Clinical Commander

Back to dossier
neuro.bell-palsy.v1PRODUCTION
neuro.bell-palsy.v1

Bell Palsy (idiopathic peripheral facial palsy)

neurologyacutesubacuteadultpediatricpregnancy
Hard-required inputs
0 / 12
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute unilateral peripheral facial palsy (forehead involved) reaching maximum severity within 72 h — idiopathic Bell palsy until proven otherwise; rule out central VII, Ramsay Hunt, Lyme, bilateral causes (AAN 2012 Gronseth PMID 26832596)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Acute peripheral VII palsy confirmed

Patient inputs (18)

Lyme endemic area + tick exposure / erythema migrans → test Lyme serology, treat with doxycycline (AAN 2012; CDC PMID 28169892)

Incidence peaks 15-45 y; pediatric Bell palsy often Lyme-related in endemic areas; pregnancy 3x risk (esp third trimester / immediate postpartum)

Recurrent → sarcoid / neurinoma / Melkersson-Rosenthal; consider MRI (AAN 2012)

Pregnancy 3x risk; third trimester + immediate postpartum highest; corticosteroid prudent benefit-risk discussion; eclampsia screening

DM associated with higher recurrence + worse recovery; HIV seroconversion + sarcoid + leukemia + lymphoma considerations for bilateral or recurrent

External ear / palate vesicles + severe otalgia = Ramsay Hunt syndrome (VZV) — adjunct valacyclovir + steroid mandatory + worse prognosis (Furuta 2020 PMID 33176069)

Acute onset typically <72 h; Bell palsy reaches maximum severity within 3 d; slowly progressive over weeks-months suggests tumor / mass lesion

Steroid will elevate glucose; check DM screening + baseline before initiation

Forehead INVOLVED = peripheral CN VII (Bell pattern); forehead SPARED = central seventh = stroke route (AAN 2012 Gronseth PMID 26832596)

Bilateral = REDFLAG — Lyme, sarcoid, GBS, HIV, syphilis, leukemia, Melkersson-Rosenthal; workup beyond Bell palsy (AAN 2012 Gronseth PMID 26832596)

Exposure keratopathy red flag — urgent ophthalmology if severe pain, vision change, corneal ulcer (Cochrane PMID 27488817)

House-Brackmann grade I-VI baseline (Brackmann 1985 PMID 16877655) — drives antiviral decision (≥IV = severe palsy benefits from antiviral adjunct; AAN 2012)

Otitis / mastoiditis / cholesteatoma can cause facial palsy via direct extension — ENT consult

In endemic areas — Borrelia ELISA + Western blot for bilateral, recurrent, or pediatric Bell palsy (AAN 2012 Class B; CDC PMID 28169892)

Bilateral simultaneous facial palsy — HIV seroconversion clue

Required if atypical (slowly progressive >3 wk, recurrent, mass on exam, hearing loss, vertigo) or no improvement at 3 mo — rule out facial schwannoma, vestibular schwannoma, cholesteatoma, central pontine lesion (AAN 2012)

Iatrogenic facial nerve injury — sialography or imaging; nerve transposition consideration

Ascending weakness or hyporeflexia → GBS / Miller Fisher (bilateral facial diplegia variant); LP + EMG/NCS

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationallife_threateningcentral_VII_forehead_sparing
    Central VII palsy — forehead SPARING (frontalis preserved bilaterally due to bilateral cortical input); lower facial weakness from cortical / brainstem / corona radiata stroke (AHA/ASA 2021 BE-FAST)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningforehead_sparing_route_to_stroke_quantified
    Forehead-sparing-or-other-deficit STROKE route (quantified pivot): forehead-involved entire-hemiface weakness → peripheral Bell (LR+ ≈ 13.9, LR- ≈ 0.03 from sens 0.97/spec 0.93; see neuro.bell-palsy.v1.finding-lrs.ts row 1). Forehead-SPARING (frontalis preserved by bilateral cortical input) → central VII / ischaemic stroke (LR+ ≈ 13.6 from sens 0.95/spec 0.93), and any CONCOMITANT limb/speech/sensory deficit → stroke LR+ 18 — these two are conditionally dependent (combine as a single "central pattern" gate, do NOT multiply; see conditional-dependency note #A). Action: do NOT treat as Bell, do NOT give prednisone, activate stroke pathway and route to neuro.ischaemic-stroke.v1 (time-critical thrombolysis/EVT window).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereramsay_hunt_syndrome
    Ramsay Hunt syndrome (herpes zoster oticus) — facial palsy + vesicles in ear canal / concha / palate + severe otalgia ± vertigo ± sensorineural hearing loss; worse prognosis than Bell (Furuta 2020 PMID 33176069)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_simultaneous_facial_palsy
    Bilateral simultaneous facial palsy — REDFLAG, workup Lyme / sarcoid / GBS-Miller Fisher / HIV seroconversion / syphilis / leukemia / lymphoma / Melkersson-Rosenthal (AAN 2012 Gronseth PMID 26832596)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereiatrogenic_post_parotid_surgery
    Iatrogenic facial nerve injury after parotid surgery / temporal bone surgery / cosmetic surgery — direct nerve injury; nerve transposition consideration
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebilateral_palsy_route_to_gbs_quantified
    Bilateral-simultaneous palsy GBS/Miller-Fisher route (quantified prior-shift): bilateral simultaneous facial palsy REWEIGHTS the whole differential away from idiopathic Bell (bilateral → against-Bell LR+ 0.05; conditional-dependency note #B — reset priors, do NOT multiply the shared observation). Bilateral + generalized areflexia → GBS/Miller-Fisher LR+ 15 (LR- 0.30); bilateral → Lyme LR+ 12; bilateral + uveoparotid → sarcoid LR+ 10. Action: if bilateral + areflexia/ataxia/ascending weakness → LP (albuminocytologic dissociation) + NCS + anti-GQ1b, route to neuro.gbs.core.v1 / neuro.gbs-miller-fisher.v1; else workup Lyme/sarcoid/HIV/syphilis/leukaemia.
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateclassic_bell_palsy
    Classic Bell palsy — acute unilateral peripheral facial palsy with onset <72 h, House-Brackmann I-III at presentation; idiopathic (AAN 2012 Gronseth PMID 26832596)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_facial_palsy
    Recurrent facial palsy — sarcoid (Heerfordt), neurinoma, Melkersson-Rosenthal (facial palsy + cheilitis granulomatosa + fissured tongue), or recurrent idiopathic
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_associated_facial_palsy
    Pregnancy-associated facial palsy — 3x risk; third trimester / immediate postpartum highest; rule out pre-eclampsia + gestational hypertension (route to ob.pre-eclampsia.core.v1 if BP elevated)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepediatric_bell_palsy
    Pediatric Bell palsy — frequently Lyme-associated in endemic areas; consider Lyme serology routinely; doxycycline only in ≥8 y; amoxicillin <8 y (CDC PMID 28169892)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatelyme_associated_facial_palsy
    Lyme-associated facial palsy — tick exposure, erythema migrans, endemic area, positive Lyme serology (ELISA + Western blot); doxycycline 14-21 d treats facial palsy + prevents progression (CDC PMID 28169892)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateearly_corticosteroid_window_quantified
    Early-corticosteroid trigger (quantified): start oral prednisone/prednisolone 50-60 mg/d ×5-7 d then 5-d taper WITHIN 72 h of onset — Sullivan NEJM 2007 (PMID 17942873) 9-mo complete recovery 94.4% (steroid) vs 81.6% (no steroid), 3-mo 83.0% vs 63.6% (ARR ≈ 12.8%, NNT ≈ 8 at 9 mo); Cochrane Madhok 2016 (PMID 27428352) incomplete recovery 17% vs 28%, RR 0.63 (95% CI 0.50-0.80), NNT 10 (6-20), motor-synkinesis RR 0.64; AAN 2012 (PMID 23136264) Level A, pooled risk difference 12.8-15%. ANTIVIRAL is adjunct-only: antiviral alone confers NO benefit (acyclovir 9-mo 85.4% vs 90.8%, adj P=0.10; Cochrane antivirals PMID 26559436 RR vs placebo 1.10), antiviral+steroid adds ≤7% (AAN Level C) — reserve for Ramsay Hunt or severe Bell (HB V-VI: Cochrane severe-subgroup RR 0.64, 95% CI 0.41-0.99, n=478).
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespecial_populations_quantified
    Special-population branch (quantified as data). PREGNANCY: Bell palsy is over-represented in pregnancy, 68.82% in the 3rd trimester / immediate postpartum (Carmel Neiderman 2023 meta-analysis PMID 36811230, 809 pregnant BP / 11,813 BP); SCREEN pre-eclampsia/eclampsia (pooled 9.54%) + gestational HTN (13.97%) + GDM (6.3%); corticosteroid benefit-risk discussed with OB, prednisone preferred (lower placental transfer than dexamethasone — but dexamethasone if specialist-managed); prognosis FAVOURABLE (children & pregnant women up to 90% complete recovery, AFP 2023 PMID 37054419). PAEDIATRIC: exclude Lyme (leading cause of paediatric facial palsy in endemic areas — doxycycline only if ≥8 y, else amoxicillin) and otogenic causes; weight-based steroid dosing; up to ~90% complete recovery. DIABETIC: steroid raises glucose — baseline + day-3/day-7 glucose monitoring on the 60 mg course; DM associated with higher recurrence/worse recovery. EYE PROTECTION is MANDATORY for any impaired closure (AAO-HNS 2013 strong rec PMID 24189771) — artificial tears q1-2 h + ointment HS + mechanical closure prevents exposure keratopathy/corneal ulceration; ophthalmology if pain/redness/corneal staining.
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
Loading…

Recommended regimen

Bell palsy acute Rx — corticosteroid + eye care core; antiviral for Ramsay Hunt or severe Bell; doxycycline for Lyme (AAN 2012 Gronseth PMID 26832596)
axis: bell_palsy_acute_managementstep 1 - Step 1 — Corticosteroid within 72 h (Class I AAN 2012; Sullivan NEJM 2007 PMID 18987343; Cochrane Madhok 2016 PMID 23165816)
Selected step "Step 1 — Corticosteroid within 72 h (Class I AAN 2012; Sullivan NEJM 2007 PMID 18987343; Cochrane Madhok 2016 PMID 23165816)" — Acute peripheral facial palsy with onset <72 h; no absolute contraindication to systemic steroid
  • prednisone
    first line
    glucocorticoid
    60 mg PO daily × 5-7 d, then 5-d taper (e.g., 50/40/30/20/10 mg) • PO • daily
    triggers: onset_<72h, no_steroid_contraindication
    Sullivan NEJM 2007 PMID 18987343 — prednisolone alone improved recovery vs placebo + improved over acyclovir alone; Cochrane Madhok 2016 PMID 23165816 — high-quality evidence; AAN 2012 Gronseth PMID 26832596 Class I
    rxcui 8640
  • prednisolone
    first line
    glucocorticoid
    60 mg PO daily × 5-7 d, then 5-d taper • PO • daily
    triggers: onset_<72h, liver_disease_or_prednisone_intolerance
    Sullivan NEJM 2007 used prednisolone; equivalent to prednisone in non-hepatic-disease patients; preferred in hepatic dysfunction
    rxcui 8638
  • dexamethasone
    second line
    glucocorticoid
    10 mg PO/IV × 1, then 8 mg q8h × 24 h, then taper • PO/IV • q8h then taper
    triggers: pregnancy_third_trimester_specialist_managed
    Less placental transfer than prednisone (preferred in pregnancy when steroid indicated); collaborate OB-GYN
    rxcui 3264

outpatient playbook — drug actions (3)

  1. 1. preservative-free artificial tears + ocular ointment
    Drops q1-2 h awake + ointment HS as long as lagophthalmos persists • topical • q1-2 h + HS
    trigger: Persistent lagophthalmos
    Cochrane PMID 27488817 — until full closure restored
  2. 2. sertraline or other SSRI 25-200 mg daily
    25 mg PO daily titrate • PO • daily
    trigger: PHQ-9 ≥10 — post-Bell-palsy depression
    Standard SSRI; address QoL impact
  3. 3. botulinum toxin chemodenervation
    Per oculoplastic + neurology • IM • q3-6 mo
    trigger: Synkinesis or contracture in chronic phase
    Standard for facial nerve sequelae; oculoplastic / facial nerve specialist

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute (<72 h) unilateral facial weakness involving forehead (peripheral CN VII — Sullivan NEJM 2007 PMID 18987343); Inability to close the eye on the affected side (orbicularis oculi paresis; exposure risk); Drooping of the corner of the mouth + drooling on affected side.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Bell Palsy (idiopathic peripheral facial palsy)** (neuro.bell-palsy.v1).
Phenotype framing: Phenotype assignment: classic Bell / Ramsay Hunt / bilateral simultaneous / recurrent / pregnancy / pediatric / Lyme / iatrogenic / central VII (forehead-sparing — stroke)
Scope: Acute unilateral peripheral facial palsy (forehead involved) reaching maximum severity within 72 h — idiopathic Bell palsy until proven otherwise; rule out central VII, Ramsay Hunt, Lyme, bilateral causes (AAN 2012 Gronseth PMID 26832596)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Bell palsy acute Rx — corticosteroid + eye care core; antiviral for Ramsay Hunt or severe Bell; doxycycline for Lyme (AAN 2012 Gronseth PMID 26832596)** — step "Step 1 — Corticosteroid within 72 h (Class I AAN 2012; Sullivan NEJM 2007 PMID 18987343; Cochrane Madhok 2016 PMID 23165816)".
1. prednisone 60 mg PO daily × 5-7 d, then 5-d taper (e.g., 50/40/30/20/10 mg) PO daily (glucocorticoid, first line) — Sullivan NEJM 2007 PMID 18987343 — prednisolone alone improved recovery vs placebo + improved over acyclovir alone; Cochrane Madhok 2016 PMID 23165816 — high-quality evidence; AAN 2012 Gronseth PMID 26832596 Class I
2. prednisolone 60 mg PO daily × 5-7 d, then 5-d taper PO daily (glucocorticoid, first line) — Sullivan NEJM 2007 used prednisolone; equivalent to prednisone in non-hepatic-disease patients; preferred in hepatic dysfunction
3. dexamethasone 10 mg PO/IV × 1, then 8 mg q8h × 24 h, then taper PO/IV q8h then taper (glucocorticoid, second line) — Less placental transfer than prednisone (preferred in pregnancy when steroid indicated); collaborate OB-GYN

Setting playbook (outpatient) — Follow-up after ED/clinic start of steroid — re-grade House-Brackmann 2-4 wk; ensure eye protection; refer facial PT at 3 wk if no recovery; MRI brain at 4 mo if no recovery; oculoplastic + botulinum referral for chronic synkinesis or contracture
4. preservative-free artificial tears + ocular ointment Drops q1-2 h awake + ointment HS as long as lagophthalmos persists topical q1-2 h + HS — Persistent lagophthalmos (Cochrane PMID 27488817 — until full closure restored)
5. sertraline or other SSRI 25-200 mg daily 25 mg PO daily titrate PO daily — PHQ-9 ≥10 — post-Bell-palsy depression (Standard SSRI; address QoL impact)
6. botulinum toxin chemodenervation Per oculoplastic + neurology IM q3-6 mo — Synkinesis or contracture in chronic phase (Standard for facial nerve sequelae; oculoplastic / facial nerve specialist)

Non-pharmacologic actions:
- Facial PT / neuromuscular retraining starting at 3 wk if no recovery (Cochrane facial PT)
- Mirror feedback exercises
- Oculoplastic referral if chronic lagophthalmos at 4 mo — consider gold weight, lateral tarsorrhaphy
- MRI brain with facial nerve protocol at 4 mo if no recovery — rule out facial schwannoma, vestibular schwannoma, cholesteatoma, central pontine lesion
- ENT referral for Ramsay Hunt + audiogram if hearing loss
- Counseling + support groups for facial disfigurement adjustment
- Photographic documentation (with consent) for objective serial assessment
- Driving safety re-evaluation if visual issues from chronic lagophthalmos

AVOID / contraindication checks:
- Start_steroid_within_72h_of_onset (Sullivan NEJM 2007 PMID 18987343)
- Antiviral_adjunct_for_ramsay_hunt_and_severe_bell_HB_>=IV (Furuta 2020 PMID 33176069; AAN 2012 Class C)
- Doxycycline_for_lyme_facial_palsy (CDC PMID 28169892); switch_to_amoxicillin_if_pregnant_or_peds_<8
- MANDATORY_eye_care_artificial_tears_q1 2h_ointment_HS_tape_closure_at_night (Cochrane PMID 27488817)
- Check_glucose_baseline_in_diabetes_before_steroid (DM is risk factor for Bell palsy + steroid raises glucose)
- Pregnancy_third_trimester_consult_OBGYN_steroid_use; prefer_prednisone_to_dexamethasone_for_lower_placental_transfer
- Central_VII_forehead_sparing_route_to_stroke_protocol (AHA/ASA 2021)
- Bilateral_simultaneous_palsy_workup_lyme_sarcoid_GBS_HIV_syphilis_leukemia (AAN 2012 Gronseth PMID 26832596)
- Slowly_progressive_over_weeks_months_consider_tumor_facial_schwannoma_acoustic_neuroma_MRI_with_facial_nerve_protocol
- No_recovery_at_4_months_obtain_MRI_to_exclude_mass_lesion

Monitoring

Regimen monitoring:
- Daily eye care compliance + comfort log
- Glucose check on day 3 and day 7 of steroid in patients with DM
- Office visit 2-4 wk for House-Brackmann re-grading
- Facial PT referral at 3 wk if no improvement
- Ophthalmology if any corneal pain, redness, or vision change
- MRI at 4 mo if no recovery to rule out tumor
- ENT if hearing loss / vertigo / no improvement at 3 mo

Setting (outpatient) monitoring:
- 2-4 wk House-Brackmann re-grade
- 6 wk + 12 wk visits
- 4 mo + 6 mo visits
- MRI at 4 mo if no recovery

Follow-up plan: Expect recovery onset within 2-3 wk for most; full recovery 70% no treatment, 80-85% with steroid by 6 mo; if HB ≥IV at 4 mo OR no recovery at 4 mo → MRI brain with facial nerve protocol to rule out tumor; consider surgical decompression rarely (controversial, AAN 2012 Level U); chemodenervation (botulinum) for synkinesis or contracture in chronic phase
- Close-out criterion: Recovery documented or atypical course routed

Monitoring phase: Daily eye care log; weekly call check (week 1-2) for compliance + eye comfort; office visit at 2-4 wk for grade re-check; if HB ≥IV at 3 wk → facial PT referral; ophthalmology if any corneal symptoms; ENT if hearing loss / vertigo / no improvement at 3 mo

Disposition

Current setting: outpatient — Follow-up after ED/clinic start of steroid — re-grade House-Brackmann 2-4 wk; ensure eye protection; refer facial PT at 3 wk if no recovery; MRI brain at 4 mo if no recovery; oculoplastic + botulinum referral for chronic synkinesis or contracture

Disposition criteria:
- Recovery → discharge from facial nerve clinic
- Chronic sequelae (synkinesis, contracture, lagophthalmos) → facial nerve specialist + oculoplastic + neurology long-term

Escalation triggers (move to higher acuity):
- No improvement at 3 wk → facial PT + close follow-up
- No improvement at 4 mo → MRI brain to rule out tumor; consider neurology + ENT
- Worsening at any point → MRI brain + neurology consult (atypical for Bell — consider tumor or other diagnosis)
- Severe corneal ulcer → urgent ophthalmology
- Recurrent facial palsy → MRI + sarcoid + Lyme workup; Melkersson-Rosenthal consideration

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Central VII palsy — forehead SPARING (frontalis preserved bilaterally due to bilateral cortical input); lower facial weakness from cortical / brainstem / corona radiata stroke (AHA/ASA 2021 BE-FAST)
- [LIFE_THREATENING] Forehead-sparing-or-other-deficit STROKE route (quantified pivot): forehead-involved entire-hemiface weakness → peripheral Bell (LR+ ≈ 13.9, LR- ≈ 0.03 from sens 0.97/spec 0.93; see neuro.bell-palsy.v1.finding-lrs.ts row 1). Forehead-SPARING (frontalis preserved by bilateral cortical input) → central VII / ischaemic stroke (LR+ ≈ 13.6 from sens 0.95/spec 0.93), and any CONCOMITANT limb/speech/sensory deficit → stroke LR+ 18 — these two are conditionally dependent (combine as a single "central pattern" gate, do NOT multiply; see conditional-dependency note #A). Action: do NOT treat as Bell, do NOT give prednisone, activate stroke pathway and route to neuro.ischaemic-stroke.v1 (time-critical thrombolysis/EVT window).
- [SEVERE] Ramsay Hunt syndrome (herpes zoster oticus) — facial palsy + vesicles in ear canal / concha / palate + severe otalgia ± vertigo ± sensorineural hearing loss; worse prognosis than Bell (Furuta 2020 PMID 33176069)

Citations

- 2013 AAO-HNS Clinical Practice Guideline: Bell’s Palsy (Baugh, PMID 24189771) + 2012 AAN Evidence-Based Guideline Update: steroids and antivirals for Bell palsy (Gronseth, PMID 23136264) + Sullivan Scottish Bell Palsy Trial NEJM 2007 (PMID 17942873) + Cochrane corticosteroids (Madhok 2016, PMID 27428352) + Cochrane antivirals (Gagyor/Madhok, PMID 26559436); Lyme floor IDSA/AAN/ACR 2021 (Lantos, DOI 10.1093/cid/ciaa1215; AAN parameter PMID 17522387 retired) [PMID:24189771](https://pubmed.ncbi.nlm.nih.gov/24189771/)
- Cited evidence (PMID 24190889) [PMID:24190889](https://pubmed.ncbi.nlm.nih.gov/24190889/)
- Cited evidence (PMID 23136264) [PMID:23136264](https://pubmed.ncbi.nlm.nih.gov/23136264/)
- Cited evidence (PMID 17942873) [PMID:17942873](https://pubmed.ncbi.nlm.nih.gov/17942873/)
- Cited evidence (PMID 27428352) [PMID:27428352](https://pubmed.ncbi.nlm.nih.gov/27428352/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2013 AAO-HNS Clinical Practice Guideline: Bell’s Palsy (Baugh, PMID 24189771) + 2012 AAN Evidence-Based Guideline Update: steroids and antivirals for Bell palsy (Gronseth, PMID 23136264) + Sullivan Scottish Bell Palsy Trial NEJM 2007 (PMID 17942873) + Cochrane corticosteroids (Madhok 2016, PMID 27428352) + Cochrane antivirals (Gagyor/Madhok, PMID 26559436); Lyme floor IDSA/AAN/ACR 2021 (Lantos, DOI 10.1093/cid/ciaa1215; AAN parameter PMID 17522387 retired) — PMID:24189771
  • Cited evidence (PMID 24190889) — PMID:24190889
  • Cited evidence (PMID 23136264) — PMID:23136264
  • Cited evidence (PMID 17942873) — PMID:17942873
  • Cited evidence (PMID 27428352) — PMID:27428352