Efficacy of Prednisolone for Bell Palsy in Children: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

BACKGROUND AND OBJECTIVES

Corticosteroids are used to treat the early stages of idiopathic facial paralysis (Bell palsy) in children, but their effectiveness is uncertain. We set out to determine whether prednisolone improves the proportion of children with Bell palsy with complete recovery at 1 month.

METHODS

We conducted a double-blind, placebo-controlled, randomized trial of prednisolone in children presenting to emergency departments with Bell palsy. Patients aged 6 months to younger than 18 years were recruited within 72 hours after the symptom onset and were randomly assigned to receive 10 days of treatment with oral prednisolone (approximately 1 mg/kg) or placebo. The primary outcome was complete recovery of facial function at 1 month rated on the House-Brackmann scale. Secondary outcomes included facial function, adverse events, and pain up to 6 months. Target recruitment was n = 540 (270 per group).

RESULTS

Between October 13, 2015, and August 23, 2020, 187 children were randomized (94 to prednisolone and 93 to placebo) and included in the intention-to-treat analysis. At 1 month, the proportions of patients who had recovered facial function were 49% (n = 43/87) in the prednisolone group compared with 57% (n = 50/87) in the placebo group (risk difference -8.1%, 95% CI -22.8 to 6.7; adjusted odds ratio [aOR] 0.7, 95% CI 0.4 to 1.3). At 3 months, these proportions were 90% (n = 71/79) for the prednisolone group vs 85% (n = 72/85) for the placebo group (risk difference 5.2%, 95% CI -5.0 to 15.3; aOR 1.2, 95% CI 0.4 to 3.0) and, at 6 months, 99% (n = 77/78) and 93% (n = 76/82), respectively (risk difference 6.0%, 95% CI -0.1 to 12.2; aOR 3.0, 95% CI 0.5 to 17.7). There were no serious adverse events and little evidence for group differences in secondary outcomes.

DISCUSSION

In children with Bell palsy, the vast majority recover without treatment. This study, although underpowered, does not provide evidence that early treatment with prednisolone improves complete recovery.

TRIAL REGISTRATION INFORMATION

Registered with the Australian New Zealand Clinical Trials Registry ACTRN12615000563561, registered June 1, 2015. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368505&isReview=true.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that for children with Bell palsy, prednisolone does not significantly change recovery of complete facial function at 1 month. However, this study lacked the precision to exclude an important harm or benefit from prednisolone.

BCG vaccination to reduce the impact of COVID-19 in healthcare workers: Protocol for a randomised controlled trial (BRACE trial)

INTRODUCTION

BCG vaccination modulates immune responses to unrelated pathogens. This off-target effect could reduce the impact of emerging pathogens. As a readily available, inexpensive intervention that has a well-established safety profile, BCG is a good candidate for protecting healthcare workers (HCWs) and other vulnerable groups against COVID-19.

METHODS AND ANALYSIS

This international multicentre phase III randomised controlled trial aims to determine if BCG vaccination reduces the incidence of symptomatic and severe COVID-19 at 6 months (co-primary outcomes) compared with no BCG vaccination. We plan to randomise 10 078 HCWs from Australia, The Netherlands, Spain, the UK and Brazil in a 1:1 ratio to BCG vaccination or no BCG (control group). The participants will be followed for 1 year with questionnaires and collection of blood samples. For any episode of illness, clinical details will be collected daily, and the participant will be tested for SARS-CoV-2 infection. The secondary objectives are to determine if BCG vaccination reduces the rate, incidence, and severity of any febrile or respiratory illness (including SARS-CoV-2), as well as work absenteeism. The safety of BCG vaccination in HCWs will also be evaluated. Immunological analyses will assess changes in the immune system following vaccination, and identify factors associated with susceptibility to or protection against SARS-CoV-2 and other infections.

ETHICS AND DISSEMINATION

Ethical and governance approval will be obtained from participating sites. Results will be published in peer-reviewed open-access journals. The final cleaned and locked database will be deposited in a data sharing repository archiving system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04327206.

Protocol for a single patient therapy plan: A randomised, double-blind, placebo-controlled N-of-1 trial to assess the efficacy of cannabidiol in patients with intractable epilepsy

AIM

This paper describes the use of the single patient therapy plan (SPTP). The SPTP has been designed to assess the efficacy at an individual level of a commercially available cannabinoid product, cannabidiol, in reducing seizure frequency in paediatric patients with intractable epilepsy.

METHODS

The SPTP is a randomised, double-blind, placebo-controlled N-of-1 trial designed to assess the efficacy of treatment in a neurology outpatient setting. The primary objective of the SPTP is to assess the efficacy of cannabidiol in reducing seizure frequency in each patient with intractable epilepsy, with change in seizure frequency being the primary outcome of interest. The analysis adopts a Bayesian approach, which provides results in the form of posterior probabilities that various levels of benefit (based on the primary outcome measure, seizure frequency) have been achieved under active treatment compared to placebo, accompanied by decision rules that provide thresholds for deciding whether treatment has been successful in the individual patient. The SPTP arrangement is most accurately considered part of clinical practice rather than research, since it is aimed at making clinical treatment decisions for individual patients and is not testing a hypothesis or collecting aggregate data. Therefore, Human Research Ethics Committee approval was considered not to be required, although it is recommended that hospital Clinical Ethics Committees provide ethical oversight.

CONCLUSION

These SPTP resources are made available so that they may inform clinical practice in the treatment of severe epilepsy or adapted for use in other conditions.

Protocol for a double blind, randomised placebo-controlled trial using ondansetron to reduce vomiting in children receiving intranasal fentanyl and inhaled nitrous oxide for procedural sedation in the emergency department (the FON trial)

INTRODUCTION

Intranasal fentanyl and nitrous oxide (N₂O) can be combined to create a non-parenteral procedural sedation regimen for children in the paediatric emergency department. This combination of intranasal fentanyl and N₂O provides effective pain relief for more painful procedures, but is associated with a higher incidence of vomiting than N₂O alone. Our aim is to assess whether ondansetron used preventatively reduces the incidence of vomiting associated with intranasal fentanyl and N₂O for procedural sedation compared with placebo.

METHODS AND ANALYSIS

This study is a double blind, randomised placebo-controlled superiority trial. This is a single-centre trial of 442 children aged 3-18 years presenting to a tertiary care Paediatric Emergency Department at the Royal Children's Hospital (RCH), Melbourne, Australia, requiring procedural sedation with intranasal fentanyl and N₂O. After written consent, eligible participants are randomised to receive ondansetron or placebo along with intranasal fentanyl, 30-60 min prior to N₂O administration. The primary outcome is vomiting during or up to 1 hour after procedural sedation. Secondary outcomes include: number of vomits and retching during procedural sedation, vomiting 1-24 hours after procedural sedation, procedural sedation duration and associated adverse events, procedure abandonment, parental satisfaction and the value parents place on the prevention of vomiting. This trial will allow refinement of a non-parenteral sedation regimen for children requiring painful procedures.

ETHICS AND DISSEMINATION

This study has ethics approval at the RCH, Melbourne, protocol number 36174. The results from this trial will be submitted to conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12616001213437).

Circulating immunoreactive substance P in man

Immunoreactive substance P (iSP) has been measured in plasma in 77 normal subjects and in 125 hospital patients. Factors affectingin-vitro degradation of iSP were studied.In vivo, iSP is degraded in the liver and its level in the circulation is independent of kidney excretory function.During insulin-induced hypoglycaemic stress and also during glucose-tolerance test, iSP in plasma decreased transiently. No circadian rhythm of iSP was observed, but in a study in sleeping volunteers episodic secretory bursts were seen, separated by one- to two-hour intervals, the first peak appearing about 90 minutes after the subjects fell asleep.In a patient with carcinoid metastases in the liver, an elevated level of iSP was found in the general circulation with a marked gradient at the hepatic venous effluent.

The community development in health project

This paper describes the purpose and process of a 15 month project established to develop resources to assist people who are seeking to use a community development approach in addressing health issues.

Carotid Artery Angioplasty for Restenosis Following Endarterectomy

INTRODUCTION

The higher complication rate associated with the surgical treatment of restenosis following carotid endarterectomy (CEA) has led several authors to advocate angioplasty as the treatment of choice in the management of restenosis. We describe our experience with internal carotid artery angioplasty for post-endarterectomy restenosis over 7 years.

PATIENTS AND METHODS

From January 1994 to April 2001, all patients with a >90% restenosis following CEA were considered for angioplasty. Thirty angioplasties were carried out in 25 patients, 80% (24/30), for asymptomatic recurrent stenosis. There was no difference between those who had intervention for recurrent stenosis (n=31) and those who did not (n=545) in age, sex, smoking status or incidence of diabetes or hypertension. A significantly greater number of patients who underwent angioplasty were hypercholesterolaemic (p<0.05, Chi-squared test).

RESULTS

Mean time from surgery to angioplasty was 13 months (range 1-23). Angioplasty was technically successful in 29 cases (97%). Three patients (10%) experienced transient neurological symptoms during the procedure. There were no strokes. Ninety-six percent (28/29) of patients were followed up with duplex scanning. Mean follow-up was 20 months (range 2-48). Three patients developed a greater than 90% restenosis.

CONCLUSION

Angioplasty is an acceptable alternative to surgery in the management of internal carotid artery restenosis following endarterectomy.

Quality assurance: what is the consumers' role?

We commenced with the question: what is the "proper" role for consumers in quality assurance? Quality assurance has been discussed as encompassing three phases: clinical review, linkage and drive. We have discussed a range of mechanisms which can contribute to expressing a consumer perspective or the consumers' interest in each of these phases of quality assurance. It is clear that the consumers' experience is a useful and legitimate input to clinical review. It is clear that mechanisms for listening more carefully to the consumers' perspective could be introduced more widely. It is clear that greater consumer understanding of an involvement in the whole quality assurance cycle is practicable and, from the point of view of many consumers, highly desirable. Whilst more detailed answers have not been brought forward, a useful framework for considering how to proceed from here has been presented.

Therapeutic arterial embolisation in children

Arterial embolisation was performed in five paediatric patients. Indications were hypersplenism in two, gastrointestinal bleeding in two and treatment of an aneurysmal bone cyst in one. Embolisation provided definitive treatment in each case with no complications.

Computed tomographic arteriography in the pre-surgical evaluation of hepatic tumours

Five patients with hepatic neoplasms considered suitable for surgical resection were examined by computed tomography (CT), hepatic angiography and then a combination of angiography and CT (CTA). In each patient the tumour was more clearly defined and its extent more accurately determined than by routine CT. Three patients were spared surgery when further hepatic tumour was shown by CTA. The left lobe was shown to be free of tumour in the other two patients and surgical resection was carried out. Examination by CTA is recommended in all patients with hepatic tumours considered suitable for hepatic resection.

Therapeutic arterial embolisation: report of five years' experience

Therapeutic arterial embolisation was performed in 48 patients. Gelfoam, Oxycel, Bucrylate, Gianturco wire coils and lyophilised dura mater were used. Indications included control of acute haemorrhage, pre-operative vascular reduction, palliation of inoperable lesions, or to render such lesions operable, and elective definitive treatment. The technique was not considered to be of significant value as a pre-operative measure but was successful for the control of haemorrhage, the management of inoperable lesions and as an elective definitive treatment for various unusual lesions. One patient died and three had complications. The choice of occlusive material is discussed and depends upon the nature and vascularity of the lesion and whether short- or long-term occlusion is required.

Minimising side effects in lumbar radiculography

An attempt was made to reduce the side effects associated with the use of Metrizamide in lumbar radiculography by the removal of the contrast medium on completion of the examination. Almost complete removal was achieved in 103 patients and of these 73% had no symptoms after examination, while 8% had severe symptoms. Eleven of 14 patients in whom removal was not attempted or was not successful had significant symptoms after examination. It is concluded that aspiration of Metrizamide will reduce the incidence and severity of the side effects associated with the use of this contrast medium.

Glucagon as a hypotonic agent in cholangiography

The effects of Glucagon on 35 cholangiographic studies was examined. Relief of spasm at the choledochoduodenal sphincter resulted in consistently improved demonstration of this area. Diminished spasm-induced pain was also recorded. The use of intravenous Glucagon is recommended for cholangiographic studies where there is total biliary obstruction, or where there is unsatisfactory demonstration of the choledocho-duodenal area.

Percutaneous needle biopsy in the management of solitary lesions of bone

Needle biopsies were performed in 12 patients with solitary bone lesions, employing a simple 18 gauge cutting needle. Material sufficient for reliable diagnosis was obtained from eight of our 12 cases, thereby avoiding exploratory surgery. It is concluded that percutaneous needle biopsy of bone is a safe and simple procedure of value in the management of solitary lesions of bone.

Angiographic evaluation of gastrointestinal haemorrhage complicating pancreatic disease

Seven patients with gastro-oesophageal varices due to splenic or portal vein obstruction from a diseased pancreas have been seen at the Mater Hospital during the past three years. Four of these patients had episodes of acute and massive gastrointestinal bleeding and this paper emphasises the role of angiography in the management of this complication. In three instances the bleeding was the result of the varices, but in one patient with carcinoma of the head of the pancreas the bleeding was shown to result from invasion of the tumour into the duodenum.

The use of prostaglandin F2-alpha in selective pancreatic and left gastric angiography

Prostaglandin F2-Alpha has been used in 10 superselective angiographic studies of the pancreas and 10 left gastric studies. Injection of Prostaglandin into the dorsal pancreatic or gastroduodenal artery increased opacification of small pancreatic vessels and better demonstrated the angiographic changes in three cases of carcinoma of the pancreas. Injection of the drug into the left gastric artery increased opacification of the left gastric vein, allowed identification of the direction of flow of the contrast medium and enhanced demonstration of gastro-oesophageal varices. It is concluded that Prostaglandin improves the quality of pancreatic and left gastric angiographic studies.

The use of prostaglandin F2 alpha in selective hepatic angiography

Comparison has been made between slow infusion hepatic angiographic studies obtained before and after the intra-arterial injection of prostaglandin F2 alpha. The prostaglandin injection resulted in increased caliber of the hepatic arteries, increased opacification of the parenchyma of the liver and improved visualization of the wall of the gallbladder. Poorly vascularized metastatic lesions were better shown on the prostaglandin studies, and carcinoma of the gallbladder was diagnosed in two instances. The demonstration of highly vascularized metastatic tumor was enhanced on the prostaglandin studies, but further improved after the injection of angiotensin.

Cross-modal induction of changes in sensory thresholds

Two experiments are reported in which subliminal stimulation of one modality with emotional material impairs detection performance in a different modality. In the first experiment the visual awareness threshold for neutral material was raised by simultaneous auditory presentation of emotional words. This result supports the hypothesis that threshold changes induced by emotional stimulation are mediated centrally. In the second experiment a similar effect was obtained when the experimental roles of the two modalities were reversed. An analysis of the effect in terms of the parameters of Signal Detectability Theory indicates that it is mediated by a lowering of the sensitivity of the detection mechanism. This may be caused either by attenuation of incoming signals, or by an increase in the level of “noise” against which the signal is received.