Decrease In Discomfort Research Articles

Moving away from benzodiazepine as a primary sedative in the intensive care unit; is clonidine a viable alternative?

Current pain, agitation, and delirium (PAD) guidelines endorse a benzodiazepine-sparing approach to aid in achieving optimal patient outcomes.[1] Several benzo-sparing strategies, including protocolized and frequent pain, sedation and delirium assessments, achieving the goal of awake and alert, utilization of bolus and symptom-triggered, patient-specific pharmacotherapy, interruption of sedatives, a pain-first approach or analagosedation, early mobilization, rotation of medications, and adjustment of ventilator settings are nonmedication specific principles shown to improve clinical outcomes in mechanically ventilated (MV), intensive care unit (ICU) patients. These techniques and strategies have been associated with some of the most relevant clinical outcomes including a decrease in discomfort, ventilator-associated pneumonia, length of MV, and ICU and hospital length of stay.[2,3] Interestingly, extremely few well-conducted sedative versus sedative trials show improvements in these hard clinical outcomes. Dexmedetomidine is an effective agent for PAD management and a viable alternative to benzodiazepine therapy. Dexmedetomidine maintains a light level of sedation, while minimizing the deep sedation commonly seen with benzodiazepines. In randomized, controlled trials, dexmedetomidine has been associated with shorter duration of delirium and MV compared to benzodiazepine infusion, specifically midazolam.[4] It should be noted, however, that these trials showing a reduction in MV duration are not without criticism. For example, the mean dose of midazolam in the SEDCOM trial was approximately 5 mg/h (based on the average patient weight of 88 kg); an extremely high dose by clinical standards when the goal is to keep a patient awake and alert.[5] Dexmedetomidine is relatively safe with fairly predictable cardiovascular (CV) effects (most frequently hypotension and bradycardia). These CV risks can often be mitigated by avoiding the use of bolus therapy and extending titration intervals to no more frequently than every 30 min.[6] The cost of dexmedetomidine is often a concern in many parts of the world. There are several strategies to address the cost of dexmedetomidine including use of alternative medication or by following restrictive institution specific guidelines. A recent publication on dexmedetomidine stewardship showed an institution's approach to managing the benefits of the drug versus the cost. The guideline followed in this analysis supports judicious use of dexmedetomidine in patients who fail traditional therapy.[7] Another important note in terms of cost is in certain parts of the world dexmedetomidine will lose its patent in the near future and is likely going to be price reduced. We commend the investigators for their fine analysis entitled “comparison of clonidine and dexmedetomidine for short term sedation of ICU patients” published in this month's journal.[8] This trial examined the efficacy and safety of clonidine as an alternative to dexmedetomidine in MV patients. The authors conclude both agents are effective, although clonidine is associated with a higher risk of hypotension. This paper adds to the literature suggesting clonidine may be a useful medication for PAD management although further investigation is needed to confirm these findings. We support the author's conclusion although we think there are some key critiques of this analysis. (1) The authors assessed and titrated to Ramsay Sedation Score (RSS) but pain and delirium assessment scores were not reported. Therefore, it is hard to tell if the pain-first approach was employed prior to the use of either sedative. (2) The goal RSS in this trial was 3-4 yet an RSS of 5, corresponding to awake and alert, may have been a more appropriate goal and these patients may have been more deeply sedated than would be desired in clinical practice. (3) Dexmedetomidine performed better statistically than clonidine, therefore lumping them both as effective may be slightly misleading. It is also important to note that the relatively high incidence of hypotension in the clonidine arm is concerning. A recent trial published on clonidine in noncardiac surgery patients highlights safety concerns with a troubling increase in clinically important hypotension and nonfatal cardiac arrest.[9] Although a different patient population than this study, when combined with the results of this analysis it raises concerns about the safety of this medication. The current analysis should be considered hypothesis generating and clonidine should be further investigated before it is systematically used for management of PAD.

Effectiveness of computerized risk assessment system on enhancing workers' occupational health and attitudes towards occupational health

Efforts have been paid to lower the health risks associated with use of computers at the workplace. Computerized risk assessment systems are available in the market for adoption by companies. The Display Screen Equipment Risk Assessment and Management System was designed for conducting risk assessment and providing intelligent-driven solutions for DSE-related occupational health problems. This report summarizes two consecutive research work conducted on evaluating its effect in reducing body discomfort and mental fatigue, and enhancing sedentary workers' occupational health. Convenience sampling was adopted to recruit participants (111 participants for Study 1 and 75 participants for Study 2 who were randomly assigned to an immediate or a delayed intervention group. The intervention was using DSE RAM System to perform a risk assessment followed by an immediate modification of participant's workstation based on the recommendations generated by the System. Face to face interview was conducted and participants completed three sets of questionnaires right before the assessment and two weeks after the intervention. The results of Study 1 revealed that the DSE RAM System was effective for alleviating the discomfort and fatigue levels by rectifying the workstation-worker match. These mismatches were identified to be the heights of monitor, keyboard and chair with the workers. The results of Study 2 indicate that the System was specific for promoting participants to take more frequent rest breaks (OR: 3.65) and pay more attention to occupational safety and health information (OR: 3.90). In particular, the take frequent rest breaks behavior was found to predict decrease in discomfort in the eyes and mental fatigue (lack of energy). Nevertheless, there was no strong evidence on the use of the System can lead to immediate attitudinal changes towards occupational health and safety. The findings support the notion that workers' participation and integration of ergonomics into the management are important for successful implementation of occupational health programs. Together with educational and skill training sessions on occupational health at the workplace, the DSE RAM System offers a venue for implementing participatory ergonomics at the workplace.

Optimal correction in spectacles: Intervention effects on eyestrain and musculoskeletal discomfort among postal workers

The static posture of postal workers when sorting mail can lead to musculoskeletal discomfort. Research has shown a connection between eyestrain and upper-body musculoskeletal discomfort in general, including postal workers. A previous study of postal workers found that most of those with eye strain were in need of a new correction in their existing spectacles. Evaluate intervention effects on eyestrain and musculoskeletal discomfort with new spectacles for postal workers. Postal workers subjectively reported eyestrain, musculoskeletal discomfort and their opinions of the visual environment via questionnaires pre- and post-intervention. After an eye examination the postal workers were divided into two groups: those who needed new spectacles and those who did not. Those who needed new spectacles showed a higher prevalence of eyestrain and musculoskeletal discomfort pre-intervention. Post-intervention, the postal workers rated their vision better and the average eyestrain and musculoskeletal discomfort decreased for both groups. These workers also experienced a decrease in discomfort on the left (static) side of the neck while sorting mail. An intervention providing the optimal correction reduces eyestrain and decreases musculoskeletal discomfort, especially from the neck.

Warming Intravenous Fluids for Improved Patient Comfort in the Emergency Department: A Pilot Crossover Randomized Controlled Trial

Introduction:The purpose of this study was to test if intravenous (IV) fluids warmed to body temperature are associated with greater patient comfort than room temperature IV fluids in adult emergency department (ED) patients.Methods:This was a pilot double-blind, crossover, randomized controlled trial. Enrolled subjects sequentially received boluses of body temperature (36°C) and room temperature (22 °C) IV fluid, with the order of boluses randomized. Each subject’s level of discomfort was assessed prior to and after each bolus, using a 10 cm visual analog scale (Discomfort VAS), with higher scores indicating greater discomfort. We calculated the change in Discomfort VAS score associated with body temperature IV fluid (ΔVASbody) and room temperature IV fluid (ΔVASroom) by subtracting the score reported before the bolus from the score reported after that bolus. We compared changes in Discomfort VAS score with body temperature and room temperature IV fluid using the Wilcoxon matched-pairs signed-rank test.Results:Twenty-seven subjects were included. Treatment with body temperature IV fluid was associated with a significant decrease in discomfort (median ΔVASbody: −0.7 cm; interquartile range (IQR): −4.5 cm to +0.4 cm) compared to room temperature IV fluid (median ΔVASroom: +1.2 cm; interquartile range: −0.1 cm to + 3.6 cm) (P = 0.001).Conclusion:In this small trial of adult ED patients, infusing IV fluids warmed to body temperature was associated with improved comfort compared to standard, room temperature IV fluids.

Use of mini scleral contact lenses in moderate to severe dry eye

To evaluate fitting feasibility and efficacy of mini scleral contact lenses in moderate to severe dry eye patients. Prospective interventional case series, this study included those patients with grades III and IV dry eye disease, whose symptoms could not be controlled by conventional treatments. Demographic data, UCVA, BSCVA were evaluated before fitting. Mini scleral lens fit was assessed by single experienced practitioner and best corrected vision with mini scleral lens was assessed. After dispensing mini scleral lens, BCVA with mini scleral lens, and possible contact lens related problems were assessed in each visit. Ocular comforts, frequency of artificial tear use, contact lens handling problems were asked in each follow up visit. For those who did not choose to wear lenses, the reason was asked. All data were analyzed using descriptive statistical tests. Twenty eyes of 13 patients were fitted. Mini scleral lens was dispensed for 19 eyes in them assessment of fit was either ideal (n=9) or acceptable (n=10). Seven patients got their lenses; four patients (seven eyes) of them were satisfied with their lenses based on decrease in discomfort and dry eye symptoms, decrease artificial tear need frequency and improvement in visual acuity during mean follow up period of 18.25 months (range: 15-20). None of them was affected with any contact lens related complication. Mini scleral contact lenses can be considered helpful in management of moderate to severe dry eye.

Observation of Resident Clinical Skills: Outcomes of a Program of Direct Observation in the Continuity Clinic Setting

Objective To assess the feasibility of a new multi-institutional program of direct observation and report what faculty observed and the feedback they provided. Methods A program of direct observation of real patient encounters was implemented in 3 pediatric residency programs using a structured clinical observation (SCO) form to document what was observed and the feedback given. Outcome variables included the number of observations made, the nature of the feedback provided, resident attitudes about direct observation before and after implementation, and the response of the faculty. Results Seventy-nine preceptors and 145 residents participated; 320 SCO forms were completed. Faculty provided feedback in 4 areas: content, process of the encounter, patient-centered attitudes and behaviors, and interpersonal skills. Feedback was 85% specific and 41% corrective. Corrective feedback was most frequent for physical examination skills. After program implementation, residents reported an increase in feedback and a decrease in discomfort with direct observation; in addition, they agreed that direct observation was a valuable component of their education. Participation rates among faculty were high. Conclusions Direct observation using SCOs results in timely and specific feedback to residents about behaviors rarely observed in traditional precepting models. Resident competency in these clinical skill domains is critical for assessing, diagnosing, and managing patients. The SCO methodology is a feasible way to provide formative feedback to residents about their clinical skills.

Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation

Water immersion is an alternative colonoscopy technique that may reduce discomfort and facilitate insertion of the instrument. This was a prospective study to compare the success of colonoscopy with minimal sedation using water immersion and conventional air insufflation. A total of 229 patients were randomized to either water immersion or the standard air insertion technique. The primary outcome was success of minimal sedation colonoscopy, which was defined as reaching the cecum without additional sedation, exchange of the adult colonoscope or hands-on assistance for trainees. Patient comfort and satisfaction were also assessed. Successful minimal-sedation colonoscopy was achieved in 51 % of the water immersion group compared with 28 % in the standard air group (OR, 2.66; 95 % CI 1.48 - 4.79; P = 0.0004). Attending physicians had 79 % success with water immersion compared with 47 % with air insufflation (OR, 4.19; 95 % CI 1.5 - 12.17; P = 0.002), whereas trainees had 34 % success with water compared with 16 % using air (OR, 2.75; 95 % CI 1.15 - 6.86; P = 0.01). Using the water method, endoscopists intubated the cecum faster and this was particularly notable for trainees (13.0 +/- 7.5 minutes with water vs. 20.5 +/- 13.9 minutes with air; P = 0.0001). Total procedure time was significantly shorter with water for both experienced and trainee endoscopists ( P < 0.05). Patients reported less intraprocedural pain with water compared with air (4.1 +/- 2.7 vs. 5.3 +/- 2.7; P = 0.001), with a similar level of satisfaction. There was no difference in the neoplasm detection rates between the groups. Colonoscopy insertion using water immersion increases the success rate of minimal sedation colonoscopy. Use of the technique leads to a decrease in discomfort, time to reach the cecum, and the amount of sedative and analgesic used, without compromising patient satisfaction.

Transpedicle body augmenter for vertebral augmentation in symptomatic multiple osteoporotic compression fractures

Background:Multiple osteoporotic vertebral compression fractures (VCFs) have been treated with polymethylmethacrylate augmentation; however, there are cement complications and long-term fracture healing that are unknown. Transpedicle body augmenter (a porous titanium spacer) has been reported as an internal support to reconstruct the vertebral body combining short-segment fixation in burst fracture and Kümmell's disease with cord compression. Transpedicle body augmenter for vertebral augmentation (TpBA) also has been reported successfully in treating single painful VCF and vertebral metastasis lesions including pending fractures and pathologic compression fractures. To test the hypothesis that TpBA can effectively and safely treat the symptomatic multiple VCFs, this retrospective study was done by analyzing the radiographic and clinical results.Materials and Methods:We retrospectively reviewed clinical and radiographic results of TpBA for symptomatic multiple (more than two levels) VCFs in 62 patients with a total of 236 levels, i.e. 3.8 VCFs per patient. Manual reduction and TpBA via paramedian incisions with blunt dissection were done. One incision was made for two continuous levels and alternative side was selected for next incision. Mean age was 74.3 years (range, 62-87 years), and female-male ratio was 5.2:1. Anterior vertebral height and wedge angle by radiographic findings were measured at preoperative, initial follow-up and final follow-up. Clinical results were assessed by questionnaires and clinical observations. By July 2008, 58 patients returned to answer the questionnaire including quantification of pain on the visual analog scale, the response to operations (better, same, or worse after operation), returned to their pre-fracture function (yes/no) and satisfaction (a scale of 0 = completely dissatisfied to 10 = completely satisfied).Results:The mean symptom duration was 7 months, and follow-up, 48 months. The average operation time was 21 min per level, blood loss was 74 cc per level and hospitalization was 4.4 days. No patient had neurological deterioration. There was no dislodgement of implant in the final visit. Forty-eight patients (77.4%) could walk within 6-8 h after operation and the others, within 24 h. The anterior vertebral restoration was 7.3 mm initially and 6.2 mm at final follow-up. Wedge angle correction was 10.4° initially and was 9.3° at final follow-up. Pain, by the visual analog scale, was 8.5 preoperatively, 2.7 at day 7 follow-up and 2.9 at final follow-up. By the questionnaire, 52 of 58 respondents reported a decrease in discomfort after TpBA and 48 of 58 patients reported a return to normal activity after operation. The final satisfaction rate was 89.7%.Discussion:The symptoms of multiple osteoporotic compression fracture may be due to unstable fracture, radiculopathy, and global traumatic kyphosis with posture changes, which can be corrected by multiple TpBA. The transpedicle body augmenter was initially stabilized by the sinking and locking mechanism and finally by bone ingrowth.Conclusions:TpBA via a minimally invasive method led to early and medium-term clinical improvements and anatomic restoration of multiple symptomatic VCFs.

Using Wheelchair Sports to Complement Disability Awareness Curriculum Among College Students

The purpose of this study was to examine the effects of a campus-wide intramural wheelchair sports program on attitudes toward people with disabilities. The sample consisted of 126 participants at a large, western university. A quasi-experimental pre-post design was used. Results indicated that there was a significant decrease in discomfort in interaction with people with disabilities after participation in the program. Additional findings indicated that recreation majors who were required to have some disability awareness training in their coursework had statistically lower pre- and post-test scores than other majors and demonstrated the greatest change in attitude toward people with disabilities. Implications and recommendations are discussed.

The effect of the impedance of a thin hydrogel electrode on sensation during functional electrical stimulation

Surface functional electrical stimulation results in stimulation of cutaneous receptors and discomfort. The degree of non-uniformity of current distribution in the cutaneous layers in the vicinity of the electrode may influence the sensation experienced. This paper describes the effects on sensation of a thin, high impedance electrode designed to reduce the non-uniformity of current distribution. Sensation associated with stimulation via a self-adhesive electrode with much higher impedance than conventional electrodes was compared with a low impedance electrode in a single-blinded, crossover study. The high impedance electrode does not alter either the current at which sensation is first registered. However, at higher currents, the high impedance electrode allows 9% more current to be passed for an equivalent sensation to that experienced with the conventional electrode. A 28% decrease in discomfort with the use of the high impedance electrode was also reported.

Transpedicle body augmenter in painful osteoporotic compression fractures.

Osteoporotic compression fractures (VCFs) can result in progressive kyphosis and chronic pain. Polymethylmethacrylate has been used for augmentation of VCFs; however, there are cement complications, and long-term fracture healing is unknown. The transpedicle body augmenter (TpBA), a porous titanium spacer, has been reported as an internal support to reconstruct the vertebral body combining short segment fixation in burst fracture. We retrospectively reviewed radiographic and clinical results of TpBA vertebroplasty for single symptomatic VCF in 80 patients. Manual reduction and TpBA vertebroplasty via a paramedian incision with blunt dissection was done. Mean age was 72.3 years (range 51-87 years), and female-male ratio was 66:14. The mean symptom duration was 5 months, and follow-up 44 months. Peri-operative variables and radiographic and clinical results were evaluated. The average operation time was 26.1 min, blood loss 92 cc, and hospitalization 2.3 days. No patient had neurological deterioration. TpBA was found sinking into vertebral body initially, then locked by residual cortex, and finally stabilized within the vertebra. There was no dislodgement of TpBA in the final visit. Sixty-two patients (77.5%) could walk within 3-6 h after operation and the others within 24 h. The anterior vertebral restoration was 8.0 mm initially and 6.1 mm at final follow-up. Wedge angle correction was 11.5 degrees initially and 9.4 degrees at final follow-up. Pain, by the visual analog scale, was 8.6 pre-operatively, 2.5 at day 7 follow-up, and 2.9 at final follow-up. By the questionnaire, 72 of 76 respondents reported a decrease in discomfort after TpBA vertebroplasty, and 63 of 76 patients reported a return to normal activity after operation. The final satisfaction rate was 93.4%. TpBA vertebroplasty led to early and medium-term clinical improvement and anatomic restoration of painful VCFs.

Circadian heart rate patterns and schizophrenia

Cold water immersion (CWI) and ice massage (IM) are commonly used treatments to prevent the delay onset of muscle soreness (DOMS); however, little is known on their relative benefits and effectiveness to lower tissue temperature. This study was designed to evaluate the effectiveness of IM and CMI on tissue temperature and potential benefit to preventing DOMS. The research encompassed 36 subjects divided into three groups of twelve depending on the form of recovery: ice massage (IM), cold-water immersion (CWI), or passive recovery (PAS). All the participants were asked to jump as high as possible from a full squat for one minute. Thermal imaging was conducted at rest, immediately following the exercise, immediately after the trial, following the recovery treatment, and after 30 min of rest. Their pain levels were assessed using the Visual Analogue Scale (VAS). After applying the selected method for supporting recovery, the LA level decreased by 4.25 mmol/L in the IM group, and by 4.96 mmol/L in the CWI group (IM vs. CWI p>0.05). The 2.75 mmol/L decrease in lactate concentration in the PAS group was significantly lower than in the other groups (IM vs. PAS p<0.05/ CWI vs. PAS p<0.01). In both groups, Tsk after 30 min was significantly lower (ΔTsk~0.5 °C) than at rest (p<0.05). In turn, Tsk in the PAS group returned to the resting values (p>0.05). Seventy-two hours after the exercise, a clear decrease in discomfort was observed in the IM and CWI groups compared to the PAS group. The two applied treatments have proven to be effective both in utilizing lactate and preventing DOMS. Depending on training requirements, we recommend the use of IM when athletes experience localized muscle fatigue. One the other hand, CWI is recommended in situations of global or generalized muscle injury or fatigue.

Decreasing Workload by Increasing Workers – The Effect on Discomfort, Heart Rate and Muscle Activity

As a temporary measure to reduce the risk of injury at the Chipping Line in a foundry, the number of workers was increased from three to four per shift. To examine the effects of the intervention, electromyography (EMG), heart rate, and questionnaire measures were taken eight months before the intervention and four months after the intervention. Questionnaire measures were repeated approximately every two months throughout the year. Decreases in discomfort were found in most body parts in the intervention group, but not in the comparison groups (p&lt;0.10 for the left shoulder and wrist between groups). There was a decrease in absolute heart rate in the intervention group (p&lt;0.05). Changes in forearm muscle activity were not apparent.

Assessment and Treatment of Discomfort for People with Late-Stage Dementia

People with dementia have often been excluded from pain studies. However, there is evidence supporting that people with dementia experience frequent pain, often poorly assessed and undertreated, and that the etiology for pain descriptions is poorly documented. The Assessment of Discomfort in Dementia (ADD) Protocol is designed to: a) more accurately assess discomfort in people with dementia who can no longer verbally describe physical pain or affective discomfort; b) more accurately and thoroughly treat physical pain and affective discomfort; and c) decrease inappropriate use of psychotropic medication. The use of the ADD Protocol was studies with a convenience sample of 104 residents of long-term care with end-stage dementia. Use of the ADD Protocol was associated with a significant decrease in discomfort (t = 6.56, p = 0.000). The most frequently seen behavioral symptoms associated with discomfort were tense body language, sad facial expression, fidgeting, perseverant verbalizations, and verbal outburts. The ADD Protocol was also associated with a significant increase in the use of scheduled analgesics and non-pharmacological comfort interventions. The protocol was not associated with an increase in the use of prn analgesics or with prn or scheduled psychotropics. This study has provided some support for the notion that the needs of people with significant dementia can be discerned and treated.

Managing difficult staff interactions: effectiveness of assertiveness training for SCI nursing staff.

Sixty-one members of the nursing staff of a spinal cord injury (SCI) center at a Department of Veterans Affairs Medical center were assessed before and after a 3-hour class on managing difficult staff interactions. The assessment consisted of two questionnaires that were developed to assess staff discomfort when dealing with common interpersonal situations in rehabilitation. The class involved a lecture and discussion, modeling, and behavior rehearsal. Repeated measures analysis of variance showed an overall effect of training. There was also a statistically significant relationship between staff members' educational levels and the level of discomfort related to interpersonal interactions that they experienced after attending the class. Registered nurses reported a statistically significant decrease in discomfort. The conclusion was that the class was effective in helping registered nurses reduce their discomfort in some difficult rehabilitation situations.

Perceived Discomfort and Electromyographic Activity of the Upper Trapezius While Working at a VDT Station.

Ten female participants performed work at a video display terminal (VDT) station over a whole working day. Subjective local muscular fatigue was evaluated by means of the Category Ratio 10 scale. Electromyographic activity of the upper right and left trapezius was measured. A comparison was made between 5 participants who had previous complaints and 5 participants who reported no musculoskeletal problems in the shoulder-neck region. The subjective scores for the shoulder differed significantly between the two groups, being higher for the group with complaints. Both groups showed a decrease in discomfort after the lunch break. The activity of the trapezius increased significantly for both groups, in a more pronounced way for the group with disorders. Although it is found in literature that VDT work is a task with very low static loads, it seems from this study that the EMG activity increase can be an indication of muscle fatigue: More effort was required to accomplish the same VDT task at the end of the day.

Predictors of tinnitus discomfort, adaptation and subjective loudness

In a nation-wide investigation, covering all the hearing centres in Sweden, a study was made of adaptation processes, subjective discomfort from tinnitus, subjective loudness of tinnitus and psychological complaints in 3372 subjects by means of a questionnaire. The most important predictors of discomfort from and adaptation to tinnitus were found to be the controllability and the degree of maskability by external sounds, i.e. the subject's coping abilities or internal-external locus of control. Increased control and masking effects from the environment imply a decrease in discomfort and better adaptation. The most important predictor of worsened subjective loudness of tinnitus was the duration of the tinnitus. That is, subjects who had had tinnitus for a longer time perceived the loudness as more intense. The psychosomatic factors which most strongly predicted increased discomfort from and decreased tolerance to tinnitus were depression and insomnia. These findings have theoretical and practical implications for the management and treatment of tinnitus.

Using the electric pulp tester with gloves: A simplified approach

A method is presented which simplifies the use of the electric pulp tester for the dentist who routinely wears gloves in practice. Advantages of this method include a reduction in patient apprehension as well as a possible decrease in discomfort for the patient.

Discomfort and bite force in painful masseter muscles after intramuscular injections of local anesthetic and saline solution

Thirty women with a history of daily pain in the masseter muscles were injected with either lidocaine or saline. The participants were told that they were being given an anesthetic injection to reduce their muscular discomfort. The dentist performing the injections did not know which fluid was used. The discomfort in the masseter muscle was assessed by using Borg's new rating scale before and 10 minutes after injection. The evaluation was followed up on day 1, day 3, and day 7. Bite force was registered between the first molars on the injection side. When scale values were compared individually within groups before and after injection, a significant decrease in discomfort was found in both groups, with the exception of day 1 for the lidocaine group and days 1 and 3 in the saline group. The total lidocaine and saline groups assessed the discomfort similarily except on day 3 when the lidocaine group showed significantly less discomfort. The intraindividual force values increased significantly after injection in the saline group. This effect was not found in the lidocaine group. Despite the minor tendencies for lidocaine to have a better effect, the placebo effect was considered to be high and important.

Evaluation of transsphenoidal hypophysectomy in the management of patients with advanced malignant melanoma.

Transsphenoidal hypophysectomy was performed in 13 patients with advanced malignant melanoma. Although three minor responses were observed, there were no complete or partial responses. All three patients with bone pain had a decrease in discomfort lasting 1-2 months. All five patients with minor responses or stable disease had postoperative decreases in the excretion of the dihydroxyphenylalanine (DOPA) metabolite 3-O-methyldopamine; all but one patient with clinical progression had postoperative increases in excretion. Average survival of those whose postoperative excretion fell (143 +/- days; range, 60-217+) was significantly longer (P less than 0.004) than that of those whose postsurgical values rose (30 days; range, 15-58).