Prevalence of self-reported symptoms of sexually transmitted infections, knowledge and sexual behaviour among youth in semi-rural Tanzania in the period of adolescent friendly health services strategy implementation.

BACKGROUND: Global evidence shows that sexually transmitted infections (STIs) prevalence and sexual risk behaviours are high among youth, and knowledge about STIs is low. In Tanzania, there is limited recent evidence regarding these issues. The aim of this study was to describe the health seeking behaviour of youth reporting STI symptoms in semi-rural Tanzania and to evaluate the association of socio-demographic characteristics, STI knowledge and sexual risk behaviour with STI symptom reporting. METHODS: This was a cross-sectional study involving 2251 sexually experienced youth (15-24 years), who participated in a larger baseline survey of a cohort within Ifakara town. Interview data were electronically collected by trained field workers. Logistic regression analysis was used to identify factors that influence the risk of reporting STI symptoms within the past year, using Stata 12.1. RESULTS: The prevalence of self-reported STI symptoms in the past year was 19.9%. Almost all of youth had heard of STIs and 32.7% of youth could mention at least one sign. 34.4% had sought care for their STI symptoms, the majority at private facilities. Only 20% of HIV-STI co-infected youth was aware of their HIV status. Youth with more knowledge of STI symptoms reported to have had symptoms more often (OR = 1.28; 95% CI 1.01-1.62), and those reporting having first sex at 16 or under were more likely to report STI symptoms than those who delayed to 17-19 years (OR 1.27; 95% CI 1.003-1.62). CONCLUSION: These findings highlight the need to improve the implementation of Adolescent Friendly Health Services available in Tanzania (especially in semi-rural areas). The inclusion of private facilities and pharmacies in AFHS scale-up would potentially raise the level of STI knowledge, lower the STI prevalence and reduce HIV incidence among youth.

Socio-demographic inequalities in HIV testing behaviour and HIV prevalence among older adults in rural Tanzania, 2013.

Most HIV research in Sub-Saharan Africa (SSA) ignores persons aged 50 years and above, though a few studies have reported a high HIV prevalence among older people. This study aimed to estimate socio-demographic inequalities in HIV testing behaviour and HIV prevalence among adults aged 50+ years, living in Ifakara town, Tanzania. This cross-sectional study used data from the baseline measurement of the Ifakara MZIMA cohort study in 2012/13. Consenting participants were interviewed and tested for HIV. Associations between HIV testing behaviour and HIV prevalence with socio-demographic indicators were explored with multivariable logistic regression. Among the 1643 adults 50+ years included in the study, HIV prevalence and the HIV testing rate (ever tested) were 6% and 11.4% respectively. The HIV testing rate was lower for older people (aOR = 0.19 (95% CI 0.09-0.41 for 75+ versus 50-54 years); higher for those separated/divorced/widowed than those married (aOR = 1.46; 1.02-2.10); higher for "other Christians" than Muslims (aOR = 1.95; 1.06-3.58); and higher for primary (aOR = 1.54; 1.01-2.33) and secondary (aOR = 3.47; 2.11-5.70) school graduates than those without education. HIV prevalence was lower for older people (aOR = 0.27; 0.11-0.66 for 75+ versus 50-54); and for Catholics compared to Muslims (aOR = 0.54; 0.34-0.85). The high HIV prevalence among older adults and the low HIV testing behaviour call for more efforts on HIV prevention, treatment and care.

Quality of primary care for resettled refugees in the Netherlands with chronic mental and physical health problems: a cross-sectional analysis of medical records and interview data.

BACKGROUND: A high prevalence of mental and physical ill health among refugees resettled in the Netherlands has been reported. With this study we aim to assess the quality of primary healthcare for resettled refugees in the Netherlands with chronic mental and non-communicable health problems, we examined: a) general practitioners' (GP) recognition of common mental disorders (CMD) (depression and anxiety, and post-traumatic stress disorder (PTSD) symptoms); b) patients' awareness of diabetes type II (DMII) and hypertension (HT); and c) GPs' adherence to guidelines for CMD, DMII and HT. METHODS: From 172 refugees resettled in the Netherlands, interview data (2010-2011) and medical records (n = 106), were examined. Inclusion was based on medical record diagnoses for DMII and HT, and on questionnaire-based CMD measures (Hopkins Symptom Checklist for depression and anxiety; Harvard Trauma Questionnaire for PTSD). GP recognition of CMD was calculated as the number of CMD cases registered in the medical record compared with those found in interviews. Patient awareness of HT and DMII was scored as the percentage of subjects diagnosed by the GP who reported their condition during the interview. GPs' adherence to guidelines for CMD, DMII and HT was measured using established indicators. RESULTS: We identified 37 resettled refugees with CMD of which 18 (49%) had been recognised by the GP. We identified 16 refugees with DMII and 14 with HT from the medical record; 24 (80%) were aware of their condition. Thirty-five out of these 53 (66%) resettled refugees with chronic mental and non-communicable disorders received guideline-adherent treatment. CONCLUSION: This study shows that awareness in resettled refugees of GP diagnosed DMII and HT is high, whereas GP recognition of CMD and overall guideline adherence are moderate.

Course of post-traumatic stress disorder and health care utilisation among resettled refugees in the Netherlands.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a major health problem among refugees worldwide. After resettlement, the prevalence of PTSD remains high despite the fact that various PTSD treatments are known to be effective. METHODS: We examined the course of PTSD and the role of mental health care utilisation at a 7-year interval (2003-2010) among a cohort of refugees from Iran, Afghanistan, and Somalia after resettlement in the Netherlands. RESULTS: The unchanged high prevalence of PTSD (16.3% in 2003 and 15.2% in 2010) was attributable in part to late onset of PTSD symptoms (half of the respondents with PTSD at T2 were new cases for whom PTSD developed after 2003). The second reason concerned the low use of mental health care services at T1. Whereas the multivariate analyses showed the effectiveness of mental health care, only 21% of respondents with PTSD at T1 had had contact with a mental health care provider at that time. Use of mental health care during the first wave increased the odds of improvement in PTSD symptoms between both measurements (OR 7.58, 95% CI 1.01; 56.85). CONCLUSIONS: The findings of this study suggest there are two possible explanations for the persistently high prevalence of PTSD among refugees. One is the late onset of PTSD and the other is the low utilisation of mental health care. Health care professionals should be aware of these issues, especially given the effectiveness of mental health care for this condition.

Ubiquitous burden: the contribution of migration to AIDS and Tuberculosis mortality in rural South Africa.

The paper aims to estimate the extent to which migrants are contributing to AIDS or tuberculosis (TB) mortality among rural sub-district populations. The Agincourt (South Africa) health and socio-demographic surveillance system provided comprehensive data on vital and migration events between 1994 and 2006. AIDS and TB cause-deleted life expectancy, and crude death rates by gender, migration status and period were computed. The annualised crude death rate almost tripled from 5·39 [95% CI 5·13-5·65] to 15·10 [95% CI 14·62-15·59] per 1000 over the years 1994-2006. The contribution of AIDS and TB in returned migrants to the increase in crude death rate was 78·7% [95% CI 77·4-80·1] for males and 44·4% [95% CI 43·2-46·1] for females. So, in a typical South African setting dependent on labour migration for rural livelihoods, the contribution of returned migrants, many infected with AIDS and TB, to the burden of disease is high.

Challenges with using estimates when calculating ART need among adults in South Africa.

BACKGROUND: The Foundation for Professional Development (FPD) collects information annually on HIV/AIDS service provision and estimates service needs in the City of Tshwane Metropolitan Municipality (CTMM). METHODS: Antiretroviral therapy (ART) data from the Department of Health and Statistics South Africa (SSA) mid-year population estimates were used to approximate the ART need among adults in the CTMM. RESULTS: According to SSA data, ART need decreased dramatically from 2010 to 2011 and was lower than the number of adults receiving ART. Although the noted difference was probably due to changes in the calculations by SSA, no detailed or confirmed explanation could be offered. CONCLUSIONS: We provide a constructive contribution to the discussion about the use of model-derived estimates of ART need.

Provision and need of HIV/AIDS services in the City of Tshwane Metropolitan Municipality, 2010.

OBJECTIVES: To determine the need for HIV/AIDS service provision in the City of Tshwane Metropolitan Municipality (CTMM), especially in municipal areas. METHODS: The Foundation for Professional Development initiated the Compass Project. Using a questionnaire, data were collected during May - June 2010 from organisations providing HIV/AIDS services in the CTMM (organisational information and types of HIV/AIDS services). The need for HIV counselling and testing (HCT), antiretroviral treatment (ART), prevention of mother-to-child transmission (PMTCT), and care for orphans and vulnerable children (OVC) was estimated using data from various sources. RESULTS: A total of 447 service providers was included in the study: 72.3% non-governmental organisations (NGOs); 18.1% in the public sector; 5.1% in the private sector; and 4.5% faith-based organisations. The majority of the prevention- (70.2%) and support-related services (77.4%) were provided by NGOs, while the majority of treatment-related services originated from the public sector (57.3%). Service need estimates included: HCT - 1 435 438 adults aged 15 - 49 years (11 127/service provider); total ART - 75 211 adults aged 15+ years (1 213/service provider); ART initiation - 30 713 adults aged 15+ years (495/service provider); PMTCT-HCT - 30 092 pregnant women (510/service provider); PMTCT-ART - 7 734 HIV+ pregnant women (221/service provider); and OVC care - 54 590 children (258/service provider). CONCLUSIONS: Service gaps remain in the provision of HCT, PMTCT-ART and OVC care. ART provision must be increased, in light of new treatment guidelines from the Department of Health.

Gender differences in health and health care utilisation in various ethnic groups in the Netherlands: a cross-sectional study.

BACKGROUND: To determine gender differences in health and health care utilisation within and between various ethnic groups in the Netherlands. METHODS: Data from the second Dutch National Survey of General Practice (2000-2002) were used. A total of 7,789 persons from the indigenous population and 1,512 persons from the four largest migrant groups in the Netherlands -- Morocco, Netherlands Antilles, Turkey and Surinam -- aged 18 years and older were interviewed. Self-reported health outcomes studied were general health status and the presence of acute (past 14 days) and chronic conditions (past 12 months). And self-reported utilisation of the following health care services was analysed: having contacted a general practitioner (past 2 months), a medical specialist, physiotherapist or ambulatory mental health service (past 12 months), hospitalisation (past 12 months) and use of medication (past 14 days). Gender differences in these outcomes were examined within and between the ethnic groups, using logistic regression analyses. RESULTS: In general, women showed poorer health than men; the largest differences were found for the Turkish respondents, followed by Moroccans, and Surinamese. Furthermore, women from Morocco and the Netherlands Antilles more often contacted a general practitioner than men from these countries. Women from Turkey were more hospitalised than Turkish men. Women from Morocco more often contacted ambulatory mental health care than men from this country, and women with an indigenous background more often used over the counter medication than men with an indigenous background. CONCLUSION: In general the self-reported health of women is worse compared to that of men, although the size of the gender differences may vary according to the particular health outcome and among the ethnic groups. This information might be helpful to develop policy to improve the health status of specific groups according to gender and ethnicity. In addition, in some ethnic groups, and for some types of health care services, the use by women is higher compared to that by men. More research is needed to explain these differences.

Malaria incidence in Limpopo Province, South Africa, 1998-2007.

BACKGROUND: Malaria is endemic in the low-altitude areas of the northern and eastern parts of South Africa with seasonal transmission. The aim of this descriptive study is to give an overview of the malaria incidence and mortality in Limpopo Province for the seasons 1998-1999 to 2006-2007 and to detect trends over time and place. METHODS: Routinely collected data on diagnosed malaria cases and deaths were available through the provincial malaria information system. In order to calculate incidence rates, population estimates (by sex, age and district) were obtained from Statistics South Africa. The Chi squared test for trend was used to detect temporal trends in malaria incidence over the seasons, and a trend in case fatality rate (CFR) by age group. The Chi squared test was used to calculate differences in incidence rate and CFR between both sexes and in incidence by age group. RESULTS: In total, 58,768 cases of malaria were reported, including 628 deaths. The mean incidence rate was 124.5 per 100,000 person-years and the mean CFR 1.1% per season. There was a decreasing trend in the incidence rate over time (p < 0.001), from 173.0 in 1998-1999 to 50.9 in 2006-2007. The CFR was fairly stable over the whole period. The mean incidence rate in males was higher than in females (145.8 versus 105.6; p < 0.001); the CFR (1.1%) was similar for both sexes. The incidence rate was lowest in 0-4 year olds (78.3), it peaked at the ages of 35-39 years (172.8), and decreased with age from 40 years (to 84.4 for those > or = 60 years). The CFR increased with increasing age (to 3.8% for those > or = 60 years). The incidence rate varied widely between districts; it was highest in Vhembe (328.2) and lowest in Sekhukhune (5.5). CONCLUSION: Information from this study may serve as baseline data to determine the course and distribution of malaria in Limpopo province over time. In the study period there was a decreasing trend in the incidence rate. Furthermore, the study addresses the need for better data over a range of epidemic-prone settings.

Assessing the introduction of universal human papillomavirus vaccination for preadolescent girls in The Netherlands.

A persistent infection with human papillomavirus (HPV) is a prerequisite for the development of cervical cancer. Clinical trials with HPV-vaccines have been very successful in preventing persistent HPV16/18 infections, the two most oncogenic HPV-genotypes. We assessed the introduction of universal HPV-vaccination for preadolescent girls in the Dutch National Immunization Programme. Long-term vaccine efficacy, the need and extent of a catch-up programme for young women, and the impact of vaccination on the cervical cancer screening programme are major unresolved issues. Preliminary conservative estimates (80% vaccine efficacy and no effects on the screening programme, transmission rate, non-cervical cancer incidence, and cross protection) predict an acceptable cost-effectiveness ratio for universal vaccination of preadolescent girls.

Surgery is more cost-effective than splinting for carpal tunnel syndrome in the Netherlands: results of an economic evaluation alongside a randomized controlled trial.

BACKGROUND: Carpal tunnel syndrome (CTS) is a common disorder, often treated with surgery or wrist splinting. The objective of this economic evaluation alongside a randomized trial was to evaluate the cost-effectiveness of splinting and surgery for patients with CTS. METHODS: Patients at 13 neurological outpatient clinics with clinically and electrophysiologically confirmed idiopathic CTS were randomly allocated to splinting (n = 89) or surgery (n = 87). Clinical outcome measures included number of nights waking up due to symptoms, general improvement, severity of the main complaint, paraesthesia at night and during the day, and utility. The economic evaluation was performed from a societal perspective and involved all relevant costs. RESULTS: There were no differences in costs. The mean total costs per patient were in the surgery group EURO 2,126 compared to EURO 2,111 in the splint group. After 12 months, the success rate in the surgery group (92%) was significantly higher than in the splint group (72%). The acceptability curve showed that at a relatively low ceiling ratio of EURO 2,500 per patient there is a 90% probability that surgery is cost-effective. CONCLUSION: In the Netherlands, surgery is more cost-effective compared with splinting, and recommended as the preferred method of treatment for patients with CTS.

Use of health care services by Afghan, Iranian, and Somali refugees and asylum seekers living in The Netherlands.

BACKGROUND: Although asylum seekers have been coming to The Netherlands since the 1980s, very few epidemiological studies have focused on this group of inhabitants, or on the refugees who have resettled in this country. The objective of this study is to estimate the use of health care services by refugees and asylum seekers and to identify determinants for this utilisation. METHODS: A population-based study was conducted in The Netherlands from June 2003 to April 2004 among adult refugees and asylum seekers from Afghanistan, Iran, and Somalia. A total of 178 refugees and 232 asylum seekers, living in 3 municipalities and 14 reception centres, participated. RESULTS: This study showed that there are no differences between refugees and asylum seekers in the self-reported use of health care services. Respondents from Somalia reported less contacts with a general practitioner, less use of mental health services, and less medication use than respondents from Afghanistan and Iran. Both female gender and older age were related to more contacts with a general practitioner and a medical specialist, and with higher medication use. Poor general health was related to more contacts with a medical specialist and mental health services, and with higher medication use. CONCLUSION: Asylum seekers and refugees seem to have equal access to the Dutch health care system in general. However, there are differences in the self-reported use of health care services by the different ethnic groups.

Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands.

CONTEXT: Worldwide, the number of refugees and asylum seekers is estimated to be about 11.5 million plus a much larger number of former refugees who have obtained a residence permit in a new country. Although asylum seekers have been coming to the Netherlands since the 1980s, very few epidemiological studies have focused on this group of inhabitants or on the refugees who have resettled in this country. OBJECTIVES: The objectives of this study were to estimate the prevalence rates of physical and mental health problems and to identify the risk factors for these complaints. DESIGN, SETTING, AND PARTICIPANTS: A population-based study was conducted in the Netherlands from June 2003 to April 2004 among adult refugees and asylum seekers from Afghanistan, Iran and Somalia. Asylum seekers were living in 14 randomly selected reception centres, and random samples of refugees were obtained from the population registers of three municipalities (Arnhem, Leiden and Zaanstad). A total of 178 refugees and 232 asylum seekers participated (response rates of 59 and 89%, respectively). MAIN OUTCOME MEASURES: General health and physical health were measured with the Short-Form 36 and a list of 19 chronic conditions, respectively; symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, were measured with the Harvard Trauma Questionnaire and the Hopkins Symptoms Checklist-25. RESULTS: More asylum seekers (59.1%) than refugees (42.0%) considered their health to be poor (P=0.001). In both groups, approximately half of the respondents suffered from more than one chronic condition. More asylum seekers than refugees had symptoms of PTSD (28.1 and 10.6%, respectively; P=0.000) and depression/anxiety (68.1 and 39.4, respectively; P=0.000). Respondents from Afghanistan and, in particular, from Iran had a higher risk for PTSD and depression/anxiety. Female gender was associated with chronic conditions, PTSD and depression/anxiety, and higher age was associated with poor general health and chronic conditions. A greater number of traumatic events was associated with all health outcomes, and more post-migration stress and less social support were associated with PTSD and depression/anxiety symptoms. CONCLUSIONS: Both physical and mental health problems are highly prevalent among refugees and asylum seekers in the Netherlands. Although higher prevalence rates for most health outcomes were found among asylum seekers, both the specific health services for asylum seekers and the general health services in the municipalities should be aware of these problems.

Correlating nerve conduction studies and clinical outcome measures on carpal tunnel syndrome: lessons from a randomized controlled trial.

The reported relationships between nerve conduction studies (NCS) and outcome measures in carpal tunnel syndrome (CTS) are weak to moderate. However, selection of patients may have confounded nonrandomized studies. NCS have potentially great value in selecting patients for a specific treatment and in objectively assessing the efficacy of treatments in CTS, especially if they correlate significantly with clinical outcome measures. To investigate the relationship between clinical outcome measures for the severity of complaints and NCS in patients treated for CTS, data were obtained from a multicenter randomized controlled trial on the efficacy of splinting versus surgery for CTS. At baseline and 12 months after randomization, clinical outcome measures were assessed and NCS were performed. In total, 138 patients completed the questionnaires and underwent repeated NCS. Relationships were analyzed with Spearman rank correlation coefficients and Pearson correlation coefficients. All NCS parameters showed highly significant improvement compared with baseline (P < 0.001). Modest correlations (< 0.4) were found between the neurophysiologic and clinical outcome measures after 12 months, and between the changes in these different categories of outcome measures. This study confirms that the parameters of NCS improve significantly after treatment for CTS, but the modest correlations between neurophysiologic and clinical outcome measures do not support that NCS are routinely performed in clinical practice to evaluate treatment effects. However, studies investigating the effects of treatment for CTS should incorporate both clinical outcome measures and NCS, because they are complementary. Furthermore, NCS can provide additional information to the clinician when treatment effects are unsatisfactory.

Health and health care utilisation among asylum seekers and refugees in the Netherlands: design of a study.

BACKGROUND: This article discusses the design of a study on the prevalence of health problems (both physical and mental) and the utilisation of health care services among asylum seekers and refugees in the Netherlands, including factors that may be related to their health and their utilisation of these services. METHODS/DESIGN: The study will include random samples of adult asylum seekers and refugees from Afghanistan, Iran and Somali (total planned sample of 600), as these are among the largest groups within the reception centres and municipalities in the Netherlands. The questionnaire that will be used will include questions on physical health (chronic and acute diseases and somatization), mental health (Hopkins Symptoms Checklist-25 and Harvard Trauma Questionnaire), utilisation of health care services, pre- and post-migratory traumatic experiences, life-style, acculturation, social support and socio-demographic background. The questionnaire has gone through a translation process (translation and back-translation, several checks and a pilot-study) and cross-cultural adaptation. Respondents will be interviewed by bilingual and bicultural interviewers who will be specifically trained for this purpose. This article discusses the selection of the study population, the chosen outcome measures, the translation and cross-cultural adaptation of the measurement instrument, the training of the interviewers and the practical execution of the study. The information provided may be useful for other researchers in this relatively new field of epidemiological research among various groups of asylum seekers and refugees.

Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomized controlled trial.

CONTEXT: Carpal tunnel syndrome (CTS) can be treated with nonsurgical or surgical options. However, there is no consensus on the most effective method of treatment. OBJECTIVE: To compare the short-term and long-term efficacy of splinting and surgery for relieving the symptoms of CTS. DESIGN, SETTING, AND PATIENTS: A randomized controlled trial conducted from October 1998 to April 2000 at 13 neurological outpatient clinics in the Netherlands. A total of 176 patients with clinically and electrophysiologically confirmed idiopathic CTS were assigned to wrist splinting during the night for at least 6 weeks (89 patients) or open carpal tunnel release (87 patients); 147 patients (84%) completed the final follow-up assessment 18 months after randomization. MAIN OUTCOME MEASURES: General improvement, number of nights waking up due to symptoms, and severity of symptoms. RESULTS: In the intention-to-treat analyses, surgery was more effective than splinting on all outcome measures. The success rates (based on general improvement) after 3 months were 80% for the surgery group (62/78 patients) vs 54% for the splinting group (46/86 patients), which is a difference of 26% (95% confidence interval [CI], 12%-40%; P<.001). After 18 months, the success rates increased to 90% for the surgery group (61/68 patients) vs 75% for the splinting group (59/79 patients), which is a difference of 15% (95% CI, 3%-27%; P =.02). However, by that time 41% of patients (32/79) in the splint group had also received the surgery treatment. CONCLUSION: Treatment with open carpal tunnel release surgery resulted in better outcomes than treatment with wrist splinting for patients with CTS.

Enabling meta-analysis in systematic reviews on carpal tunnel syndrome.

Possible solutions to the problems of clinical heterogeneity of outcome measures and inadequate reporting of results for randomized controlled trials (RCTs) on carpal tunnel syndrome (CTS) are presented. Meta-analysis was impeded by these problems in 2 systematic reviews concerning conservative and surgical treatment options for CTS. A solution to the problem of inadequate data presentation is to add explicit information on minimal requirements with regard to data presentation to guidelines for the reporting of studies. To resolve the problem of clinical heterogeneity of the outcomes there should be consensus on the (validated) outcomes that should be used in RCTs. For CTS there is little evidence available on the reliability, validity, and responsiveness to change of the commonly used outcomes in RCTs. Resolving both problems will increase the comparability of RCTs, enabling the calculation of a pooled estimate of effect in a meta-analysis.

Conservative treatment options for carpal tunnel syndrome: a systematic review of randomised controlled trials.

Carpal tunnel syndrome (CTS) is a common disorder, for which various conservative treatment options are available. The objective of this study is to determine the efficacy of the various conservative treatment options for relieving the symptoms of CTS. Computer-aided searches of MEDLINE (1/1966 to 3/2000), EMBASE (1/1988 to 2/2000) and the Cochrane Controlled Trials Register (2000, issue 1) were conducted, together with reference checking. Included were randomised controlled trials evaluating the efficacy of conservative treatment options in a study population of CTS patients, with a full report published in English, German, French or Dutch. Two reviewers independently selected the studies. Fourteen randomised controlled trials were included in the review. Assessment of methodological quality and data-extraction was independently performed by two reviewers. A rating system, based on the number of studies and their methodological quality and findings, was used to determine the strength of the available evidence for the efficacy of the treatment. Diuretics, pyridoxine, non-steroidal anti-inflammatory drugs, yoga and laser-acupuncture seem to be ineffective in providing short-term symptom relief (varying levels of evidence) and steroid injections seem to be effective (limited evidence). There is conflicting evidence for the efficacy of ultrasound and oral steroids. For providing long-term relief from symptoms there is limited evidence that ultrasound is effective, and that splinting is less effective than surgery. In conclusion, there is still little known about the efficacy of most conservative treatment options for CTS. To establish stronger evidence more high quality trials are needed.