The cyclooxygenase-2 (COX-2) selective inhibitor parecoxib is widely used in the treatment of pain and inflammation. Parecoxib has been adopted for use for postoperative analgesia following a range of surgical procedures . Total knee or total hip arthroplasty (THA) surgery is mostly done in older patients, so postoperative analgesics need to be used more carefully, and the safety and efficacy of parecoxib in this type of surgery need to be further verified. The aim of this study was to investigate the effects of parecoxib on patient safety, cumulative morphine consumption and was at 24 and 48 hours in the analgesic treatment of total knee or THA for meta-analysis and systematic review, with few studies in this area so far.I2, the random-effect model or fixed-effect model was supposed to combine data from studies, respectively. Publication bias was assessed through funneling plot and Beggs test. Review Manager 5.3 and Stata 16.0 software were applied to perform the statistical analyses.We searched the Online Database Cochrane Library, PubMed, Web of Science, EMBASE, and CBM (SinoMed), CNKI, VIP, WANFANG up to January 2021. According to the value of Eleven RCTs which involved 1690 participants were included in this study. The meta-analysis indicated parecoxib sodium could not significantly reduce the incidence of adverse events after total knee or THA compared with placebo. There was no statistical significance in incidence of nausea and vomiting. 24 hours resting VAS score was statistically significant between the group. The 48-hour resting VAS scores did not indicate a significant difference between the groups.Parecoxib can reduce the incidence of adverse events after total knee or total hip surgery to some extent but cannot reduce the incidence of nausea and vomiting. Twenty-four hour postoperative analgesia is better than placebo, but 48 hours after operation analgesia is the same as placebo. After >50 years of clinical practices, the therapeutic effect of artificial joint replacement has been fully affirmed and has developed into a reliable treatment. The 25-year combined survival rate of total knee or total hip replacement is 77.6%. In the United States, 1 million total knees or total hip arthroplasty (THA) and total knee arthroplasty (TKA) are performed each year,,4 which is expected to increase in the next few years. The incidence of complications in total knee or THA is 3.2% to 8.0%. How to reduce the safety and pain after total knee or THA is an effective way to improve postoperative complications.It is estimated that 310 million patients worldwide undergo surgery every year. Use of opioids after orthopedic surgery varies greatly, and there is no consensus on the establishment of appropriate nursing standards. Many patients who take opiates before operation continue to use opioids after joint replacement. Some patients who have not used opioids still use opioids, but the continuous use of opioids has nothing to do with joint pain. There is no consensus on the best method of anesthesia and analgesia for total knee or THA.–14 The purpose of our clinical practice is to control postoperative pain effectively and minimize the risk of using opioids.Morphine is an opiate receptor agonist, which has a good effect on all kinds of pain. The most common adverse reaction is nausea and vomiting, and extensive use can also make patients addicted.,17 Studies have demonstrated that COX-2, as an isomer of cyclooxygenase, is induced by preinflammatory stimulation, so it is speculated that COX-2 plays the most important role in the synthesis of prostaglandin-like transmitters related to pain, inflammation and fever. Dozens of studies have shown that in the absence of pain, adverse events and other negative factors, early activity after joint replacement can shorten the hospital stay of about 1.8 days, and there are positive benefits to achieve early activity within 24 hours after operation. However, it is not clear whether pareoxib can effectively reduce the negative factors after knee or hip arthroplasty. This study is based on a randomized controlled meta-analysis and systematic review to evaluate the clinical role of pareoxib in pain relief of total knee or THA.Pareoxib is the prodrug of valdicoxib, and valdicoxib is a selective cyclooxygenase (COX)-2 inhibitor in the clinical dose range, which has been widely used in postoperative analgesia.For patients who receive THA or TKA, their race, nationality and course of disease are not limited.There are no ethical issues with our article.The observation group was treated with pareoxib, and the control group was treated with placebo. Routine anesthesia was used in both groups, and the results were consistent between the 2 groups.① Overall adverse events, ② nausea and vomiting events, ③ 24-hour resting VAS score, and ④ 48-hour resting VAS score . Meanwhile, the heterogeneity was quantitatively judged by 2I. If there is no statistical heterogeneity among the studies, the fixed-effect model is used for Meta-analysis; if there is statistical heterogeneity among the studies, the source of heterogeneity is further analyzed. After excluding the influence of obvious clinical heterogeneity, the data are analyzed by random-effect model for Meta-analysis. The level of Meta-analysis was set as α = 0.05. The obvious clinical heterogeneity was treated by subgroup analysis or sensitivity analysis, or only descriptive analysis.The data were analyzed by RevMan5.3 software and Stata16. The mean difference was used as the effect analysis statistic for the measurement data, and the risk ratio (RR) was used as the effect analysis statistic for the 2-category variables, and each effect quantity provided its 95% CI. The heterogeneity among the included studies was analyzed by χA total of 318 related articles were obtained in the initial examination. After layer-by-layer screening, 13 RCTs (including 1868 patients) were included. The literature screening process and results are shown in Figure  This instrument is referred to as the “Jadad scale.” Scale scores can range from 0 to 5 points, with higher scores indicating better quality , suggesting that although pareoxib sodium can reduce the incidence of adverse events after hip surgery, the degree of reduction is not statistically significant, that is, from a statistical point of view, there was no significant difference in adverse events between pareoxib sodium and placebo.The 10 RCTs in this study have been tested for heterogeneity, and Q test P = .695 > .05 from Egger test) and no publication bias, which indicates that the conclusion of this study is accurate and reliable , which means that the overall adverse event rate of parecoxib sodium after knee or hip joint surgery is only 0.84 times that of the placebo group. It is statistically significant , suggesting that although pareoxib sodium can reduce the incidence of adverse events after knee or hip surgery, the degree of reduction is not statistically significant, that is, from a statistical point of view, there was no significant difference in nausea and vomiting between pareoxib sodium and placebo , and there is no publication bias conclusion, suggesting that the conclusions of this study are accurate and reliable , that is, in the baseline period, there is no difference in the VAS scores between the 2 groups, and subsequent Meta-analysis can be performed.Before performing meta-analysis, it is necessary to ensure that the baseline periods of the 2 groups of VAS are consistent, so that subsequent meta-analysis can be performed. Finally, 4 articles provided VAS baseline data, and the results are as follows. From the above forest diagram, we can clearly see that there is no heterogeneity in the VAS baseline period difference (effect size) between the 2 groups  is not statistically significant, and the fixed-effect model is selected to combine the effect size, and the combined effect size is −0.51 , statistically significant. That is, intravenous injection of parecoxib sodium for pain relief after knee or hip joint surgery can reduce the 24-hour resting VAS score compared with intravenous placebo  is not statistically significant, and the fixed effect model is selected to combine the effect size, and the combined effect size is −0.05 , the 48-hour resting VAS score was not statistically significant. That is, compared with intravenous injection of placebo, intravenous injection of parecoxib sodium for pain relief after knee or hip joint surgery can reduce the 48-hour resting VAS score, but the reduction does not reach statistical significance. That is, from a statistical point of view, there is no difference between the 2 -2 inhibitor, which plays a reverse regulatory role. The most frequent adverse events after operation are nausea and vomiting. Severe nausea and vomiting may not only affect the comfort of patients but also lead to a variety of other complications, such as surgical suture cracking, bleeding, and so on. Nausea and vomiting not only reduces patients’ satisfaction with the health care system, but also prolongs hospital stay and health care costs. The safety of pareoxib sodium in postoperative pain relief of total knee joint and total hip joint is relatively stable. As can be seen from figure II, although the overall incidence of adverse events and the incidence of nausea and vomiting events were not statistically significant, they may also be superior to the placebo group to some extent. There was mild heterogeneity in overall adverse events and nausea and vomiting events, considering differences in adverse event statistics and placebo use in different studies. Pareoxib sodium belongs to COX-2 inhibitors. COX-2 inhibitors play an analgesic role by reducing the synthesis of peripheral prostaglandins to reduce inflammation and inhibit the expression of peripheral and central COX-2, and ultimately reduce the sensitivity of the central nervous system. A meta-analysis shows that perioperative use of pareoxib sodium can reduce pain and opioid intake in patients with TKA, and there are no serious complications, which is consistent with our study.After operation, except that the injured cells released inflammatory mediators such as histamine and bradykinin, immune cells were attracted to the injured site and released proinflammatory cytokines , which increased the expression of inducible cyclooxygenase (COX)-2 in monocytes, macrophages, fibroblasts, chondrocytes, and endothelial cells from 10-fold to 80-fold.–23,28,32 Orthopedic surgeons account for a large proportion of the prescription of opioids for the management of postoperative pain. How to minimize the use of opioids and effectively control postoperative pain is a long-term topic. Although dozens of evidences supporting nonopioid analgesia, there is still no multimodal scheme that can completely eliminate the use of opioids. In this study, the combined use of pareoxib sodium reduced the use of opioids to some extent, which is of great clinical significance.Due to the different opinion doses given during initial anesthesia and the combination of other painkillers, there is a 100% heterogeneity in the quantitative analysis of cumulative opioid consumption, so the researchers did not make a meta-analysis of opioid intake. However, from the related studies, it can be seen that the combined use of pareoxib sodium for pain relief can significantly reduce the consumption of opioids.,24,25,31 The results of another study were about 24-hour and 48-hour resting VAS score, although only 4 articles were eventually included in the study, but there was no significant difference in the baseline VAS of the 4 studies. One of the 4 studies used articular pain relief as a placebo and the other 3 placebos were injected intravenously, so a subgroup analysis was performed. After subgroup analysis, it was found that pareoxib sodium showed the greatest advantage in the role of 24-hour resting VAS score, which could significantly improve the pain of patients. Another 48-hour resting VAS score was not statistically significant, but the outcome showed that pareoxib sodium was still beneficial in relieving pain. The analgesic effect of pareoxib sodium is similar to that of placebo after 2 days, so there is no need to further extend the analgesic time of pareoxib sodium. The description of pareoxib sodium manual describes limited clinical experience after 3 days of use, and the results of this study partly suggest that it is not necessary to use pareoxib sodium for >3 days.Since total knee or hip surgery usually improves a patient’s mobility, it is important in order to assess postoperative pain. The purpose of this study was to determine whether the use of nonopioid analgesia regimens can effectively control VAS pain score after total knee or hip surgery. Due to the inconsistency of exercise intensity, there is a great heterogeneity in the results of dynamic 24-hour and 48-hour VAS, and it is difficult to get a unified conclusion, so the researchers do not make too many comments on this content.The major limitation in this study is that the small sample size weakens our analysis results. The inconsistency of adverse events included in each study is an important reason for the heterogeneity of overall adverse events associated with pareoxib sodium. The time of the study is short and lack of long-term clinical significance. The placebo for postoperative pain relief of the knee joint or hip joint is mostly given intravenously, and more research is needed to support the analgesic effect of intracranial injection.Our result suggest that he combination of pareoxib for pain relief did not lead to an increase in adverse events and the analgesic effect of combined use of pareoxib sodium was the most obvious 24 hours after operation. In order to further confirm our conclusions, more high-quality studies need to be carried out to verify them.We thank Jinlong Xu, Caimu Wang, Hai-Yan Xie, who have been a source of encouragement and inspiration.Each author has undertaken all of the following tasks listed:conceived or designed the study, or both;drafted the review or commented on it critically for intellectual content;provided final approval of the document to be published.


Background. This study aimed to investigate the effects of different final irrigation solutions on postoperative pain following root canal treatment.Methods. Eighty-nine nonvital premolar and molar teeth with periapical lesions (PAI: 3‒4) without any clinical symptoms were included. The patients were randomly assigned to three groups according to the final irrigation solutions used: G1: 2 mL of Qmix (n=29), G2: 2 mL of 17% ethylenediaminetetraacetic acid (EDTA) (n=30), and G3: 2 mL of 2% chlorhexidine gluconate (CHX) (n=30). All the patients were prescribed 100 mg of flurbiprofen to use as needed for pain. The patients were asked to rate their pain status according to the verbal rating scale at 12, 24, 48, and 72 hours, and one week. The data were analyzed using Pearson’s chi-squared test, Fisher’s exact test, and chi-squared analysis with Monte Carlo simulation. The significance level was set at P≤0.05.Results. No significant differences were observed in postoperative pain rates at 12, 48, and 72 hours and one week (P>0.05). However, in the Qmix group, a significantly lower pain level was observed at 24 hours with EDTA and CHX (P=0.019). The rate of mild pain in the EDTA group at 72 hours (18.8%) was significantly higher in premolar teeth than in molar teeth (P=0.012). The moderate pain level in the EDTA group at 12 hours was significantly higher in those>60 years of age (P=0.008).Conclusion. The use of Qmix as an irrigation solution resulted in lower postoperative pain levels at 24 hours compared to other solutions. Therefore, Qmix can be considered a proper final irrigation solution in endodontic treatment regarding postoperative pain. A systematic review showed that the incidence of postoperative pain following root canal treatment ranged from 3% to 58%.2The instrumentation process depends on the clinician’s experience3 and factors such as instrument type, instrument kinematics, etc. Therefore, postoperative pain is considered multifactorial. Debris extrusion to the periapical tissues might occur during root canal preparation.4 Debris, which includes infected dentin and bacteria, is a primary cause of postoperative pain.5Irrigation solutions and medicaments used during root canal preparation procedures might cause irritation and chemomechanical injury of periradicular tissues, resulting in postoperative pain.6Sodium hypochlorite (NaOCl), ethylenediaminetetraacetic acid (EDTA), and chlorhexidine gluconate (CHX) solutions are recommended during instrumentation to optimize root canal disinfection.7 No irrigation solution has both sufficient antibacterial efficacy and the ability to dissolve organic and inorganic tissues, which are the main features expected from an irrigation solution.8For these reasons, NaOCl, EDTA, or CHX are used routinely as the final irrigation solutions in root canal treatment.9Many studies have reported that removing the smear layer is important to achieve effective adhesion between root canal filling and dentin.10It has been reported that the smear layer can be completely removed by NaOCl and EDTA in combination.12Qmix 2in1  contains EDTA, CHX, a nonspecific detergent, and water. It is an endodontic irrigation solution that is as effective as 17% EDTA in removing the smear layer.14In addition, many studies have shown Qmix to be effective in destroying microorganisms15 and recommended its use as the final irrigation solution after following irrigation with NaOCl.14 The main goal of root canal treatment is to hermetically obturate the root canal system with sufficient biomechanical material to heal periradicular tissues while minimizing patient discomfort.16This study aimed to evaluate the effects of EDTA, CHX, and Qmix as the final irrigation solutions in endodontic treatment on postoperative pain. The primary outcome measure of the study was to assess if different final irrigation solutions influence the occurrence of postoperative pain. The secondary outcome measure of the study was to compare postoperative pain levels between the groups by tooth type. To the best of our knowledge, there are few studies in the literature to have investigated the effect of Qmix as the final irrigation solution in endodontic treatment on postoperative pain. The method and design of this prospective, randomized, double-blind clinical trial were approved by the Ethics Board of the University (No: 929). The study protocol was published and registered at www.clinicaltrials.gov (identifier: NCT04310254). Before inclusion, all the patients were informed of the study protocol, aims, complications, and possible risks, and written informed consent was obtained from each patient. Patients who met the inclusion criteria were treated by a single endodontist (SIY) from the Faculty of Dentistry, Department of Endodontics, between October 2019 and February 2020. A sample size estimation was determined using G*Power software (Version 3.1.9.7) to achieve a minimum 20% decrease in postoperative pain at 80% study power with an effect size of 35% and a significance level of 5%. Accordingly, it was concluded that there should be a minimum of 28 patients in a group. Systemically healthy individuals, 18‒69 years of age Nonvital mandibular premolar and molar teeth without periapical lesions and clinical symptoms Asymptomatic nonvital teeth with a negative response to electrical and cold tests and a negative response to percussion and palpation tests Premolar and molar teeth with a diameter of 2‒5 mm (PAI: 3‒4) of the periapical lesion without any calcification and obliteration in the pulp chamber on radiographic examination Teeth without fractures, cracks, or apical resorption Patients that used drugs for pain and infection control, such as analgesics, anti-inflammatory agents, and antibiotics in the previous 12 hours Patients with a history of susceptibility or adverse reactions to any drugs or materials used in the study Presence of calcified root canals or severe periodontal problems in the tooth in question Missing opposite or adjacent teeth Pregnant or breastfeeding women https://www.randomizer.org, a free resource for researchers to generate random numbers or randomly assign participants to experimental conditions. The patients were assigned to study groups according to the number sequence obtained on the site. Eighty-nine patients were randomly assigned to three groups and blinded to the study group allocation. The randomization protocol was implemented at  For blinding purposes, sealed numbered syringes containing the final irrigation solutions were covered with identical tape, prepared, and packaged by a dental nurse not involved in the study so that the syringe contents were not visible and could not be distinguished. Freshly prepared solutions were matched with the group number for each patient and noted on the syringe. A dental assistant gave each solution to the dentist according to the patient’s group number. Therefore, neither the patient nor the physician knew which solution was applied. In addition, the statistician did not have any information about the characteristics of the groups during the statistical evaluation phase of the study. The groups were statistically analyzed using group numbers only. All the root canal treatments were completed in a single session by one endodontist (SIY) with nine years of experience. Inferior alveolar nerve local anesthesia was applied using a 27-gauge, 2-inch dental needle  with 1.5 mL of 40-mg/mL articaine and 0.01-mg/mL epinephrine . A conventional root canal access cavity was prepared using round diamond burs  under rubber dam isolation. The working length was determined with a #15 K-file  using the Root ZX apex locater  and checked with a diagnostic radiograph. Root canals were instrumented with ProTaper Next  rotary instruments with a torque-controlled endomotor . The apical diameters of the mesial roots were 25.06, and the distal root was 30.06. A lubricant  was used between each file to prevent rotary files from getting stuck in the root canal. During the instrumentation, 2 mL of 2.5% NaOCl  was applied to each root canal for 30 sec using a 30-gauge side-vented endodontic injector , 1 mm shorter than the working length. After the irrigation protocol was completed using NaOCl, the final irrigation solutions were applied with a 30-gauge side-vented endodontic injector (Dentsply), 1 mm shorter than the working length, using the following protocols:Group 1 : After applying 2 mL of saline solution to each root canal for 30 sec, 2 mL of Qmix solution was applied for 60 seconds. Group 2 : After applying 2 mL of saline solution to each root canal for 30 sec, 2 mL of 17% EDTA was applied for 60 seconds. Group 3 : After applying 2 mL of saline solution to each root canal for 30 sec, 2 mL of 2% CHX was applied for 60 seconds.  After all the irrigation procedures were completed, the root canals were dried using sterile paper points . Next, the root canals were obturated with a single cone technique using gutta-percha  suitable for master apical file and a root canal paste  with epoxy resin content. After obturation, root canal filling was checked by radiography. Permanent restorations of the teeth were made with composite material , and the patients were prescribed 100 mg of flurbiprofen to use when there was unbearable pain. All occlusal contacts were avoided following root canal treatment to prevent inappropriate traumatic occlusion. Postoperative pain was evaluated using the verbal rating scale (VRS). Following the endodontic treatment, each patient was given a form to record their pain level. The patient was informed about the treatment procedure and the use of the form. Postoperative pain was recorded using a 4-level VRS 12, 24, 48, and 72 hours and one week after treatment. The patients were contacted at each time interval to remind them to record their pain level. The tooth types were also compared to each other (premolar and molar teeth). Pain levels were categorized as follows:No pain; tooth feels normal Mild pain that does not require taking analgesics Moderate pain that diminishes with an analgesic Severe pain that does not decrease with analgesics  To maintain statistical blindness, the data obtained in this study were encoded into a Microsoft Excel (2010) spreadsheet . The statistician did not have any information about the working groups. SPSS 21  was used for statistical evaluation. Categorical variables were analyzed using Pearson’s chi-squared test. In addition, Fisher’s exact test and chi-squared analysis with Monte Carlo simulation were used. The significance level was set at 0.05 for all the tests. Of 266 patients referring to the clinic between October 2019 and February 2020, 92 met the inclusion criteria and agreed to participate in the study. Three patients were lost during the follow-up period. Therefore, 89 patients were statistically evaluated . No flarP = 0.434). The ages of the patients ranged from 20 to 69, with a mean age of 36.19 ± 13.77 years. A significantly higher pain level was observed in the EDTA group at 12 hours in patients over 60 years of age  were female, and 47 (53%) were male. There was no statistically significant difference between gender and experimental groups (P = 0.751) was higher than that in the other groups. Although the group with the highest “no pain” ratio was the Qmix group (62.1%), there were no statistically significant differences between the groups at 12 hours (P = 0.751). At 24 hours, the highest incidence of “mild pain” was observed in the EDTA group at 33.3%. CHX and EDTA resulted in a higher pain severity than Qmix (P = 0.019). There were no significant differences between groups in postoperative pain values at 48- and 72-hour and 1-week intervals (P > 0.05). At 72 hours in the Qmix group, 100% of the patients reported “no pain” postoperatively. At the 1-week interval in the EDTA group, 100% reported “no pain” postoperatively. However, at the 1-week interval in the CHX group, “mild pain” was still reported (6.7%). Postoperative pain distribution among the groups, according to time intervals, is shown in P = 0.012). At 72 hours in the EDTA group, reports of mild pain in premolar teeth were statistically higher than in other groups (P = 0.012). No significant differences in pain level were observed between tooth types and groups at other time intervals (P = 0.054)  was significantly higher than in molar teeth at 72 hours (= 0.054) . There w17 Previous studies have compared postoperative pain and irrigation solutions used during root canal treatment.18 This study was designed to investigate the effects of various final irrigation solutions on postoperative pain following root canal treatment. Postoperative pain following root canal treatment negatively affects patients’ quality of life.19 A rotary system was used in all the patients, following the manufacturer’s instructions. In the present study, all the treatment procedures were performed in a single session to avoid possible factors that might cause pain, such as intracanal medication or leakage of temporary fillings. The working length was detected with an electronic apex locater and confirmed by radiographs. The Root ZX apex locater was used to determine the working length because of its accuracy.12the concentration of NaOCl used in this study was 2.5% to minimize toxic effects and benefit from antimicrobial properties. In the present study, 2.5% NaOCl, saline, and 17% EDTA were used sequentially in the EDTA group. Additionally, a saline solution was used to prevent brown toxic precipitates when CHX and NaOCl solutions were combined. Due to its low biocompatibility and incidence of toxic effects on periradicular tissues,13As indicated by previous studies, no irrigation solution possesses all the desired properties.7The present study showed that the use of Qmix as a final irrigation after NaOCl positively affects and decreases postoperative pain in patients. This decrease is statistically significant at 24 hours. This positive effect of the Qmix solution might be related to its effective role in removing the smear layer14 and high antibacterial efficacy.13 In a study by Yılmaz et al,16 postoperative pain level after root canal treatment using Qmix with Endo Activator , was significantly lower compared to NaOCl. Yilmaz et al16 attributed the reduction in postoperative pain to the use of EA. Since there are no other clinical studies comparing Qmix as a final irrigation solution concerning postoperative pain following root canal treatment, it is not possible to compare the data. One study found Qmix more biocompatible than other irrigation solutions.20 Another study found Qmix more effective than NaOCl in biofilm removal.21The authors attributed this finding to the effective removal of the smear layer by the ingredients in Qmix. In the present study, patient pain level was significantly lower with Qmix than other groups, similar to previous studies.16Thus, the null hypothesis was rejected. Qmix, containing EDTA, CHX, and surfactants, such as detergents, has shown high antimicrobial properties. While the EDTA component of Qmix dissolves the smear layer, the CHX ingredient has strong antimicrobial properties.22In a previous study conducted by Almeida et al,23no differences occurred in postoperative pain following root canal treatment between two groups treated with 5.25% NaOCl and 2% CHX. In another study, greater postoperative pain was reported when CHX was used as an intracanal medicament, compared to calcium hydroxide.24Contrary to these studies, Bashetty and Hegde25used 5.25% NaOCl and 2% CHX in nonvital teeth and the pain level was statistically lower in the first 6 hours with CHX. In the present study, more severe pain was reported with CHX versus Qmix at 24 hours. Although CHX is a biocompatible solution, Qmix is thought to have higher biocompatibility due to its components.14In addition, more severe postoperative pain at 24 hours with EDTA, compared to Qmix and CHX, might be due to the detergent structure of EDTA, resulting in the exacerbation of an existing inflammatory state. Due to its wide antimicrobial effect and low cytotoxicity, making it effective in root canal irrigation and medication, CHX is used as an endodontic irrigation solution.26In the current study, only nonvital mandibular posterior teeth (premolar and molar) were used. In previous studies, more severe postoperative pain was reported in molar teeth compared to premolar and anterior teeth.27In addition, the complex anatomy of mandibular molar teeth affects cleaning of the lateral canals in the apical region of the root canal and healing of periapical lesions. Therefore, mandibular molars with necrotic pulp allow the evaluation of the worst case scenario.28In the present study, while there were no statistically significant differences between premolar and molar teeth and groups at 12, 24, and 48 hours, there was a statistically higher pain level in the EDTA group at 72 hours in molar teeth. However, in the present study, the number of premolar teeth was lower compared to molar teeth. Therefore, additional studies with an equal number of premolar and molar teeth are recommended. Preoperative pulpal and periapical status are important factors in postoperative pain.29The VRS scale allows for identification of pain and quantification with numerical data. In addition, the visual analog scale (VAS) is a valid and reliable method for pain measurement. The VAS scale exactly predicts pain, not by range, but by ratio. However, pain is influenced by various factors; therefore, the VRS scale, with only 4 categories, was used to facilitate the rating process for the patient. In the current study, postoperative pain severity was evaluated using VRS. It was categorized as no pain, mild, moderate, and severe. Patients in this study were instructed to use analgesics as needed. These instructions were given to prevent psychological anxiety related to pain and prevent patient anxiety from influencing the results of the study.30In the present study, randomization was performed regularly, the operator did not interfere with the allocation of patients to any treatment group, and the preoperative status of patients in each group was similar. The patients were randomized prior to treatment. Randomization reduces bias in treatments. Various randomization methods have been used in clinical studies to prevent bias between the operator and patients . Qmix caused less pain levels in 24 hours than other solutions. There was no difference between irrigation solutions after one week. Qmix was associated with less severe postoperative pain, and it can be concluded that using Qmix as a final irrigation solution in endodontic treatment is appropriate. The authors thank Dr Karakaş for statistical analysis. SIY contributed to the study concept and design, acquisition of data, drafting of the manuscript, and critical revision. KO performed the analysis and interpretation of data and critical revision. None. The study design was approved by the Ethics Committee of Istanbul Medipol University (No: 929). And ClinicalTrials.gov. with the Ref No. NCT04310254. The authors deny any conflict of interest.


The aim of the study is to explore the impact of perioperative pain care management on patients' pain, comfort, and defecation in anorectal surgery.  From January to December 2021, 126 patients who underwent anorectal surgery in our department were selected for the study and were randomly divided into a study group and a control group of 63 patients each after consent was obtained from the patients. The control group was given the usual care protocol and the study group was given the perioperative pain care management on top of the usual care. The two groups of patients were compared in terms of postoperative anal pain rating, comfort score, time to first bowel movement and time spent in bowel movement, the Pittsburgh sleep quality index (PSQI) scores at night, related complications, and satisfaction with care. P < 0.05). ② Postoperative comfort scores were higher in the study group than in the control group (P < 0.05). ③ The time to first bowel movement and its duration after surgery were shorter in the study group than in the control group (P < 0.05). ④ Patients in the study group had lower postoperative night-time PSQI scores than the control group (P < 0.05). ⑤ Patients in the study group had a lower rate of postoperative complications than the control group (P < 0.05). ⑥ Patients in the study group had higher postoperative care satisfaction scores than the control group (P < 0.05).  ① Postoperative anal pain was less severe in the study group than in the control group ( The application of perioperative pain care management to patients undergoing anorectal surgery plays an important role in reducing anal pain, improving treatment comfort, and relieving difficult defecation symptoms, with significant improvement in postoperative sleep quality and reduction in complications. It is worthy of clinical reference and promotion. Department of Proctology is one of the most important departments in the hospital. The study of diseases that occur in the organs at the end of digestion, i.e., between 8 and 12 cm from the anal opening to the rectum, treats constipation, anal fistula, haemorrhoids, perianal abscesses, anal fissures, and rectal cancer, with a tendency to be located in the anus and rectum , 4. In rP > 0.05).A total of 126 patients who underwent anal surgery in our department from January to December 2021 were selected for the study. The inclusion criteria were as follows: ① those who met the diagnostic criteria for relevant anorectal diseases in anorectal pathology  and the Both the groups performed the relevant anal surgery with reference to the relevant protocols in practical anorectal surgery . The conThe pain care management team was formed by the head of our anorectal department, consisting of experienced attending physicians and head nurses. The members were responsible for analysing the patient's condition, formulating a pain prevention and management plan in conjunction with the clinical reality, updating and improving the plan to ensure its effective implementation and to improve the quality of pain management.The training focused on the rational use of analgesic drugs, various modes of analgesic methods, and several measures to prevent wound infection. The training of nursing staff was regularly evaluated and the results were linked to their salaries, thus increasing their motivation to work.① Dietary interventions: The patient's diet was under strict control before and after the operation; the patients were strictly prohibited from consuming spicy, cold, greasy, and other foods to avoid stimulation of the gastrointestinal tract, especially for patients with haemorrhoids, before and after the operation, the diet should mainly contain liquid or semiliquid food, as far as possible to reduce the amount of bowel movements, in order to reduce the pain in the anus. During the later stages of hospitalisation, the diet was adjusted appropriately according to the patient's recovery although no stimulating foods could be used, and vegetables and fruits of coarse fibre and that were easy to digest could be added appropriately. In addition, the nursing staff could communicate with the patients and adapt recipes to their daily dietary preferences to provide better quality care. ② Wound pain care: Postoperative caregivers needed to select a pain rating scale to assess the patient's pain level on a continuous basis and make a dynamic scale of the specific data collected to reflect the various stages of the patient's recovery. The nursing staff should give corresponding nursing care according to the specific pain degree of the patient. When the pain was mild, they could be instructed to choose the knee bending lateral position or deep breathing method to relieve the pain; when the pain was obvious, the attending doctor could be informed, and the patient could be given analgesic drugs in strict accordance with the doctor's advice. At the same time, the patient should be warned not to stand for a long time during normal activities and should also avoid pulling the wound due to impulsive movement of the lower limbs. ③ Dressing change care: Regular postoperative wound dressing changes are required. Sitz bath fumigation was provided 30 minutes prior to dressing change to improve peri-incisional subcutaneous blood circulation and enhance the drug absorption. When changing the dressing, the exact location of the wound should be determined, the existing dressing should be removed with warm water and the skin should be wiped dry, and a new dressing should be applied, following aseptic standards to prevent postoperative infection. The movement in the process must be smooth and gentle, and the drainage gauze should be properly placed to avoid the pain caused by dressing and pressing. Attention should be paid to creating a private space for patients during the whole dressing change procedure. ④ Functional exercise: In the recovery stage, the nursing staff should guide the patients to carry out the corresponding rehabilitation training, including moderate simple exercises such as raising and shrinking the anus. During exercise, the nursing staff should help the patient to maintain a state of muscular and psychological relaxation, with a variety of options such as autonomous deep breathing, distraction methods and if necessary, music or television programmes. It was important to advise the patient to pay attention to the strength of the muscle contraction during the specific exercise and not to rush it, but to gradually increase the strength of the contraction to ensure that the wound could adapt to the intensity of the exercise. If pain was felt in the wound during training, it was necessary to stop immediately and continue only after the pain has disappeared; if the pain was not relieved for a long time, the wound was needed to be checked for secondary tears and treated promptly. ⑤ Defecation care: Creating a private space for patients to defecate, eliminating their nervousness, shyness, and embarrassment, etc., and promoting smooth bowel movements; patients were advised not to squat/sit for long periods of time when toileting and not to use excessive force to avoid retearing the wound and increasing perianal pain; it was important to clean thoroughly after defecation and to maintain anal and perianal hygiene and to take one to two sitz baths per day as directed by your doctor to reduce the risk of infection and relieve pain. ⑥ Psychological care: Some patients had severe postoperative pain that was also associated with factors such as psychological cues. For those with such tendencies, caregivers could eliminate the negative effects of tension, anxiety, fear, and other negative emotions on postoperative pain through music therapy and distraction methods to increase their comfort with treatment and improve their satisfaction with care. Nursing staff could also introduce patients to success stories on the ward to help build their confidence in recovery in a patient-directed way, as well as increase the communication between patients and alleviate negative psychology.At regular intervals, patient feedback was used to assess the content of nursing care and to identify the oversights and shortcomings during the work and improve them. The nursing staff were rewarded for excellent performance with pay and goods to stimulate their motivation and enthusiasm for their work. Nursing staff who performed poorly were punished with verbal criticism or bonuses. In this way, the management was improved and quality care was provided to patients.The verbal rating scale (VRS)  was usedKolcaba's general comfort questionnaire (GCQ) , 13 was The time to first bowel movement and duration of bowel movement after surgery were compared between the two groups.The Pittsburgh sleep quality index (PSQI)  was usedThe occurrence of complications related to the care period was compared between the two groups.The self-made nursing satisfaction scale in hospital was used as the basis for assessing satisfaction with nursing care, which consisted of 24 items; all assessed on a 5-point scale from 0 to 4, with a total score of 0–96, the higher the score, the better the satisfaction with nursing care.s) by the t test and the count data were described as (%) by the χ2 test, with P < 0.05 being a statistically significant difference.The statistics and validation of this care outcome were completed by using the SPSS 20.0 statistical software. The measurement data were expressed as (P < 0.05). See Postoperative anal pain was less severe in the study group than in the control group (P < 0.05). See Postoperative comfort scores were higher in the study group than in the control group (P < 0.05). See Figures The time to first bowel movement and its duration after surgery were shorter in the study group than in the control group (P < 0.05). See Patients in the study group had lower postoperative night-time PSQI scores than the control group (P < 0.05). See Patients in the study group had a lower rate of postoperative complications than the control group (P < 0.05). See Patients in the study group had higher postoperative care satisfaction scores than the control group (Pain is an unpleasant sensory and emotional experience that occurs when the body is injured and is accompanied by existing or latent tissue damage , 16 . AlIn the conventional model of care, the healthcare provider only pays attention to the changes associated with the patient's incision after surgery. Pain management, on the other hand, means caring for the patient's postoperative incision recovery status while also being mindful of the patient's physical and mental health, resulting in a significant reduction in pain and a further increase in patient comfort. In recent years, our department has advocated the implementation of pain care management for surgical patients, focusing on six aspects of dietary intervention, wound pain care, dressing change care, functional exercise, bowel care, and psychological care. It is also a continuous process of improvement and refinement of care measures, with the main aim of reducing anal pain triggers and adverse factors affecting the wound recovery, in order to provide a more detailed, quality and comfortable healthcare experience for patients.The results of this study showed that patients in the study group who were managed with timely pain care after surgical treatment had significantly better pain relief, postoperative comfort, bowel movement, and sleep quality than the control group who were treated with routine perioperative care during the same period and that the study group had fewer postoperative complications and higher patient satisfaction, making it more valuable. Possible reasons for the analysis of the above results are the following: ① enhanced postoperative dietary interventions not only avoid painful irritation from irritating foods but also reduce the risk of haemorrhoids and are beneficial in enhancing the prognosis of patients; ② anal function training can be done by lifting and retracting the anal sphincter to promote postoperative smooth bowel movements and to reduce the anal stimulation caused by the prolonged toilet time and the retearing of the anal opening caused by difficult defecation, so as to reduce the pain symptoms; ③ trauma pain care through the development of a dynamic pain score scale, which allows healthcare professionals to understand the patient's specific situation at each stage of recovery in real time and to provide appropriate care and pain relief instructions; ④ during dressing change care, attention is paid to maintaining appropriate strength and protecting the wound, as well as to the psychological needs of the patient, focusing on the protection of the patient's privacy, so that the patient is more receptive psychologically, reducing the sense of rejection and facilitating the postoperative rehabilitation treatment; ⑤ the study also improved the quality of patients' prognosis through defecation instructions, which consisted of three components: creating a private space, controlling the intensity of defecation, and cleaning after defecation to shorten the defecation time improve the incidence of complications such as infection and pain, and to improve the quality of care from both a physical and psychological perspective; and ⑥ given that 60% of the patients' postoperative pain levels were related to their poor psychological cues, the nursing staff in this study alleviated the patients' adverse emotions by means of positive psychological suggestion, distraction, and playing soothing music to improve the adverse effects of adverse emotions on pain, thereby reducing postoperative pain symptoms and improving the prognosis. Finally, by waiting for the regular summarisation and assessment of nursing work content, this study records the various problems that arise in clinical work, considers the subsequent improvement plans, and links the assessment results and management effects with the performance of nursing staff, which helps the continuous self-reflection and self-improvement of medical and nursing staff, and ultimately improves the level of nursing management and the quality of nursing services.The application of perioperative pain care management to patients undergoing anorectal surgery has an important role in reducing anal pain, improving treatment comfort, and relieving difficult defecation symptoms, with significant improvement in postoperative sleep quality and reduction in complications. It is worthy of clinical reference and promotion.


Research suggests that pain assessment involves a complex interaction between patients and clinicians. We sought to assess the agreement between pain scores reported by the patients themselves and the clinician’s perception of a patient’s pain in the emergency department (ED). In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.We conducted a prospective observational study in the ED of a tertiary academic medical center. Using a standard protocol, trained research personnel prospectively enrolled adult patients who presented to the ED. The entire triage process was recorded, and triage data were collected. Pain scores were obtained from patients on a numeric rating scale of 0 to 10. Five physician raters provided their perception of pain ratings after reviewing videos.A total of 279 patients were enrolled. The mean age was 53 years. There were 141 (50.5%) female patients. The median self-reported pain score was 4 (interquartile range 0–6). There was a moderately positive correlation between self-reported pain scores and physician ratings of pain , with a weighted kappa coefficient of 0.39. Some discrepancies were noted: 102 (37%) patients were rated at a much lower pain score, whereas 52 (19%) patients were given a much higher pain score from physician review. The distributions of chief complaints were different between the two groups. Physician raters tended to provide lower pain scores to younger (P = 0.02) and less ill patients (P = 0.008). Additionally, attending-level physician raters were more likely to provide a higher pain score than resident-level raters (P <0.001).Patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement between the two. Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should consider both patient and physician factors. Acute pain is one of the most common complaints of patients presenting to the emergency department (ED).7Inappropriate pain management, such as oligoanalgesia, remains common in the ED.Therefore, in this prospective study we sought to assess the agreement between pain scores reported by patients and those gauged by physicians. In addition, we attempted to identify patient and physician factors that lead to greater discrepancies in pain assessment.From May 2020–January 2021, we conducted a prospective observational study in the ED of the National Taiwan University Hospital (NTUH). The NTUH is a tertiary academic medical center with approximately 2,400 beds and 100,000 ED visits per year. Trained research personnel prospectively enrolled patients who presented to the ED using a standard protocol. Inclusion criteria were age ≥20 years  and the ability to provide informed consent. We excluded patients who needed immediate cardiopulmonary resuscitation, those with psychiatric complaints or consciousness disturbance, or those who needed isolation for infection control. A high-sensitivity camera and a clip-on Bluetooth microphone were set up to record the entire triage process, including patient facial images and conversations between patients and triage nurses .What do we already know about this issue?Research suggests that pain assessment involves a complex interaction between patients and clinicians.What was the research question?We measured the agreement between pain scores reported by patients and pain assessed by emergency physicians via video review.What was the major finding of the study?Patients’ self-reported pain scores correlated positively with the pain score provided by physicians , with only a moderate agreement.How does this improve population health?Under- and over-estimations of pain in ED patients occur in different clinical scenarios. Pain assessment in the ED should encompass both patient and physician factors.In Taiwan, ED triage is conducted by senior ED triage nurses who are familiar with a computerized triage software called the Taiwan Triage and Acuity Scale (TTAS). The TTAS was adapted from the Canadian Triage and Acuity Scale (CTAS) and has been validated against hospitalization, length of ED stay, and resource utilization.15We also retrieved the computerized TTAS system that contains information on a total of 179 structured chief complaints. Based on the computerized algorithms, the TTAS classifies patients in the following order of acuity: level 1, resuscitation; level 2, emergent; level 3, urgent; level 4, less urgent; and level 5, non-urgent. Other triage data were collected, including demographics, mode of arrival, trauma mechanisms, work-related injury, past medical history, structured chief complaints, vital signs , body weight, height, and levels of consciousness coded per the Glasgow Coma Scale (GCS).The recorded videos underwent quality checks to ensure adequate sound and image quality. Five emergency physician reviewers (three senior residents and two attending physicians) were recruited and trained via educational meetings. Reviewers were provided with triage electronic health records but were blinded to the pain score documented; however, they may have overheard self-reported pain scores during the video review. Reviewers were asked to provide their perceived pain scores based on not only self-reported pain scores, but also objective clues, including chief complaints, facial expressions, body posture, vocalization, and vital signs.This study was approved by the NTUH Institutional Review Board, and informed consent was obtained from all participants.Summary statistics are presented as proportions , means (with SD), or medians (with interquartile ranges [IQRs]). We examined bivariate associations using Student’s t-tests, Mann-Whitney tests, Fisher’s exact tests, and chi-square tests, as appropriate. The agreement of pain scoring was measured by the kappa statistic with quadratic weighting. We also used the ICC and Spearman’s correlation. A Bland-Altman plot was performed to assess the agreement of pain scoring between patient self-report and physician ratings of pain. We used a two-way scatterplot to depict the relationship between the two scoring approaches with a best-fit linear regression line.Previous studies have shown that an approximately 1.30- to 1.65-point is the minimal clinically important difference (MCID) in the NRS from 0–10.P-values are two-sided, with P <0.05 considered statistically significant.We anticipated that the mean of differences between self-reports and physician ratings would be 0.5 and the SD of differences would be 0.65.P < 0.001). There was a 0.3-point increase in physician rating per 1-unit increase in self-reported pain score. The correlation coefficient also showed a moderately positive correlation . The ICC between the two scoring systems was 0.55. Among the 279 patients, 102 patients were rated at a much lower pain score (group A), whereas 52 patients were given a much higher pain score (group B). The baseline characteristics of patient groups A and B are listed in In a subgroup analysis of group B, 49 patients were considered to have vague pain . The mosIn this prospective videotaped study, we found a moderate agreement between pain scores reported by patients and those given by physicians. In addition, physician raters tended to give lower pain scores to younger patients and patients with a lower triage level. By contrast, attending-level physician raters were more likely to provide a higher pain score, particularly for those suffering from illnesses not directly related to pain.For group A, the results revealed that many patients reported higher pain scores than those based on physicians’ evaluations, a finding that is consistent with previous reports.29For group B, physician raters perceived that some patients might be experiencing a greater deal of pain than they reported. For the vague-pain group (a subset of group B), physician raters perceived some pain when none was reported by the patient. Patients may appear to have suffered from their non-painful symptoms , which may have resulted in the perception of pain by the physician. For example, the physician raters in our study may have noticed non-verbal cues from patients’ facial expressions, body language, and conversations with triage nurses and assigned a non-zero pain score.31Previous studies have shown that younger age, female gender, and ED diagnoses of headache and back pain were associated with higher self-reported pain scores.36Moreover, race and ethnicity play an important role in a physician’s perception of a patient’s pain. For example, the pain of Black Americans is often underdiagnosed and undertreated in the US, compared to that of their White counterparts.This study has some potential limitations. First, self-reported pain scores may be limited by patients’ personal experiences, educational levels, and cognitive status.In this prospective videotaped study, patients’ self-reported pain scores correlate positively with the pain score provided by physicians, with only a moderate agreement. Under- and over-estimations of pain in ED patients occur in different clinical scenarios that deserve a closer look by the treating physician. Pain assessment in the ED requires a multifaceted approach considering both patient- and physician-related factors.


While high-quality data are rather limited, studies generally show that these remedies are at least as effective as placebo, and are well tolerated with minimal side effects. We will need more placebo-controlled, double-blind, and unbiased prospective studies to document and quantify efficacy.Chronic abdominal pain is one of the most common problems seen by both pediatricians and pediatric gastroenterologists. Abdominal-pain-related functional gastrointestinal disorders (AP-FGIDs) are diagnosed in children with chronic and recurrent abdominal pain meeting clinical criteria set forth in the Rome IV criteria. AP-FGIDs affect approximately 20% of children worldwide and include functional dyspepsia (FD), irritable bowel syndrome (IBS), functional abdominal pain (FAP), and abdominal migraine. IBS accounts for 45% of pediatric AP-FGIDs. The pathophysiology of functional abdominal pain involves an interplay of factors including early life events, genetics, psychosocial influences, and physiologic factors of visceral sensitivity, motility disturbance, altered mucosal immune function, and altered central nervous system processing. Treatment approaches are varied and can include dietary, pharmacologic, and complementary medicine interventions, as well as psychosocial support, depending on the many aspects of the disorder and the needs of the individual patient. There is a strong interest in complementary and integrative medicine approaches to pediatric pain from both patients, providers, and families. In this article, we discuss popular herbal treatments typically used in the field of complementary medicine to treat pediatric AP-FGIDs: peppermint oil, Iberogast Chronic abdominal pain is one of the most common gastrointestinal symptoms seen by both pediatricians and pediatric gastroenterologists. Abdominal-pain-related functional gastrointestinal disorders (AP-FGIDs) are diagnosed in children with chronic and recurrent abdominal pain meeting clinical criteria set forth in the Rome IV criteria . AP-FGIDThe pathophysiology of functional abdominal pain involves an interplay of multiple factors including early life experiences, genetics, psychosocial influences, and physiologic factors of visceral sensitivity with altered central nervous system processing, abnormal motility, and abnormal mucosal immunity . TreatmeIn the following sections, we present an overview consisting of a non-systematic summation and analysis of the literature available on the topic of herbal approaches to pediatric functional abdominal pain, noting that there is a paucity of data in this area. The herbs selected for review in this paper were determined by consensus among pediatric gastroenterologists with expertise in Integrative Medicine who also participate in the Integrative Medicine Special Interest Group of the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN). We selected six herbal treatments that are commonly used in clinical practice and which have been addressed in the medical literature. Relevant articles were identified using the PubMed, Cochrane, and Scopus databases, searched between January and May 2022. Search terms included “peppermint,” “Mentha × peperita,” “fennel,” “Foeniculum vulgare,” “licorice,” “Glycyrrhiza glabra,” ”Iberogast,” “STW5,” “marijuana,” “cannabis,” “cannabidiol,” “THC,” “tetrahydrocannabinol,” “ginger,” “Zingiber,” and “herbal medications” in combination with the terms “clinical trial,” “review,” “systematic review,” “meta-analysis,” and “pediatric” or “children.” We included full manuscripts, prospective studies, retrospective studies, review articles, systematic reviews, and meta-analyses. We excluded studies that were not published in the English language. We did not perform meta-analyses or standardized literature reviews, but rather have presented highlights and impressions which may be of use to fellow clinicians. These are also summarized in 2+ channels and reduction of acetylcholine release from enteric nerves via its action on nicotinic receptors in the GI tract [®—187 mg of peppermint oil) or placebo (Arachis oil capsule) for 2 weeks. Patients weighing 45 kg or more received two PMO or placebo capsules three times a day. Children with weights between 30 kg to 45 kg were given one capsule three times a day. Of the 42 children that completed the study, 75% who received PMO reported significant improvement in severity of abdominal pain as compared to 19% in the placebo group (p < 0.001) [® capsules (Bacillus coagulans + fructooligosaccharide), PMO (Colpermin®—187 mg of peppermint oil), or a placebo (folic acid) for one month. The dosing protocol in this study was the same as mentioned in the Kline study above. From the data analysis of 88 children who completed the study, significant improvements in pain duration, severity, and frequency were seen in the PMO group as compared to placebo . PMO was also found to be superior to Lactol in decreasing pain duration and severity . No side effects were reported in any of the study groups.Peppermint oil (PMO) is extracted from fresh peppermint leaves by steam distillation and contains menthol as the primary ingredient . PMO hasGI tract ,15. The < 0.001) . Similar< 0.001) . ChildreThere has been one pediatric study to date assessing the motility effects of PMO in children. This study included 30 children with functional abdominal pain and demonstrated a decrease in whole gut mean peak contraction with PMO but without any significant change in the whole gut transit time . This coPeppermint oil is generally well tolerated at the commonly recommended dosage. It is contraindicated in patients with hiatal hernia or gastroesophageal reflux disease (GERD) as it can worsen reflux symptoms due to its effects on the lower esophageal sphincter ,18.Fennel, also known as Foeniculum vulgare, is an herb that grows year long and is one of the oldest plants utilized in traditional medicine . It poss®) to reduce episodes of crying in infants with colic  through four randomized controlled trials (RCT) [Pediatric studies assessing the efficacy of fennel for FGIDs are lacking, although fennel tea has been explored for the treatment of infant colic. In a descriptive study assessing the usage of herbal preparations in Turkey, fennel tea was used by approximately 77% of mothers to treat their children’s gas pain and constipation . A systels (RCT) ,9,10,11.p = 0.005). The mixture was found to be safe and well-tolerated [®, a product with extracts of turmeric and fennel oil, in improving symptom severity index and quality of life in 211 IBS patients, especially those with diarrhea-predominant IBS [® drops  in comparison with metoclopramide drops in patients ages 18–85 years with upper abdominal symptoms (n = 60). Lomatol® drops were superior to metoclopramide with greater improvement in abdominal pain (p = 0.02), nausea (p = 0.02), heartburn (p = 0.016), and gastric spasms (p = 0.002). It was also better tolerated with fewer adverse effects than treatment with metoclopramide [Studies in adults with IBS have shown some promising findings. In an RCT of 121 adults with IBS, fennel essential oil combined with curcumin improved IBS symptom severity scores and quality of life. A higher response was noted in the treatment compared with the control group  may have promise for the treatment of pediatric FGIDs. The main constituent of licorice root is the triterpenoid saponin glycyrrhizin , which is usually found in concentrations ranging from 6% to 10%. The intestinal flora is believed to hydrolyze glycyrrhizin, yielding the aglycone molecule (glycyrrhetinic acid) and a sugar moiety, which are both absorbed ,27. The ®, Karnataka, India) for 30 days. Compared to placebo, those receiving the licorice extract showed a significant decrease in total symptom scores and improved quality of life [Deglycyrrhizinated licorice (DGL), a processed licorice extract made by removing the glycyrrhizin molecule to eliminate its mineralocorticoid properties, has been used for several gastrointestinal disorders secondary to its anti-inflammatory, antibacterial, and antiviral pharmacologic actions . DGL is The dose of licorice for clinical use is based on the content of glycyrrhetinic acid. The standard dosage for DGL in adults is two to four 380 mg chewable tablets 20 min before meals . It is e® is a combination of multiple herbs including an extract from bitter candytuft (Iberis amara), angelica root (Angelica radix), milk thistle (Silybi mariani fructus), celandine herb (Chelidonium majus), caraway fruit (carvi fructus), licorice root (Liquiritiae radix), peppermint (Menthae piperitae folium), lemon balm leaves (Melissa folium), and chamomile flower (Matricariae flos). Bitter candytuft (I. amara) selectively inhibits binding to muscarinic M3 receptors, while extracts of celandine and chamomile inhibit binding to 5-HT4 receptors and licorice root to 5-HT3 receptors [STW5 or Iberogasteceptors ,35.  and cannabidiol (CBD) are produced in large amounts by cultivated cannabis plants and used for their psychoactive and therapeutic effects. Over 100 minor cannabinoids are present in smaller amounts. Cannabinoids exert their effects through the endocannabinoid system, with the primary receptors being CB1 and CB2. Additional receptors, including GPR55, GPR119, PPAR-alpha, PPAR-gamma, and TRPV1, may respond to cannabinoids and modulate CB receptor activity .clinicaltrials.gov, there are no controlled trials of THC or dronabinol in children for treatment of GI symptoms or abdominal pain. Of note, THC use may have the unintended effect of causing severe recurrent vomiting, a condition known as cannabinoid hyperemesis syndrome (CH). Patients may continue to escalate their cannabis use after developing CH in an attempt to manage their nausea and vomiting, leading to a persistent cycle of symptoms.THC is perhaps best known for its psychoactive effects, but also is used by many to stimulate appetite, decrease nausea, and reduce pain and anxiety. Medical marijuana is not universally legal in the United States. However, a synthetic form of THC, dronabinol, is FDA-approved in the adult population for appetite stimulation in the setting of AIDS as well as for nausea and vomiting in the setting of cancer chemotherapy. There is very little research on the use of THC for treatment of functional pain syndromes. As of this writing, according to In contrast to THC, CBD does not have psychoactive effects. It has been or is currently being studied in children and adolescents for indications including spasticity, epilepsy, and behavioral disorders in the setting of autism or intellectual disability. However, there are no controlled trials of CBD in children for the purposes of treating GI symptoms or abdominal pain.Among adults, one study has investigated the effectiveness of CBD for functional abdominal pain. A placebo-controlled trial of 50 women with IBS, using chewing gum formulated with 50 mg CBD, found no statistically significant differences in pain scores among those in the CBD group vs. placebo .There are remarkably little data about the use of cannabis for management of abdominal pain, particularly in the setting of functional disorders rather than in inflammatory bowel disease. Enthusiasm over the use of cannabis as a natural product for treatment of abdominal pain must be tempered both by the association of regular use with cannabis hyperemesis syndrome and the impaired executive functioning and school performance associated with adolescent cannabis or THC use.The rhizome of the ginger plant, Zingiber officinale, has traditionally been used both as a dietary flavoring and as an herbal medication, with its first documentation in Chinese medicine dating to 400 BC. Chemically, ginger contains over 400 compounds, prominent among which are phenols including gingerol and shogaol, and terpenes including zingiberene and bisabolene .Physiologically, ginger has been found to accelerate gastric emptying by 24% at a dose of 1.2 g powdered ginger root in capsule form in a double-blind study of 11 adults with functional dyspepsia, although this change was not associated with an improvement in GI symptoms as measured on a visual analogue scale. The authors did not identify any changes in levels of motilin, ghrelin, or GLP-1 which might explain the increase in emptying rate, although note that they did not check cholecystokinin levels . A studyThe effects of ginger on chemotherapy-induced nausea and vomiting and for nausea and vomiting during pregnancy have been described in multiple studies, with a recent systematic review concluding that a divided daily dosage of 1500 mg ginger is beneficial for relief of nausea . There ap = 0.003), acute moderate to severe vomiting , delayed moderate to severe nausea  and delayed moderate to severe vomiting  in the ginger group compared to the placebo group [A randomized controlled study of children and young adults aged 8–21 years receiving cisplatin/doxorubicin for osteosarcoma or malignant fibrohistiocytoma compared the effects of powdered ginger and placebo. A total of 60 chemotherapy cycles were studied. Patients weighing 20–40 kg received 1 g of ginger powder or a placebo powder divided into three daily doses on the three days when they received chemotherapy, and patients weighing 40–60 kg received 2 g in three daily doses for the three days. There was a decreased rate of acute moderate to severe nausea . The ginger product used was a liquid containing 10 mg of ginger extract per 20 drops (1% ginger by weight), given at a dose of 10 mg every 8 h until the resolution of vomiting [A study of 150 children aged 1–10 years with vomiting due to acute gastroenteritis compared the effects of ginger vs. placebo. A total of 33% of patients treated with ginger had resolution of vomiting after the first dose, compared to 13% in the placebo arm (vomiting .Ginger is considered safe in the amounts typically found in foods, with few adverse effects reported in clinical trials. Doses above 5 g per day are more likely to cause side effects. The most common adverse effects are irritation of the mouth and throat, abdominal discomfort, heartburn, burping, and diarrhea. Some of these symptoms may be avoided or reduced by taking ginger in capsule form. Constipation has also been reported with ginger. Ginger bolus from insufficiently chewed pieces of raw ginger, leading to small bowel obstruction, has been reported in four cases .There is a range of herbal medicines which may improve symptoms in pediatric patients suffering from pain-related FGIDs. However, there are so far very few pediatric studies to confirm their efficacy, dosage, safety, and tolerability, with most data available currently regarding the use of peppermint oil. There are more data available on the use of herbal compounds in adults, but many of these trials have been small, observational, use preparations or formulations which are not commercially available, or are not yet replicated to confirm their findings. Thus, limitations include the paucity of clinical studies available and an absence of reporting on the strength of the evidence provided in each study.Herbs have the potential to be additional tools for pediatric providers to have in their arsenal, as many are generally well-tolerated and inexpensive. Additionally, patients and families are interested in complementary medicine approaches for symptom management. Many patients perceive herbal treatments as more natural and thus more benign, without an awareness that these same treatments can cause untoward side effects, drug reactions, and interactions. These patients may prefer herbal treatments to manufactured pharmaceuticals and are appreciative of recommendations and guidance from their health care team . The con


Growing pains (GP), a common and benign pain syndrome of unknown etiology, is characterized by bilateral recurrent leg pain in childhood. There are no standardized diagnostic criteria for GP, and the diagnosis is often made by exclusion. To identify clinical and laboratory features, we included patients < 12 years with GP at National Taiwan University Children’s Hospital between April 2006 and April 2019 in a retrospective study. We also compared body weight and body height z-scores between diagnosis and up to 2 years post-diagnosis to determine if rapid growth was associated with GP. This cohort study included 268 patients with a mean age of 4.7 ± 2.2 years. The most common features of GP were bilateral leg pain, no limitation of activity, intermittent pain, normal physical examination, and being well physically. The average number of Walters' criteria fulfilled by the patients with GP was 6.7 ± 0.9. Elevated serum levels of alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were observed in 37.5% and 15.6% of patients, respectively. Symptomatic medications were used in 33% of patients. Our study indicates that ALP and LDH may be biomarkers associated with GP. There was no significant association between GP and rapid growth within 2 years of diagnosis. There are no standardized and universally accepted diagnostic criteria or diagnostic tests for GP, and the diagnosis is often made by exclusion in clinical practice. The proposed combined diagnostic criteria for GP by Walters et al. described the key clinical features: (1) usually pain in both legs; (2) pain starts between ages 3 and 12 years; (3) pain typically occurs at the end of the day or during the night; (4) no limitation of activity nor limping; (5) typical distribution in the anterior thigh, calf, and posterior knee muscles; (6) intermittent pain with some pain-free days and nights; (7) normal physical examination, no evidence of orthopedic disorders, trauma, or infections; (8) unremarkable results of laboratory tests (such as erythrocyte sedimentation rate), radiograph and bone scan; (9) pain for at least 3 months; and (10) no associated lack of well-being6. GP is prevalent in children aged 4–6 years4. Although familial cases are common, the etiology and pathophysiology of GP are still unclear. Laboratory tests usually yield normal results7. The prognosis is good as GP is self-limiting, and most of the symptoms resolve by adolescence8. The current study analyzed the clinical features, laboratory findings, and growth outcomes of Taiwanese children with GP.GP is the most common cause of musculoskeletal pain in early childhood. Previous studies showed a wide range of estimated prevalence from 2.6 to 49.4% due to different definitions of GP, poor population sampling, and disparate age ranges1. The exclusion criteria were symptoms and signs of arthritis , limping gait or limitation of activity, abnormal radiograph findings, abnormal inflammatory markers (such as C-reactive protein or erythrocyte sedimentation rate), or any systemic disease. Clinical features, especially the fulfillment of Walters’ diagnostic criteria, laboratory data, and medication records were analyzed. This study was approved by National Taiwan University’s Hospital Research Ethics Committee . Informed consent was waived by National Taiwan University’s Hospital Research Ethics Committee because of the retrospective nature of the study and the analysis used anonymous clinical data. All experiments were performed in accordance with relevant guidelines and regulations.This study was conducted retrospectively at National Taiwan University Children’s Hospital, a large medical center. Patients aged less than 12 years who presented with intermittent leg pain from April 2006 to April 2019 were enrolled based on clinical diagnosis of GP11. To test the association between GP and BH or BW, we compared the baseline BH or BW with BH or BW at 1 year before diagnosis, and 6 months, 1 year, and 2 years after diagnosis of GP, respectively.Body weight (BW), body height (BH), and body mass index (BMI) were collected from every patient’s medical record at every visit. Each value was transformed to the percentile and z-score based on the growth curves of the WHO and Taiwanese Child Growth Standards12. Independent samples t-test was used to compare continuous variables. Fisher’s exact test was used for categorical variables. Paired samples t-test was used to compare percentiles and z-scores assessed at two different times. Z-score is a score indicating how many standard deviations an observation is from a population median, adjusted for age and sex. The figures were generated by GraphPad Prism (version 7.0). A P value < 0.05 was considered significant.Data analysis was conducted using SPSS Statistics for Windows (version 22.0). Z-scores for BH, BW, and BMI were calculated using a macro for SPSS obtained from the WHO websiteThis study identified 307 patients with intermittent leg pain. Eight patients older than 12 years were first excluded  with slight male predominance (54%). For clinical presentation, 226 patients (84.3%) had bilateral leg pain, and all had pain in the lower extremities. Symptomatic treatments were used in 88 patients (33%), including 34 patients (12.7%) treated with only oral acetaminophen or non-steroidal anti-inflammatory drugs, 50 patients (18.7%) treated with only topical analgesics, and three patients (1.1%) received both treatments (Table P = 0.003)  levels were found in 6 out of 16 patients (37.5%) using age-adjusted normal ranges of ALP, and none had elevation above 1.5 times the upper limit of the normal range. Elevated serum levels of lactate dehydrogenase (LDH) were observed in 15.6% of patients. Patients with elevated serum ALP levels had significantly higher mean levels of LDH . No patients developed fibromyalgia or sleep disorder, either.Researchers observed an overlap between GP and restless legs syndrome (RLS) (Willis–Ekbom disease) in children. RLS is a neurological sensorimotor disease that profoundly disturbs sleep and quality of life. However, the association between GP and RLS ranges from no association to a substantial overlap. GP is experienced in 27–80.6% of children with RLS19, lower pain threshold21, lower skeletal vascular perfusion22, reduced bone strength24, and psychological factors27. Various factors, individually or in association, might be responsible for the onset of GP. In our study, we excluded 31 patients with other musculoskeletal diagnoses or autoimmune diseases. Normal levels of antinuclear antibodies, rheumatoid factor, CRP, and ESR could exclude autoimmune diseases, especially JIA. Careful evaluation by orthopedic surgeons for anatomical abnormalities in children with aching legs is important28. In a study by Lee et al., over-pronated feet account for 75% of pediatric patients with GP, and pain episodes were significantly reduced using foot orthoses18.There are several other proposed hypotheses for GP, including anatomical factors such as flat feet, over-pronated feet, and joint hypermobility29. Our patients with elevated ALP levels have similar distributions in age, sex, BH, BW, and BMI, compared with patients with normal ALP levels. Patients with GP did not have rapid growth of body height and weight within 2 years of onset of symptoms in our study. In our study, patients with elevated ALP levels had significantly higher levels of LDH at diagnosis. Patients with elevated ALP and LDH levels could have mild inflammation that may cause musculoskeletal pain.We found that serum levels of ALP and LDH were elevated in 37.5% and 15.6% of patients with GP, respectively. Serum ALP level was recognized as an indicator of osteoblastic activity and a valid marker of active bone formation. ALP level is higher in growing children than fully grown adults, and the highest ALP level is detected during infancy and puberty2-vitamin D, retinoic acid, and parathyroid hormone30. Hypovitaminosis D reduces calcium absorption and serum calcium levels, triggering secondary hyperparathyroidism, which subsequently increases bone resorption and serum ALP level31. In an observational study by Qamar et al., elevated ALP, vitamin D insufficiency, and vitamin D deficiency were found in 38%, 22%, and 72% of 100 children with GP32. Most patients (97.4%) with GP and elevated ALP had vitamin D deficiency32. However, the association between serum ALP levels and GP was insignificant in previous studies34. In GP, whether there is a causal relationship with hypovitaminosis D or whether hypovitaminosis D is a risk factor for severe pain through peripheral and central mechanisms is unclear. A high prevalence (57–94%) of hypovitaminosis D was found among the children with GP compared to the prevalence in the general population in children38. Oral vitamin D supplementation has been shown to be effective in reducing pain severity in children with GP, although there were no control groups for comparison in these studies37.ALP expression is regulated by 1,25 (OH)To our knowledge, this is the first study that validated Walters’ diagnostic criteria for GP in a large pediatric cohort. Study strengths included high diagnostic accuracy by the exclusion of musculoskeletal and autoimmune diseases that were diagnosed by specialists. Our study did have weaknesses, including missing information regarding laboratory data, BH, and BW during follow-up. It also lacked a group of healthy children to compare laboratory parameters, especially the levels of ALP and LDH. The current study compared laboratory parameters with an age-adjusted normal range in our hospital. The major limitation of our study was that we did not check serum vitamin D3 and parathyroid hormone (PTH) levels at disease diagnosis. Therefore, we could not clarify the association between hypovitaminosis D and GP in our cohort due to the retrospective study design. We speculated that vitamin D deficiency may be a risk factor for GP. However, the elevation of ALP or LDH might be associated with stimulated bone growth or mild inflammation in certain patients with GP. Further large-scale prospective case–control studies to investigate the association between vitamin D, PTH, ALP, LDH levels, and the severity of GP are warranted.In conclusion, GP is a common and self-limited leg pain syndrome in children. It was not associated with RLS syndrome in our cohort. ALP and LDH may be potential biomarkers associated with the disease, and mild inflammation may cause musculoskeletal pain. There was no significant association found between GP and rapid growth or higher BMI within 2 years of diagnosis.Supplementary Information.


Compared to the placebo group, gabapentin treatment reduced the demand for morphine on the first postoperative day  and the total number of metamizole doses (median 1 vs. 2 p = 0.04). Patient satisfaction was significantly greater in the gabapentin group . Anxiety and postoperative side effects were similar in both groups (p > 0.05). Pre- and postoperative gabapentin administration as part of a multimodal analgesic regimen may decrease postoperative pain, opioid consumption and demand for a “rescue drug”, as well as improve patient satisfaction.The aim of the study was to investigate whether the use of pre- and postoperative gabapentin can decrease postoperative pain, morphine consumption, anxiety and side effects, as well as improve patient satisfaction. A total of 56 patients, 9–17 years of age, undergoing a modified Ravitch procedure, were randomised  to receive multiple perioperative doses of gabapentin  or a placebo. All the patients received intravenous infusion of morphine, paracetamol and non-steroidal anti-inflammatory drugs. Metamizole was given as a “rescue drug”. The observation period included the day of surgery and three postoperative days. The primary outcomes were postoperative pain intensity . Additional outcomes included the consumption of morphine, the total number of doses of metamizole, anxiety, postoperative side effects and patient satisfaction. Median average and maximal pain scores (on the day of surgery and on the second postoperative day) were significantly lower only in the gabapentin group at rest ( The Ravitch procedure is the reconstructive operation of an anterior chest wall deformity . Next toDue to the area of operation, which is well innervated by the intercostal nerves, the procedure is one of the most painful. The pectoralis major and the rectus abdominis muscle are subject to surgical trauma. Moreover, a drain placed in the retrosternal space can cause pain . The paiThe optimal postoperative pain management involves a multimodal approach. Multimodal analgesia regimens can utilise varying combinations of opioid and non-opioid analgesics and regional analgesic techniques . ThoraciThe perioperative administration of gabapentin is an increasingly common element of multimodal therapy. The drug has been approved for the treatment of neuropathic pain in adults  and epilepsy in all age groups ,12. As aWith this background, we designed this trial to investigate if the use of gabapentin as a component of a multimodal analgesic regimen reduced pain scores, consumption of intravenous morphine, anxiety and side effects, as well as whether it improved patient satisfaction following the Ravitch procedure in paediatric patients.This was a single-centre, randomised, blinded, placebo-controlled, parallel-group , phase 4 trial conducted in Poland. The trial took place at the Department of Thoracic Surgery of the Institute of Tuberculosis and Lung Disease, Rabka Zdrój Branch, from May 2017 to December 2020. The trial protocol, in line with the Declaration of Helsinki, was approved by the Local Bioethics Committee at the National Institute of Tuberculosis and Lung Diseases in Warsaw . The trial was registered with Clinicaltrails.gov (ID: NCT03393702) and was reported in accordance with CONSORT 2010 guidelines .Patients were eligible for enrolment in the trial if they were between 9 and 17 years of age, with an American Society of Anesthesiologists (ASA) physical classification of 1  or 2 (patients with mild systemic disease), scheduled for an elective Ravitch procedure, in whom postoperative intravenous morphine analgesia was used, and written informed consent was obtained from the patients (from the age of 16) or their legal guardians. Exclusion criteria were lack of postoperative chest drainage, inability to rate pain, a known allergy or sensitivity to gabapentin or morphine, chronic pain or daily analgesic use and those diagnosed with psychiatric disorders or epilepsy or treated oncologically, in whom postoperative thoracic epidural analgesia was used.The patients were randomly assigned to the gabapentin  or placebo group . In the experimental group, oral gabapentin was supplemented one hour before surgery (in a dose of 15 mg/kg), and 2 times per day on the first, second and third postoperative day (at 6.00 a.m. and 6.00 p.m. in a dose of 7.5 mg/kg). Patients in the control group were given placebo capsules instead of gabapentin. The nursing staff administered the trial medication.The perioperative medicine protocol was standardised in both groups. It included premedication with oral midazolam (0.2–0.5 mg/kg), intravenous antiemetic prophylaxis with ondansetron hydrochloride (0.1 mg/kg up to 4 mg), pre-emptive analgesia with paracetamol (15 mg/kg intravenous) and non-steroidal anti-inflammatory drugs . Anaesthesia was induced with an injection of fentanyl (1–5 μg/kg) and propofol (3–5 mg/kg). A neuromuscular blockade was achieved with rocuronium bromide (1 mg/kg in children up to 10 years of age) or pancuronium bromide (0.1 mg/kg). Anaesthesia was maintained with propofol infusions and desfluranum in an oxygen/air mixture. Intraoperative analgesia was obtained with fentanyl (1–5 μg/kg) administered every 20–30 min.Postoperative analgesia included continuous intravenous infusion of morphine (0.02–0.06 mg/kg/h), intravenous paracetamol administered every 6 h  and non-steroidal anti-inflammatory drugs every 8 h . All patients, in case of pain > 2/10, could receive a supplemental opioid ). Metamizole was given as a “rescue drug” . In case of a sedation score ≥ 3, nurses could decrease the flow rate of morphine by 10–30%.Postoperative bundle also contained intravenous antiemetics. Ondansetron hydrochloride was given every 8 h (0.1 mg/kg up to 4 mg) up to the second postoperative day. In patients who failed prophylaxis with ondansetron, metoclopramide hydrochloride (0.1–0.2 mg/kg) and/or dexamethasone (0.15 mg/kg up to 5 mg) were used according to physician decision.Blood pressure, heart rate, respiratory rate and oxygen saturation measured by pulse oximetry were monitored continuously during the observational postoperative period (in the postoperative intensive care unit).The primary endpoint with respect to efficacy of pain management was postoperative pain intensity. Additional outcomes included the consumption of morphine , the total number of doses of a “rescue drug”, anxiety, postoperative side effects and patient satisfaction.Assessment of postoperative pain utilised an 11-point Numerical Rating Scale  according to the three-step method . This meThe State-Trait Anxiety Inventory for adolescents (STAI) and children between 9 and 14 years of age (STAI-C) was used to measure state and trait anxiety ,18. StatAnalgesia-related adverse effects, including nausea and vomiting, urinary retention, pruritus, dizziness, oxygen desaturation , bradycardia , a sedation score ≥ 3 points and others, were documented. Sedation levels were controlled together with pain using a 5-point scale as follows: 1 = patient anxious, agitated; 2 = patient cooperative, oriented, tranquil; 3 = patient asleep, easy to wake up; 4 = patient asleep, difficult to wake up; 5 = patient asleep, does not respond to painful stimulus. If excessive sedation occurred, the nurses could reduce or stop the flow rate of morphine.Patient satisfaction with their postoperative analgesia was obtained after the end of the trial. Satisfaction was evaluated on an 11-item scale: 0 = very dissatisfied, 10 = very satisfied.p < 0.001). Assuming alpha of 0.01 and the same standard deviation for mean pain scores 2.6, at least 19 patients in each group were needed to obtain 90% power of difference detection.Pain intensity was the primary endpoint measure used to evaluate the efficacy of gabapentin in our trial. The minimal sample size was calculated based on Rusy at al.’s study , who shoThe clinical trial nurse and physician enrolled patients in the intervention . The cliThe children and their parents, nursing staff, surgeons, anaesthesiologists, investigators and data analysts were blinded to group assignments. It should be noted that the principal investigator performed both the duties of the study director and was responsible for data analysis.p < 0.05 for all analyses. Glass’s delta or Cohen’s d were reported as measures of effect size . Effect size estimates were interpreted as small (0.2 to <0.5), medium (0.5 to <0.8) and large effects (≥0.8) . Apart from this, we found urinary retention in 46.4% of patients, but only three patients required bladder catheterisation due to insufficient pharmacological provocation. There were no significant differences in postoperative haemodynamic variables  (p > 0.05).Common side effects during the postoperative period were nausea and vomiting (50%), despite antiemetic administration. No statistically meaningful differences between the gabapentin and placebo groups were observed in the frequency of antiemetics used  and was significantly greater in the gabapentin group compared to the placebo group: median 10 [9: 10] vs. 9 ; 2.37; Z = 2.22; The findings of this trial indicate that the perioperative use of oral gabapentin as a component of a multimodal pain management protocol may reduce postoperative pain at rest, consumption of morphine and demand for a “rescue drug”, as well as improve patient satisfaction following the Ravitch procedure in paediatric patients. There was no difference in anxiety or in the side effect profile between the gabapentin group and the placebo group.Both the present trial and previous trials ,21 foundIn our institution, proper postoperative pain relief is our priority. The median average pain scores were <1/10, whereas, in adolescents after scoliosis surgery, in the study by Mayell et al. , this waOne objective of this trial was to evaluate satisfaction with the pain control provided to the paediatric patients, which is being used increasingly as an indicator of quality of care. Past studies looking at gabapentin associated with postoperative satisfaction have yielded mixed results. Doleman et al. , in a stAnxiety is the most common emotion experienced by patients scheduled for surgery . Over 80The major strength of this trial is that it is randomised and double-blind. The trial was developed according to CONSORT guidelines. However, the trial, being single-centre and conducted chiefly among boys , limits the possibility of generalising our results to all paediatric patients. The study was also limited by the small sample size and subjective nature of pain assessment. Findings related to patient satisfaction may be limited due to the lack of measurement using validated tools.Gabapentin, used as a component of a multimodal analgesic regimen, had a medium effect size on reducing pain intensity at rest, on the consumption of morphine during the early postoperative period and on the demand for a “rescue drug”, as well as on improving patient satisfaction, following the Ravitch procedure in paediatric patients.Taking into account the medium effect size of gabapentin on the above-mentioned postoperative variables and the similar profile of the side effects to a placebo, we believe that gabapentin may be used as a part of a multimodal analgesic regimen, though only in patients with a higher level of pain than those in our study. Postoperative administration of gabapentin should be limited to the second postoperative day, as the benefits of its administration are not apparent beyond this period. Our observations are consistent with the results of Anderson et al.’s research . We agre