***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: Abstract  Variability  in patients ' response to interventions in pain and other clinical setting s is large . Many explanations such as trial methods , environment or culture have been proposed , but this paper sets out to show that the main cause of the variability may be r and om chance , and that if trials are small their estimate of magnitude of effect may be incorrect , simply because of the r and om play of chance . This is highly relevant to the questions of ‘ How large do trials have to be for statistical accuracy ? ’ and ‘ How large do trials have to be for their results to be clinical ly valid ? ’ The true underlying control event rate ( CER ) and experimental event rate ( EER ) were determined from single‐dose acute pain analgesic trials in over 5000 patients . Trial group size required to obtain statistically significant and clinical ly relevant ( 0.95 probability of number‐needed‐to‐treat within ±0.5 of its true value ) results were computed using these values . Ten thous and trials using these CER and EER values were simulated using varying group sizes to investigate the variation due to r and om chance alone . Most common analgesics have EERs in the range 0.4–0.6 and CER of about 0.19 . With such efficacy , to have a 90 % chance of obtaining a statistically significant result in the correct direction requires group sizes in the range 30–60 . For clinical relevance nearly 500 patients are required in each group . Only with an extremely effective drug ( EER>0.8 ) will we be reasonably sure of obtaining a clinical ly relevant NNT with commonly used group sizes of around 40 patients per treatment arm . The simulated trials showed substantial variation in CER and EER , with the probability of obtaining the correct values improving as group size increased . We contend that much of the variability in control and experimental event rates is due to r and om chance alone . Single small trials are unlikely to be correct . If we want to be sure of getting correct ( clinical ly relevant ) results in clinical trials we must study more patients . Credible estimates of clinical efficacy are only likely to come from large trials or from pooling multiple trials of conventional ( small ) size OBJECTIVE To determine the effect of preoperative dexamethasone sodium phosphate administration on posttonsillectomy morbidity for electrocautery ( " hot " ) and sharp ( " cold " ) dissection techniques . DESIGN Prospect i ve , r and omized , double-blind study . SETTING University pediatric hospital and county teaching hospital . Subjects A total of 219 children , aged 9 months to 12 years , undergoing tonsillectomy .  Intervention Participants who underwent tonsillectomy  were r and omly assigned to receive either intravenous dexamethasone sodium phosphate ( 1 mg/kg ) or placebo . OUTCOME MEASURES Pain scores , oral intake , and emesis on postoperative day ( POD ) 1 . RESULTS A total of 106 subjects ( 62 undergoing hot and 44 cold tonsillectomies ) received preoperative steroids , and 113 ( 56 hot and 57 cold tonsillectomies ) received placebo . On POD 1 , pain scores reported by patients ( P = .02 ) , parents ( P = .002 ) , and physicians ( P<.001 ) were significantly lower in subjects receiving steroids than in those receiving placebo .  Emesis was reduced from a mean of 2.1 ( placebo group ) to 1.2 episodes ( steroid group ) ( P = .02 ) . Oral intake improved from 24.5 % of normal diet ( placebo ) to 31.7 % ( steroid group ) ( P = .004 ) . When all 4 groups were compared ( cold placebo , cold steroid , hot placebo , and hot steroid ) , pain scores reported by physicians and parents were significantly lower in the cold steroid group than in the other groups . CONCLUSIONS Perioperative dexamethasone use reduces posttonsillectomy morbidity in pediatric patients in the early postoperative period after hot or cold tonsillectomy . The combination of steroid and cold dissection technique provided the greatest advantage in reducing posttonsillectomy subjective pain levels & NA ; The efficacy of ketorolac , a non‐steroidal anti‐inflammatory drug , in the management of moderate to severe pain in adults , has led us to conduct a trial of this analgesic in children following tonsillectomy . Children were r and omized to receive intramuscular ( i.m . ) ketorolac ( 1 mg/kg , EXP group , n = 45 ) or saline ( CTL group , n = 42 ) at the completion of surgery . Intravenous ( i.v . ) fentanyl ( 0.5 & mgr;g/kg/dose ) was administered in repeated doses postoperatively . Pain intensity was measured using both the Oucher and the Children 's Hospital of Eastern Ontario Pain Scale ( CHEOPS ) to allow for comparison between self‐report and behavioral measures of pain intensity . Severity of postoperative bleeding was measured using a 4‐point rating scale . The EXP group had a significant reduction in total fentanyl dose ( mean : 35.9 & mgr;g ) compared to the CTL group ( mean : 48.3 & mgr;g , t = −2.21 , P < 0.03 ) . There was a statistically significant decrease in pre‐fentanyl CHEOPS scores in the Post‐Anesthesia Care Unit ( PACU ) in the ketorolac group ( F ( 2,30 ) = 5.34 , P < 0.01 ) , but not in the saline group ( F ( 2.24 ) = 2.46 , P > 0.05 ) . In the first hour postoperatively , the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids , in both groups . In the PACU , children were unable to provide a self‐report of pain intensity potentially due to a variety of factors ( e.g. , emergence delirium , agitation , excitement , sedation , and /or pain ) . However , during the remainder of the postoperative stay , the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS . There were no differences between the 2 groups in the severity of postoperative bleeding . Children in the EXP group were discharged significantly earlier ( i.e. , 30 min , t = −2.22 , P < 0.03 ) . Our data demonstrate that i.m . administration of ketorolac , at the end of surgery , significantly reduces opioid requirements and shortens length of stay without any evidence of increased bleeding . In addition , our data suggest that the patient 's altered level of consciousness and attention span may diminish the utility of self‐report measures of  pain intensity  in the immediate postoperative period OBJECTIVE Pain is major problem regarding quality of life in children undergoing tonsillectomy . Preemptive analgesia by medicine given before commencement of surgery is a new way recommended for relief of pain during and after operation . The purpose in this study to evaluate preemptive efficacy and safety of lower dose of tramadol , which was recently introduced in children undergoing tonsillectomy . METHODS This study was performed on 45 children undergoing tonsillectomy with or without adenoidectomy as a double-blinded trial , by using tramadol in two dosages ( 1 and 0.5 mg kg(-1 ) ) and placebo .  Pain assessment was done by facial pain score ( FPS ) , visual analog scale ( VAS ) and postoperative analgesic requirement ; further , duration of anesthesia and duration of awakening time , heart rate ( HR ) and mean arterial pressure ( MAP ) during and after anesthesia , postoperative nausea and vomiting ( PONV ) and recall of intraoperative events were recorded . RESULTS It was found that 73 % children in placebo group needed  analgesic medicine  at the end of the first hour after operation , although no analgesic medicine was needed in tramadol groups ( chi(2 ) test , P<0.001 ) . However , statistically significant decrease in FPS and VAS in tramadol groups were only found up to 15th and 30th min after operation , respectively ( Kruskall-Wallis test , P<0.05 ) . On the other h and , intraoperative HR ( 10th , 20th and 30th min ) and MAP ( 10th and 20th min ) were found to be higher in placebo groups ( ANOVA variance analysis , Tukey-Kramer test adjusted paired t-test , P<0.001 and < 0 . 01 , respectively ) . No significant difference was found in the other parameters , and no surgical complication and adverse side effect were occurred in this number of study sample . CONCLUSION Tramadol in lower doses ( 0.5 - 1 mg kg(-1 ) ) was an efficient preemptive analgesic that could be used at induction of anesthesia in adenotonsillectomies of children for providing both good analgesia during operation as supplementation to propofol anesthesia and postoperative analgesia in only early period 127 children scheduled for elective tonsillectomy or adenotonsillectomy were studied . Anaesthesia was induced with propofol and maintained with a volatile agent . At induction the child received either rectal diclofenac 1 mg.kg-1 with or without fentanyl 0.75 microgram.kg-1 i.v . , or intravenous tenoxicam 0.4 mg.kg-1 with or without fentanyl 0.75 microgram.kg-1 i.v . Blood loss was measured peroperatively . Nausea and vomiting scores , sedation scores and pain scores were recorded in the recovery room , at one , two , four and eight h postoperatively and at discharge . There were no significant differences in blood loss between the groups or between nausea and vomiting scores . Pain scores in the tenoxicam without fentanyl group were significantly higher in recovery ( P < 0.05 ) than the diclofenac group without fentanyl and both fentanyl groups . This group required supplemental analgesia earlier although this was not significant . The pain scores in the diclofenac with fentanyl group were significantly lower at one h and four h than the group receiving diclofenac alone ( P = 0.008 and 0.02 respectively ) BACKGROUND We investigated the effect of preincisional rectal diclofenac on pain scores and postoperative morphine requirements of children undergoing tonsillectomy after remifentanil-propofol anaesthesia  in a r and omized clinical trial . METHODS Induction and maintenance of anaesthesia were with remifentanil and propofol .  Forty children were r and omly assigned into two groups before incision . The diclofenac group ( n=20 ) received diclofenac suppositories ( approximately 1 mg x kg(-1 ) ) and the control group ( n=20 ) received no treatment . Following discontinuation of remifentanil , patient-controlled analgesia ( PCA ) with morphine ( a loading dose 50 micro g x kg(-1 ) , a background infusion 4 micro g x kg(-1 ) x h(-1 ) and a dem and dose 20 micro g x kg(-1 ) with 5-min intervals ) was started . We assessed pain score [ verbal analogue scales ( VAS ) , 0 - 10 ] and sedation level at 5-min intervals and recorded the total morphine consumption of the first hour in the PACU . Patients were discharged to the ward with a new PCA morphine programme ( a dem and dose 20 micro g.kg-1 with a lockout time of 30 min , for 4 h ) , and total morphine consumption was recorded . RESULTS The mean VAS score of the diclofenac group was significantly lower than the control group on arrival in the PACU ( 2.85 + /- 0.77 , 7.60 + /- 0.83 , respectively , P < 0.01 ) and it remained significantly lower in the PACU stay of the children . The mean total morphine consumption of the diclofenac group was less than the control group in the PACU ( 130.33 + /- 11.26 and 169.92 + /- 9.22 , respectively , P=0.012 ) and the ward ( 50.80 + /- 11.38 and 87.77 + /- 10.55 , respectively , P=0.021 ) . CONCLUSIONS Preemptive diclofenac given rectally reduced pain intensity and morphine requirements of children anaesthetized with remifentanil for tonsillectomy Summary Oral transmucosal fentanyl citrate ( OTF ) was compared with midazolam as a premedicant in a prospect i ve , r and omised , placebo‐controlled , double‐blind trial . Eighty children ( ASA grade 1or 2 , aged 3–9 years ) who presented for tonsillectomy were r and omly allocated to receive either 2.5 ml OTF ( 15–20 µg.kg−1 ) in a lollipop format and 0.5 ml.kg−1 placebo syrup , or midazolam syrup ( 0.5 mg.kg−1 ) and a placebo lollipop ( 2.5 ml ) . The acceptability of sedation , anxiety and compliance with anaesthetic induction were assessed . The children were given an ‘ emergence ’ score for their recovery . Analgesia requirements , the incidence of vomiting , itching and any behavioural changes were assessed for 6 h postoperatively . Oral transmucosal fentanyl citrate was as effective as midazolam in aiding compliance with anaesthesia , but is significantly better in its appeal to children ( p < 0.001 ) and emergence ( p < 0.001 ) characteristics . In conclusion , OTF may be particularly useful as a premedicant in paediatric practice Various clinical protocol s are used to manage early postoperative tons 
    Output:
    
No analgesic in single prophylactic dose provided analgesia for day of operation .