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Carvedilol superior to metoprolol for preventing death from CHF
Among white patients with symptomatic systolic dysfunction on stable treatment with diuretics and angiotensin-converting enzyme (ACE) inhibitors, the addition of the nonselective beta-blocker carvedilol extends survival by 17% per year compared with metoprolol. This benefit translates into a number needed to treat (NNT) of 17 for 5 years. This extrapolates to an added 1.4 years of life.
It is unclear whether this benefit holds true for nonwhite patients. Carvedilol should be considered over metoprolol for treating patients with congestive heart failure to improve survival.
Among white patients with symptomatic systolic dysfunction on stable treatment with diuretics and angiotensin-converting enzyme (ACE) inhibitors, the addition of the nonselective beta-blocker carvedilol extends survival by 17% per year compared with metoprolol. This benefit translates into a number needed to treat (NNT) of 17 for 5 years. This extrapolates to an added 1.4 years of life.
It is unclear whether this benefit holds true for nonwhite patients. Carvedilol should be considered over metoprolol for treating patients with congestive heart failure to improve survival.
Among white patients with symptomatic systolic dysfunction on stable treatment with diuretics and angiotensin-converting enzyme (ACE) inhibitors, the addition of the nonselective beta-blocker carvedilol extends survival by 17% per year compared with metoprolol. This benefit translates into a number needed to treat (NNT) of 17 for 5 years. This extrapolates to an added 1.4 years of life.
It is unclear whether this benefit holds true for nonwhite patients. Carvedilol should be considered over metoprolol for treating patients with congestive heart failure to improve survival.
How accurate are the history and physical examination in diagnosing carpal tunnel syndrome (CTS)?
BACKGROUND: Approximately 3% of adults in population-based studies have symptomatic CTS confirmed by electrodiagnostic studies. Clinicians use many different historical and physical findings to diagnose CTS. This study is a systematic review of the accuracy of history and physical examination findings in diagnosing CTS using electrodiagnostic studies as the gold standard.
POPULATION STUDIED: Because this is a systematic review, patients from several different populations were studied. Details were not given on the demographics of patients in the included studies, although none were performed in the family practice setting. This is a possible limitation for family physicians wishing to apply these data to their practices.
STUDY DESIGN AND VALIDITY: The authors searched MEDLINE from January 1966 to February 2000 for relevant articles. Included studies had to meet the following criteria: patients presented to the clinician for symptoms suggestive of CTS; the physical examination maneuvers were clearly described; there was an independent comparison with 1 or more electrodiagnostic parameters; and the authors could extract the data needed to calculate sensitivity, specificity, and likelihood ratios. Twelve articles met these inclusion criteria. Likelihood ratios were pooled if the overall accuracy between studies was homogeneous (ie, studies generally reported similar results). The search could have been improved by contacting the authors of studies that had insufficient data to calculate sensitivity and specificity.
OUTCOMES MEASURED: The primary outcomes were the sensitivity, specificity, and likelihood ratios for each history and physical examination finding.
RESULTS: The flick test had the best positive likelihood ratio (LR+=21.4; 95% confidence interval [CI], 10.8-42.1) and negative likelihood ratio (LR-=0.1; 95% CI, 0.0-0.1), but was only reported in a single study. It is performed as follows: When asking the patient, “What do you actually do with your hand(s) when the symptoms are at their worst?” the patient demonstrates a flicking movement of the wrist and hand similar to that used in shaking down a thermometer. Slightly to moderately useful tests for ruling in CTS include a decreased ability to perceive painful stimuli along the palmar aspect index finger when compared with the ipsilateral little finger (LR+=3.1), the Katz hand diagram with classic or probable patterns (LR+=2.4), weak thumb abduction (LR+=1.8), abnormal monofilament testing (LR+=1.5), and the Phalen sign (LR+=1.3). The confidence intervals of the LR+ and LR- of the following signs and symptoms included 1.0, signifying no diagnostic utility: nocturnal paresthesias, thenar atrophy, 2-point discrimination, abnormal vibration sense, pressure provocation test, and tourniquet test. The square wrist sign (LR-=2.7) and closed fist sign (LR-=7.3) were each only reported in 1 study but show promise. Only the Flick test had an LR- of less than 0.5.
This useful systematic review found that the flick test, a classic or probable Katz hand diagram, hypalgesia, and weak thumb abduction increase the likelihood that a patient will have a positive electrodiagnostic study result for CTS. See the figures and tables in the original article for more details on performing these tests. The Tinel and Phelan tests used by many physicians are less accurate and should be discarded in favor of the tests described. The flick, abduction, and hypalgesia tests in particular can easily be adapted to the family practice setting. Use of these findings can help physicians choose the appropriate initial therapy for their patients, select patients who need further testing, and help focus the work-up on alternative diagnoses if the electrodiagnostic findings are negative.
BACKGROUND: Approximately 3% of adults in population-based studies have symptomatic CTS confirmed by electrodiagnostic studies. Clinicians use many different historical and physical findings to diagnose CTS. This study is a systematic review of the accuracy of history and physical examination findings in diagnosing CTS using electrodiagnostic studies as the gold standard.
POPULATION STUDIED: Because this is a systematic review, patients from several different populations were studied. Details were not given on the demographics of patients in the included studies, although none were performed in the family practice setting. This is a possible limitation for family physicians wishing to apply these data to their practices.
STUDY DESIGN AND VALIDITY: The authors searched MEDLINE from January 1966 to February 2000 for relevant articles. Included studies had to meet the following criteria: patients presented to the clinician for symptoms suggestive of CTS; the physical examination maneuvers were clearly described; there was an independent comparison with 1 or more electrodiagnostic parameters; and the authors could extract the data needed to calculate sensitivity, specificity, and likelihood ratios. Twelve articles met these inclusion criteria. Likelihood ratios were pooled if the overall accuracy between studies was homogeneous (ie, studies generally reported similar results). The search could have been improved by contacting the authors of studies that had insufficient data to calculate sensitivity and specificity.
OUTCOMES MEASURED: The primary outcomes were the sensitivity, specificity, and likelihood ratios for each history and physical examination finding.
RESULTS: The flick test had the best positive likelihood ratio (LR+=21.4; 95% confidence interval [CI], 10.8-42.1) and negative likelihood ratio (LR-=0.1; 95% CI, 0.0-0.1), but was only reported in a single study. It is performed as follows: When asking the patient, “What do you actually do with your hand(s) when the symptoms are at their worst?” the patient demonstrates a flicking movement of the wrist and hand similar to that used in shaking down a thermometer. Slightly to moderately useful tests for ruling in CTS include a decreased ability to perceive painful stimuli along the palmar aspect index finger when compared with the ipsilateral little finger (LR+=3.1), the Katz hand diagram with classic or probable patterns (LR+=2.4), weak thumb abduction (LR+=1.8), abnormal monofilament testing (LR+=1.5), and the Phalen sign (LR+=1.3). The confidence intervals of the LR+ and LR- of the following signs and symptoms included 1.0, signifying no diagnostic utility: nocturnal paresthesias, thenar atrophy, 2-point discrimination, abnormal vibration sense, pressure provocation test, and tourniquet test. The square wrist sign (LR-=2.7) and closed fist sign (LR-=7.3) were each only reported in 1 study but show promise. Only the Flick test had an LR- of less than 0.5.
This useful systematic review found that the flick test, a classic or probable Katz hand diagram, hypalgesia, and weak thumb abduction increase the likelihood that a patient will have a positive electrodiagnostic study result for CTS. See the figures and tables in the original article for more details on performing these tests. The Tinel and Phelan tests used by many physicians are less accurate and should be discarded in favor of the tests described. The flick, abduction, and hypalgesia tests in particular can easily be adapted to the family practice setting. Use of these findings can help physicians choose the appropriate initial therapy for their patients, select patients who need further testing, and help focus the work-up on alternative diagnoses if the electrodiagnostic findings are negative.
BACKGROUND: Approximately 3% of adults in population-based studies have symptomatic CTS confirmed by electrodiagnostic studies. Clinicians use many different historical and physical findings to diagnose CTS. This study is a systematic review of the accuracy of history and physical examination findings in diagnosing CTS using electrodiagnostic studies as the gold standard.
POPULATION STUDIED: Because this is a systematic review, patients from several different populations were studied. Details were not given on the demographics of patients in the included studies, although none were performed in the family practice setting. This is a possible limitation for family physicians wishing to apply these data to their practices.
STUDY DESIGN AND VALIDITY: The authors searched MEDLINE from January 1966 to February 2000 for relevant articles. Included studies had to meet the following criteria: patients presented to the clinician for symptoms suggestive of CTS; the physical examination maneuvers were clearly described; there was an independent comparison with 1 or more electrodiagnostic parameters; and the authors could extract the data needed to calculate sensitivity, specificity, and likelihood ratios. Twelve articles met these inclusion criteria. Likelihood ratios were pooled if the overall accuracy between studies was homogeneous (ie, studies generally reported similar results). The search could have been improved by contacting the authors of studies that had insufficient data to calculate sensitivity and specificity.
OUTCOMES MEASURED: The primary outcomes were the sensitivity, specificity, and likelihood ratios for each history and physical examination finding.
RESULTS: The flick test had the best positive likelihood ratio (LR+=21.4; 95% confidence interval [CI], 10.8-42.1) and negative likelihood ratio (LR-=0.1; 95% CI, 0.0-0.1), but was only reported in a single study. It is performed as follows: When asking the patient, “What do you actually do with your hand(s) when the symptoms are at their worst?” the patient demonstrates a flicking movement of the wrist and hand similar to that used in shaking down a thermometer. Slightly to moderately useful tests for ruling in CTS include a decreased ability to perceive painful stimuli along the palmar aspect index finger when compared with the ipsilateral little finger (LR+=3.1), the Katz hand diagram with classic or probable patterns (LR+=2.4), weak thumb abduction (LR+=1.8), abnormal monofilament testing (LR+=1.5), and the Phalen sign (LR+=1.3). The confidence intervals of the LR+ and LR- of the following signs and symptoms included 1.0, signifying no diagnostic utility: nocturnal paresthesias, thenar atrophy, 2-point discrimination, abnormal vibration sense, pressure provocation test, and tourniquet test. The square wrist sign (LR-=2.7) and closed fist sign (LR-=7.3) were each only reported in 1 study but show promise. Only the Flick test had an LR- of less than 0.5.
This useful systematic review found that the flick test, a classic or probable Katz hand diagram, hypalgesia, and weak thumb abduction increase the likelihood that a patient will have a positive electrodiagnostic study result for CTS. See the figures and tables in the original article for more details on performing these tests. The Tinel and Phelan tests used by many physicians are less accurate and should be discarded in favor of the tests described. The flick, abduction, and hypalgesia tests in particular can easily be adapted to the family practice setting. Use of these findings can help physicians choose the appropriate initial therapy for their patients, select patients who need further testing, and help focus the work-up on alternative diagnoses if the electrodiagnostic findings are negative.
What are the benefits and risks associated with the use of benzodiazepines to treat insomnia?
BACKGROUND: insomnia is a common problem encountered by family physicians. Benzodiazepines have been the treatment of choice despite questions about their efficacy and their potential to cause adverse effects, such as confusion, falls, and memory loss. The authors of this systematic review summarize the literature on the efficacy and common adverse effects of bezodiazepines compared with both placebo and other treatments for insomnia.
POPULATION STUDIED: Using MEDLINE and the Cochrane Controlled Trials Register, the authors identified randomized controlled trials of benzodiazepines compared with placebo or other active drugs for treatment of insomnia. Only studies in English were included in the evaluation. The manufacturers of the medications were contacted for any studies that may not have been published. The 45 studies included in the meta-analysis represented 2672 patients, 47% of whom were women. The mean age of the patients studied ranged from 29 to 82 years. The duration of the studies ranged from 1 day to 6 weeks with a mean of 12.2 days and median of 7.5 days. The drugs studied included flurazepam (14 studies), temazepam (13), midazolam (5), nitrazepam (4), estazolam (2), and 1 each used lorazepam, brotizolam, quazepam, loprazolam, and flunitrazepam. Nonbenzodiazepines studied included zopiclone, diphenhydramine, glutethimide, and promethazine.
STUDY DESIGN AND VALIDITY: This was a meta-analysis that combined data from the 45 studies that met the inclusion criteria. The quality of the individual reports was assessed on a scale from 0 to 5 on the basis of the quality of randomization, blinding, follow-up, and control for baseline differences in the groups. Interrater reliability was assessed and overall agreement was 98%. The meta-analysis of end points was appropriately limited to those presented in a comparable way. Tests for homogeneity were applied, and if study results were heterogeneous, the studies were subdivided into predetermined groups. This was a well-executed meta-analysis.
OUTCOMES MEASURED: The primary outcomes reported were sleep latency, sleep duration, and patient reports of adverse effects.
RESULTS: The pooled mean difference in sleep latency between benzodiazepines and placebo was 4.2 minutes (95% confidence interval [CI], -0.7 to 9.2 minutes). These data were taken from 4 studies of 159 patients. Two studies of 35 patients measured total sleep duration and were combined; patients in the benzodiazepine group slept 61.8 minutes (95% CI, 37.4-86.2) longer than those given placebo. Patient estimates of sleep latency were measured in 8 studies of 539 patients. Benzodiazepines were superior to placebo, with a perceived reduction in sleep latency of 14.3 minutes (95% CI, 10.6-18.0). Seven studies involving 821 patients evaluated patient reporting of adverse drug effects. The authors found that patients randomized to the benzodiazepine group were more likely than those taking placebo to report adverse drug effects (odds ratio=1.8; 95% CI, 1.4-2.4). The absolute rates of any adverse event during a week of treatment were 59% for patients taking benzodiazepines and 44% for those taking placebo (number needed to harm=6.8). Zopiclone was compared with a benzodiazepine in 3 studies of 96 patients. There was no difference between these drugs in sleep latency or total sleep duration, but there was no comparison with placebo. Only one study followed patients for more than 2 weeks.
This meta-analysis shows that benzodiazepines help patients sleep longer, but it also shows that adverse drug effects are more likely than with placebo. The short duration of most of the studies, usually 2 weeks or less, limits the usefulness of these data because treatment of insomnia is often needed for much longer periods. Benzodiazepines are reasonable for short-term use while further research is done to clarify the most efficacious treatment for insomnia. The authors point out many areas where further research is needed, especially in the area of nonpharmacologic therapy.
BACKGROUND: insomnia is a common problem encountered by family physicians. Benzodiazepines have been the treatment of choice despite questions about their efficacy and their potential to cause adverse effects, such as confusion, falls, and memory loss. The authors of this systematic review summarize the literature on the efficacy and common adverse effects of bezodiazepines compared with both placebo and other treatments for insomnia.
POPULATION STUDIED: Using MEDLINE and the Cochrane Controlled Trials Register, the authors identified randomized controlled trials of benzodiazepines compared with placebo or other active drugs for treatment of insomnia. Only studies in English were included in the evaluation. The manufacturers of the medications were contacted for any studies that may not have been published. The 45 studies included in the meta-analysis represented 2672 patients, 47% of whom were women. The mean age of the patients studied ranged from 29 to 82 years. The duration of the studies ranged from 1 day to 6 weeks with a mean of 12.2 days and median of 7.5 days. The drugs studied included flurazepam (14 studies), temazepam (13), midazolam (5), nitrazepam (4), estazolam (2), and 1 each used lorazepam, brotizolam, quazepam, loprazolam, and flunitrazepam. Nonbenzodiazepines studied included zopiclone, diphenhydramine, glutethimide, and promethazine.
STUDY DESIGN AND VALIDITY: This was a meta-analysis that combined data from the 45 studies that met the inclusion criteria. The quality of the individual reports was assessed on a scale from 0 to 5 on the basis of the quality of randomization, blinding, follow-up, and control for baseline differences in the groups. Interrater reliability was assessed and overall agreement was 98%. The meta-analysis of end points was appropriately limited to those presented in a comparable way. Tests for homogeneity were applied, and if study results were heterogeneous, the studies were subdivided into predetermined groups. This was a well-executed meta-analysis.
OUTCOMES MEASURED: The primary outcomes reported were sleep latency, sleep duration, and patient reports of adverse effects.
RESULTS: The pooled mean difference in sleep latency between benzodiazepines and placebo was 4.2 minutes (95% confidence interval [CI], -0.7 to 9.2 minutes). These data were taken from 4 studies of 159 patients. Two studies of 35 patients measured total sleep duration and were combined; patients in the benzodiazepine group slept 61.8 minutes (95% CI, 37.4-86.2) longer than those given placebo. Patient estimates of sleep latency were measured in 8 studies of 539 patients. Benzodiazepines were superior to placebo, with a perceived reduction in sleep latency of 14.3 minutes (95% CI, 10.6-18.0). Seven studies involving 821 patients evaluated patient reporting of adverse drug effects. The authors found that patients randomized to the benzodiazepine group were more likely than those taking placebo to report adverse drug effects (odds ratio=1.8; 95% CI, 1.4-2.4). The absolute rates of any adverse event during a week of treatment were 59% for patients taking benzodiazepines and 44% for those taking placebo (number needed to harm=6.8). Zopiclone was compared with a benzodiazepine in 3 studies of 96 patients. There was no difference between these drugs in sleep latency or total sleep duration, but there was no comparison with placebo. Only one study followed patients for more than 2 weeks.
This meta-analysis shows that benzodiazepines help patients sleep longer, but it also shows that adverse drug effects are more likely than with placebo. The short duration of most of the studies, usually 2 weeks or less, limits the usefulness of these data because treatment of insomnia is often needed for much longer periods. Benzodiazepines are reasonable for short-term use while further research is done to clarify the most efficacious treatment for insomnia. The authors point out many areas where further research is needed, especially in the area of nonpharmacologic therapy.
BACKGROUND: insomnia is a common problem encountered by family physicians. Benzodiazepines have been the treatment of choice despite questions about their efficacy and their potential to cause adverse effects, such as confusion, falls, and memory loss. The authors of this systematic review summarize the literature on the efficacy and common adverse effects of bezodiazepines compared with both placebo and other treatments for insomnia.
POPULATION STUDIED: Using MEDLINE and the Cochrane Controlled Trials Register, the authors identified randomized controlled trials of benzodiazepines compared with placebo or other active drugs for treatment of insomnia. Only studies in English were included in the evaluation. The manufacturers of the medications were contacted for any studies that may not have been published. The 45 studies included in the meta-analysis represented 2672 patients, 47% of whom were women. The mean age of the patients studied ranged from 29 to 82 years. The duration of the studies ranged from 1 day to 6 weeks with a mean of 12.2 days and median of 7.5 days. The drugs studied included flurazepam (14 studies), temazepam (13), midazolam (5), nitrazepam (4), estazolam (2), and 1 each used lorazepam, brotizolam, quazepam, loprazolam, and flunitrazepam. Nonbenzodiazepines studied included zopiclone, diphenhydramine, glutethimide, and promethazine.
STUDY DESIGN AND VALIDITY: This was a meta-analysis that combined data from the 45 studies that met the inclusion criteria. The quality of the individual reports was assessed on a scale from 0 to 5 on the basis of the quality of randomization, blinding, follow-up, and control for baseline differences in the groups. Interrater reliability was assessed and overall agreement was 98%. The meta-analysis of end points was appropriately limited to those presented in a comparable way. Tests for homogeneity were applied, and if study results were heterogeneous, the studies were subdivided into predetermined groups. This was a well-executed meta-analysis.
OUTCOMES MEASURED: The primary outcomes reported were sleep latency, sleep duration, and patient reports of adverse effects.
RESULTS: The pooled mean difference in sleep latency between benzodiazepines and placebo was 4.2 minutes (95% confidence interval [CI], -0.7 to 9.2 minutes). These data were taken from 4 studies of 159 patients. Two studies of 35 patients measured total sleep duration and were combined; patients in the benzodiazepine group slept 61.8 minutes (95% CI, 37.4-86.2) longer than those given placebo. Patient estimates of sleep latency were measured in 8 studies of 539 patients. Benzodiazepines were superior to placebo, with a perceived reduction in sleep latency of 14.3 minutes (95% CI, 10.6-18.0). Seven studies involving 821 patients evaluated patient reporting of adverse drug effects. The authors found that patients randomized to the benzodiazepine group were more likely than those taking placebo to report adverse drug effects (odds ratio=1.8; 95% CI, 1.4-2.4). The absolute rates of any adverse event during a week of treatment were 59% for patients taking benzodiazepines and 44% for those taking placebo (number needed to harm=6.8). Zopiclone was compared with a benzodiazepine in 3 studies of 96 patients. There was no difference between these drugs in sleep latency or total sleep duration, but there was no comparison with placebo. Only one study followed patients for more than 2 weeks.
This meta-analysis shows that benzodiazepines help patients sleep longer, but it also shows that adverse drug effects are more likely than with placebo. The short duration of most of the studies, usually 2 weeks or less, limits the usefulness of these data because treatment of insomnia is often needed for much longer periods. Benzodiazepines are reasonable for short-term use while further research is done to clarify the most efficacious treatment for insomnia. The authors point out many areas where further research is needed, especially in the area of nonpharmacologic therapy.