specifically addressed the interobserver reliability of the history and physical examination findings in pneumonia, other studies of chest findings typically found variable reproducibility. In a study by Spiteri and associates,² 24 physicians examined 24 patients with a variety of respiratory conditions: only 4 had pneumonia on chest x-ray. The most reliable findings (dullness to percussion and wheezing) had only fair agreement among examiners (kappa approximately 0.5).

Nine symptoms (cough, dyspnea, sputum production, subjective fever, chills, night sweats, myalgias, sore throat, and rhinorrhea) and 3 items in the past medical history (asthma, immunosuppression, and dementia) were associated with pneumonia. For most elements of history, both the positive and negative likelihood ratios (LR+, LR−) were in the indeterminate range of 0.5 to 2.0. No single feature was sufficient to either rule in or rule out the diagnosis.¹

Regarding the physical examination, tachypnea, tachycardia, and fever had LR+s between 1.5 and 2.4 in an ambulatory setting. In one study, the absence of any vital sign abnormalities reduced the likelihood of pneumonia substantially (LR− = 0.18), but did not rule out the diagnosis completely.¹ Egophony had an LR+ of 5.3. Other physical findings (rhonchi, crackles, decreased breath sounds, dullness to percussion, and bronchial breath sounds) yielded LR+s from 1.5 to 3.5, respectively. Most individual findings were insufficient to diagnose pneumonia. For example, if the baseline prevalence of pneumonia was 5%, the presence of crackles raised the probability to 10% and their absence decreased the probability to 3%.

The sensitivity and specificity of clinical diagnosis varied with the prevalence of pneumonia. In a general practice setting, 20 of 402 patients with cough were diagnosed with pneumonia by chest x-ray.³ Physicians correctly diagnosed 7 patients clinically, and incorrectly diagnosed pneumonia in 22 additional patients.³ At a Veterans Administration hospital, a prospective cohort of 52 men with acute cough and change in sputum production underwent sequential blinded examination by 3 physicians. Rales and bronchial breath sounds were common, and chest x-ray confirmed pneumonia in 28 patients. Sensitivity of clinical diagnosis ranged from 47% to 69%, and specificity from 58% to 75%.⁴

Several researchers improved diagnostic accuracy by combining multiple elements from the history and physical examination. For example, according to Metlay and colleagues,¹ Heckerling et al calculated the probability of pneumonia if up to 5 predictors were present. However, if the prevalence of pneumonia in a primary care population is 5%, the presence of all 5 predictors raises the probability of pneumonia only to 53%.¹ The absence of 4 of the 5 findings (fever >37.8°C, heart rate >100 beats per minute, decreased breath sounds, crackles) reduces the risk of pneumonia to 1%, thus eliminating the need for radiography or antibiotics in most situations. If the patient also has asthma, the risk drops even further.

Recommendations from others

The Infectious Diseases Society of North America states that a chest x-ray is necessary for accurate diagnosis. In otherwise healthy adults with acute cough illness, antibiotic therapy is indicated only for pneumonia. A normal chest x-ray obviates the need for antibiotics.^5,6

Evidence summary

Metlay and colleagues¹ found only 4 high-quality, prospective cohort trials evaluating the sensitivity and specificity of the clinical history and physical examination in pneumonia. In each of the 4 studies, the reference standard for the diagnosis of pneumonia was a new infiltrate on chest radiograph. Subjects were community-dwelling adults with acute cough who were seen in ambulatory settings, and who had an average pneumonia prevalence of 7% (range, 3%–38%).¹ Although no study specifically addressed the interobserver reliability of the history and physical examination findings in pneumonia, other studies of chest findings typically found variable reproducibility. In a study by Spiteri and associates,² 24 physicians examined 24 patients with a variety of respiratory conditions: only 4 had pneumonia on chest x-ray. The most reliable findings (dullness to percussion and wheezing) had only fair agreement among examiners (kappa approximately 0.5).

Nine symptoms (cough, dyspnea, sputum production, subjective fever, chills, night sweats, myalgias, sore throat, and rhinorrhea) and 3 items in the past medical history (asthma, immunosuppression, and dementia) were associated with pneumonia. For most elements of history, both the positive and negative likelihood ratios (LR+, LR−) were in the indeterminate range of 0.5 to 2.0. No single feature was sufficient to either rule in or rule out the diagnosis.¹

Regarding the physical examination, tachypnea, tachycardia, and fever had LR+s between 1.5 and 2.4 in an ambulatory setting. In one study, the absence of any vital sign abnormalities reduced the likelihood of pneumonia substantially (LR− = 0.18), but did not rule out the diagnosis completely.¹ Egophony had an LR+ of 5.3. Other physical findings (rhonchi, crackles, decreased breath sounds, dullness to percussion, and bronchial breath sounds) yielded LR+s from 1.5 to 3.5, respectively. Most individual findings were insufficient to diagnose pneumonia. For example, if the baseline prevalence of pneumonia was 5%, the presence of crackles raised the probability to 10% and their absence decreased the probability to 3%.

The sensitivity and specificity of clinical diagnosis varied with the prevalence of pneumonia. In a general practice setting, 20 of 402 patients with cough were diagnosed with pneumonia by chest x-ray.³ Physicians correctly diagnosed 7 patients clinically, and incorrectly diagnosed pneumonia in 22 additional patients.³ At a Veterans Administration hospital, a prospective cohort of 52 men with acute cough and change in sputum production underwent sequential blinded examination by 3 physicians. Rales and bronchial breath sounds were common, and chest x-ray confirmed pneumonia in 28 patients. Sensitivity of clinical diagnosis ranged from 47% to 69%, and specificity from 58% to 75%.⁴

Several researchers improved diagnostic accuracy by combining multiple elements from the history and physical examination. For example, according to Metlay and colleagues,¹ Heckerling et al calculated the probability of pneumonia if up to 5 predictors were present. However, if the prevalence of pneumonia in a primary care population is 5%, the presence of all 5 predictors raises the probability of pneumonia only to 53%.¹ The absence of 4 of the 5 findings (fever >37.8°C, heart rate >100 beats per minute, decreased breath sounds, crackles) reduces the risk of pneumonia to 1%, thus eliminating the need for radiography or antibiotics in most situations. If the patient also has asthma, the risk drops even further.

Recommendations from others

The Infectious Diseases Society of North America states that a chest x-ray is necessary for accurate diagnosis. In otherwise healthy adults with acute cough illness, antibiotic therapy is indicated only for pneumonia. A normal chest x-ray obviates the need for antibiotics.^5,6