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Benzocaine lozenges are popular in symptomatic treatment of acute sore throat. The aim of this study was to evaluate if sucking a benzocaine lozenge was superior to a placebo lozenge in patients with pain while swallowing. Volunteers with acute, uncomplicated sore throat received randomly and double-blind either a benzocaine 8 mg or a placebo lozenge. Pain was assessed on a numerical visual rating scale. The primary outcome measure was the sum of the pain intensity differences (SPID) over 2 h. Secondary outcome measures included the number of patients who reported 50% or more of their baseline pain score (responders) and those with worthwhile and complete pain relief, the times to worthwhile/complete pain relief and to pain recurrence and the occurrence of any adverse effects. A predefined interim analysis after including 50 patients revealed the superiority of benzocaine versus placebo in the SPID (p = 0.0086). At this time, a total of 165 patients had been recruited (full analysis set, FAS) and underwent statistical analysis. In the FAS, median SPID had significantly more decreased in patients receiving benzocaine compared to placebo (−12 vs. − 5, p = 0.001). There were significantly more responders and patients with worthwhile pain relief in group benzocaine. The number of patients with complete pain relief was very small. Median time to worthwhile pain relief was 20 min (benzocaine) and >45 min (placebo). Adverse events were not observed. Benzocaine lozenges are superior to placebo lozenges and a useful, well-tolerated treatment option to reduce painful pharyngeal discomfort.

BACKGROUND: Virtual reality immersion (VRI), an advanced computer-generated technique, decreased subjective reports of pain in experimental and procedural medical therapies. Furthermore, VRI significantly reduced pain-related brain activity as measured by functional magnetic resonance imaging. Resemblance between anatomical and neuroendocrine pathways of pain and pruritus may prove VRI to be a suitable adjunct for basic and clinical studies of the complex aspects of pruritus.OBJECTIVES: To compare effects of VRI with audiovisual distraction (AVD) techniques for attenuation of pruritus in patients with atopic dermatitis and psoriasis vulgaris.METHODS: Twenty-four patients suffering from chronic pruritus – 16 due to atopic dermatitis and eight due to psoriasis vulgaris – were randomly assigned to play an interactive computer game using a special visor or a computer screen. Pruritus intensity was self-rated before, during and 10 min after exposure using a visual analogue scale ranging from 0 to 10. The interviewer rated observed scratching on a three-point scale during each distraction program.RESULTS: Student’sttests were significant for reduction of pruritus intensity before and during VRI and AVD (P=0.0002 and P=0.01, respectively) and were significant only between ratings before and after VRI (P=0.017). Scratching was mostly absent or mild during both programs.CONCLUSIONS: VRI and AVD techniques demonstrated the ability to diminish itching sensations temporarily. Further studies on the immediate and late effects of interactive computer distraction techniques to interrupt itching episodes will open potential paths for future pruritus research.

Despite the findings that pain and depression are not always directly linked, enough evidence suggest that a complex relationship between pain and depression exists. Using an electronic pressure algometer placed on the sternum, the changes in pressure pain threshold (PPThr) and pressure pain tolerance (PPTol) were evaluated in 19 patients affected by refractory major depression without psychotic features, throughout a full course of electroconvulsive therapy (ECT) treatment. Measurements were done before the first treatment, after the 6th treatment and after the last treatment. After the 6th treatment, mean (+/- SD) PPThr increased significantly from 11.48 (+/- 4.81) kg/cm2 at baseline, to 13.7 (+/- 5.59) kg/cm2 (p=0.0076) while PPTol did not change significantly (from 18.46 (+/- 6.75)kg/cm2 to 17.4 (+/- 8.1)kg/cm2). At the end of the treatment course, mean (+/- SD) PPThr did not increase further significantly (15.06 (+/- 5.21)kg/cm2 (p=0.0234)) while PPTol increased significantly to 21.34 (+/- 7.8)kg/cm2 (p=0.0047). ECT's efficacy was measured with the 21-item Hamilton Rating Scale for Depression (21-HAM-D). Mean (+/- SD) 21-HAM-D scores decreased significantly from 30.9 (+/- 4.15) at baseline, to 10.47 (+/- 5.78) (p=0.0001) after the 6th treatment, with no further significant change at the end of the treatment course (9.94 +/- 3.07; p=0.0254). Both pain threshold and pain tolerance increased following the alleviation of the depressive disorder and a possible usefulness of ECT may be postulated for treating severe, chronic pain syndromes. However, a more significant conclusion is that the increase of the PPThr noted early during ECT treatment may serve as an early outcome possible detector of ECT efficacy in depressed patients.

Virtual reality immersion has been advocated as a new effective adjunct to drugs for pain control. The attenuation of pain perception and unpleasantness has been attributed to the patient's attention being diverted from the real, external environment through immersion in a virtual environment transmitted by an interactive 3-D software computer program via a VR helmet.To investigate whether VR immersion can extend the amount of time subjects can tolerate ischemic tourniquet pain.The study group comprised 20 healthy adult volunteers. The pain was induced by an inflated blood pressure cuff during two separate, counterbalanced, randomized experimental conditions for each subject: one with VR and the control without VR exposure. The VR equipment consisted of a standard computer, a lightweight helmet and an interactive software game.Tolerance time to ischemia was significantly longer for VR conditions than for those without (P0.001). Visual Analogue Scale (0-10) ratings were recorded for pain intensity, pain unpleasantness, and the time spent thinking about pain. Affective distress ratings of unpleasantness and of time spent thinking about pain were significantly lower during VR as compared with the control condition (P0.003 and 0.001 respectively).The VR method in pain control was shown to be beneficial. The relatively inexpensive equipment will facilitate the use of VR immersion in clinical situations. Future research is necessary to establish the optimal selection of clinical patients appropriate for VR pain therapy and the type of software required according to age, gender, personality, and cultural factors.

Deep pressure pain threshold (PPT) and pressure pain tolerance (PPtol) were measured by pressure algometry at the mastoid processes, external malleoli, and sternum in 24 healthy volunteers. The algometer consisted of a force displacement transducer with a 0.25cm2 pressure tip linked to a recorder. The rate of force application was approximately 1kg/sec/0.25cm2. High intersubject variation was noted at all sites for both PPT and PPtol. Mean PPT and PPtol values at the sternum were 5.2kg ± 2.1 and 8.1kg ± 2.4, respectively, and significantly higher than at the other sites. PTT did not differ significantly between the sexes or between dominant and nondominant sides. PPtol, on the other hand, was lower in the women, but significantly so only at the malleoli. On repeat examination, comparison between the mean values at each site showed no statistical differences in any instance. Pressure algometry, as used in this study in healthy subjects, proved a reliable technique for the estimation of deep PPT and PPtol values. It may possibly serve for screening the response to experimental pain in various groups of pain patients.

Plasma concentrations of methadone were measured by gas chromatography in 16 patients receiving extradural methadone by continuous infusion for relief of postoperative pain. Venous blood samples were taken after a loading dose of extradural methadone 2 mg and during infusion of 0.46 mg h-1 plus patient-controlled increments of 0.2-1 mg. Mean (SD) plasma concentration of methadone was 9.8 (2.1) ng ml-1 at 15 min; this did not change significantly during the first 2 h, after which it increased gradually to 32.2 (4.6) ng ml-1 (P less than 0.001) at the end of 24 h. The mean quantity of extradural methadone required to produce effective analgesia was 10.3 (1.8) mg during the first 12 h after operation and 6 (1.0) mg for the subsequent 12 h. The mean amount of methadone for effective analgesia on the second day was 7.6 (1.1) mg. No adverse effects were detected during the 2-3 days of methadone therapy. Plasma concentration of methadone increased significantly during patient-controlled infusion of extradural methadone in the first 24 h after operation, suggesting rapid vascular uptake. Systemic activity of the drug contributes to the analgesic effect of extradural methadone.

Intravenous injection of lignocaine relieves pain in animals with experimentally induced pain, and in man, mainly those with neuropathic pain. 106 patients were treated with intravenous lignocaine during a period of 18 months (212 treatment sessions). Blood pressure, heart rate and pain scores were continuously monitored after an intravenous bolus of lignocaine, 1 mg/kg, followed by continuous infusion of lignocaine, 5 mg/kg during 1 hour. There was significant pain relief after each session in most patients, lasting from a few hours to 4 weeks. There were no significant side effects. We present 2 of our patients. Due to its simplicity, efficacy and safety, intravenous lignocaine injection is recommended for those with neuropathic pain unrelieved by other therapeutic modalities.

Seventy cancer patients suffering from visceral or somatic pain received continuous epidural methadone (EM) analgesia. Initially, 4 mg of 0.1% methadone was given three times daily. If this dose proved ineffective, it was gradually increased to 8 mg four times daily. With this regimen good pain control was obtained in 56 patients (80%). Patients continued the EM therapy for periods up to 140 days, with an average duration of 27 days. Morphine was substituted for methadone in 14 patients (20%). Four of these patients responded well and continued treatment for an average of 18 days. No serious side effects have been observed with EM. With a proper selection of patients and following strict therapy guidelines, epidural methadone is efficacious in treating cancer pain.

Control of postoperative pain is an important element in preventing the modification of the excitability of the dorsal horn neurons. We studied the efficacy of bupivacaine 0.5% wound infiltration for postoperative pain management following thyroid surgery. Forty consecutive ASA I-II patients, scheduled for thyroidectomy, were assigned randomly to two groups. Group I (n = 20) consisted of patients receiving bupivacaine 0.5% (10 ml) wound infiltration at the end of surgery and group II (n = 20 included patients without infiltration. The patients did not know whether the wound had been anaesthetized or not. All patients received balanced inhalational anaesthesia, including fentanyl (a total dose of up to 4 micrograms.kg-1). Postoperative pain medication included morphine IV or IM, as needed. Twenty-four hours after surgery the worst pain was recorded using a visual analogue scoring system, from 0 to 10. Twenty-four hour postoperative morphine requirement was recorded. Groups did not differ in demographic data. Pain scores significantly different in the two groups. In group I, the mean pain score was 3.7 +/- 1.6 compared with 6.9 +/- 1.7 in group II (P0.05). Only six patients (30%) in group I received opioids and only one of these (5%) had a pain score above 5. In comparison, 18 patients (90%) in group II received morphine during the first postoperative day. The local injection of bupivacaine corresponds to a block of the superficial branches of the cervical plexus. This study demonstrated a simple, efficient and safe way to reduce pain perception following a thyroidectomy.

We studied the postoperative analgesia in 25 patients scheduled for a thyroidectomy or a parathyroidectomy. In 15 patients we used wound infiltration of bupivacaine 0.5%. In both groups we compared the pain score and the analgesic drugs administered after the surgery, within the first 24 hours. We found that wound infiltration is a very efficient way to prevent and to treat the postoperative pain.

The electrophysiological behavior of an isometric contraction sustained to fatigue, was examined in 6 long distance runners and 9 athletes involved in explosive (burst) sports, by on line computer analysis of the electrical activity of vastus medialis, rectus femoris and vastus lateralis. The experiments were carried out with a counterload of 50% of the maximal strength of the muscle. The duration of spike increased and the frequency decreased in the 3 examined muscles, in both types of sport. In the burst sports the changes of value of both parameters were statistically significant in the 3 muscles. In endurance sports the variations of duration were not significant and the changes of frequency were statistically significant only in the vastus lateralis. These results could be explained by the gradual activation of motor units of more strikingly different sizes in burst sports. Thus it may be speculated that prolonged training in burst sports may result in the automatic mobilization of higher number of small motor units, for the initiation of contraction while in endurance sports the onset of contraction is more gradual and carried out by large motor units.

Bupivacaine hydrochloride 0.25% and 0.50% solutions, were administered 115 times by the i.v. regional route to 64 surgical patients and in 38 subjects suffering from pain syndromes. The clinical effects were limb numbness up to 20 h following cuff release, while analgesia and weakness of the limb muscles were evident 5 h after the tourniquet. Clinical and electrophysiological findings revealed a dose relationship of the effects. Toxic signs were noted in three patients in whom the cuff was released in a one-step fashion. In 11 patients, mean arterial plasma concentrations of bupivacaine reached 3.7 micrograms ml-1 after administration of 0.5% bupivacaine 40 ml, 5 min after final cuff release, and decreased gradually thereafter. In selected conditions which do not require a bloodless field and in certain intractable pain states, i.v. regional anaesthesia with high-dose bupivacaine (200 mg of 0.5% solution) may be a simple and effective technique.

Two hundred and ninety-two patients suffering from a wide range of pain syndromes were treated with transcutaneous electrical stimulation (TES). Electrical stimulation of the painful area was administered on the skin by externally applied electrodes, attached to a portable battery-operated apparatus. The results, determined according to a subjective scoring system, were good in 50.7%, moderate in 24.3% and poor in 25% of the patients. TES is a non-invasive technique, has no side effects and may easily be self-administered. It is concluded that it should be tried in pain syndromes for which no specific therapy is available.

Sleep was obtained in man by induction with electrical current. Behavioural observationS as well as recordings of respiration, electrocardiogram and electroencephalogram in the state obtained resembled physiological sleep. Tremor in Parkinsonian patients as well as involuntary movements in a patient with dystonia musculorum disappeared in the electrically induced state of sleep, as is known to happen in physiological sleep. No ill effects were observed after repeated experiments in the same and different individuals.

Percutaneous electrical stimulation (PES) for relief of acute postoperative pain was applied in 10 patients after cesarean section and in 20 women who had undergone various gynecological operations. Thirty other women, subjected to identical surgical interventions, served as controls. In the latter group, the electrodes were attached to a nonfunctioning apparatus. In all patients, including the controls, the two electrodes were introduced intradermally, one on each side of the incision. Implantation was carried out at the end of the surgical procedure while the patient was still anesthetized, and stimulation was commenced immediately. The electrical stimulation was applied continuously for 1 to 3 postoperative days. The generation of pulses was perceived by the patients as a tingling sensation. Complete pain relief was obtained in 40% of the patients treated with PES, whilst in 27% the pain was markedly diminished. Postoperative analgesic medication in this group was reduced by 50-80% as compared to the analgesic requirements in the control group. Other beneficial effects observed in the treated patients included early ambulation, early peristalsis, postpartum uterine contractions and absence of respiratory complications.

The lungs of 25 patients were ventilated with intermittent mandatory ventilation (IMV) during anaesthesia using the Manley Servovent Model MS. This ventilatory mode is especially suitable for prolonged operations in which there is no need for muscle relaxation. While incorporating the advantages of spontaneous and mechanical ventilation, it is superior to both in selected cases. The Manley Servovent Model MS ventilator is capable of delivering IMV without modification, using a single source of gas.

Twenty-eight patients with spastic and obstructive vascular disease were treated with intravenous regional guanethidine (IRG). The drug was injected into the affected hand or foot in doses of 10 or 20 mg, respectively. Temper ature and strain-gauge plethysmography curves of the extremity were recorded before treatment, and three to four times during the subsequent 10 days. The effects of IRG, as observed by clinical laboratory examinations, were good in 8 of 12 patients. But in patients suffering from Bürger's disease or from major vessel obstructive disease, the results were not as good. However, in most pa tients IRG proved beneficial in relieving pain, an effect which sometimes out lasted objective improvements. IRG treatment is a simple and safe method for prolonged chemical sympathectomy.

Combined extradural bupivacaine and methadone analgesia was investigated in 144 patients who underwent extracorporeal shock wave lithotripsy (ESWL). Patients were assigned randomly to one of three groups: group I--extradural 0.5% bupivacaine hydrochloride 0.75 mg kg-1; group II--extradural 0.1% methadone hydrochloride 4 mg after the bupivacaine; group III--as group II, plus a continuous extradural infusion of methadone 0.3 mg h-1 after operation. In all patients, only partial motor deficit occurred. During ESWL, patients who received extradural bupivacaine and methadone had significantly less pain compared with those who had bupivacaine alone (P less than 0.025). Extradural anaesthesia and immersion in the warm water bath were accompanied by only mild fluctuations in arterial pressure. After ESWL, significantly more patients with continuous methadone infusion were pain free (P less than 0.05) and they required less systemic analgesics. The anaesthesia during and after the ESWL procedure may be carried out safely and effectively by the administration of small doses of bupivacaine combined with methadone followed by infusion of the opioid.

SUMMARY A decrease in blood viscosity and haematocrit values was found after the intravenous administration in man of droperidol. This change seems to be related to the sedative and sympatholytic effects of this agent.

Epidural injections of a 2 mg morphine were given to 10 patients with severe acute or chronic pain. All cases had considerable amelioration of pain, which commenced within 2-3 min, reached a peak in 10-15 min, and was effective for 6-24 h. It is suggested that the morphine reached the subarachnoid space and produced its effect by direct action on the specific opiate receptors in the substantia gelatinosa of the posterior-horn cells of the spinal cord.

Sciatic nerve block using the anterior approach is described, together with an account of the authors'experience with the technique in 44 patients.

In a comparative study of 1024 low back pain and healthy subjects, prelysis was found in 16.4%, lysis in 10.5% and olisthesis in 2%. No relation between prelysis and lysis, and low back pain was found. Lysis seemed to be associated with a higher severity of low back pain. All the subjects with olisthesis suffered from low back pain. Based on these findings, it is concluded that lysis or pre-lysis should not be a ground for the exclusion of candidates to any occupation, but that olisthesis should, and that both lysis and olisthesis should be accepted as roentgenological findings in which the severity of low back pain may be higher, thus justifying a more prolonged sick leave.

12 observations. La methadone par voie epidurale est aussi efficace comme analgesique que la morphine mais les effets secondaires et complications sont moindres: retention d'urine, depression respiratoire

A method is described for measurement of plasma methadone concentrations using a gas chromatic technique that is rapid and specific and enables the detection of concentrations of less than 1 ng/ml in plasma samples of only 1 ml. The method, when used to determine the plasma methadone levels in patients given continuous epidural infusions of methadone plus on-demand supplementation for relief of postoperative pain, showed plasma methadone plateaus of around 10 ng/ml (starting at 15 min and lasting over 2 hr) and 20 ng/ml (starting at 3 hr and lasting over the period of treatment) (P less than 0.001) after an initial 2-mg methadone epidural bolus and with continuous epidural methadone. Mean plasma methadone levels of around 10 ng/ml were associated with pain relief. Analgesia could be safely maintained for 24 hr.

Twenty-one patients suffering from severe pain associated with ureteric stones and spasm of the bladder which did not respond to repeated systemic injections of pethidine and papaverine received continuous epidural morphine. The morphine, 3-4 mg per dose, was injected into the lumbar-epidural space, and 15-20 min later all patients were pain free for at least 24 h. Administration of morphine was continued for periods ranging from 2 days to 2 weeks according to need. Eleven of the patients with ureterolithiasis passed the stone spontaneously. Epidural morphine analgesia is indicated for persistent ureteral colic and for spasm of the bladder when conventional treatment fails or systemic drugs are contraindicated. It abolishes pain and spasm for prolonged periods of time and does not interfere with the spontaneous elimination of stone.

Blood viscosity, haematocrit and plasma protein concentration were examined before and during anaesthesia in 58 patients anaesthetized with one of the following: halothane, cyclopropane, thiopentone, ketamine. Blood viscosity and fibrinogen concentration were reduced significantly during anaesthesia with halothane and cyclopropane, but unchanged with thiopentone and ketamine. The haematocrit was also decreased significantly with all agents except ketamine which caused an increase. The total protein concentration was decreased only during cyclopropane anaesthesia.

Percutaneous chemical lumbar sympathectomy with alcohol (PCLSA) using computed tomography (CT) control was performed in 8 patients suffering from advanced peripheral arterial occlusive disease. PCLSA under CT guidance was found to be a simple and safe procedure. The use of CT control added precision in the guidance of needle placement. Positive results were obtained in all patients, without significant morbidity. PCLSA may be an alternative to surgical sympathectomy.

Blood viscosity, hematocrit and plasma protein concentrations were determined simultneously in five different vessels of the systemic and pulmonary circulations, before and immediately after cardiopulmonary bypass and again after surgery. There was a reduction in all these measurements after bypass and a lesser reduction one day after operation. At any one stage, however, values in the pulmonary artery and pulmonary vein were not significantly different from those in the superior vena cava, radial artery and a peripheral vein.

21 ambulatory patients with acute or chronic pain localized to the chest, were treated successfully by continuous intercostal block. They included 6 women and 15 men, aged 39-70. Treatment was initiated in the outpatient clinic and continued at home for usually 5-6 days. Between 15-20 ml of 0.5% marcaine were continuously injected over the course of 6-12 hours through a catheter introduced into the intercostal space by a Touhy needle. 76% of the patients had substantial relief of pain during the block and required only minimal systemic medication. During a 3 month follow-up after cessation of the block, up to 65% were still pain-free. Results were poor or only fair in those with malignancy and long-standing intercostal neuralgias. There were no serious side-effects during treatment. This method is an important new tool in the treatment of pain.

Electrical stimulation in the treatment of postoperative ophthalmologic pain was applied in 25 patients. In 21, stimulation was applied by means of subcutaneously implanted wires and in four patients the therapy was administered by externally placed electrodes. The subcutaneous electrodes were introduced near the supraorbital and infraorbital nerves at the end of the surgical procedures, and stimulation was immediately begun. Duration of treatment varied between one and three days. The nerve stimulator is a portable, battery-operated apparatus. The implanted electrodes avoid skin resistance and are extremely stable, thus affording uniform current intensity that does not change during sudden movements. As a result, the stimuli are perceived as a pleasant sensation. Complete pain relief was attained in nine patients, and in 13 patients the pain was diminished. The therapy is appropriate and effective in postoperative ocular pain, because the pain is restricted to a limited area, innervated by superficial nerves that are easily accessible to electrical stimulation.

The relation between LBP and SBO was studied in 1244 subjects, of which 800 had LBP and 444 served as controls. Sex, age, occupational characteristics, spine curvatures, spinal movements and work history were compared. It is concluded that SBO does not play a causative role, does not cause a proneness to LBP and does not influence the chronicity of LBP. Some data seem to indicate that the severity of LBP may be increased by SBO.

7 cases are reported demonstrating that intrathecal or epidural administration of somatostatin intraoperatively reduced the requirement for other anaesthetics. Somatostatin acts as a potent analgesic, which does not impair circulatory parameters and which possesses no centrally depressing effect. Spinal administration of somatostatin could therefore gain importance in high-risk category patients with normal metabolism.

Electromyogram (EMG) studies were carried out in seven patients with thyrotoxic ophthalmoplegia and one post-thyrotoxic case without clinical evidence of extraocular paresis. Fifteen extraocular muscles were examined, 12 were paretic and 3 clinically healthy. Of the 12 paretic muscles, one exhibited a myasthenic reaction while the other 11 were myopathic. The three clinically normal muscles were also myopathic from the EMG point of view.

SUMMARY Exposure of thirty-three patients to one hour of electrical sleep current resulted in a decrease in the values of blood viscosity, haematocrit, haemoglobin and total plasma protein concentrations. Similar decreases in all these parameters were also observed in a control group of ten patients on whom the electrical current was not turned on. The decreased values in both groups seems, therefore, to be related to sedation and not to a specific action of the electrical current.