***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 : The administration of analgesics to patients with acute abdominal pain due to acute appendicitis is controversial . A study was undertaken to assess the analgesic effect of morphine in patients with acute appendicitis . Methods : A r and omised double-blind clinical trial was conducted in Sina hospital , a general teaching hospital , from January 2004 to March 2005 . Patients scheduled for appendectomy were r and omised to receive 0.1 mg/kg morphine sulfate or saline ( 0.9 % ) to a maximum dose of 10 mg over a 5 min period . Patients were examined by surgeons not involved in their care before and after drug administration and their pain intensity and signs were recorded at each visit . The physicians were also asked to indicate their own treatment plan . The main outcome measures were pain intensity using a visual analogue scale ( VAS ) and signs of acute appendicitis . A favourable reduction in VAS score was defined as a change of > 13 mm . Results : Of the 71 patients enrolled in the study , 35 were allocated to receive morphine and 36 to receive placebo . One patient left the hospital before receiving morphine . No significant differences were seen between the two groups with regard to age , sex and initial VAS score . A more favourable change in VAS score was reported in the morphine group with a significantly greater reduction in the median VAS score than in the placebo group . Morphine administration did not cause significant changes in patients ’ signs or in the physicians ’ plans or diagnoses . No adverse events were seen in either group . Conclusion : Morphine can reduce pain in patients with acute appendicitis without affecting diagnostic accuracy . Trial registration number : NCT00477061 BACKGROUND Acute and chronic pain is common in hospitalized demented elderly people , yet there are limited data about the performance of pain assessment tools in this population . The aim of this study was to evaluate the feasibility and reliability of four  pain self- assessment scales  in this population and compare their performance to an observational pain rating scale . METHODS Our prospect i ve clinical study was conducted in an acute-care and intermediate-care geriatric hospital on 160 consecutive inpatient referrals to the dementia consultation who met Diagnostic and Statistical Manual of Mental Disorders-IV criteria for dementia . Exclusion criteria were delirium , terminal care , and severe sensory impairment .  Four unidimensional self- assessment tools -- the verbal , horizontal visual , vertical visual , and faces pain scales -- were administered in r and omized order to mild , moderate , and severely demented patients . An observational pain rating scale was independently completed by the nursing team . RESULTS Only 12 % of the 160 patients ( mean age 85 years , 71 % women ) understood no scale . Respectively , 97 % , 90 % , and 40 % of patients with mild , moderate , and severe dementia understood at least one scale ( p < .05 ) . There was a nonsignificant trend toward poorer comprehension of the faces scale . Test-retest reliability was high for all four self- assessment scales , and the correlation between these scales was very strong ( Spearman 's r(s ) = 0.81 - 0.95 ; p < .001 ) . Observational rating correlated moderately with self- assessment and tended to underestimate pain intensity ( r(s ) = 0.31 - 0.40 ; p < .05 ) . CONCLUSIONS Self- assessment pain scales  can be used reliably in the vast majority of older hospitalized patients with mild to moderate dementia and in nearly half of those with severe dementia . Observational pain rating scales correlate only moderately with self- assessment and should be reserved for those few patients who have demonstrated that they can not complete a self- assessment To determine whether reliable and valid rankings of pain and discomfort result ing from hospital procedures encountered by advanced dementia patients could be developed from interviews with cognitively intact adults , rankings of pain and discomfort result ing from 16 common procedures were obtained from two sample s of hospitalized , nondemented adults using ten- ( N = 100 ) and five- ( N = 35 ) point numeric rating scales ( NRS ) . Reliability was assessed by having 30 additional subjects complete ten-point NRS representing the ten most frequent procedures in a re-arranged order . By repeated measure analysis of variance , the scales discriminated between procedures ( F = 35.1 , P < 0.001 ) . Subjects could discriminate between pain and discomfort ( F = 21.6 , P < 0.001 ) . The five-point NRS exhibited better subject discrimination between experiences . Reliability was also acceptable . A five-point NRS produced reliable and valid pain and discomfort rankings for 16 common hospital procedures and experiences . These rankings should prove useful in reducing suffering and can serve as surrogates for quantifying pain and discomfort in dementia patients BACKGROUND Universal pain screening with a 0–10 pain intensity numeric rating scale ( NRS ) has been widely implemented in primary care . OBJECTIVE To evaluate the accuracy of the NRS as a screening test to identify primary care patients with clinical ly important pain . DESIGN Prospect i ve diagnostic accuracy study PARTICIPANTS 275 adult clinic patients were enrolled from September 2005 to March 2006 . MEASUREMENTS We operationalized clinical ly important pain using two alternate definitions : ( 1 ) pain that interferes with functioning ( Brief Pain Inventory interference scale ≥ 5 ) and ( 2 ) pain that motivates a physician visit ( patient-reported reason for the visit ) . RESULTS 22 % of patients reported a pain symptom as the main reason for the visit . The most common pain locations were lower extremity ( 21 % ) and back/neck ( 18 % ) . The area under the receiver operator characteristic curve for the NRS as a test for pain that interferes with functioning was 0.76 , indicating fair accuracy . A pain screening NRS score of 1 was 69 % sensitive ( 95 % CI 60–78 ) for pain that interferes with functioning . Multilevel likelihood ratios for scores of 0 , 1–3 , 4–6 , and 7–10 were 0.39 ( 0.29–0.53 ) , 0.99 ( 0.38–2.60 ) , 2.67 ( 1.56–4.57 ) , and 5.60 ( 3.06–10.26 ) , respectively . Results were similar when NRS scores were evaluated against the alternate definition of clinical ly important pain ( pain that motivates a physician visit ) . CONCLUSIONS The most commonly used measure for pain screening may have only modest accuracy for identifying patients with clinical ly important pain in primary care . Further research is needed to evaluate whether pain screening improves patient outcomes in primary care Abstract The present study investigated whether the level of cognitive impairment ( CI ) affects acute pain behavior and how it is manifested . Participants were 159 individuals ( mean age 42 ± 12 ) , 121 with CI ( divided into four groups according to the level of CI : mild , moderate , severe , profound ) and 38 with normal cognition ( controls ) . The behavior of the participants before and during acute pain ( influenza vaccination ) was coded by two raters with the Facial Action Coding System ( FACS – scores facial reactions to pain ) and the Non‐Communicating Children ’s Pain Checklist ( NCCPC‐R – scores both facial and general body reactions ) . Individuals with severe – profound CI exhibited elevated FACS and NCCPC‐R values at baseline compared with all other groups ( p < 0.01 ) . Both FACS and NCCPC‐R scores of individuals with mild – moderate CI and controls increased significantly during vaccination ( p < 0.001 ) . In contrast , individuals with severe – profound CI exhibited high rates of “ freezing reaction ” ( stillness ) during vaccination , manifested mainly in the face and therefore result ing in elevation of only NCCPC‐R scores but not of FACS ’s . The results suggest that the level of CI affects baseline as well as pain behavior and it is therefore necessary to choose an appropriate behavioral tool to measure pain in these individuals accordingly . For example , tools based on facial reactions alone might provide the false impression that individuals with severe – profound CI are insensitive to pain ( due to freezing ) OBJECTIVES To evaluate the effect of emergency department ( ED ) crowding on assessment and treatment of pain in older adults . DESIGN Retrospective review of ED records from a prospect i ve cohort study . SETTING Urban , academically affiliated , tertiary medical center . PARTICIPANTS One hundred fifty-eight patients , aged 50 and older , evaluated and hospitalized from the ED with hip fracture . MEASUREMENTS Patient-related risk factors : age , sex , nursing home residence , ED triage status , dementia , Acute Physiology in Age and Chronic Health Evaluation II physiological score , and R AND comorbidity score . ED crowding risk factors : ED census and mean length of stay . OUTCOMES documentation of pain assessment , time to pain assessment , time to pain treatment , patients reporting pain receiving analgesia , and meperidine use . RESULTS Mean age was 83 ( range 52 - 101 ) , 81.0 % of patients complained of pain , mean time to pain assessment was 40 minutes ( range 0 - 600 ) , time to treatment was 141 minutes ( range 10 - 525 ) , and mean delay to treatment was 122 minutes ( range 0 - 526 ) . Of those with pain , 35.9 % received no analgesia , 7.0 % received nonopioids , and 57.0 % received opioids . Of those receiving opioids , 32.8 % received meperidine . ED crowding at census levels greater than 120 % bed capacity was significantly associated with a lower likelihood of documentation of pain assessment ( P = .05 ) and longer times to pain assessment ( P = .01 ) . CONCLUSION Older adults with hip fracture are at risk for under assessment of pain , considerable delays in analgesic administration after pain is identified , and treatment with inappropriate analgesics ( e.g. , meperidine ) in the ED . Higher levels of ED census are significantly associated with poorer pain management BACKGROUND Successfully managing pain for the trauma patient decreases morbidity , improves patient satisfaction , and is an essential component of critical care . Using patient-controlled analgesia ( PCA ) morphine to control pain may be complicated by concerns of respiratory depression , hemodynamic instability , addiction , urinary retention , and drug-induced ileus . Morphine is rapidly absorbed by mucosal surfaces in the respiratory tract , achieving systemic concentrations equal to 20 % of equivalent intravenous doses . The purpose of this study was to evaluate the safety , efficacy , and utility of nebulized morphine in patients with posttraumatic thoracic pain . METHODS This double-blinded , prospect i ve study r and omized patients with severe posttraumatic thoracic pain into two groups . The experimental group ( NMS ) received nebulized morphine every 4 hours and normal saline by PCA . The control group ( PCA ) received nebulized saline every 4 hours and morphine by PCA . Dose adjustments were made based on patient response to treatments using a 10-point visual analog scale ( VAS ) for pain . Pulmonary function , pain relief ( VAS ) , level of sedation ( 0 - 3 ) , total drug administration , and systematic side effects were recorded . RESULTS Forty-four patients were r and omized ( 22 per group ) . Seven hundred seventy observations were made . The mean 4-hour dose of morphine was 11.96 + /- 3.4 mg for NMS and 6.22 + /- 4.7 mg for PCA ( p < 0.001 ) . Patients with NMS had lower heart rates compared with PCA ( 79 + /- 11 bpm versus 92 + /- 12 bpm ; p < 0.001 ) and were less se date d ( 0.33 + /- 0.7 versus 0.56 + /- 0.9 ; p = 0.03 ) . The mean pain level ( VAS ) was 3.38 + /- 1.8 for NMS and 3.84 + /- 2.7 for PCA ( p = 0.2 ) . There was no difference between pain levels before and after dosing . There were no differences between groups with respect to arterial blood pressure , respiratory rate , vital capacity , mean forced expiratory volume in 1 second , spirometric volumes , or Sao2 . CONCLUSION Nebulized morphine can be safely and effectively used to control posttraumatic thoracic pain . Pain can be successfully managed while vital capacity , mean forced expiratory volume in one second , and spirometric volumes are maintained . Compared with PCA morphine , nebulized morphine provides equivalent pain relief with less sedative effects OBJECTIVE The objective of this study was to identify the underlying causes of respiratory-related critical events associated with  intravenous patient-controlled analgesia ( i.v . PCA ) . DESIGN The design is an observation study of prospect ively collected data . SETTING An Acute Pain Service ( APS ) was established for the management of all patients receiving i.v . PCA therapy for pain management . As part of ongoing care , all respiratory-related critical events were documented and analyzed by staff members of the APS team . PATIENTS All patients receiving i.v . PCA therapy through the APS during the period of May 1990 through October 1992 were enrolled in the study . INTERVENTIONS Evaluation of all respiratory-related critical events was attempted to identify the underlying cause of the event and to determine if measures could be taken to prevent recurrence of similar events . OUTCOME MEASURES Any clinical event that could have or did lead to adverse patient outcome was used as an outcome measure . RESULTS A total of 3,785 patients received P 
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RESULTS We found no evidence that directly linked the timing , frequency , or method of pain assessment with outcomes or safety in medical in patients .
There is good evidence that treating abdominal pain does not compromise timely diagnosis and treatment of the surgical abdomen .
Pain management teams and other systemwide interventions improve assessment and use of analgesics , but do not clearly affect pain outcomes .
The safety and effectiveness of PCA  in medical patients have not been studied .
There is weak evidence that most cognitively impaired individuals can underst and at least one self- assessment measure .
Almost no evidence is available to guide management of pain in delirium .
Pain is a prevalent problem for medical in patients .