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By Vijay Kumar Malesu Nov 23 2023 Reviewed by Lily Ramsey, LLM

In a recent study published in Journal of Clinical Medicine, researchers systematically reviewed and analyzed the therapeutic efficacy of low-dose local anesthetics (LAs) in various clinical conditions, highlighting gaps in current research for future exploration.

Study:  Therapeutic Use of Low-Dose Local Anesthetics in Pain, Inflammation, and Other Clinical Conditions: A Systematic Scoping Review . Image Credit: daniiD/Shutterstock.com Background 

Since the first use of cocaine as an LA by Carl Koller in 1894, LAs have evolved significantly in therapeutic applications. Initially utilized for their immediate pain-relieving properties, their scope expanded with the discovery of procaine in 1905 and its inflammation-reducing effects.

This evolution gave rise to neural therapy (NT), predominantly in Europe, employing LAs for more than just pain management. Modern applications extend to targeting the autonomic nervous system (ANS) to provide sustained relief from pain and other dysfunctions.

Further research is needed to comprehensively understand the scope, efficacy, and safety of low-dose local anesthetics in various conditions, as current studies vary in design, and a unified understanding is yet to be established. About the study 

In the present study, the researchers conducted a systematic scoping review using the Arksey and O’Malley framework, comprising five stages: defining the research question, identifying relevant studies, selecting studies, charting data, and summarizing and reporting results.

The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guidelines, and the research question sought to understand the therapeutic applications of low-dose LAs in various medical conditions.

The team selected studies focusing solely on LAs, emphasizing measuring efficacy or safety. The review included a wide array of study designs, from experimental setups like randomized controlled trials (RCTs) to observational analyses including cohort and case-control studies. Systematic reviews, qualitative studies, and meta-analyses that met the inclusion criteria were also considered, excluding narrative reviews, expert opinions, and studies involving LAs combined with other treatments.

The literature search was comprehensive, covering major databases like MEDLINE, Cochrane Library, and LILACS, with no language or publication date restrictions. They supplemented this with searches on Google Scholar and references from included studies.

Two reviewers independently screened titles and abstracts, with full-text reviews for those meeting the inclusion criteria. Conflicts were resolved through discussion or a third reviewer's input. The study used Rayyan Qatar Computing Re­search Institute (QCRI) for data management during the screening phases. Related StoriesDay-to-day painkiller use doesn't lower empathy levels, but misuse might, according to recent surveyStudy finds pleasurable music and 'chills' predict music-induced hypoalgesiaNew insights into migraine etiology: the role of hepatocyte growth factor

Data extraction was thorough, capturing key information such as authorship, publication year, study objectives, population characteristics, study type, intervention details, outcomes, and main findings. Special attention was given to data on the safety of the interventions. A third reviewer resolved any discrepancies in data extraction.

Finally, the team performed a narrative synthesis of the results, using text and tables from the studies for a descriptive summary.

This synthesis not only outlined the characteristics and findings of the studies but also highlighted gaps in the evidence and offered potential interpretations and implications of the results. Study results 

The initial search across Medline, LILACS, and the Cochrane Library yielded 9614 publications, supplemented by 52 articles from citation searches and grey literature.

After duplicate removal, 7,670 publications were manually screened based on titles and abstracts, excluding 7,250 publications. This process left 420 articles for full-text assessment, with ten being inaccessible, and after thorough evaluation, 315 studies were further excluded. 

The researchers also considered 52 publications identified through citation searching, of which six could not be retrieved. Out of the 46 assessed for eligibility, 12 were excluded for being opinion articles, and 129 studies were included in the review. 

These included studies comprising 49 clinical trials (both non-randomized and randomized), 71 observational studies, and nine systematic reviews. The observational studies varied, including case reports or series, cohort studies, qualitative studies, and before-and-after studies.

The median patient number across these studies was 44. The studies primarily reported on procaine, lidocaine, and bupivacaine, focusing on their therapeutic applications and potential adverse effects.

Geographically, the studies spanned multiple countries, with the most contributions from Türkiye, Germany, the United States, and Cuba, among others. The median publication year was 2016, with a concentration of studies published between 2011 and March 2022.

These studies were predominantly published in general medical journals, although some appeared in specialized journals focused on pain management, neurology, psychiatry, and anesthesiology.

Regarding indications, the primary use of low-dose, short-acting LAs was in managing chronic pain, followed by acute pain. The most common conditions treated were musculoskeletal and/or myofascial pain and migraines. Additionally, 14% of the studies focused on non-pain-related indications.

In the studies, LAs were applied in various ways, including segmental application, local application, ganglion injections, and mixed approaches. The study’s Figure 5 highlights the evidence gaps in the literature regarding the types of indications and study designs.

The review found that 96.12% of the studies primarily assessed the efficacy of LAs, with a smaller portion focusing on safety. The key outcomes included pain relief, improvements in quality of life, reduced analgesic intake, and better scores on anxiety and depression scales.

While 53.48% of these studies also considered safety, reporting mild and transient adverse reactions, no severe adverse allergic responses or reactions were documented.

The study revealed that lidocaine and procaine were the most researched LAs, with lidocaine showing a slightly higher frequency of adverse events, though neither exhibited major adverse effects.

The interventions predominantly showed positive or potentially positive effects, with a minority reporting no effect or providing unclear evidence. A specific focus on acute stress revealed positive impacts, with studies on anxiety and depression as secondary outcomes showing varying degrees of improvement. Journal reference:

Vinyes D, Muñoz-Sellart M, Fischer L. (2023) Therapeutic Use of Low-Dose Local Anesthetics in Pain, Inflammation, and other Clinical Conditions: A Systematic Scoping Review. Journal of Clinical Medicine. doi:https://doi.org/10.3390/jcm12237221. https://www.mdpi.com/2077-0383/12/23/7221 

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Red Sox 1B Casas out for year after knee surgery

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Red Sox 1B Casas out for year after knee surgery

BOSTON — Boston Red Sox first baseman Triston Casas suffered a ruptured tendon in his left knee and is out for the remainder of the season, the team said.

The 25-year-old Casas ruptured his patellar tendon running to first on a slow roller up the line and fell awkwardly in Boston’s victory over the Minnesota Twins on Friday night. After laying on his back in pain — not moving the knee — he was carted off on a stretcher before being taken to a Boston hospital.

The team announced Sunday that he had surgery for a left patellar tendon repair at Massachusetts General Hospital. The surgery was performed by Dr. Eric Berkson.

“I talked to him last night,” chief baseball officer Craig Breslow said in a news conference on Saturday discussing the injury outside Boston’s clubhouse. “We exchanged text messages [Saturday]. We all care deeply about just his overall wellbeing.”

Manager Alex Cora said Casas worked hard during the offseason to play every day after missing a large amount of last year with torn cartilage in his rib cage.

“He did an outstanding job in the offseason to put himself in that situation. It didn’t start the way he wanted it to,” Cora said of Casas’ struggles. “He was going to play and play a lot. Now we’ve got to focus on the rehab after the surgery and hopefully get him back stronger than ever and ready to go next year.”

Casas batted just .182 with three homers and 11 RBIs, but Breslow said his loss will be felt, especially with the team’s lack of depth at the position.

“He certainly struggled through the first month of the season but that didn’t change what we believe his production was capable of being,” Breslow said. “It’s a big loss. In addition to what we think we were going to get on the offensive side, he was kind of like a stabilizing presence on the defensive side of the field — also a big personality and a big part of the clubhouse.”

During spring training, Casas talked about how his focus at the plate this season was being more relaxed.

“You really want it until you don’t,” he said, explaining his thoughts while standing at his locker. “Then you can’t want it that much.”

Now, he’ll have to focus on his recovery plan for next season.

Casas, a left-handed batter, was placed on the 10-day injured list Saturday with infielder/outfielder Abraham Toro selected from Triple-A Worcester.

Cora said Toro — a switch-hitter — will split time at first along with Romy Gonzalez. who bats right-handed.

Breslow said the team might be exploring a long-term replacement.

“This is unfortunately an opportunity to explore what’s available,” he said. “We’ll look both internally and outside as well.”

Cora said there are no plans to move Rafael Devers, who was replaced at third by offseason free-agent acquisition Alex Bregman and moved to DH.

“We asked him to do something in spring training that in the beginning he didn’t agree with it and now he’s very comfortable doing what he’s doing,” Cora said. “Like I told you guys in spring training, he’s my DH.”

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Police foil bomb plot targeting Lady Gaga’s biggest-ever show on Copacabana beach

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Police foil bomb plot targeting Lady Gaga's biggest-ever show on Copacabana beach

Brazilian police say they foiled a bomb attack planned for a Lady Gaga concert on Rio de Janeiro’s Copacabana beach that attracted an estimated 2.1 million people.

The plot was orchestrated by a group promoting hate speech and the radicalisation of teenagers, including self-harm and violent content as a form of social belonging, according to the Civil Police of Rio de Janeiro, which worked in coordination with the country’s justice ministry.

“The suspects were recruiting participants, including minors, to carry out coordinated attacks using improvised explosives and Molotov cocktails,” the force said.

The justice ministry said the recruiters identified themselves as Gaga’s fans, known as “Little Monsters”.

It said Operation Fake Monster was based on a report by the ministry’s cyber operations lab following a tip-off from Rio state police intelligence, which uncovered digital cells encouraging violent behaviour among teenagers using coded language and extremist symbolism.

Authorities carried out over a dozen search and seizure warrants, and a man described as the group’s leader was arrested in the southern state of Rio Grande do Sul for illegal possession of a firearm, and a teenager was detained in Rio de Janeiro for storing child abuse images.

Lady Gaga performing at the huge open-air concert. Pic: Reuters
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Lady Gaga performing at the huge open-air concert. Pic: Reuters

Gaga’s biggest ever show

Some 500,000 tourists travelled to watch the concert, which was paid for by the city in an attempt to boost the struggling economy.

Saturday night’s two-hour show, which marked Gaga’s biggest ever, marked the first time she had played in Brazil since 2012, having cancelled an appearance at the Rock in Rio festival in 2017 over health issues.

Gaga, who released her seventh studio album, Mayhem, in March, opened with a dramatic, operatic edition of her 2011 track Bloody Mary, before launching into Abracadabra, a recent track.

Lady Gaga performs during her free concert on Copacabana Beach in Rio de Janeiro, Saturday, May 3, 2025. (AP Photo/Silvia Izquierdo)
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Pic: AP

Lady Gaga, centre, performs during her free concert on Copacabana Beach in Rio de Janeiro, Saturday, May 3, 2025. (AP Photo/Silvia Izquierdo)
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Pic: AP

“Brazil! I missed you. I missed you so much,” she exclaimed, before launching into Poker Face, one of her biggest hits.

The American pop star drew in a similar crowd to Madonna’s in May last year, who performed at the same beach, which is transformed into an enormous dance floor for the shows.

Addressing the crowd in English and through a Portuguese translator, Gaga became emotional as she said: “I’m so honoured to be here with you tonight.

People attend Lady Gaga's open concert at Copacabana beach in Rio de Janeiro, Brazil, May 3, 2025. REUTERS/Tita Barros
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Gaga addresses the crowd. Pic: Reuters

Gaga seen performing on giant screens set up across the beach. Pic: Reuters
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Gaga seen performing on giant screens set up across the beach. Pic: Reuters

“Tonight we’re making history, but no one makes history alone. Without all of you, the incredible people of Brazil, I wouldn’t have this moment. Thank you for making history with me.

“The people of Brazil are the reason I get to shine today. But of all the things I can thank you for, the one I most am grateful for is this: that you waited for me. You waited more than 10 years for me.”

She said it took so long to come back because she was “healing” and “getting stronger”. The pop sensation cancelled many of her shows in 2017 and 2018 due to her fibromyalgia condition, which can cause pain and fatigue.

It is estimated Gaga’s show will have injected around 600 million reais (£79.9m) into the economy, nearly 30% more than Madonna’s show.

People gather to attend Lady Gaga's open concert, in Copacabana beach in Rio de Janeiro, Brazil May 3, 2025. REUTERS/Pilar Olivares
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Pic: Reuters

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The large-scale free shows are set to continue annually until at least 2028, always taking place in May, which is considered the economy’s “low season”, according to the city’s government.

A hefty security plan was in place, including the presence of 3,300 military and 1,500 police officers, along with 400 military firefighters.

‘A dream come true’

Fans find a spot to watch the show. Pic: AP
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Pic: AP

The city has been swarmed with Gaga fans since her arrival on Tuesday, with some even keeping vigil outside of the hotel she has been staying at.

Many arrived at the beach at the crack of dawn on Saturday to secure good spots on the beach, despite the show not starting until 9.45pm.

An aerial view shows fans gathering on Copacabana beach ahead of Lady Gaga's arrival. Pic: Reuters
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An aerial view shows fans gathering on Copacabana beach ahead of Lady Gaga’s arrival. Pic: Reuters

Ana Lara Folador, who attended with her sister, said it was “a dream come true”, and that Gaga had “really shaped a part of my personality, as a person and an artist”.

Ingrid Serrano, a 30-year-old engineer who made a cross-continent trip from Colombia to Brazil to attend the show, turned up in a T-shirt featuring Lady Gaga’s outlandish costumes over the years.

“I’ve been a 100% fan of Lady Gaga my whole life,” she said, adding the 39-year-old megastar represented “total freedom of expression – being who one wants without shame”.

A fan dons an unusual face mask. Pic: AP
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A fan dons an unusual face mask. Pic: AP

A fan strikes a pose. Pic: AP
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A fan strikes a pose. Pic: AP

Matheus Silvestroni, 25, an aspiring DJ and a Gaga fan since the age of 12, endured an eight-hour bus ride from Sao Paulo for the show.

He said it was Gaga who had inspired him to embrace his sexuality and pursue his dream of becoming an artist.

“I was bullied because I was a fat, gay kid, so I was an easy target,” he said. “Gaga was very important because she sent a message that everything was okay with me, I wasn’t a freak, because I was ‘Born This Way’.”

Rio is known for holding massive open-air concerts, with Rod Stewart holding a Guinness World Record for the four million-strong crowd he drew to Copacabana beach in 1994.

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John Lithgow on JK Rowling’s trans stance backlash: ‘She’s handled it fairly gracefully’

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John Lithgow on JK Rowling's trans stance backlash: 'She's handled it fairly gracefully'

John Lithgow is a man well aware of cancel culture and its ability to destroy careers in the blink of an eye.

The Oscar-nominated actor tells Sky News: “It is terrible to be so careful about what you say. Even in an interview like this. It goes into the world, and you can get misconstrued and misrepresented and cancelled in [the click of a finger].”

Pic: Johan Persson
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Roald Dahl is the subject of West End play Giant, by Mark Rosenblatt. Pic: Johan Persson

It’s a theme that runs parallel with his latest work – the stage show Giant – which through the lens of one explosive day in children’s author Roald Dahl‘s life, poses the question, should we look for moral purity in our artists?

The writer of great works including The Witches, Matilda and The BFG, Dahl revolutionised children’s literature with his irreverent approach, inspiring generations of readers and selling hundreds of millions worldwide. But his legacy is conflicted.

Lithgow describes Dahl as “a man with great charm, great wit and literary talent. A man who really cared about children and loved them. But a man who carried a lot of demons.”

Specifically, the play – which explores Palestinian rights versus antisemitism – deals with the fallout from controversial comments the children’s author made over the Israeli invasion of Lebanon in 1982. Its themes couldn’t be more timely.

Lithgow explains: “Things are said in the play that nobody dares to say out loud… But God knows this is a complicated and contradictory issue.”

More on Jk Rowling

Pic: Johan Persson
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John Lithgow plays Dahl – a man capable of ‘great compassion’ and ‘enormous cruelty’. Pic: Johan Persson

‘It didn’t start as an idea about Roald Dahl at all’

So controversial are some of the play’s themes, the 79-year-old star admits his own son warned him: “Prepare yourself. There’ll be demonstrations in Sloane Square outside the Royal Court Theatre.”

Indeed, the play’s first run carried an audience warning flagging “antisemitic language; graphic descriptions of violence; emotional discussion of themes including conflict in the Middle East, Israel and Palestine; and strong language”.

But it didn’t put audiences off. Following a sold-out run at the Royal Court, the role won Lithgow an Olivier. Now, it’s transferring to London’s West End.

The play was written by Mark Rosenblatt, a seasoned theatre director but debut playwright.

He tells Sky News: “It didn’t start as an idea about Roald Dahl at all. It was about the blurring of meaningful political discourse with racism, specifically when, in 2018, the inquiry into antisemitism in the Labour Party started to come out.”

Rosenblatt describes Dahl’s Revolting Rhymes and Dirty Beasts as the “wallpaper” of his childhood, and says he had no desire to “smash the Roald Dahl pinata”.

But despite the fond recollections, he was conflicted: “Understanding that [Dahl] also, possibly, didn’t like someone like me because I’m Jewish felt complicated.” It was Rosenblatt’s exploration of “how you hold those two things at the same time” that led to Dahl becoming the play’s focus.

Elliot Levey plays Dahl's Jewish publisher, and Aya Cash plays an American Jewish sales executive. Pic: Johan Persson
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Elliot Levey plays Dahl’s Jewish publisher, and Aya Cash plays an American Jewish sales executive. Pic: Johan Persson

‘He’s not cancelled in our home’

Rosenblatt describes him as “a complex man, capable of great compassion, great passionate defence of oppressed people, and also capable of enormous cruelty and manipulation. He was many things at once”.

And as for Dahl’s place in his life now? Rosenblatt says: “I still read his books to my kids. He’s certainly not cancelled in our home.”

It’s likely that Dahl’s comments, if uttered today, would lead to swift social media condemnation, but writing in a pre-social media age, the judgment over his words came at a much slower pace.

Dahl died in 1990, and his family later apologised for antisemitic remarks he made during his lifetime. But the debate of whether art can be separated from the artist is still very much alive today.

Earlier this month, Lithgow found himself drawn into a different row over artists and their opinions – this time concerning author JK Rowling.

Author and Lumos Foundation founder J.K. Rowling attends the HBO Documentary Films premiere of ...Finding the Way Home" at 30 Hudson Yards on Wednesday, Dec. 11, 2019, in New York. (Photo by Evan Agostini/Invision/AP)
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JK Rowling in 2019. Pic:AP

‘A matter of nuance’

Soon to play Dumbledore in the Harry Potter TV series, he has been criticised by some fans for working with the author known for her gender critical beliefs.

Lithgow told Sky News: “It’s a question I’m getting asked constantly. I suppose I should get used to that, but JK Rowling has created an amazing canon of books for kids…

“I have my own feelings on this subject. But I’m certainly not going to hesitate to speak about it. Just because I may disagree… It’s a matter of nuance… I think she’s handled it fairly gracefully.”

The actor ignored calls not to take the role.

He goes on: “Honestly, I’d rather be involved in this than not. And if I’m going to speak on this subject, I’m speaking from inside this project and very much a partner with JK Rowling on it.”

Demanding an eight-year commitment and a move to the UK for the part, the stakes are high.

And with a legion of Harry Potter fans watching on from the wings, only time will tell if the Lithgow-Rowling partnership will prove a magical one.

Giant is playing at the Harold Pinter Theatre in London until Saturday, 2 August.

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