BACKGROUND: Dental practitioners desire non-pharmacological methods to alleviate anxiety, fear, and pain in children receiving dental care; high-quality evidence, however, is required to evaluate methods\' efficacy.
OBJECTIVE: This study aimed to develop and validate an observation-based coding approach (paediatric dental pain, anxiety, and fear coding approach [PAFCA]) to evaluate non-pharmacological behavior management techniques for anxiety, fear, and pain.
METHODS: Objective (video-based) and subjective (self-reported) anxiety, fear, and pain data were collected from a pilot clinical trial evaluating animal-assisted therapy (AAT) in paediatric dentistry, in which 37 children aged 7-14 were assigned to AAT or control before dental treatment (restorations or extractions). A coding approach utilizing a codebook, a gold standard calibration video, and a user training guide was developed. Trained examiners coded the gold standard video for inter-rater agreement, and masked, calibrated examiners analyzed videos using the Noldus Observer XT software.
RESULTS: A novel, software-based coding approach was developed, with moderately high inter-rater agreement. Using PAFCA, we found children reporting higher levels of pain, fear, and anxiety exhibited treatment-interfering behaviors, including crying/moaning, attempts to dislodge instruments, and more upper and lower body movements.
CONCLUSIONS: PAFCA shows promise as a reliable tool for assessing anxiety, pain, and fear in behavioral research for paediatric dentistry.

OBJECTIVE: The purpose of this scoping review was to evaluate literature involving opioid-sparing medications in critically ill patients with a focus on clinically meaningful outcomes.
METHODS: Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.
METHODS: Intensive care unit.
METHODS: Adult patients in an intensive care unit setting.
METHODS: None.
METHODS: PubMed and Cochrane Library were searched from October 1, 2019 to June 1, 2023. Inclusion criteria consisted of randomized controlled trials evaluating adjunctive analgesic use in adult patients in an intensive care unit setting.
RESULTS: There were 343 citations and titles identified in the initial search, with 328 remaining after removal of duplicates, 294 excluded at title and abstract screening, 34 available for full text review, and six included in the scoping review. Most studies reported modest reductions in opioid use as a secondary endpoint. Improvement in clinical outcomes such as reduction in duration of mechanical ventilation or delirium were reported in two trials with dexmedetomidine.
CONCLUSIONS: In recently published trials of adjunctive agents in critically ill patients, opioid-sparing effects were small. Data to support improvements in clinical outcomes remains limited.

OBJECTIVE: Refractory cancer-induced bone pain (CIBP) affects a patient\'s functional capacity and quality of life, but there is limited evidence to guide opioid choice. We assessed the feasibility, tolerability and possible efficacy of methadone rotation (MR) compared to other opioid rotations (OOR) in this cohort.
METHODS: Adults with CIBP and worst pain intensity ≥ 4/10 and/or opioid toxicity graded ≥ 2 on the Common Terminology Criteria for Adverse Events were randomised 1:1 to methadone or another opioid rotation. Standardised assessment tools were used at pre-defined study time points up to 14 days.
RESULTS: Of 51 eligible participants, 38 (74.5%) consented, and 29 (76.3%, MR: 14, OOR: 15) completed the fourteen days follow-up post-opioid rotation. Both groups displayed significant reduction in average (MR: d =  - 1.2, p = 0.003, OOR: d =  - 0.8, p = 0.015) and worst pain (MR: d =  - 0.9, p = 0.042, OOR: d =  - 0.6, p = 0.048) and total pain interference score (MR: d =  - 1.1, p = 0.042, OOR: d =  - 0.7, p = 0.007). Oral morphine equivalent daily dose was reduced significantly in MR compared to the OOR group (d =  - 0.8, p = 0.05). The incidence of opioid-related adverse events following MR was unchanged but lower in the OOR group (d = 0.9, 95% CI 0.1,1.7, p = 0.022). There were no within-group or between-group differences in satisfaction with analgesia at the end of the study.
CONCLUSIONS: This pilot study demonstrated that MR and OOR in patients with refractory CIBP are feasible, safe and acceptable to patients. Appropriately powered multi-centre randomised controlled studies are needed to confirm the efficacy of MR and OOR in this cohort.
BACKGROUND: ACTRN12621000141842 registered 11 February 2021.

Dercum\'s disease (DD) is a rare and poorly understood disease characterized by obesity and painful lipomas throughout the body. Although the entity is well described in the literature, its etiology, prevalence, and treatment remain unclear. Currently, treatment is focused on pain management. We describe a case of a patient with DD who showed improvement with infliximab and methotrexate.

BACKGROUND: Effective pain management is crucial for the successful completion of dental procedures in children. Research has examined whether computerized intraosseous anesthesia (CIOA) could serve as a safe and viable substitute for the conventional inferior alveolar nerve block (IANB) technique in pediatric patients. This study investigates the efficacy of CIOA, aiming to determine its effectiveness as an alternative anesthesia method.
OBJECTIVE: This study compared the efficacy of local intraosseous anesthesia using a computerized device (QuickSleeper 5) to conventional IANB anesthesia on cooperation and pain perception in children, using a randomized controlled trial design.
METHODS: The study included 88 healthy children, aged between 6 and 9 years, who required pulpotomy for their mandibular second primary molars. The study was approved by the local research ethics committee and registered at clinicaltrials.gov (NCT05193487). The heart rate and Venham behavior rating scale were recorded and analyzed. Categorical data were analyzed using Fisher\'s exact test. Age and heart rate were compared using an independent t-test for intergroup comparison. The intragroup comparison was carried out using repeated measures ANOVA, followed by the Bonferroni post hoc test. The Mann-Whitney U-test was used to analyze the Venham scale scores. The significance level was set at p < .05 RESULTS: The mean Venham score was slightly higher in the IANB group than in the CIOA group, but was not statistically significant (p = .852). One minute after anesthesia administration, the heart rate (beats per minute [BPM]) was significantly higher in the IANB group (92.30 ± 13.45) than in the CIOA group (83.20 ± 10.40) (p < .001). Additionally, there was a significant difference in heart rate values measured at different intervals within the IANB group.
CONCLUSIONS: The QuickSleeper 5 device was found to be a feasible alternative for IANB in children over 6 years old.

BACKGROUND: Nalbuphine, a synthetic k-agonist and µ-antagonist, provides efficient pain relief while reducing opioid-related adverse effects. This study aims to compare the efficacy of intrathecal nalbuphine (ITN) with intrathecal morphine (ITM) for post-TKA pain.
METHODS: A retrospective cohort analysis of 131 patients who underwent TKA with spinal anesthesia (SA), a single shot of adductor canal block, and periarticular injections was conducted. The patients were divided into 2 groups, Group N received 0.8 mg nalbuphine, and Group M received 0.2 mg morphine as an adjuvant to SA. Propensity-score matching was employed to compare the visual analog scales (VAS) of postoperative pain intensity, cumulative morphine use (CMU), maximum knee flexion angle, straight leg raise (SLR) ability, incidence of postoperative nausea and vomiting (PONV), and length of hospital stay (LHS).
RESULTS: The mean VAS of group M were significantly lower than group N at 6, 12, 18, and 24 h (P < 0.01). Group M had lower CMU than group N at 24 h (P < 0.01) and 48 h (P < 0.01), while there was no significant difference between groups in terms of knee flexion angle and SLR at any time point. Additionally, 29.3 and 57.9% of patients in group N and M experienced PONV, respectively (p = 0.04), and group N had significantly shorter LHS compared to group M (P < 0.001).
CONCLUSIONS: Although, intrathecal morphine (ITM) still provides better pain control particularly in the first 24 h, patients who received intrathecal nalbuphine (ITN) had significantly fewer incidence of PONV, and shorter LHS.

Background/Objectives: The aim of this study was to establish a histologic baseline for cryoanalgesia of 2 min duration and evaluate the effects of different freeze durations. Methods: A porcine model was used in which the application of bilateral cryoanalgesia from intercostal spaces T3-T7 was completed via partial median sternotomy. The animals were kept alive for 7 days and the ribcages were sent to a specialized center for histopathologic analysis of the freezing injury. Results: Forty freezing lesions were completed and analyzed histologically. Thirty-eight (95%) of the cryo-lesions presented 100% nerve fiber degeneration at or distal to the ablation site, with preservation of the perineural connective tissue, as intended. The two unaffected nerves were found to be physically located outside of the freezing area. Conclusions: The complete axonal degeneration with preservation of the perineural tissue opens the possibility to shorter freezing times than the recommended 2 min. Visualization of the nerve and positioning of the probe is important in ensuring the proper effect on the nerve. This histologic analysis confirms the process triggered by cryoanalgesia that, until now, had only been assumed.

BACKGROUND: In this study, we investigate the effects of smoking on pain scores, vital signs, and analgesic consumption in the intraoperative and postoperative period in patients undergoing tympanomastoidectomy surgery.
METHODS: A total of 100 patients with American Society of Anesthesiologists I-II status, aged 18-55 years, and who were planned to undergo tympanomastoidectomy surgery were divided into two groups: smokers (Group 1) and non-smokers (Group 2). The patients were compared for preoperative, intraoperative, and 24-hour postoperative carboxyhemoglobin, blood pressure, oxygen saturation, respiratory rate, heart rate, pain intensity and verbal numerical rating scales, the extent of patient-controlled tramadol dose, nausea, and vomiting.
RESULTS: There were 50 individuals in each group. Postoperative analgesic consumption and pain scores were higher in Group 1, and the first postoperative pain was felt earlier. Furthermore, in Group 1, preoperative carboxyhemoglobin levels and postoperative nausea were statistically higher before, after, and at the tenth minute after induction, whereas oxygen saturation was lower. The two groups had no statistical difference regarding intraoperative and postoperative vital signs. Postoperative analgesic consumption was not affected by age or gender.
CONCLUSIONS: Smoking changes postoperative pain management, especially for this kind of operation, and these patients feel more pain and need more postoperative analgesic doses. Therefore, effective postoperative pain control should take account of smoking behavior, and analgesic doses may need to be adjusted for patients who smoke.

BACKGROUND: In patients who are candidates for craniotomy, scalp nerve blocks have been shown to be effective in relieving pain intensity as well as postoperative hemodynamic stability after surgery, but the results have been inconsistent. We aimed to assess the effect of scalp block on pain control, intraoperative drug use under Analgesia Nociception Index (ANI) monitoring, and postoperative pain in patients who were candidates for elective craniotomy.
METHODS: In this randomized, single-blinded clinical trial study, candidates for craniotomy were randomly (using the block randomization method) divided into 2 groups before entering the operating room. The first group received a scalp block with bupivacaine (intervention), and the second group did not receive a scalp block (control) besides the routine anesthetic procedure in these patients. ANI, hemodynamic parameters, and the amounts of received remifentanil were conducted and compared.
RESULTS: Patients under scalp block received less dosage of fentanyl than the nonscalp block group (mean = 57.14 ± 15.59 mcg vs. 250.00 ± 65.04 mcg, respectively). Similarly, the dose of remifentanil required in the scalp block group was less (mean = 3.04 ± 1.95 mg and 5.54 ± 2.57 mg, respectively). No difference was observed in hemodynamic parameters such as blood pressure and heart rate (before, during, and after surgery). However, the group receiving scalp block had higher ANI means than the control group.
CONCLUSIONS: Scalp nerve block has an effective role in pain control (increasing ANI), consequently reducing the need for analgesic drugs such as fentanyl and remifentanil following craniotomy without changing the hemodynamic condition.

The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures.
Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023.
The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient\'s directives, family feelings and representatives\' desires, and all decisions should be shared.
The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.