***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background This r and omized controlled study evaluated the efficacy of intravenous patient-controlled analgesia ( IV-PCA ) with fentanyl and ketorolac for neurosurgical patients , and compared the effectiveness of IV-PCA with intermittent analgesics injection . Methods The patients undergoing craniotomy were r and omly assigned to two groups . Patients of group P ( n = 53 ) received fentanyl ( 0.2 µg/kg/hr ) and ketorolac ( 0.3 mg/kg/hr ) via IV-PCA , and those of group N ( n = 53 ) received intermittent fentanyl or ketorolac injection as needed . Pain was evaluated using a 0 - 10 visual analogue scale ( VAS ) at postoperative 1 , 4 , and 24 hr . The amount of infused analgesic drugs , Glasgow Coma Scale ( GCS ) score , systolic arterial pressure , heart rate , respiratory rate , and the incidence of nausea and miosis were measured at the same time points . Results Although VAS of pain ( VASp ) was comparable at postoperative 1 hr ( P = 0.168 ) between the two groups , the group P had significantly lower VASp at postoperative 4 hr ( P = 0.007 ) and 24 hr ( P = 0.017 ) . In group P , less analgesic drugs were administered at postoperative 1 hr , and more analgesic drugs were administered at postoperative 24 hr . There were no differences between two groups with respect to nausea , GCS , systolic arterial pressure , and heart rate . IV-PCA did not further incur respiratory depression or miosis . Conclusions IV-PCA with fentanyl and ketorolac after craniotomy is more effective analgesic technique , without adverse events , than the intermittent administration of analgesics OBJECTIVE Postcraniotomy headache causes considerable pain and can be difficult to treat . We therefore tested the hypothesis that a single 100-mg preoperative dose of diclofenac reduces the intensity of postcraniotomy headache , and reduces analgesic requirements . METHODS 200 patients having elective craniotomies were r and omly assigned to diclofenac ( n = 100 ) or control ( n = 100 ) . Pain severity was assessed by an independent observer using a 10-cm-long visual analog scale the evening of surgery , and on the 1st and 5th postoperative days . Analgesics given during the first five postoperative days were converted to intramuscular morphine equivalents . Results were compared using Mann-Whitney-tests ; P < 0.05 was considered statistically significant . RESULTS Baseline and surgical characteristics were comparable in the diclofenac and control groups . Visual analog pain scores were slightly , but significantly lower with diclofenac at all times ( means and 95 % confidence intervals ) : the evening of surgery , 2.47 ( 1.8 - 3.1 ) vs. 4 . 37 ( 5.0 - 3.7 ) , ( P < 0.001 ) ; first postoperative day , 3.98 ( 3.4 - 4.6 ) vs. 5.6 ( 4.9 - 6.2 ) cm ( P < 0.001 ) and 5th postoperative day : 2.8 ( 2.2 - 3.4 ) vs. 4.0 ± ( 3.3 - 4.7 ) cm ( P = 0.013 ) . Diclofenac  reduced systemic analgesic requirements over the initial five postoperative days ( mean and 95 % CI ) : 3.3 ( 2.6 - 3.9 ) vs. 4.3 ( 3.5 - 5.1 ) mg morphine equivalents ( P < 0.05 ) . CONCLUSIONS Preoperative diclofenac administration reduces postcraniotomy headache and postoperative analgesic requirements - a benefit that persisted throughout five postoperative days Introduction Acute pain is common during the endotracheal extubation period , and is related to complications and adverse outcomes . Patients with delayed extubation after craniotomy are vulnerable to pain and complications of extubation . However , pain control during extubation is still inadequate . Remifentanil , a new opioid with rapid onset and short duration of action , provides adequate analgesia during procedures with minimal effect of respiratory depression . Methods and analysis The study is a prospect i ve , r and omised , double-blinded , controlled parallel-group design . Patients with delayed extubation after intracranial surgery are screened daily . Adult patients ready for extubation are enrolled and assigned r and omly to one of the two treatment study groups , labelled as the ‘ Remi group ’ or ‘ Saline group ’ . Patients in the Remi group receive an intravenous bolus dose of remifentanil 0.5 μg/kg over 60 s followed by a continuous infusion 0.05 μg/kg/min for 20 min . Patients in the Saline group receive an intravenous infusion of 0.9 % sodium chloride at a volume and rate equal to that of remifentanil  . Pain intensity is measured by the visual analogue scale ( VAS ) pain score . Adverse events during drug infusion are documented and reported . Patients will be followed up until hospital discharge , death or 60 days after the trial intervention on a first come , first served basis . Details of the incidence of reintubation and reoperation within 72 h after extubation , length of stay in the intensive care unit and hospital and mortality are collected . The primary end point is the incidence of severe pain ( defined as a VAS pain score more than 5 cm ) during the periextubation period ( defined as the period of time from immediately before extubation to 20 min after extubation ) . Ethics and dissemination The study was approved by the Institutional Review Board ( IRB ) of the Beijing Tiantan Hospital , Capital Medical University . The study findings will be disseminated through peer- review ed publications and conference presentations . Trial registration number Clinical Trials ( NCT ) : ChiCTR-PRC-13003879 Background : Gender differences in access to high quality care for chronic illnesses have been suggested yet little work in this potentially vital area of health care ine quality has been undertaken in Africa . We explored the influence of patient gender on the care of people with diabetes within a multi- method , national study of diabetes management in primary care in Tunisia . Methods : Method ologies used were quantitative ( nationwide r and omized study of 2160 medical records ) and qualitative ( participant observation , focus groups and interviews of patients and health care professionals )  . Results : Differences in patient characteristics , treatments prescribed , process and outcome data and access to care variables were demonstrated . The most striking disparity found was the high female to male ratio of patients attending for diabetes care ( 61.1 % ) . A number of possible explanations for this emerged : Men were thought to under-attend for practical , financial and behavioural reasons whereas women were thought to have increased morbidity and potentially over-attend for social and psychological reasons . Conclusion : We have demonstrated a number of disparities in the care of men and women with diabetes in Tunisian primary care . In particular , a dual but related problem emerges from the data : more women than men attend for diabetes care and yet women do not get the same level of risk factor control as men . A number of local explanations for these disparities have emerged , which inform our analysis of the impact of gendered beliefs on diabetes care . Strategies to address these disparities will require a careful consideration of local beliefs and practice Context : Scalp infiltration and scalp block are being used to manage postcraniotomy pain .  Dexmedetomidine has been successfully used as an adjuvant in regional anesthesia . The study was intended to compare whether addition of dexmedetomidine prolonged the duration of analgesia as well as to compare the two techniques . Aims : The primary objective was to assess whether addition of dexmedetomidine to bupivacaine prolonged the duration of analgesia . The secondary objective was to compare between scalp nerve block and scalp infiltration as techniques for pain relief . Setting s and Design : The r and omized control study was conducted in a tertiary care center from November 2013 to October 2014 . Material s and Methods : A total of 150 American Society of Anesthesiologists Physical Status I – II patients , aged 18–70 years undergoing elective craniotomy were included . Patients were r and omized into three groups of 50 patients , i.e. , Group BI ( bupivacaine infiltration ) , Group BDI ( bupivacaine and dexmedetomidine infiltration ) , and Group BDNB ( bupivacaine and dexmedetomidine scalp nerve block )  . Patient 's pain score , pain-free interval , rescue analgesic requirement , and hemodynamic and respiratory parameters were noted for 48 h. Patients were followed up at 1 and 3 months to assess postcraniotomy pain . Results : Pain-free period was significantly longer in Group BDNB than Groups BDI and BI ( P < 0.0001 ) and pain control was better in dexmedetomidine containing groups than in bupivacaine group ( BI ) ( P < 0.0001 ) . The rescue analgesic requirement was significantly lower in Group BDNB and Group BDI compared to Group BI . Conclusion : The addition of dexmedetomidine ( 1 μg/kg ) to bupivacaine prolonged the pain-free period . Scalp nerve block is a superior technique than scalp infiltration Context A clear preference for intravenous or inhalational anaesthesia has not been established for craniotomy in patients without signs of cerebral hypertension . Objectives The NeuroMorfeo trial was design ed to test equivalence of inhalational and intravenous anaesthesia maintenance techniques in the postoperative recovery of patients undergoing elective supratentorial surgery . Design This trial is a multicentre , r and omised , open-label , equivalence design . A balanced stratified r and omisation scheme was maintained using a central ised r and omisation service . Equivalence was tested using the two one-sided tests procedure . Setting Fourteen Italian neuroanaesthesia centres participated in the study from December 2007 to March 2009 . Patients Adults , 18 to 75 years old , scheduled for elective supratentorial intracranial surgery under general anaesthesia were eligible for enrolment if they had a normal preoperative level of consciousness and no clinical signs of intracranial hypertension . Interventions Patients were r and omised to one of three anaesthesia maintenance protocol s to determine if sevoflurane – remifentanil or sevoflurane – fentanyl were equivalent to propofol – remifentanil . Main outcome measures The primary outcome was the time to achieve an Aldrete postanaesthesia score of at least 9 after tracheal extubation . Secondary endpoints included haemodynamic parameters , quality of the surgical field , perioperative neuroendocrine stress responses and routine postoperative assessment s. Results Four hundred and eleven patients [ 51 % men , mean age 54.8 ( SD 13.3 ) years ] were enrolled . Primary outcome data were available for 380 . Median ( interquartiles ) times to reach an Aldrete score of at least 9 were 3.48 ( 2.02 to 7.56 ) , 3.25 ( 1.21 to 6.45 ) and 3.32 min ( 1.40 to 8.33 ) for sevoflurane – fentanyl , sevoflurane – remifentanil and propofol – remifentanil anaesthesia respectively , which confirmed equivalence using the two one-sided tests approach . Between-treatment differences in haemodynamic variables were small and not clinical ly relevant . Urinary catecholamine and cortisol responses had significantly lower activation with propofol – remifentanil . Postoperative pain and analgesic requirements were significantly higher in the remifentanil groups . Conclusion Equivalence was shown for inhalational and intravenous maintenance anaesthesia in times to reach an Aldrete score of at least 9 after tracheal extubation . Haemodynamic variables , the quality of surgical field and postoperative assessment s were also similar . Perioperative endocrine stress responses were significantly blunted with propofol – remifentanil and higher analgesic requirements were recorded in the remifentanil groups . Trial registration : Eudract 2007–005279 - 32 BACKGROUND Pain after craniotomy is often under-treated . Opiates carry distinct disadvantages . Non-steroidal anti-inflammatory drugs have an anti-platelet action and carry a bleeding risk . Cyclo-oxygenase 2 inhibitors such as parecoxib are not associated with a bleeding risk and would be welcome analgesics if shown to be effective . METHODS In a prospect i ve double-blind , r and omized , placebo-controlled study , we investigated the analgesic effect of a single dose of parecoxib 40 mg given at dural closure in 82 patients undergoing elective craniotomies .  Remifentanil was used intraoperatively , and i.v . morphine was titrated to the requirement in the post-anaesthetic unit . On the ward , i.m . morphine 5 mg as required and regular acetaminophen was prescribed . Morphine use and visual analogue pain scores were recorded at 1 , 6 , 12 , and 24 h after surgery . RESULTS Parecoxib reduced pain scores at 6 h and morphine use at 6 and 12 h after operation . However , overall , it had only minimal impact on postoperative 
    Output:
    
There is high- quality evidence that NSAIDs reduce pain up to 24 hours postoperatively .
There is low- quality evidence that scalp blocks and dexmedetomidine may reduce additional analgesics requirements .