326 Best evidence topic reports

Table 5
Author, date Study type (level of
and country Patient group evidence) Outcomes Key results Study weaknesses

Sheikh A et al, 527 patients, from 3 studies, Meta-analysis Early (days 2–5) RR 1.31 (99% CI Inclusion criteria of swab proven
1999, UK with acute bacterial clinical remission 1.11 to 1.55) acute bacterial conjunctivitis in
conjunctivitis randomised to only 2 of the 3 studies
receive either topical antibiotic Late (days 6–10) RR 1.27 (99% CI Different topical antibiotic
preparation or placebo clinical remission 0.92 to 1.74) preparations in each of the 3
studies
Selected specialist care patient
populations

paralysis OR exp Facial nerve OR bell palsy.af OR bells palsy.af

Bell’s palsy and acyclovir
Report by Man-Cheuk Yuen, Senior Medical
Officer, Kwong Wah Hospital, Hong Kong
Search checked by Ian Crawford, Clinical
Research Fellow
Abstract
A short cut review was carried out to establish whether
acyclovir improves functional recovery in Bell’s palsy. Alto-
gether 49 papers were found using the reported search, of
which two presented the best evidence to answer the clinical
question. The author, date and country of publication, patient
group studied, study type, relevant outcomes, results and
study weaknesses of these papers are tabulated. A clinical bot-
tom line is stated.
Clinical scenario
A 45 year old man presents to the emergency department with
a one day history of left side facial weakness. Physical exam-
ination confirms that the patient has an incomplete left sided
Bell’s palsy. As prednisone has a limited role in improving the
recovery of incomplete Bell’s palsy and medical literature pos-
tulates a viral aetiology in Bell’s palsy, you wonder whether
acyclovir would improve the outcome for this patient.
Three part question
In [an adult patient with Bell’s palsy] does [acyclovir] improve
[functional recovery]?
Search strategy
Medline 1966–04/02 using the OVID interface. Cochrane
Library, Issue 1 2002. Medline: [exp Bell palsy or exp Facial
OR (facial adj5 palsy).af OR (facial adj5 paralysis).af OR
(facial adj5 weakness).af] AND [exp Acyclovir or acyclovir.af
OR zovirax.af] LIMIT to Human AND English language.
Cochrane: (Bell palsy)
Search outcome
Altogether 49 papers were found of which two were relevant
and had been included in a systematic review by the Cochrane
Neuromuscular Disease Group.1 A meta-analysis was not per-
formed, as the two studies were not directly compatible. This
review was last updated on the 19 November 2001. No further
relevant papers were identified after this date. These papers
are shown in table 6.
Comment(s)
The results from the Adour trial suggest that treatment with
acyclovir and prednisolone is more effective than treatment
with prednisolone alone. However, the results from the De
Diego trial suggest that treatment with prednisolone alone is
more effective than treatment with acyclovir alone. Both
studies are small and a significant number of patients were
lost to follow up in each. A large PRCT with a real placebo
control group is needed to clarify the effectiveness of acyclovir
in the treatment of Bell’s palsy.
c CLINICAL BOTTOM LINE
Current evidence does not support the use of acyclovir alone in
Bell’s palsy. The combination of acyclovir and prednisone may
have a small benefit in the final functional recovery.
Adour KK, Ruboyianes JM, Von Doersten PG, et al. Bell’s palsy treatment with
acyclovir and prednisone compared with prednisone alone: A double-blind,
randomized, controlled trial. Ann Otol Rhinol Laryngol 1996;105:371–8.

Table 6
Study type
Author, date and (level of
country Patient group evidence) Outcomes Key results Study weaknesses

Adour KK et al, 119 patients presented within PRCT Visual assessment of Small treatment effect was Small study
1996, USA the first 72 hours motor recovery by demonstrated in the acyclovir and 20% patients (16.8%)
Acyclovir and prednisolone v FPRP & FPRI prednisolone group (p=0.04) were lost to follow up
placebo and prednisolone
Acyclovir 2000 mg per day Electrical testing Acyclovir and prednisolone group No intention to treat
for 10 days had less partial nerve degeneration analysis
Prednisolone 1 mg/kg for 5 (p=0.05)
days tapered to 10 mg/day
for next 5 days
De Diego JI et al, 113 patients presenting within PRCT Visual assessment of Prednisone was beneficial Small study
1998, Spain the first 96 hours motor recovery by (p=0.0338) No real placebo control
Acyclovir alone v FPRP group
prednisolone alone
Acyclovir 2400 mg per day Electrical testing Prednisone had less degeneration of 12 patients (10.6%) were
for 10 days marginal branch of facial nerve lost to follow up
Prednisolone 1 mg/kg for 10 (p=0.02) No intention to treat
days tapered to zero over the analysis
next 6 days

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Best evidence topic reports 327

Table 7
Study type
Author, date (level of
and country Patient group evidence) Outcomes Key results Study weaknesses

Singer AJ et 68 alert adult patients requiring PRCT Pain during Less with tape stripping 29.7 Adult patients
al, 1998, intravenous cannulation in the ED. cannulation mm v 39 mm p=0.017 No blinding of person
USA Patients were randomised to performing IV cannulation
receive tape stripping. All
Pain during tape 4.8 mm +/−7.4 mm Convenience sample rather
measurements made on 100 mm
stripping than sequential
VAS. Scotch tape was applied and
stripped 20 times to remove the Success rate for 91% for tape stripping v Only small differences in VAS
stratum corneum. cannulation 74% without p=0.056 scores found

De Diego JI, Prim MP, De Sarria MJ, et al. Idiopathic facial paralysis: A
randomized, prospective and controlled study using single-dose prednisone
versus acyclovir three times daily. Laryngoscope 1998;108:573–5.
1 Sipe J, Dunn L. Aciclovir for Bell’s palsy (idiopathic facial paralysis)
(Cochrane Review). In: The Cochrane Library Issue 1. Oxford: Update
Software, 2002.
Tape stripping the stratum
corneum and the effectiveness
of EMLA
Report by Simon Carley, Specialist Registrar
Checked by Kerstin Hogg, Clinical Research
Fellow
Abstract
A short cut review was carried out to establish whether there
is any evidence to show that stripping the stratum corneum
with adhesive tape reduces time to analgesia after application
of EMLA in children undergoing venepuncture. Altogether 43
papers were found using the reported search, of which one
presented the best evidence to answer the clinical question.
The author, date and country of publication, patient group
studied, study type, relevant outcomes, results and study
weaknesses of this paper are tabulated. A clinical bottom line
is stated
Search outcome
Altogether 47 papers were found of which one was relevant to
the three part question. This paper is shown in table 7.
Comment(s)
The single study found shows a small benefit to tape stripping,
but only involves adult patients undergoing venepuncture. It
is debatable whether the small differences in VAS seen are
clinically important (normally at least a change of 10 mm
would be considered significant). In our practice EMLA is
almost exclusively used in children. There is an amount of
pain that is attributable to the tape stripping procedure,
though this is a low value. However, applying the tape and
stripping it 20 times is likely to be distressing for many
children. This adult study does not investigate the probable
difficulties in applying this technique in children. It is our per-
ception that they would find the tape stripping distressing. For
this reason we do not feel that it is possible to extrapolate the
results of this study to children.
c CLINICAL BOTTOM LINE
Tape stripping the stratum corneum increases the effective-
ness of EMLA in adults by a small degree. Its effectiveness in
children is unknown.
Singer AJ, Shallat J, Valentine SM, et al. Cutaneous tape stripping to
accelerate the anesthetic effects of EMLA cream: a randomized, controlled
trial. Acad Emerg Med 1998;5:1051–6.

Clinical scenario
A 2 year old child presents to the emergency department with
a limp. The child is mildly feverish and has some limitation of
movement. You decide to take blood as part of your diagnostic
strategy to exclude septic arthritis. The parents are keen to get
on with the tests and are disappointed that the EMLA cream
you intend to use takes so long to work. The paediatric emer-
gency nurse suggests using tape to “clean” the skin before
application to get the EMLA to work faster. You have no idea
what she is talking about but wonder whether there is any
evidence to show that she is right.
Three part question
In [children undergoing venepuncture after EMLA cream]
does [stripping the stratum corneum with adhesive tape]
reduce [time of onset, pain and distress of the procedure]?
Search strategy
Medline 1966–04/02 using the OVID interface. [EMLA.mp OR
eutectic.mp OR ({exp anesthesia, local OR exp anesthetics,
local OR exp Lidocaine OR local anaesthetic$.mp OR local
anesthetic$.mp} AND {exp administration, topical OR topi-
cal.mp})] AND [exp adhesives OR exp bandages OR
TAPE.mp] LIMIT to human AND English.
Staples or sutures for repair of
scalp laceration in adults
Report by Kerstin Hogg, Clinical Research
Fellow
Search checked by Simon Carley, Specialist
Registrar
Abstract
A short cut review was carried out to establish whether staples
are better than sutures for scalp wound repair in adults. Alto-
gether 42 papers were found using the reported search, of
which four presented the best evidence to answer the clinical
question. The author, date and country of publication, patient
group studied, study type, relevant outcomes, results and
study weaknesses of these best papers are tabulated. A clinical
bottom line is stated.
Clinical scenario
An elderly lady is admitted to the emergency department after
collapsing in the street. She has a 3 cm laceration in the left
parietal area. Neurological examination and skull radiograph

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