Background: There are many surgical and anesthetic factors that affect pain and the endocrine–metabolic response to trauma. The ability of anesthetic agents and neuronal blockade to modify the response to surgical trauma has been widely studied in the last few years. Objective: To evaluate if the anterior quadratus lumborum block contributes to improved surgical recovery, using as parameters analgesia, pulmonary function and neuroendocrine response to trauma. Methods: We carried out a prospective, randomized, controlled, and blinded study, in which 51 patients scheduled for laparoscopic cholecystectomy. Patients were randomly selected and assigned to 2 groups. The control group received balanced general anesthesia and venous analgesia, and the intervention group was treated under general, venous analgesia and anterior quadratus lumborum block. The parameters evaluated were: demographic data, postoperative pain, respiratory muscle pressure and inflammatory response to surgical stress with the plasma dosage of IL-6 (Interleukin 6), CRP (C-Reactive protein) and cortisol. Results: Anterior quadratus lumborum block induced the slowing of IL-6 cytokine production and a decrease in cortisol release. This effect was accompanied by the significant reduction of postoperative pain scores. Conclusion: Anterior quadratus lumborum block is an important strategy for analgesia in abdominal laparoscopic surgery and contributes to reducing the inflammatory response to surgical trauma with an early return of preoperative baseline physiological functions. The introduction of laparoscopic surgery was an important milestone in the evolution of the surgical treatment of gallbladder pathologies. This technique is now known to shorten recovery and attenuate the inflammatory response resulting from surgical procedures . It is aVideo laparoscopy promotes hemodynamic changes by the combination of factors such as pneumoperitoneum, hypercapnia, positioning and anesthetic technique administered to the patient . The use2, which affect 35 to 60% of patients [Although postoperative pain (POP) is less frequent and more easily controlled after minimally invasive procedures than after procedures performed via laparotomy, there is still no consensus on the effectiveness of control measures. With the video laparoscopic technique, the most frequent complaint is related to visceral pain and shoulder pain, resulting from diaphragmatic irritation in pneumoperitoneum caused by COpatients . Three types of pain occur after laparoscopy : visceraIncisional pain produces a shallow breathing pattern and restrictive dysfunction, which lead to hypoxemia and pulmonary complications. The degree of pain like has an important role in the generation of this cascade. The incisions, the damage to visceras and traction by the pneumoperitoneum lead to inflammatory responses that may affect patients’ postoperative rehabilitation .Trauma triggers an organized tissue response involving the central nervous system, the hypothalamic–pituitary–adrenal axis, and the immune system. Tissue damage is identified by peripheral and central nociceptors that elicit an axonal membrane depolarization response. The electrical impulse generated by the activation of these nociceptors is transmitted by nerve fibers to the dorsal horn of the spinal cord, initiating the activation of the central nervous system and an immediate sympathetic neurological response. After the immediate adrenergic response, different times of systemic endocrine, tissue and hemodynamic response follow .The immune response to trauma is mediated by the perioperative expression of cytokines. Cytokines indicate the activation pathway of the immune response and cell type involved. They are soluble proteins and polypeptides that act as messengers of the immune system. Produced by a variety of cell types, including monocytes, macrophages, lymphocytes, and endothelial cells, they may exert a pro-inflammatory or anti-inflammatory function depending on the effector site. Cytokines are essential for physiological and immunological homeostasis. They are produced in response to a variety of physiological and pathological stimuli. The increase in Interleukin-6 (IL-6) has been associated with an exacerbated response to trauma, being used as a global inflammatory marker. It is believed that IL-6 is the main inducer of acute-phase proteins, such as hepatocyte C-reactive protein (CRP), in addition to causing the differentiation, proliferation and maturation of hematopoietic progenitors ,13.IL-6 is a pro-inflammatory cytokine that exerts local and systemic effects, promoting the activation of the immune system, fighting its infection and initiating biochemical mechanisms of healing and tissue repair. It is the main cytokine to be released after surgery and can be considered a reliable marker of the inflammatory response to surgical trauma .It is produced by macrophages and T helper type 2 (Th2) lymphocytes. It activates the inflammatory cascade, acts on the activation of lymphocytes and the differentiation of antibody-producing B cells, promotes the production of acute-phase proteins and has an endogenous pyrogenic effect. In a clinical study carried out to evaluate the relationship between the magnitude of the trauma and the increase in serum IL-6 in an emergency setting, a direct relationship was found between the increase in IL-6, and the degree of trauma, morbidity and mortality. Therefore, dampening the release of IL-6 may mean control the response to trauma .CRP is considered an opsonin and an activator of innate immune cells, particularly neutrophils, in addition to having anti-inflammatory and pro-inflammatory properties. Elevations in CRP levels begin approximately 4–6 h after operative injury and usually peak within 48 h. After uncomplicated operations, its levels begin to decline and usually normalize within 72–168 h. Therefore, it is perhaps not surprising that, given their relationship and plasma kinetics, both IL-6 and CRP seem to similarly reflect the magnitude of surgical trauma.The response to surgical stress is characterized by the secretion of pituitary hormones and the activation of the central nervous system . ControlThere are many surgical and anesthetic factors that affect the response to trauma, and the control of the inflammatory factor is considered of great importance . It has Truncal blocks, as part of perioperative pain management, were introduced into clinical practice over 40 years ago. Initially used with the ilioinguinal–iliohypogastric block and the rectus sheath block, they are more commonly used in the pediatric anesthesia population. Initially, these blocks were performed without ultrasound guidance, using reference techniques. However, the clinical use of truncal block techniques has developed over time and its expansion has been driven by the introduction of ultrasound in the practice of anesthesiology. Although anatomical markers are reliably detected by ultrasound, anterior abdominal wall blocks vary in both the distribution of local anesthetics and the field of coverage. In the search for greater analgesia coverage and a longer duration of postoperative analgesia, fascia transverse plane block and quadratus lumborum block (QLB) were developed .The successful use of QLB with all approaches has been reported in case reports for the following surgical procedures: proctosigmoidectomy, hip surgery, above-knee amputation, abdominal hernia repair, breast reconstruction, colostomy, closure, radical nephrectomy, lower extremity vascular surgery, total hip arthroplasty, laparotomy, and colectomy. Several other cases report a variety of indications for QLB, documenting that sensory blockades include the T7–L2 dermatomes .The objective of this study is to evaluate if blocking in the form of anterior QLB, also known as type 3, contributes in a way which attenuates surgical repercussions, having as its primary parameter analgesia and as its secondary parameters the pulmonary function and neuroendocrine response to trauma.The patients were treated in the Deparment of Surgery of the Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO). The surgical clinic and anesthesiology departments are accredited by the Federal Ministry of Education and the Brazilian Society of Anesthesiology (SBA). Standard anesthetic techniques and protocols were used. The study was conducted after receiving approval by the Ethics and Research Committee of the mentioned hospital in June 2020 with CAAE nº 26859319.90000.5258 and was registered on the Brazilian clinical trial registration platform (RBR-96xv826).After applying and signing the informed consent form (ICF), 51 of 56 patients with American Society of Anesthesiology (ASA) I and II were treated by laparoscopic cholecystectomy from October 2020 to June 2021 at the Gaffrée e Guinle University Hospital . PatientConsidering the eligibility criteria of the study, the patients were excluded from the study for: refusal to participate in the study; body mass index (BMI) greater than or equal to 40; smoking history or obstructive pulmonary disease, presence of peripheral neuropathies; coagulopathies or hypersensitivity to drugs used for analgesia; infection at the puncture site; cholecystitis, deformities or previous spinal operations; dementia or other states that would prevent the adequate understanding of the use of the numeric VAS pain scale; immunological diseases, malignant neoplasia, use of opioids or anti-inflammatory drugs in the preoperative period; use of antidepressants and anticonvulsants; and requirement of conversion of surgery to conventional technique (open surgery).All patients upon admission to the operating room were monitored according to the recommendations of the ASA and received peripheral venous access with an 18 or 16 intravenous catheter. All surgeries were performed under balanced general anesthesia; both groups received routine venous analgesia. The intervention group additionally received ultrasound-guided anterior QLB, which was performed with the patient anesthetized soon after the induction of general anesthesia. The anesthetic drugs and their dosages were standardized so that there were no differences between the groups. The induction of general anesthesia involved the following: propofol 2.5 mg/kg, rocuronium 0.5 mg/kg and fentanyl 5 mcg/kg. Intraoperative maintenance involved the following: sevoflurane 1–2 CAM with oxygen 50% and air 50%. All patients received dipyrone at a dose of 30 mg.kg−1 intravenously and ketoprofen 100 mg EV at the end of surgery, in addition to infiltration of the surgical portals with ropivacaine 0.3% volume of 10 mL. In the immediate postoperative period, all patients received intravenous ketoprofen 100 mg in regular doses of 12/12 h, and only received common analgesics  or opioids  if pain was greater than 5. Ondansetron 4 mg was administered intravenously in the intraoperative period for the prophylaxis of nausea and vomiting. Surgical time was similar between the groups, lasting less than 3 h.Ultrasound-guided quadratus lumborum block (QLB) is a recently described fascial plane block in which the anesthetic is injected adjacently to the quadratus lumborum (QL) muscle with the goal of anesthetizing the nerves in the thoracolumbar region . It is bAs QLB is a classic method of injecting intramuscular  medication, the possibility of infection is much lower than when performing neuraxial blocks. To date, no infections have been described as a result of QLB. The advantage of the QLB over other abdominal wall blocks is the fact that the passage of the needle and the site of application of the local anesthetic are far from the peritoneal cavity, the visceral abdominal organs and the large blood vessels. Therefore, needle trauma is minimized here in terms of unintentional puncture of the peritoneum, intestine, liver, kidney, and large blood vessels associated with blind (non-ultrasound) methods of TAP and II-IH block performance. Performing QLB under ultrasound control, with mandatory monitoring of the needle tip carried out before drug injection, significantly increases the level of safety and efficiency of the technique. There are no data on neurological damage, as the local anesthetic is not injected in the immediate proximity of the large nerve but is injected into the space which is rich in small nerve endings. Therefore, it is generally accepted that QLB can be performed under general and regional anesthesia . The curIn this study, the anterior or type 3 QLB was performed right after anesthetic induction. A low-frequency curvilinear transducer was used to facilitate tissue penetration of the ultrasound and the establishment of a wide field of view. With the patient in lateral decubitus, the transducer is placed in transverse orientation on the posterior or midaxillary line at the L2–L4 level in order to visualize the QL and psoas muscle. To identify the QL muscle, it is important to observe some structures as reference, such as the aponeuroses of the abdominal wall muscles  which are located posterolaterally to the muscle. The QL muscle is often hypoechoic in relation to the psoas major muscle, which is located anteromedially. Additionally, the lumbar transverse processes are apparent due to their curved hyperechoic appearance.The recommended dose of local anesthesia varies from 0.2–0.4 mL/kg of 0.2–0.5% Ropivacaine or of 0.1–0.25% Bupivacaine. The dose was adjusted respecting the toxic dose of the local anesthetic and the anterior QLB performed bilaterally. In this study, 20 mL of 0.3% Ropivacaine was administered bilaterally  using a Stimuplex A100 needle.The efficacy of analgesia produced by the two techniques studied was evaluated at regular intervals by the numeric verbal rating scale (NVRS). Patients were asked to answer the question, “Are you feeling pain? How severe is the pain on a scale of 0–10 ?”. The intensity of pain was measured 1 h, 4 h and 24 h postoperatively by this scale, and the consumption of pain killers (tramadol) was also recorded. Categories were constructed based on the intensity of pain reported by the patients, with the value 0 being considered Painless; 1–3 being considered “Light”; 4–6 “Moderate”; and 7–10 “Severe” pain.For the determination of the markers of inflammatory response measuring IL-6, CRP and cortisol, samples were collected at anesthetic induction (preoperative) and at 4 h and 24 h after the surgical procedure had been performed. The blood samples of the research participants were collected in a tube without additives and the serum was preserved at −112 °F until the moment of analysis without freezing and thawing cycles. The trials were conducted in the laboratory of the National Program for Quality Control (NPQC), in the state of Rio de Janeiro. The research participant did not know the analgesia technique performed in each procedure. IL-6 serum concentration was determined by the electrochemiluminescence immunoassay (ECLIA) using the Roche Cobas e411 immunoassay analyzer. CRP serum concentration was determined with the immunoturbidimetric assay using the Bioclin 3000 automated analyzer. Cortisol serum concentration was determined with the chemiluminescence immunoassay (CLIA) using the Abbott Architect i1000 immunoassay analyzer. Statistical analysis was performed during the process of outcome assessment, and the research participant did not know the analgesia technique performed in each procedure.The evaluation of respiratory muscle strength, maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) was performed using an analog manovacuometer. Individual rubber ducts were used with a rigid-plastic diver-type mouthpiece with an internal diameter of 2 mm and a length of 15 mm. This was performed according to the method recommended by Black and Hyatt . EvaluatThe measurements were performed with the patient in a “beach chair” position (headboard elevated 45 degrees). Initially, they were oriented to breathe closely to the tidal volume and, after three breaths, patients were asked to perform a maximum forced expiration  and then a maximum static inspiratory effort. These methods required being sustained for 3 s, with nasal occlusion, in order to obtain the MIP. Subsequently, to measure the MEP, the patient breathed at a level close to the tidal volume for three cycles and performed a maximum inspiration effort , followed by a maximum static expiratory effort sustained for 3 s . Both maIn the present study, 56 patients were recruited. After applying selection criteria, 51 patients were included into the analysis. One participant was excluded because of spinal deformity, two were excluded because of high BMI > 40 and two others refused to take the respiratory tests. Study power analysis was calculated post hoc. Power calculation was performed for the variables of Pain 24 h after procedure and MEP 4 h after procedure, which showed the statistical significance between groups. The test power for the Pain 24 h was equal to 0.962. As for the MEP 4 h, the resulting power was 0.773. Thus, it is considered that the power of the study was 0.773, considering the minimum power calculated, and a confidence level of 95% was attained (α = 0.05).t test was chosen for quantitative variables whose data presented normal distributions through the Shapiro test, both for the control and intervention groups, and where the variances between the groups were considered homogeneous when applying the Bartlett test. The central trend measure used to perform the t test is the mean of the groups.The For the quantitative variables that, through the Shapiro test, did not present normal distributions for the control and intervention groups, the test chosen was the Mann–Whitney nonparametric test. The central trend measure used to perform the Mann–Whitney test was the median of the groups.In considering the qualitative or categorical variables, the test chosen was the non-parametric Chi-square test, which takes into account that the control and intervention groups are independent.The R software 4.0.3 version was selected to perform the hypothesis tests between the patients in both groups, and the Mann–Whitney test was applied to compare each variable between the groups.There were 51 patients enrolled in the study. The two groups were similar regarding age, BMI and comorbidities. No complications were observed, and there were no mortalities .p value = 0.0008). There was no statistically significant difference in the VAS scores obtained 1 h and 4 h after procedure between the control and intervention groups , IL-6 presented lower values preoperatively, but 4 h after, IL-6 levels were higher than 24 h after the procedure. Within the control group, there was a high variability of IL-6 for patients 4 h after the procedure. The dispersion values calculated for all the groups was 1.0146, with a value of 1.1130 for control, and for intervention the value was 0.8578 .p values presented in Observing the median values for the cortisol variable, the highest median found was 22.2 for the control group at 4 h after the procedure. The lowest median found was 9.8 for the intervention group measured preoperatively. According to the The measurement of CRP medians during the preoperative and postoperative periods did not show many alterations between the intervention and the control group, having the following values: before the procedure (Control = 2/Intervention = 2); 4 h after procedure (Control = 3/Intervention = 4); and 24 h after procedure (Control = 36.15/Intervention = 39.65) .We observed that the MEP measurement, 4 h (Control = 47.5/Intervention = 65) and 24 h (Control = 62.5/Intervention = 70) after the procedure showed a greater difference between the medians of the intervention in relation to the control Group compared to the preoperative period (Control = 85/Intervention = 80). Similarly, the MIP measurement, 4 h (Control = 35/Intervention = 40) and 24 h after the procedure (Control = 45/Intervention = 55) showed a difference between the medians of the intervention compared to the control group in relation to the preoperative period (Control = 67.5/Intervention = 60) .The triad of hypnosis, immobility and antinociception, necessary at the moment of anesthesia, is achieved through the synergism of different medications. General anesthesia can inhibit the activity of the central nervous system, reducing surgical trauma to the body, but it has no significant inhibitory effect on the noxious stimulation signal of the somatic nerve or on ascending sympathetic nerve transmission. Strategies to control the neuroinflammatory response to trauma are needed, among which pharmacological interventions are required, especially minimally invasive surgery and neural block techniques . This stAnterior QLB in this study was performed after the induction of anesthesia due to the time of the plasma peak of Ropivacaine, which is on average 40 min, aiming for greater safety and greater efficacy of the blockade at the end of the procedure. The blockade was performed bilaterally, requiring careful consideration of patient positioning and the calculation of the toxic dose of the local anesthetic. The fascial planes in the abdominal compartment follow the QL and PM, medially and laterally, through the arcuate ligaments and the aortic hiatus of the diaphragm, forming the endothoracic fascia. This provides a potential route of dissemination of the local anesthetic from the abdominal cavity to the thoracic cavity and paravertebral space, thus achieving clinical effects ,32. In aThe majority of authors agree that QLB has an outstanding analgesic effect on pain, reducing it to scores of 1–2/10 as assessed by VAS, and this usually lasts for more than 24 h. Patients who receive QLB as part of postoperative pain therapy have lower pain levels both when resting and moving, which is important for early mobilization. The analgesic effect is as good as the one achieved by opioids, and there are no unwanted opioid effects such as nausea and vomiting . According to prospective studies published by Blanco, Ansari & Girgis , in 2015QLB provides early and rapid pain relief in a high percentage of patients and allows early ambulation, which is one of the most important measures in the prevention of deep vein thrombosis and thromboembolic complications .Pain is entirely subjective and its links with pathology are indirect; the only way to successfully assess pain is to believe the patient. In this study, pain was evaluated utilizing the VAS. This method is more preferred by patients for its simplicity as well as in its greater sensitivity in comparison to other pain scales in calculating the pain intensity changes that occur ,39.Metanalysis exhibited several superiorities of QLB for patients undergoing laparoscopic surgeries. The results indicated that application of QLB was associated with a smaller number of patients requiring additional analgesia, with reduced intraoperative opioid consumption and postoperative opioid consumption, and with lower incidences of postoperative nausea and vomiting (PONV) compared to placebo . In contp value < 0.05) and, as demonstrated in two randomized controlled trials, that QLB reduces cumulative opioid consumption for 48 h after caesarean section [This study demonstrated a significant reduction in pain scores and opioid consumption in the intervention group  [During surgery, an immune/inflammatory response is initiated, determining varying degrees of clinical implications. A study of elderly patients concluded that QLB could improve postoperative cognitive function in this group undergoing laparoscopic radical gastrectomy. This may be related to the suppression of the inflammatory response after surgery. Compared with the control group, HMGB1, TNF-α and IL-6 levels were significantly decreased 1 and 3 days after surgery in the intervention group ( < 0.05) . Our resAccording to the literature, CRP was the most described biomarker, followed by the IL-6 and TNF-a responses to surgical intervention. IL-6 rose 1 h after surgery with a plasma peak at 4 to 6 h. CRP starts its rise from 4–6 h (induced by IL-6) with a plasma peak at 48 h. Although both IL-6 and CRP reflect similarly the magnitude of trauma, the kinetics of these biomarkers are not identical. When analyzing the IL-6 variable at the three time points, a high variability among patients 4 h after the procedure was observed within the control group. It was confirmed via the coefficient of variation calculations that the dispersion of the IL-6 variable was greater in the control than in the intervention group. This reduction in the coefficient of variation may demonstrate an attenuation of the immune/inflammatory response to surgical trauma in the group submitted to anterior QLB. In a study by Zhu, Qi, He, Zhang, and Mei , a signip < 0.05) in the intervention group. The data and dosage of several substances and cellular components, including some hormones, leukocyte count, inflammatory cytokines and analysis of T-lymphocyte behavior, may be useful in monitoring for systemic inflammatory syndrome (SIS) after elective surgeries. However, there are divergences in the results of some studies, which can be attributed to potential confounding factors related to the moment of collection and mediator-dosed, intrinsic factors related to the patients, and the peculiar behaviors of the mediator to be studied.Regarding CRP levels between the control and intervention group, we noticed similar level patterns without many alterations at the times evaluated. In the intervention group, there was only a change in plasma kinetics for IL-6, which did not occur with CRP. The duration of the effect of anterior QLB is about 12–24 h, having a greater effect the IL-6 kinetics . CortisoIn our study, the exclusion of ASA Status III patients who have severe systemic disease with the functional limitations of advanced age, obesity, emergency situations, and autoimmune diseases and conversion to open surgery were necessary, because such conditions can alter the inflammatory response. These comorbidities can interfere with the measurement of biomarkers. The surgical time is directly related to the magnitude of the trauma. Therefore, we limited the search to elective laparoscopic cholecystectomies that lasted an average of 2 to 3 h. The team was the same and the same researcher performed all anesthetic blocks due to their operator-dependent procedures.Our study had limitations: for the CRP parameter. A longer patient follow-up would be necessary since the plasma peak of this marker occurs 48 h after the trauma. The cortisol result may also have interfered with the surgical schedules. Our research was carried out during the COVID 19 pandemic, when elective surgeries were reduced in hospitals. The relatively small sample of patients may also have hampered our analysis.There are several studies in the literature which evaluate the QLB effect on the pain and surgical stress responses. The present clinical trial evaluated the effect of anterior QLB on the inflammatory response. Our results suggest a reduced inflammatory response to surgical trauma in cholecystectomy patients. This technique can be an important adjunct to multimodal anesthesia in minimally inivasive surgical intervention. Additional applications have been suggested; namely in the upper and lower abdomen and pelvic cavity. QLB optimizes the control of the neurohumoral response while maintaining excellent lung function and pain control.There is great importance of controlling the metabolic and inflammatory response to surgical trauma. The paradigm shift currently playing out is from patients having essentially been treated for pain with analgesics, to treating them with neuroinflammatory treatment. In fact, pain and surgical stress response are closely related. The method described by the authors of this article., expands the range of therapeutic interventions and perioperative care available to physicians, delivering improved patient satisfaction and impacting public health outcomes.


The application of artificial intelligence patient-controlled analgesia (AI-PCA) facilitates the remote monitoring of analgesia management, the implementation of mobile ward rounds, and the automatic recording of all types of key data in the clinical setting. However, it cannot quantify the quality of postoperative analgesia management. This study aimed to establish an index ) to re-monitor and re-evaluate the system, equipment, medical staff and degree of patient matching to quantify the quality of postoperative pain management through machine learning.Utilizing the wireless analgesic pump system database of the Cancer Hospital Affiliated with Nantong University, this retrospective observational study recruited consecutive patients who underwent postoperative analgesia using AI-PCA from June 1, 2014, to August 31, 2021. All patients were grouped according to whether or not the AQI was used to guide the management of postoperative analgesia: The control group did not receive the AQI guidance for postoperative analgesia and the experimental group received the AQI guidance for postoperative analgesia. The primary outcome was the incidence of moderate-to-severe pain  score ≥ 4) and the second outcome was the incidence of total adverse reactions. Furthermore, indicators of AQI were recorded.P < 0.001). There were significant differences between groups. Otherwise, the differences in the incidence of total adverse reactions between the two groups were nonsignificant.A total of 14,747 patients were included in this current study. The incidence of moderate-to-severe pain was 26.3% in the control group and 21.7% in the experimental group. The estimated ratio difference was 4.6% between the two groups (95% confidence interval [CI], 3.2% to 6.0%; Compared to the traditional management of postoperative analgesia, application of the AQI decreased the incidence of moderate-to-severe pain. Clinical application of the AQI contributes to improving the quality of postoperative analgesia management and may provide guidance for optimum pain management in the postoperative setting. Most surgical patients face acute postoperative pain, but evidence suggests that less than half of patients receive adequate postoperative pain relief –3. EffecPatient-controlled analgesia (PCA) is the standard practice, yielding greater satisfaction and preference than traditional parenteral analgesia managed by anesthesiologists and nurses , 17. PatIn the medical field, artificial intelligence (AI) has broad application prospects in the prevention, diagnosis and treatment of diseases and even in anesthesiology –24, whicWith the advent of data accumulation and the increasing application of machine learning techniques, there has been a shift towards utilizing data-driven approaches to enhance the quality of analgesic management. Analgesia quality index (AQI) is a product of the development of the Ai-PCA system and has emerged as a data-driven approach to enhance the quality of postoperative analgesia management. It addresses the need for a quantitative indicator to assess the effectiveness of analgesic interventions. The components of the AQI are derived from objective data collected from the AI-PCA system database. These data include parameters such as the autonomously controlled button pressing frequency, evaluation rate, incidence of alarms, alarm processing time, drug utilization, and basic patient information. Each of these components reflects different aspects of analgesic management, such as the quality control consciousness of medical staff and analgesic technique level, precision of medical advice, and standardization of management. To calculate the AQI, the data collected from a specific area  over a defined time period  are analyzed using machine learning techniques and algorithms. The data is processed, and a weighted intelligence score is generated. The weights assigned to each component are determined based on their relative importance in assessing the quality of analgesic management. This weighting system ensures that different aspects of analgesic management contribute appropriately to the overall AQI. By quantifying various aspects of analgesic management, the AQI allows for a more objective assessment of the effectiveness of interventions. It serves as a tool to monitor and improve the analgesic technique level, precision of medical advice, and standardization of management. The AQI enables healthcare professionals, including anesthesiologists and nurses, to identify areas of improvement in their practices and make data-driven decisions to optimize postoperative analgesia. It promotes a higher level of quality control consciousness among medical staff and helps in enhancing the overall standard of analgesic management. In summary, the AQI is a quantitative index that combines objective data and machine learning techniques to assess the quality of postoperative analgesia management. It provides a standardized measure for evaluating the effectiveness of interventions and serves as a tool for continuous improvement in the field of analgesic care.In this study, we exploited the wireless analgesic management system database of the Cancer Hospital Affiliated to Nantong University to explore the role and effect of the AQI in postoperative analgesia management and hypothesized that the AQI would better supervise anesthesiologists and nurses to improve the quality of postoperative analgesia management.The AI-PCA system combines the IoT and AI to provide advanced features and functions for pain management. AI-PCA system is composed of intelligent infusion device, disposable special liquid storage box, wireless transmission equipment, mobile ward round system, central station and information management system, which offers remote monitoring, intelligent alarm system, intelligent analysis and evaluation, data recording and storage, dynamic management of analgesia and so on. Besides, the AI-PCA system facilitates performance evaluation of healthcare providers involved in pain management. The system generates the AQI based on various objective and subjective indicators, providing a quantitative measure of the quality of analgesia delivery. This evaluation helps identify areas of improvement and promotes continuous enhancement of pain management practices.The AI-PCA system  database of the Cancer Hospital Affiliated with Nantong University was used in this retrospective study. The study was approved by the Medical Ethics Committee of our hospital, and an informed consent form was signed by the patients and their families. Created in 2014, the database gathers the usage information of all patients who have undergone postoperative analgesia using AI-PCA. Mainly composed of intelligent analgesia pump, base station (data transmission) and central analgesia monitoring station  , and the patients who received AQI guidance for postoperative analgesia management from April 1, 2018, to August 31, 2021, were taken as the experimental group . The AQI of group C was calculated by the original data in the wireless analgesic management system, and the AQI of group A was calculated by intelligent analysis of the AI-PCA system. The patient's AQI is included in the related medical staff's performance evaluation criteria in group A with the purpose of motivating them to continuously improve the quality of postoperative analgesia management according to the AQI.This was a retrospective study of postoperative analgesia involving 14,747 patients between 2014 and 2021. Despite the fact that the AI-PCA system has been in use since 2014, it was not until 2018 that an AQI was proposed and applied in the Cancer Hospital Affiliated with Nantong University. As a result, to observe the effect of the AQI in postoperative analgesia management, the patients who did not receive AQI guidance for postoperative analgesia management from June 1, 2014, to March 31, 2018, were taken as the control group . It is a comprehensive index derived through real-time monitoring and assessment of the patient experience, operation status of the wireless analgesia system, work quality and efficiency of the acute pain service team. The results are calculated in percentage terms. Taking the scoring method for the insufficient analgesia rate as an example, the data of 100 hospitals in China in one month were selected for sample analysis, and a normal distribution curve is generated from these data. The mean value (μ) of analgesia insufficiency rate is 7% and the standard deviation (σ) is 6%. Thus, the score ranges from μ-σ to μ + σ, which covers approximately 68%. When the analgesia insufficiency rate is higher than μ + σ (13%), the score is 0, and when it is lower than μ-σ (1%), the score is maximal. The range from μ-σ to μ + σ is calculated in proportion  and analyzed using the Mann–Whitney U test. Categorical data which were shown as numbers and percentages were analyzed by χ2 test or Fisher's exact test.The total AQI value of the non AQI-management group was computed based on data from 7162 patients with AI-PCA postoperative pain management from June 1, 2014, to March 31, 2018. In addition, the total AQI value of the AQI-management group was calculated based on data from 7585 patients with AI-PCA postoperative pain management by the AQI from April 1, 2018, to August 31, 2021. The Kolmogorov–Smirnov test was used to evaluate whether the data meet the normal distribution. For continuous variables, the normal distribution data was represented as mean ± standard deviation (SD) and analyzed using the independent sample P values of less than 0.05 were considered statistically significant, and two-sided statistical tests were performed. Statistical analyses were performed using either SPSS Statistical Software, version 21.0 .For all analyses, unless indicated otherwise, A total of 14,747 patients were included in this study. Table P < 0.001). There were significant differences between groups    Fig. C. Howeve01) Fig. D.P = 0.001)  Fig. .Fig. 5ThP < 0.001). Moreover, compared with the non-AQI-management group, the evaluation rate of the AQI-management group was significantly improved (74.7 (6.8) vs. 102.2 (2.7), P < 0.001), the insufficient analgesia treatment time of the AQI-management group was significantly shortened  vs. 140.5 , P = 0.019), and the rate of leaving service area was also reduced (8.5 (7.4) vs. 6.2 (5.4), P = 0.048). In addition, the average pressing times (3.1 (1.1) vs. 2.1 (0.8), P < 0.001), the insufficient analgesia rate (1.2 (0.8) vs. 0.9 (0.6), P < 0.001) and drug utilization rate (72.1 (5.0) vs. 64.0 (4.4), P < 0.001) were reduced in the AQI-management group (10.47 ± 7.23 vs. 7.23 ± 5.38) compared with those of the non-AQI-management group. However, the poor analgesia rate (0.6 (1.8) vs. 1.6 (1.1), P < 0.001) and the blockage rate (17.5 (4.0) vs. 24.2 (3.9), P < 0.001) were higher in the AQI-management group  vs. 9.0 (0), In the practice of using AI-PCA to manage postoperative analgesia, the efficiency and quality of anesthetic care will inevitably affect the quality and comfort of postoperative analgesia. In this study, as an algorithm to evaluate the work quality of anesthetic doctors and nurses, the AQI may urge anesthesiologists and nurses to continuously improve their work. The main scoring items of the AQI index are related to the important process data in AI-PCA management.On the one hand, the occurrence of insufficient analgesia and poor analgesia reflects a state in which the anesthesiologist does not fully evaluate the patients and does not have a solid grasp of the basic pharmacokinetics and interactions of analgesic drugs. Therefore, there are problems in the formulation and parameter setting of analgesic drugs, resulting in poor analgesic effects, which also urges anesthesiologists to absorb experience and improve drug formulations in their future work. On the other hand, the alarm caused by insufficient analgesia and poor analgesia can urge medical staff in charge of quality control in the department of anesthesiology to adjust the relevant parameters in time during the process of postoperative management  to alleviate the suffering of patients and improve the satisfaction and happiness of patients, which are concerns of doctors and nurses.A self-controlled pressing button is a very important part of PCA, which allows patients to administer the drug according to their own pain. Not pressing the self-control button at all may be due to a large dose of analgesic drugs or mild pain, which may increase other adverse reactions, such as excessive sedation and hypotension or even respiratory depression, which cannot be detected in time and may cause serious consequences. In addition, it is also likely that the patient does not fully understand the role of the self-control button. Therefore, the pressing frequency of the self-control button can reflect not only the accuracy of the order issued by the anesthesiologist but also whether the relevant education regarding pain and analgesic pumps was sufficient before the operation. Of course, the most important issue is that the pressing frequency is also one of the indicators of the patient's pain.Patient satisfaction with analgesia is an important index to measure the service quality of medical staff and is used as an outcome measure in QI studies , 27, 28.Approximately 90% of the alarms are triggered by blockage of the PCA pump pipeline in the process of analgesia, which may be due to the bending of pipelines resulting from body position or other reasons, and treatment would inevitably be labor-consuming and time-costing. In addition, the nurses in the ward may clamp the analgesic pump to the patient due to adverse reactions such as postoperative nausea and vomiting and excessive sedation.In the AI-PCA pump, a pressure valve has been developed and designed to effectively block liquid velocity caused by gravity (CN207614132U), which increases the safety of infusion. Moreover, the pressure self-checking device in the Ai-PCA pump can guarantee automatic detection and self-recovery of the pipeline after blockage (CN103007380B), which allows the patients to clamp or open the pipeline according to their own requirements and further facilitate patients’ self-regulation of analgesia. In conclusion, these devices in the AI-PCA pump improve the working efficiency of health care professionals and the quality of medical care.At present, the incidence of pipeline blockage indicates inadequate education on the use of AI-PCA pumps, inadequate pain assessment and the presence of too much analgesic in the AI-PCA pump, resulting in patients clamping the infusion line due to adverse reactions , painlessness, or altering the time of AI-PCA pump usage by clamping it to save the solution.The drug utilization rate can reflect the accuracy of the ordering anesthesiologist, who should avoid blindly pursuing the analgesic effect and blindly using large doses of narcotic drugs. Such evaluation also prevents the anesthesiologist from mechanically giving every patient the same analgesic formula and analgesic pump parameters and can urge the anesthesiologist to reduce unnecessary waste and decrease the hospitalization expenses of patients.Analgesia technology and analgesics are constantly updated and improved, but the incidence of postoperative moderate-to-severe pain still has not gone down , 30. In Although the application of the AQI in postoperative pain management reduced moderate-to-severe pain, the incidence of total adverse reactions was not significantly affected, which may be due to vertigo being noted and recorded in the system since June 2016 and delirium since August 2019. However, the incidence of over sedation was decreased, indicating that AQI may play a role in reducing the occurrence of adverse reactions. There was no significant change in the incidence of nausea and vomiting, which may be related to the increased proportion of endoscopic surgery , 32.The increase in the evaluation rate and the amount of basic information as well as the reduction in the rate of leaving the service area and insufficient analgesia treatment time, reflect the improvement in clinical nursing quality, which is consistent with the change in the monthly AQI.Since the application of a pressure valve and pressure self-test device in AI-PCA pumps in 2018, patients who feel uncomfortable can clamp the tube by themselves, and there is no need to wait for medical treatment. Therefore, the increase in the blockage rate may be due to the increase in occlusion of analgesic pump lines by the patients themselves.With the expansion of the applied range of minimally invasive surgery (MIS) technology, the proportion of endoscopic surgery has increased (1310/7162 vs. 3202/7585), and anesthesiologists continue to administer postoperative analgesics in the traditional manner, which explains the decrease in drug utilization. On the other hand, since April 26, 2018, nonsteroidal anti-inflammatory drugs (NSAIDs) have been added to the formulation of the AI-PCA pump, while opioid analgesics have barely decreased, resulting in a decrease rather than an increase in drug utilization. Nevertheless, the reduction in the drug utilization rate leads to the wastage of analgesics and increases the chance of illegal diversion , 34. TheIn conclusion, the AQI index can be used to reflect the quality of postoperative analgesia management. AI-PCA has been applied in anesthesia departments of more than 400 hospitals in China for postoperative analgesia. In this AI-PCA system, the AQI of the anesthesiology department of one hospital for a given period of time can be selected to directly reflect the quality of analgesia in this department; moreover, the AQI of different medical staffs, different departments and different hospitals can be selected for analysis and comparison.At present, the AQI is only a preliminary exploration of postoperative pain management, but significant results have been obtained from our study. In the future, more process indicators in clinical practice will be discovered and used to calculate the AQI, forming a more comprehensive index to evaluate postoperative pain management and promote the development of analgesia.This current study revealed that compared to the traditional management of postoperative analgesia, application of the AQI decreased the incidence of moderate-to-severe pain postoperatively and improved the quality of postoperative analgesia management. Clinical application of the AQI may provide guidance for optimum pain management in the postoperative setting. The study suggests that the AQI can be used as a monitoring tool to supervise anesthesiologists and nurses, improve the quality of postoperative analgesia management, and facilitate continuous quality improvement through the Plan-Do-Check-Act (PDCA) cycle. It emphasizes the potential of machine learning and wireless technology in providing intelligent and data-driven solutions for postoperative pain management, promoting efficiency, and enhancing patient satisfaction.


Aim and objectives: This study was carried out to compare the effectiveness of hand and rotary instrumentation techniques on postoperative pain in asymptomatic necrotic premolars with periapical lesions and instrumented by a modified step-back technique using a K file, crown down by continuous rotary motion technique using ProTaper Universal , and with the reciprocation technique using WaveOne .Materials and Methods: For this study, 66 premolars with single roots and canals were chosen. The procedure was completed in a single visit. Following access opening, the working length was initially determined using an apex locator and then confirmed after inserting K file #10 by radiograph. The canal was cleaned and shaped using a grouping system. After the master apical preparation, the canal was dried by paper point and obturated with gutta-percha and AH plus sealer, an epoxide-amine resin pulp canal sealer. In order to confirm the obturation, a radiograph was taken. After that, a permanent restoration material was used to seal the access cavity. Following that, patients to whom the visual analog scale (VAS) had already been explained were contacted by phone at six, 12, 24, and 48 hours.Results: In this study, compared to a stainless steel instrumentation technique, WaveOne instrumentation caused more noticeable pain. The results of the current study showed that, on average, postoperative pain scores decreased over the course of the 12 to 48-hour period, reaching a minimum or a maximum at 48 hours (p<0.01).Conclusion: Postoperative pain was produced by all instrumentation methods used in the study. In comparison to ProTaper and WaveOne, instrumentation using the modified step-back technique with K files caused less pain, especially over the course of a 24-hour period. One of the most completely avoidable side effects of root canal therapy is pain. The extent of tissue damage and pain intensity appear to be related. Inter-appointment or postoperative pain is brought on by periradicular inflammation caused by debris extrusion and is mediated by the nociceptors' G protein-coupled receptors being stimulated by the substances calcitonin, gene-related peptides, and substance P ,2. AllodDiseases of the dental pulp and periradicular area are treated using root canal therapy. Single vs. multiple-visit endodontic management has been a topic of discussion ever since single-visit endodontic treatment first became available . SupportThus, the present in vivo study was undertaken to evaluate the clinical assessment of incidence and intensity of postoperative pain in asymptomatic necrotic premolars with periapical lesions following single-visit root canal treatment by hand instruments, continuous rotary, and reciprocation instrumentation.Before beginning treatment, each patient's written informed consent was obtained, and ethical clearance was obtained from the Institutional Review Board of Teerthanker Mahaveer Dental College and Research Centre .Patients aged 25 to 40 years with an asymptomatic necrotic single-rooted premolar having a periapical lesion less than 2 cm in size without a sclerotic border on Intraoral periapical radiographs (IOPAR) were included in the study. Patients taking corticosteroids, opioids, or non-steroidal anti-inflammatory drugs (NSAIDs); teeth with calcified canals; an immature apex; and patients undergoing re-treatment, were excluded. Patients with pre-operative pain, root canal curvature greater than 30°, or percussion tenderness were also excluded from the study.Sixty-six individuals with single canals and single-rooted maxillary and mandibular premolars were randomly selected and divided into three groups of 22 teeth in each group. Under rubber dam isolation, the entire root canal therapy procedure was completed in a single visit. The working length was determined using the apex locator Root ZX mini  after the access was opened, and it was then confirmed by radiograph after inserting K file #10. Based on grouping, the canal was cleaned and shaped. Along with the usual irrigation procedure, irrigation with 3% sodium hypochlorite (NaOCl) and normal saline was also carried out. Finally, the canal was rinsed for one to two minutes with ethylenediamine tetraacetic acid (EDTA).The following instrumentation technique was used to clean and shape the root canal: K file's modified step-back method for Group 1, a crown-down technique utilizing ProTaper Universal in a continuous rotary motion for Group 2, WaveOne reciprocation technique (#20 to #45) for Group 3.Following preparation, the canal was dried with a paper point and obturated with gutta-percha and AH plus sealant  using a cold lateral compaction technique. To confirm the obturation, a radiograph was taken. After that, a durable restoration material was used to seal the access cavity. There was no occlusal reduction done. A second clinician then called patients who had already been told about the visual analog scale (VAS) at six, 12, 24, and 48 hours. Patients were notified and recalled if full coverage restoration was necessary after 10 days. The evaluation standards were noted. The patients were instructed to take ketorolac 10 mg (SOS) if necessary and to inform the doctor if the pain became intolerable or unavoidable. Statistical analysis was done after data collection.Pain evaluation criteria involved the presence or absence of pain recorded as a score of 1 to 4 based on the Heft-Parker VAS. The patient was asked to make a mark on a line indicating how much pain they were experiencing  version 26.0 . By using the chi-square test, the frequencies of categories were compared among groupings. A p-value <0.05 was considered to be statistically significant for all the statistical tests.Intergroup comparisonThere was a statistically non-significant difference at the sixth, 12th, and 48th hour (p>0.05). Whereas a statistically highly significant difference (p<0.01) with higher frequency for score 2 in Groups 2 (ProTaper) & 3 (WaveOne) with score 1 in Group 1 (hand K file) was found at the 24th hour  with a higher incidence of score 1 at the 48th hour, and score 2 at the 12th hour when instrumentation was carried out using a K file. In the ProTaper group, a statistically highly significant difference was seen (p<0.01) with higher incidence for score 1 at 48 hours, score 2 at 12 hours, and 24 hours. In the WaveOne group, there was a statistically highly significant difference seen (p<0.01) with higher incidence for score 1 at 48 hours, and score 2 at 12 hours Tables , 4.A single visit or multiple visits may be necessary for endodontic treatment . StudiesEven though analgesics are frequently provided, pain following endodontic treatment still poses a serious problem for patients . The incIn this study, it was discovered that K-file instrumentation had a lower prevalence of postoperative pain 24 hours after root canal therapy than ProTaper and WaveOne (p<0.01), but at six hours, 12 hours, or 48 hours, there was no statistically significant difference between the groups. In the current study, circumferential filing in the apical regions and modified step-back preparation in the coronal third was used in place of pulling and pushing motions to flare the root canals. Instead of causing debris to be extruded from the canal, these movements help to suspend debris in irrigation solutions, which lowers the likelihood of postoperative pain . AccordiAt 48 hours, the incidence and severity of pain were lower in the group instrumented using K files, while mild pain was noted at 12 hours (p<0.05). According to Pasqualini et al., manual K files for glide path files resulted in less postoperative pain than mechanical preparation with path files . WaveOneAge, sex, the condition of the pulp and periradicular tissue, preoperative pain, and instrumentation technique are some of the variables that may affect how postoperative pain manifests . The opeThe study's limitations include the requirement that future research concentrate on the method in use at the point of time as advancements in endodontic materials and methods may change the factors that influence treatment outcomes, such as postoperative endodontic pain.With a variety of techniques and materials, root canal treatment can be accomplished in a single visit as an alternative to multiple visits. This study showed that no patient required additional treatment and that all instrumentation techniques resulted in minimal pain and discomfort. In comparison to ProTaper and WaveOne, instrumentation using the modified step-back technique with K files caused less pain, particularly over a period of 24 hours. The study also found that when pain does occur, it is anticipated that it will lessen in intensity after 12 hours of root canal therapy. Dental procedures must include pain management from the very beginning to avoid exacerbation of the pain. Patients receiving dental treatment should be warned about the possibility of pain following root canal therapy and advised to take analgesics. Different instrumentation methods can be used in new studies to assess their impact on postoperative endodontic pain.


Although shoulder questionnaires validated for Brazil do exist, none of them are aimed at populations with rheumatic disease. We believe that the Oxford Shoulder Score (OSS) may be useful in this population. The objective of this study was to translate the OSS, adapt it to Brazilian culture and test its reproducibility. Validation study conducted in university outpatient clinics. The OSS was translated into Portuguese by two English teachers and was then retranslated into English by two native English teachers. These translations were reviewed by a committee to establish the version of OSS-Brazil to be administered to 30 patients with rheumatoid arthritis (RA) and shoulder pain, in order to test the cultural adaptation. The validity and reproducibility was tested among another 30 patients with RA and shoulder pain, of both genders and aged 18 to 65 years. The internal consistency and reproducibility were analyzed. The following instruments were evaluated: OSS-Brazil; a numerical scale for shoulder pain; DASH; HAQ and SF-36. The internal consistency was 0.957 and the intra and inter-rater reproducibility was 0.917 and 0.861, respectively. A high level of correlation was found between OSS-Brazil and the following: HAQ (-0.663), DASH (-0.731) and the SF-36 domains of functional capacity (0.589), physical aspects (0.507), pain (0.624), general state of health (0.444), vitality (0.634) and mental health (0.578). OSS-Brazil was successfully translated and adapted, and this version exhibited good internal consistency, reliability and construct validity. Shoulder dysfunction is an important cause of mortality and incapacity,The Oxford Shoulder Score (OSS) is an instrument that specifically evaluates pain and quality of life in relation to inflammatory and degenerative shoulder diseases.Despite the existence of validated Portuguese-language shoulder questionnaires, none are directed towards the population with rheumatological diseases. The OSS was originally validated for several diseases including osteoarthritis and inflammatory arthritis.Almost 12% of rheumatoid arthritis (RA) patients may have involvement of the shoulder joint, which can lead to pain and disability.The objective of this study was to translate the OSS, adapt it to Brazilian culture and test its reproducibility.The study was performed in two stages: firstly, the original questionnaire was translated and adapted for Portuguese; and secondly, its reproducibility and external validity were tested in relation to the Brazilian population with rheumatoid arthritis and shoulder pain.,The original authors of the OSS questionnaire authorized its use for cultural adaptation. The translation and cultural adaptation followed the standardization model proposed by Guillemin et al.The questionnaire was independently translated by two English teachers who provided two separate Portuguese translations. Both versions were presented to a committee of specialists consisting of a rheumatologist and two physiotherapists with experience in rheumatology rehabilitation. The committee analyzed the translations to check for errors, and then chose one version for each translated question, thereby creating an agreed consensus version.After this process, the consensus version was back-translated into English by two native-speaker English teachers who were also proficient in Portuguese and had not had any contact with the original instrument. During this stage, the translators were not given any information about the study or the questionnaire.The two English versions were then presented to the review committee and compared against the original questionnaire. This analysis showed that the original questionnaire and the consensus version were semantically equivalent, and the latter was then accepted as the final version. The final version of the questionnaire  was usedSixty patients with RA and shoulder pain complaints were selected consecutively at the Rheumatology Outpatient Clinic of the Federal University of São Paulo : 30 in the first stage and 30 in the second stage. The study included male and female patients aged between 18 and 65 years who were classified as presenting RA under the criteria of the American College of Rheumatology (ACR),This study was approved by the Ethics Committee of the UNIFESP, and all the patients who participated signed a written informed consent form.For the inter-observer reproducibility, the evaluations were performed during a single day by two physiotherapists and for the intra-observer reproducibility, the evaluations were carried out between 7 and 15 days after the initial evaluation, by the same physiotherapist.Oxford Shoulder Score - A questionnaire containing 12 questions for patients with inflammatory and degenerative shoulder diseases. It is not appropriate for patients with shoulder instability. Each question has 5 potential answers; carrying a score of between 0 and 4. The total score can range from 0 (worst) to 48 (best).Numerical Pain Scale (NPS) - A subjective evaluation of pain on a numerical scale of 0 to 10 centimeters, such that 0 represents absence of pain and 10 unbearable pain.Disabilities of the Arm, Shoulder and Hand (DASH) scale - An instrument containing three modules: Module 1 (Q1) relates to sports and musical activities; Module 2 (Q2) relates to work; and Module 3 (Q3) relates to performance of activities. intensity of pain, symptoms of weakness, rigidity and paresthesia, negative effects on social activities, difficulty in sleeping and psychological harm, with reference to the previous week. Modules Q1 and Q2 each contain 4 questions, while Q3 is made up of 30 questions. Each question is scored using 5 scoring levels, and the final score of Q3 is calculated using the sum of the first 30 questions, from which the number of questions answered is subtracted and divided by 1.2; whereas for Q1 and Q2 the sum is subtracted by 4 and divided by 0.15.Health Assessment Questionnaire (HAQ) - Evaluation of functional capacity: 20 questions split into 8 subscales relating to different aspects of activities within daily life in which the upper and lower limbs are used. The score is obtained by adding the highest scores from each subdivision and then dividing this partial result by 8. The scores range from 0 to 3, and the higher the resultant score is, the worse the individual’s functional capacity is.Short Form-36 (SF-36) - Thirty-six questions divided into 8 domains that evaluate quality of life, covering factors relating to: functional capacity, physical limitations, pain, general state of health, vitality, social factors, emotional factors and mental health. The scores can range from 0 (worst) to 100 (best), and the higher the score is, the better the individual’s quality of life is.The time taken to apply each questionnaire is noted.The sample was descriptively analyzed using means, standard deviations and percentages. Intraclass correlation coefficients were used to analyze inter and intra-observer reproducibility and the Spearman correlation test was used to ascertain the correlation between the OSS and the following: NPS scores for shoulder pain, DASH, HAQ and SF-36.Cronbach’s alpha test was used to evaluate the internal consistency of the OSS. All questionnaire items were examined for correlations with the general score. Cronbach’s alpha test was also calculated through eliminating a single item from the total of 12 questions.All the data were analyzed using the SPSS software for Windows, version 17.0.A total of 221 patients classified as RA in accordance with the criteria of the American College of Rheumatology (2010), who reported having shoulder pain, were interviewed. Of these, 60 were included in the present study: 30 in the first stage and 30 in the second stage . Most ofFor the cultural adaptation, the final version of the OSS was used among 30 patients in order to evaluate their comprehension of each question. Since the questions were understood by more than 90% of the patients interviewed, all the questions were retained without the need for any changes.Regarding reproducibility, the patients answered all the questionnaires at the first evaluation and the times taken were recorded. The internal consistency was high . Elimination of one answer item from each of the 12 questions in the questionnaire resulted in Cronbach’s alpha values of > 0.96. Item-total correlation analyses yielded coefficients greater than or equal to 0.52 in all cases .Construct validity was tested using Spearman’s correlation coefficient (r = 0.75). Significant correlations between the Brazilian OSS and the HAQ, DASH and SF-36 questionnaires were observed, except in the domains of social factors and limitations due to emotional factors .,The overall presence of RA in the general population ranges from 0.5% to 1% and approximately 11.5% of RA patients may have shoulder dysfunctions.,,,,,Recently, a systematic review evaluated the development process, psychometric properties and administration of specific instruments for shoulder assessment. Its authors concluded that the OSS questionnaire should be the first choice for measuring function and disability among patients with shoulder dysfunction. Moreover, this instrument has shown high reproducibility, validity and responsiveness and is easy to administer, which makes it highly recommended.The importance of translating and validating a questionnaire for which the psychometric properties have already been tested comes from its unification of the language of clinical research. Through doing this, studies can be conducted around the world using the same evaluation instrument. This also facilitates comparison of data from different populations around the world.,Falcão et al. proposed a method for translation and cultural adaptation of instruments in order to reduce the time taken and cost of these studies.We chose to apply the questionnaire using interviewers because our patients’ low educational level would make self-administered questionnaires difficult to understand and answer. Our participants presented an average of 7.43 years of schooling, thus constituting a population of low educational level. This is common among patients using the Brazilian national health system , who generally have an average of 4 years of schooling, such that they know how to read and write.,The original Oxford Shoulder Score presented a scoring range from 12 to 60 points. However, the questionnaire was recently revised and the scoring system changed such that the range is now from 0 to 48 points. Thus, this was the system of calculation that we used in our study.,The average OSS scores obtained by interviewers I and II in the evaluations were similar. These results suggest that the functional involvement of these patients in relation to the shoulder was moderate, i.e. similar to the findings from other studies.In the present study, the intraclass correlation coefficient was 0.92 for intra-observer reproducibility. This figure is the same as the level in the original instrument, which was also 0.92. This shows that the questionnaire has good reproducibility.,,The inter-observer evaluation was performed after an interval of 7 to 15 days. This period was chosen because it was highly unlikely that the patient would remember the content of the questionnaire or that any substantive changes in their disease would have occurred during that time. Other studies have used shorter intervals of between 24 and 48 hours in order to avoid occurrences of changes to the participants’ state of health. Despite our use of a longer interval than those used in other studies, this did not affect the ICC result, as compared with the findings from other studies.According to the present study, the internal consistency was high, with Cronbach’s alpha of 0.93, which was similar to that of the original version, with a value of 0.87. In the correlations using the total number of items, Cronbach’s alpha was higher than 0.52 for all questions, thus showing a good level of differentiation. After elimination of one item from the total of 12 questions, the Cronbach’s alpha results were 0.96 or 0.97. These results were similar to those in the Italian version, which showed Cronbach’s alpha of 0.93, while the correlation using the total number of items was greater than 0.57.The correlation between the OSS and the DASH, HAQ and SF-36 questionnaires was moderate. This level of correlation was expected because DASH, HAQ and SF-36 also evaluate function and quality of life. The OSS had a positive correlation with SF-36, and a negative correlation with DASH and HAQ, i.e. it was inversely proportional, since higher score are better in DASH and HAQ.The correlation between the OSS and the NPS was not significant, and this finding was similar to that of the original questionnaire because the purpose of the OSS is to measure quality of life and function. We expected to find a correlation between these variables, from the principle that with reductions in pain, there would be a positive response in relation to function and quality of life, although this is not always present in medical practice.In relation to the average time taken to apply the questionnaires used, we noted that the OSS and HAQ took longer than the other questionnaires. However, HAQ evaluates overall function in patients with RA.Within the study limitations, the greater prevalence of females in our sample may be explained by the greater prevalence of RA among females. However, we believe that this does not prevent the use of this instrument among male patients.The Oxford Shoulder Score questionnaire in Portuguese is a valid and reliable instrument for evaluating the quality of life and function of patients with rheumatoid arthritis and shoulder pain.


The role of central and/or peripheral nervous system dysfunction is basically fundamental in fibromyalgia.The aim of this position statement on behalf of the Neuropathic Pain Study Group of the Italian Society of Neurology is to give practical guidelines for the clinical and instrumental assessment of fibromyalgia (FM) in the neurological clinical practice, taking into consideration recent studies.Criteria for study selection and consideration were original studies, case-controls design, use of standardized methodologies for clinical practice, and FM diagnosis with ACR criteria .ACR criteria were revised. For diagnostic procedure of small-fiber pathology, 47 studies were totally considered.Recent diagnostic criteria should be applied . A rheumatologic visit seems mandatory. The involvement of small fibers should request at least 2 among HRV + SSR and/or laser-evoked responses and/or skin biopsy and/or corneal confocal microscopy, eventually followed by monitoring of metabolic and/or immunological/ and or/paraneoplastic basis, to be repeated at 1-year follow-up.The correct diagnostic approach to FM could promote the exclusion of the known causes of small-fiber impairment. The research toward common genetic factors would be useful to promote a more specific therapeutic approach.The online version contains supplementary material available at 10.1007/s10072-023-06836-3. Fibromyalgia (FM) is a complex and common syndrome, whose main clinical element is represented by chronic non-specific pain associated with numerous and various other symptoms, linked to the involvement of the nervous system such as fatigue, insomnia, and emotional distress. Pain in FM is most typically classified as nociplastic; the terminological definition of nociplastic pain was formulated by the IASP in 2017 and defined as “pain that arises from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain” . A more Impaired pain processing, consisting of central pain amplification or decreased pain modulation along the descending pathway, or a combination of these two types of dysfunctions, is the most distinctive element in FM . HoweverConsidering that FM is frequently comorbid with autoimmune pathologies and since in patients with FM there are measurable altered cytokine levels, it has been hypothesized that this syndrome may be due to autoimmune processes, as demonstrated in mice by transfer of purified IgG from individuals with FM .The complex and only partially known pathophysiological basis in addition to diagnostic criteria based only on subjective symptoms in the absence of specific clinical signs and recognized biomarkers means that FM is underdiagnosed and undertreated. For these reasons, an aura of stigma and the burden of inadequate medical and social support still weigh on the affected patients.The clinical features included in the diagnostic criteria are largely attributable to central and/or peripheral nervous system dysfunction; so far, the role of the neurologist is of evident utility in the diagnosis and clinical management of FM.The aim of this position statement on behalf of the Neuropathic Pain Study Group of the Italian Society of Neurology (SIN) is to give practical guidelines for the clinical and instrumental assessment of FM in the neurological clinical practice, taking into consideration recent studies.This is a position statement on diagnostic assessment of fibromyalgia, based on a not structured review.For clinical criteria, we took into consideration the American College of Rheumatology criteria for adult and childhood fibromyalgia.For instrumental assessment, studies on neurophysiological, psychophysical, autonomic, and other instrumental techniques applied to clinical assessment of FM, with special regard to sensory and autonomic neuropathy, were searched on PubMed. The search strings are reported in Table Search strings and retrieved records are reported separately for each considered instrumental technique in Table The first studies on FM date back to sixteenth century observations, which saw slow progress toward the formulation of recognized diagnostic criteria. The term FM was coined only in 1976, from the union of the words “fibro” and “mio,” to highlight the involvement of the fibrous and muscular tissue and the word “algia,” indicating pain as an essential element for the diagnosis. The first diagnostic criteria were formulated by a scientific society only in 1990, thanks to the lack of prejudices and the farsightedness of the College of Rheumatology (ACR), which, despite the absence of clinical tests to objectify the pathology, believed it could not ignore this condition. The 1990 diagnostic criteria emphasized the role of tender points, tenderness of at least 11 of 18 specific body sites, and the role of diffuse pain defined as pain persisting for at least 3 months in both supra-pelvic and subpelvic regions in addition to axial pain .A strong limitation of these criteria was represented by the fact that at least 25% of patients affected by FM do not fully satisfy the ACR criteria proposed, since in addition to the subjectivity of the response to the pressure exerted, as well as the difficulty for clinicians to apply 4 kg of strength, it has been widely experienced that acupressure tenderness in male subjects appears less evident than in female subjects, leaving many male FM patients undiagnosed. Despite the evident limitations of the first diagnostic criteria, they are considered instrumental in the recognition of the pathology and in its inclusion by the consensus group of the Declaration of Copenhagen (CD) among non-articular rheumatism in the International Classification of Disease of the World Health Organization Healthcare with the ICD code M 79.0 (ICD 10th revision).Hence, in 2010, the ACR also published the first revision of the criteria, in which the search for the positivity of tender points has seen its diagnostic role disappear, replaced by a greater weight given to subjective symptoms . SubsequAlthough fibromyalgia is highly prevalent in adulthood, it can be present also in the developmental age. In children and adolescents, its prevalence is poorly studied and varies between 7 and 15% of new visits to pediatric rheumatology clinics . Girls/bDiagnostic criteria for juvenile fibromyalgia (JFM) were first described in 1985 by Yunus and Masi  and subsGrowing pains can be considered precursors of JFM .Nerve conduction studies-NCS- and electromyography-EMG- Apart from few studies in favor of electroneurography signs compatible with sensory neuropathy [In the following paragraph, we summarize the main studies on technical procedures of small-fiber function and autonomic system assessment that fulfilled our inclusion criteria Fig. . Nerve curopathy , 7, nervuropathy -11. Lawsuropathy  or the pTen studies tested pain-related evoked potentials in patients with FM. Four studies showed increased amplitude of laser-evoked potentials (LEPs) and reduced habituation in patients with FM, supporting an abnormal central elaboration of pain and pain matrix hyper excitability -15. AccoThree studies used pain-related evoked potentials (PREPs) to detect small-fiber pathology in FM with contrasting findings , 17, 18.Two recent studies assessing multichannel LEPs in patients with FM and small-fiber impairment showed abnormal N2P2 habituation index, more marked in patients with reduced IENFD, and reduced amplitude of the P2 component, not coherent with the site of denervation , 19 . Also, in patients with a history of vasovagal syncope, a higher prevalence of FM compared to the general population has been reported . DiffereSympathetic skin response amplitude in patients is not generally different from controls , 29. HowIn conclusion, the data present in literature are strongly oriented toward an association between FM and dysautonomia that further deteriorates patients’ quality of life, so the evaluation of autonomic involvement could offer information on the severity of the disease Table .Table 3SIn the last decade, several studies showed evidence of small-fiber pathology in a variable proportion of patients with FM, with lower intraepidermal nerve fiber density (IENFD) compared with healthy subjects , 30-32. Considering the elective innervation of the cornea by C fibers, corneal confocal bio-microscopy is a reliable method to assess small nerve fiber pathology. While the study by Oudejans clearly reported diagnostic cut-off values and relied on widely agreed parameters including nerve fiber length, nerve fiber density, and branching, the study by Ramirez investigated different parameters  and did not provide diagnostic cut-off values , 41. MorMicroneurography represents an ideal technique to explore the peripheral nociceptor system and to record intraneural single C-fiber action potentials from nociceptors. Multiple C-fibers can be recorded simultaneously for hours , therebyThe application of microneurography in FM is unfortunately limited. Using this technique, C-nociceptors were recorded in female FM patients . The resQuantitative sensory testing (QST), a standardized method used to assess somatosensory system function, if a comprehensive protocol is applied, allows to detect sensory and pain profiles, and to hypothesize the underlying mechanisms  .In fibromyalgia, QST findings showed a certain heterogeneity in the sensory threshold abnormalities. However, a common result between different studies is the presence of hypersensitivity or gain of function to a broad of standardized sensory stimuli , 47, 48.Regarding thermal stimuli, several studies described cold pain hyperalgesia , and incCompared with small-fiber neuropathy, patients with FM with or without epidermal denervation have different sensory phenotypes , suggestFinally, the application of dynamic protocols of temporal summation and conditioned pain modulation (CPM) showed significant dysfunction of the diffuse noxious inhibitory control (DNIC) , 50, risIn conclusion, considering the consistent methodological heterogeneity between studies, future research needs to investigate with a multimodal approach, the potential role of QST-based algorithm in stratification of FM patients for clinical and research purposes.Patients with generalized pain should be taken into consideration for FM diagnosis.Recent diagnostic criteria should be applied . Diagnosis of FM is based on the sum of WPI (WPI) > 7 and symptom severity scale (SSS) score > 5 OR WPI of 4–6 and SSS score > 9. Severity of FM is also based on the sum between WPI and SSS scores. For fatigue, waking unrefreshed, and cognitive symptoms, the questionnaire should be followed. For headache comorbidity, International Headache Society criteria  should bA careful investigation of personal and familiar history of neurological conditions, as well as a detailed objective examination of neurological deficit, with particular regard to multimodal sensations, including tactile, vibration, nociceptive, and thermal ones, seems mandatory in the clinical approach of patients with suspected FM. The huge expression of central sensitization phenomena could contribute to hide myopathies and central and peripheral neurogenic pathologies. In the new classification, other conditions leading to pain do not exclude FM, so the definition of associated syndromes outside those included in the classification should complete the diagnosis. The clinical neurological examination would contribute to define deficit in central and peripheral nervous system, and to proceed with the adequate diagnostic measures. In the supplementary section, the neurological diseases with diffuse pain with possible association with FM are described (Supplementary section).A rheumatologic visit should also be requested, if lacking, to clarify frequent comorbid conditionsIn the case of FM diagnosis, the involvement of small somatic and autonomic fibers, frequently not associated to objective signs of sensitive and autonomic dysfunctions, would request the diagnostic procedures detailed in the above reported paragraph. At least two among HRV + SSR and/or laser-evoked responses and/or skin biopsy and/or corneal confocal microscopy should be suggested. Microneurography is rarely available. The QST could also be suggested, although this is a psychophysical technique, based on subjective responses, that may not reflect small nerve fibers dysfunctions. The presence of objective signs of small-fiber impairment should be followed by monitoring of possible metabolic and/or immunological and/or paraneoplastic basis, with basal assessment of blood tests . Such teNeurological management of FM patient-clinical criteria are as follows:This position statement was based on an expert opinion taking into consideration recent literature. However, we did not perform a systematic review, and considered main studies exploring only the last 10 years in PubMed.This shared document has the function of helping clinical neurologists and neurophysiologists in the diagnosis of FM disease although we are still far from understanding mechanisms that could sustain FM clinical picture in single cases. To clarify these mechanisms will definitively improve FM treatment with a precision medicine approach.The altered pain processing at central level and the frequent involvement of somatic and autonomic small fibers justify the interest and the competence of the neurologists, who may give an important aid to the diagnosis of associated central and peripheral nervous system conditions, as well as novel input to the research about the fundamental causes of the disease. Recent studies on voltage-gated ionic channels , 68 showThe correct diagnostic approach to FM could promote the exclusion of the known causes of small-fiber impairment, and the research toward common genetic factors, useful to promote a more specific therapeutic approach.Supplementary file1 (DOCX 30 KB)Below is the link to the electronic supplementary material.


Additionally, Spearman correlation shows significant negative correlation between resection weight and the parameter “Minimal pain since surgery” . Furthermore, average mood is impaired in the low weight resection group, indicating a statistical tendency (p = 0.06 and a Χ2 = 3.56). We found statistically significant higher maximum reported pain scores  in elderly patients. Patients with shorter surgery showed a statistically significant  increased claim for painkillers. Moreover, “mood impairment after surgery” shows a dramatic trend to be enhanced in the group with shorter OP duration . (4) Conclusions: While QUIPS has proven to be a useful tool for the evaluation of postoperative pain therapy after abdominoplasty, only continuous re-evaluation of pain therapy is a prerequisite for constant improvement of postoperative pain management and may be the first approach to develop a procedure-specific pain guideline for abdominoplasty. Despite a high satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery. (1) Background: Postoperative pain is a frequently underestimated complication significantly influencing surgical outcome and patient satisfaction. While abdominoplasty is one of the most commonly performed plastic surgery procedures, studies investigating postoperative pain are limited in current literature. (2) Methods: In this prospective study, 55 subjects who underwent horizontal abdominoplasty were included. Pain assessment was performed by using the standardized questionnaire of the Benchmark Quality Assurance in Postoperative Pain Management (QUIPS). Surgical, process and outcome parameters were then used for subgroup analysis. (3) Results: We found a significantly decreased minimal pain level in patients with high resection weight compared to the low resection weight group ( Being essential for postoperative complications, morbidity, mortality as well as rehabilitation capacity, guideline-based pain therapy has become an integral part for almost all surgical disciplines . While not only perioperative morbidity was found to be reduced by adequate pain medication, several studies describe a significant decrease in complications with a verifiable reduction of hospitalization days ,2. Therefore, postoperative pain management is essential not only for individual patients but chronification of underestimated postoperative pain represents an economic burden, with enormous potential for optimization.Pain management can be divided into non-medicinal and medicinal factors.While non-medicinal factors include psychological and physical procedures, such as the application of cold to reduce the swelling of an extremity after postoperative decongestion of an extremity after surgery, medical factors mainly focus on systemic pharmacotherapy.Among these, based on international guidelines, treatment of severe to moderate pain should be based on a combination of opioids  and non-opioid analgesics  .Although this seems to be standardized, many studies have shown insufficient pain management ,5. For fAlthough it is undoubted, that adequate pain management is essential for individual outcome, there exist almost no studies evaluating postoperative pain in plastic surgery. Especially in semi-elective surgeries, such as body contouring surgeries, characterized by large wound areas, postoperative well-being can lead to faster mobilization and reduction of hospitalization time. Nevertheless, hardly any literature is available on this topic.Single case reports describe the existence of neuropathic pain syndromes of the N. iliohypogastricus and cutaneous femoris lateralis after abdominoplasty and their avoidability . Feng etRegarding pain medication, a recommendation of reduced opioid consumption after abdominal wall surgery can be found, but there exist no concrete guidelines and this recommendation has not been evaluated .To sum up, although postoperative pain management has been excessively described to be of utmost importance for outcome and well-being, no standardized study within body contouring patients has been carried out up to now. Therefore, we used QUIPS in abdominoplasty patients for analyzing pain characteristics as well as to define risk factors for enhanced postoperative pain. This study was carried out following the guidelines of the declaration of Helsinki as well as by the dean of the university. All patients undergoing abdominoplasty according to Pitanguy at the Department for Plastic and Aesthetic Surgery, Reconstructive and Hand Surgery at the Markus Hospital in Frankfurt am Main from January 2010 to December 2015 were included in this study. For the study, all patients were excluded who underwent combination or revision procedures such as autologous breast reconstruction or repair of rectus diastasis. A standardized pain questionnaire (QUIPS) was carried out on postoperative day one by a single study nurse focusing on outcome  and procPreoperatively, the patient is marked in a standing position to define the resection lines.After proper positioning, the surgical area is sterilely covered.The skin incision is made with the scalpel and the subcutaneous preparation by using the monopolar diathermy.The belly button is incised and sutured cranially with silk as holding suture.Epifascial dissection of the fat-skin soft tissues below and above the umbilicus up to the xiphoid while sparing the lateral sub- and intercostal perforator vessels. Hereby no focus is given on nerve sparing.Insertion of wound drains and drainage at the mons pubis.Collapsing the patient at the hip and re-defining the resection area.Resection of the skin fat flap and adaptation of the skin and tissue with Vicryl 2-0 and 3-0.Placement of the new umbilical position and suturing of the umbilicus with Vicryl 4-0 subcutaneous and Prolene 4-0.Wound closure with continuous intradermal Biosyn 3-0 suture and sterile wound dressing, abdominal belt.All surgical procedures were carried out by one senior doctor with one or two residents. The surgical procedure was standardized to prevent any technical related bias: All patients received pain medication via a standardized protocol following the official German guidelines for pain management  3]..3].Data analysis was performed using SPSS version 22.0 . Initially, the database created by QUIPS was completed with the operation- and patient-related data. After conversion, analysis of descriptive data was performed. All data are given as mean and standard deviation (=SD). Nominal-distributed data were analyzed using Pearson’s chi-square test, Fisher’s exact test, and Spearman-rho correlation.p level of <0.05 was considered as statistically significant. To analyze variables and individual subgroups of this population, a univariate and multivariate correlation analysis as well as the Mann Whitney-U test and the Kruskal Wallis test were used. The median was used for division of groups. A In total, 268 patients underwent abdominoplasty within the given timeframe. Further, 110 were excluded due to surgical technique. Of the remaining 158 patients, 55 showed a complete QUIPS and gave written consent for participation. Among those, 41 (75%) were female and 14 (25%) were male, aged between 21 and 67 years. Mean age and mean height was 42.93 ± 9.9 and 169.22 cm ± 8.13 cm, retrospectively. Average weight of patients was 87.05 kg ± 19.73 kg. Average resection weight was 2913 g ± 2226 g and average duration of surgery was 129.49 ± 37.48 min, with 215 min representing the longest and 56 min the minimal surgical time. Patients were preoperatively classified using the ASA sore. Thereby, five (9%) subjects were categorized as ASA-I, 42 (76%) as ASA-II, and eight (15%) as ASA-III. No ASA-IV or V subjects underwent surgery. In total, seven (13%) patients stated regular intake of painkillers before surgery, due to chronic diseases.Mean pain on exertion was reported as 4.42 ± 1.54, with the maximum pain being 5.35 ± 2.04 and the minimum pain 1.95 ± 1.43. Thirty-eight of the 55 patients (69%) exceeded the pain level of 4, which normally is considered as the tolerance pain threshold for demanding pain killers. Patient satisfaction was reported to be 11.95 ± 3.03 in average.In terms of mobility, 34 (62%) patients reported being significantly limited due to pain. When breathing or coughing, 27 (49%) mentioned pain while they in- or exhaled. Thirteen of the respondents (24%) felt their sleep was disturbed and 12 (23%) reported their mood being affected by postoperative pain. Twenty-six (47%) of all respondents reported postoperative pain fatigue. Both nausea and vomiting were mentioned by only 12 (23%) and nine (13%), respectively. Chronic pain was previously described by seven (13%) of the total collective.Nevertheless, only 13 (24%) demanded extra painkillers. In addition, 26 (47%) of all respondents felt postoperative pain fatigue. Preoperatively, midazolam 7.5 mg per os was offered to all patients as a sedative but was taken only by six patients (11%).For intraoperative pain relief, an opioid (Sufentanil) was used in all except five (9%) cases. Non-opioids were used in seven patients (13%). In the postoperative care unit, opioids were used in 53 (96%) patients and in 35 (64%) patients, non-opioids were injected intravenously. n = 31, 56%), no opioid was needed. However, in 24 patients (44%), Piritramid 7.5 mg i.v. was used postoperatively.Postoperatively, midazolam was injected in 35 (64%) cases. Diclofenac was used as a second-line agent in five cases (9%). In addition, 15 (27%) patients did not require any analgesics. In the majority of subjects  as shown in p = 0.013 *).When considering the factor “resection weight”, we found significant decreased minimal pain in patients with high resection weight compared to the low resection weight group  in older patients, indicating enhanced pain within this group as shown in We found statistically significant higher maximum reported pain scores  increased claim for painkillers. Additionally, “mood impairment after surgery” showed a dramatic trend to be enhanced in the group with shorter OP duration . Aimed at a redefinition of the body contour, abdominoplasty is performed by wide undermining of tissue of the abdominal wall with its high density of thoracolumbal sensitive nerves . Due to Despite SOPs and guidelines, as well as an improved patient education, pain is constantly considered as the fifth vital sign  and its With a few exceptions in plastic surgery, there exists no literature of postoperative pain management in standard procedures. One of the reasonable tools for pain relief, published with a small cohort, is additional regional nerve block of the area of interest  were above a value of 4 and according to the S3-guidelines of perioperative pain treatment , therefoBy comparing our cohort result of maximal pain intensity with other different common procedures, such as an appendectomy 5.20 or a functional endoscopic sinusitis surgery 3.96, this level shows a relatively high maximum pain level. Nevertheless, in comparison to traumatological procedures (such as the cruciate ligament-plasty up to 6.0 out of 10), it shows lower maximum pain intensity . We used the median to split participants into two subpopulations regarding their resection-weight, age and duration of surgery, being consistent with our clinically experience. The cohort with medical indication can be divided into patients with a relevant, functional impairing dermatochalasis of the abdomen, a longer operation time, a higher ASA status and generally the younger patient after bariatric surgery or self-induced massive weight loss.In contrast to the previous mentioned, the aesthetic patient population comes along with a moderate low resection weight, less ptosis of skin, normally younger women after pregnancy asking for a mommy makeover or the “best ager”, who are older but healthier with a profound focus on their outward appearance and self-motivated initiative for a tummy tuck.A direct comparison between those two groups is desired and needs further research.Nevertheless, we evaluated the outcome parameters in relation to the patient specific parameters of our subgroups.A higher resection weight correlates with a higher bodyweight and this is regarded as a predictor for a higher complication rate in abdominoplasty ,21.Interestingly, none of these studies analyzed the influence of the factor “resection weight” itself (in our study ranging from 610 g up to 9600 g).In contrast to our prediction, our observations show that high resection weight goes along with significantly less pain markers and the mood impairment of patients with low resection weights.There are no data in literature which confirm those findings for this procedure.In reduction mammaplasty, Strong et al. found that patients with higher resection weights have significantly less pain than those with low resection rates .A reasonable explanation of our results is the decreased sensibility of the abdominal wall in patients with a large apron of fat and high resection weight. We assume that patients with hanging bulge of skin and fat tissue have a higher basic pain level and they tolerate postoperative surgical pain better than in lower resection weights . We can However, one has to be aware that resection weight can be high in patients with massive weight loss with normal BMI. The correlation analysis shows that older patients have significantly higher maximal pain levels, which is contrary to current literature, emphasizing young age to be a risk factor for postoperative pain ,25,26,27Morphology-wise, older skin shows dermal atrophy with less perfusion, less elastic fibers and less Meissner and Vater Pacini bodies, resulting in a lower tactile and pressure sensibility ,31. ThesEnlarged duration of surgery is broadly accepted as a risk factor for pain as well ,32. InteThe statement: “Longer operation time is a predictor for increased postoperative pain” can be rejected in our investigation.Limitation is the relatively small cohort and a single center study, as well as a relatively small time frame, which needs to be verified in ongoing investigations. Additionally, due to the structure of QUIPS, no conclusion can be drawn about pre-existing chronic disorders influencing postoperative pain medication. Abdominoplasty is a standardized procedure that is, due to its large wound area, well suited for the evaluation of pain levels. QUIPS has proven to be a successful tool for the first elevation of postoperative pain quality in abdominoplasty procedures.Despite a high overall satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery. To what extent newly found risk factors will be deemed suitable to adapt tailored pain management requires further study to pave the way for a procedures-specific pain guideline.