Have emergency department clinicians responded to the opioid epidemic through altering opioid prescription rates?In this cross-sectional study of 556 176 emergency department patient encounters and 70 218 opioid prescriptions within a single emergency department, yearly prescriptions decreased by 66.3% between 2013 and 2018. This decrease was associated with a 71.1% reduction in the number of opioid prescriptions for musculoskeletal pain  and lesser, but still marked, decreases for fractures and kidney stones.Reductions in yearly opioid prescriptions across varying indications appear to be aligned with recognition of the opioid crisis in addition to national, state, and departmental education guidelines. Opioid prescriptions for treatment of pain in emergency departments (EDs) are associated with long-term opioid use. The temporal pattern of opioid prescribing in the context of the opioid epidemic remains unknown.To examine the temporal pattern of opioid prescribing within an ED for varying pain conditions between 2009 and 2018.A population-based, cross-sectional study was conducted at the ED of an urban academic medical center. All patients treated within that ED between January 1, 2009, and December 31, 2018, were included.The proportion of patients prescribed an opioid for treatment of pain in the ED temporally by condition, condition type, patient demographics, and physician prescriber.Between 2009 and 2018, 556 176 patient encounters took place in the ED, with 70 218 unique opioid prescriptions ordered. A total of 316 632 patients (55.9%) were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Yearly opioid prescriptions decreased by 66.3% (from 16.3 to 5.5 opioids per 100 encounters) between 2013 and 2018, with a yearly adjusted odds ratio (aOR) of 0.808  compared with the prior year. In patients with musculoskeletal pain , opioid prescribing decreased by 71.1% . In patients with musculoskeletal trauma , opioid prescribing decreased by 58.0% . In patients with nonmusculoskeletal pain  opioid prescribing decreased by 53.7% . Between 2009 and 2018, patients who were black  and those who were Asian  had the lowest odds of receiving an opioid compared with other racial/ethnic groups.There was a substantial temporal decrease in the number of opioid prescriptions within this ED during the study period. This decrease was associated with substantial relative reductions in opioid prescribing for treatment of musculoskeletal pain compared with fractures and kidney stones. This cross-sectional study examines the temporal pattern of opioid prescribing for patients with pain conditions in an urban emergency department over a 10-year period. In any case, a 2015 study reported that 17.1% of all ED patients were discharged with an opioid prescription during the week of data collection,10 and a 2017 study demonstrated equal efficacy for certain pain treatment in the ED with nonopioid analgesics.11 It is challenging for prescribers to discern the benefits and risks of opioid prescribing within an encounter for acute pain,16 but with up to two-thirds of all ED patients seeking treatment for pain,19 a 22.2% nationwide reduction in all opioid prescriptions ordered from 2013 to 2017,20 and guidelines recommending judicious opioid prescribing,21 it is important to discern whether emergency medicine is reducing opioid prescribing for the treatment of pain.Heightened attention to the prescription of opioids for the treatment of pain has been a central goal in medicine over the past decade. Opioid misuse was associated with 68% of US drug overdose deaths in 2017 and more than 400 000 deaths from 1999 to 2017.22 and including ED clinicians.24 We also examined demographic factors that may be associated with opioid prescribing to assess the possibility of underlying opioid prescription bias within the ED.The aim of this study was to evaluate temporal changes in overall opioid prescribing and prescriptions for specific pain conditions in an urban academic ED between 2009 and 2018. In addition, the temporal pattern of opioid prescribing at the individual clinician level was examined, as previous studies have indicated that the decrease in opioid prescription counts may be dependent on a subset of clinicians decreasing opioid prescribing, while others maintain high-intensity prescribing, regardless of specialtyInternational Classification of Diseases, Ninth Revision (ICD-9), and International Statistical Classification of Diseases, 10th Revision (ICD-10), diagnosis codes for each patient. To fully anonymize the data, the Enterprise Data Warehouse assigned each patient and physician a randomized unique identifier, had visit dates shifted within a 10-day window, and grouped patient age within 5 years to properly deidentify the data set. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies. Exclusion criteria included any encounter without an ICD diagnosis and encounters not labeled as emergency. The study was approved by the institutional review board at Northwestern University. All data were deidentified and a waiver of informed consent was granted by the institutional review board.All patient encounters in the Northwestern Memorial Hospital ED and Northwestern Memorial Hospital Feinberg Mezzanine Emergency Room, Chicago, Illinois, between January 1, 2009, and December 31, 2018, were selected from the Northwestern Medicine Enterprise Data Warehouse. An encounter was defined by a unique patient (identified by a unique patient identifier) having a unique time and date entered into the Enterprise Data Warehouse database from the electronic health record. An encounter included the self-identified age, sex, race/ethnicity, payer status, opioid prescribed, deidentified physician prescriber, and ICD-9 and ICD-10 codes and are presented in eTable 2 in the Opioid prescriptions were manually selected by name of the drug and are included in eTable 1 in the ICD-9 code defined as primary, identifying the likely condition for which an opioid was prescribed within the encounter. After 2014, ICD-10 codes were implemented and primary codes were no longer delineated within the data set obtained. To ensure that the opioid was given for the specific condition, patients within a singular ICD-10 code were included for selection into a condition. Although data on certain patients may be lost using this criterion, yearly patient counts in each condition remained relatively consistent with the years using ICD-9 coding, demonstrating few exclusions. Patients with multiple ICD-10 codes within the same diagnostic group only, most notably fractures, were also included. Any patients with an ICD-10 code for other unspecified injury were included within this diagnostic group, as this was likely a secondary code in the ICD-10 system and kept yearly patient counts similar to ICD-9 years. Because the aim was to look at changes over time, changes from 2009 to 2014 will have consistency within the ICD-9 system, and those from 2015 to 2018 will have consistency within the ICD-10 system. From these conditions, patients were categorized into 3 groups: musculoskeletal pain , musculoskeletal trauma , and nonmusculoskeletal pain . These groupings define the source of the pain, identify the observation of objective pathologic factors by the clinician (pain vs trauma), and delineate opioid prescriptions between musculoskeletal and nonmusculoskeletal conditions. Any patient with a fracture, sprain, and/or contusion ICD-10 code in addition to an other unspecified injury diagnosis code was not double counted in the musculoskeletal trauma grouping.Twelve diagnostic conditions—back pain, joint pain, limb pain, neck pain, fracture, sprain, contusion, other unspecified injury, abdominal pain, kidney stone, respiratory distress, and pharyngitis—were selected for analyses because they had the highest opioid prescription volume. Patients with these conditions accounted for 59.4% of all opioids prescribed and allowed for distinct and convenient grouping of patients based on pain sources . Encountp(1 − p)/n]1/2). Following descriptive evaluation of the data, 2013 was chosen as the reference year for continuous and controlled estimates of the effects of time in our population because that is when opioid prescribing peaked. Opioid prescription counts were determined by sex , race/ethnicity , insurance status , and age  for all encounters and in conditions of interest.Baseline demographic characteristics and characteristics of patient subsets were determined using descriptive analyses. Absolute and relative opioid prescription changes were descriptively evaluated as a function of time, condition group , and conditions within condition groups. Proportions and their SEs were calculated with normal approximations ; age 31 to 65 years, male, white race, and private insurance were chosen as reference categories because they represented the highest proportion of opioid prescriptions among the patient subgroups. Odds ratios (ORs), adjusted ORs (aORs), and their 95% CIs were calculated. All ORs and aORs represent the odds of receiving an opioid relative to the prior year, with 2013 being the intercept. In addition, a multivariable logistic regression with interaction terms between year and race/ethnicity, year and age, year and sex, and year and insurance status were used to examine whether differences in the reduction of opioid prescriptions from 2013 to 2018 existed within patient subgroups.P = .05.Twelve clinicians were selected for having more than 10 000 encounters from 2009 to 2017. Clinician-level data—but not other data—from 2018 were not available, so this year was excluded for clinician-level analyses. These 12 clinicians were chosen because they represented the upper tercile of ED prescribers by opioid prescription numbers during this period and saw a representative caseload in a year over most years, allowing for temporal analysis. Multivariable logistic regression models, which adjusted for patient age, sex, race/ethnicity, and insurance status, were used for individual clinicians to examine their opioid prescribing over time while controlling for patient demographic characteristics. Adjusted ORs and 95% CIs for each clinician were calculated. All data were processed using SAS, version 9.4 (SAS Institute Inc). Findings were considered significant at 2-sided, 2-tailed Between 2009 and 2018, there were 556 176 patient encounters in the ED, with 70 218 unique opioid prescriptions ordered within those encounters. A total of 316 632 (55.9%) patients were female, 45 070 (42.6%) were of white race, and 43 412 (40.6%) were privately insured; the median age group was 41 to 45 years. Of patients who did not receive an opioid, 316 632 (56.1%) were female, 245 070 (41.9%) were white, and 143 412 (39.8%) were privately insured; the median age group was 41 to 45 years. No patients younger than 16 years (n = 152) received an opioid. Among patients with an opioid prescribed, 38 957 patients (55.5%) were female, 31 225 (47.6%) were white, and 19 194 (46.0%) were privately insured; the median age group was 46 to 50 years. Opioid prescribing peaked in 2013, both with regard to the absolute number of prescriptions (9499) and the number per patient encounter (16.3 prescriptions per 100 encounters) A. FollowGenerally, musculoskeletal pain conditions  were associated with the greatest proportional decrease in opioid prescribing from 2013 to 2018 , followed by musculoskeletal trauma   and nonmusculoskeletal pain  . Some heterogeneity was present within these groups of conditions. For instance, musculoskeletal pain conditions decreased between 68.5% (back pain) and 81.8% (neck pain) between 2013 and 2018. Musculoskeletal trauma conditions decreased between 45.9% (fracture) and 76.6% (sprains). Conversely, prescriptions decreased in patients with kidney stones by only 25.7% between 2013 and 2018. These differential decreases in opioid prescribing are depicted in Across all years, compared with their demographic counterparts, patients who were black , Asian , receiving Medicaid , and aged 16 to 30 years  had the lowest odds of receiving an opioid for treatment of pain. Differences in opioid prescribing for female and male patients were minimal . In addiThe peak opioid prescription rates for each clinician in any single year between 2012 and 2015 ranged from 15.1 to 19.9 opioid prescriptions per 100 encounters. All physicians decreased the number of opioid prescriptions, such that in 2017, no single physician of the 12 included in the analysis prescribed more than 8.8 opioids per 100 encounters, which was associated with a 44.7% to 61.9% decrease from 2013 to 2017. The decrease in opioid prescribing was substantial and relatively similar in magnitude across 11 of 12 clinicians when controlling for patient demographic characteristics .20 This reduction exceeds the 54% decrease in initial treatment in nationwide opioid prescribing for opioid-naive patients and is markedly greater than the 16% decrease for all patients (naive and non-naive) reported in a recent study.22Much attention has been given to the prescribing of opioids for pain by US physicians in response to the opioid epidemic. In a study of opioid prescribing within an urban academic ED, our analysis notes the expected temporal changes given the nationwide attention to opioid prescribing while providing details of prescription patterns by physicians for patients within certain conditions and demographic subgroups over time. From 2013 to 2018, the ED experienced a 66.3% decrease in opioid prescriptions—a much greater reduction than the national decrease of 22% from 2013 to 2017.25 high opioid burden,27 increased adverse effects,28 and possible increased likelihood of repeated use from a single opioid prescription.29 Likewise, many of the patients diagnosed with back, joint, limb, and neck pain have this pain chronically and present to the ED for acute pain episodes with regularity.31 Guidelines recommend against opioid prescription in these cases.21 With up to 10% to 16% of patients presenting to the ED with chronic pain,33 these musculoskeletal conditions are an important diagnostic group to target for nonopioid pharmacologic interventions.Although opioid prescribing for patients with all conditions evaluated decreased from 2013 to 2018, the magnitude of decrease was, to a major extent, associated with large decreases for patients with musculoskeletal pain. Reduction in opioid treatment of musculoskeletal pain conditions decreased by 71.1% (from 36.7 to 10.6 per 100 patients from 2013 to 2018), which is a more substantial rate of reduction than the overall ED rate of 66.3% over the same period. This decrease was not noted for patients with a musculoskeletal trauma diagnosis (58.0% decrease from 35.2 to 14.8 per 100 patients) or patients with a nonmusculoskeletal pain diagnosis (53.7% decrease from 20.1 to 9.3 per 100 patients) over the same period. This substantial reduction in opioid prescriptions for musculoskeletal pain conditions may be due to the understanding that opioids used for the treatment of musculoskeletal pain have minimal effect on pain and disability,35 Patients with Medicaid had the lowest odds of receiving an opioid—a group in which a prior study noted a high burden of opioid prescriptions in the ED for acute pain.27 In terms of patient age and in contrast to a nationwide study of ED opioid prescribing, there was no statistically significant difference in opioid prescribing between patients aged 31 to 65 and older than 65 years.36All patient demographic subgroups saw a decrease in opioids prescribed for them following the peak of opioid prescribing in 2013. Comparing racial subgroups, black race was associated with the greatest decrease in opioid prescribing, as well as the lowest odds of receiving opioids across the entire decade. This finding is consistent with data reporting lower doses of analgesics provided to patients of minority racial/ethnic groups predating the recognition of the opioid crisis, as opposed to white patients who have historically had the highest likelihood of receiving opioids.37 and during the decrease of opioid prescribing in the ED in the present study, guidelines from the Illinois Drug Monitoring Program,38 the Centers for Disease Control and Prevention, the surgeon general, and throughout emergency medicine literature were published.42 Furthermore, in 2017, a quality-control program was implemented within our ED, in which quarterly prescribing patterns were reviewed by the individual clinicians who were compared with their peers.43 The consistency of reduction in opioid prescribing among clinicians demonstrates that treatment decisions are made not only on an individual level, but also within the larger context of the medical environment in which physicians are influenced by guidelines and departmental policy.At an individual clinician level, all analyzed physicians were associated with markedly and similarly reduced prescription rates from 2013 to 2017. A recent study showed an association between guidelines and prescribing practices,ICD codes for conditions does not necessarily mean the patient was given the opioid for that condition, although steps were made to diminish this possible factor. As always, a drug prescribed for a patient does not guarantee consumption. Pharmacotherapy using nonopioid alternatives does not necessarily improve an individual outcome, and given that this study was conducted in an ED, long-term outcomes  are difficult to analyze. Data on the severity of pain were not available and comorbidities  were not analyzed, although this information likely would not change the overall conclusion. In addition, the change from ICD-9 to ICD-10 diagnosis codes in 2015 created discrepancies between the number of patients in that year compared with the other years, so caution should be used in examining 2015 data independently from the overall pattern during the study period. Another limitation is that this study did not have robust data for quantity and dose of the opioid used—this information is important because higher morphine milligram equivalents are associated with long-term opioid use and death,46 and the clinician analyses in prior studies included this factor to define high- and low-intensity prescribing patterns in clinicians.22 These data points were intermittent owing to interruptions in data collection at the Enterprise Data Warehouse from various electronic health record changes. In addition, we recognize that the generalizability of this study, given that it focuses on a single department with a single set of physicians, is limited. This study reports, however, an association between a targeted reduction in opioid prescriptions for musculoskeletal pain conditions, such as back, joint, limb, and neck pain, and a major decrease in opioid prescribing, including a collective decrease in opioid prescriptions across all clinicians within the ED.This study has several limitations. The use of 49 As noted in this study, the greatest reduction in opioid prescribing was for musculoskeletal pain disorders, and a smaller reduction was seen in musculoskeletal trauma and nonmusculoskeletal pain conditions, most notably kidney stones. Although it is difficult to discern whether the number of opioid prescriptions inherently reduces the risk of repeated use of opioids or opioid use disorder, there is an association between single ED opioid prescriptions leading to long-term use of opioids,7 and the ED accounts for over 20% of nationwide number of opioid prescriptions.50 This study suggests that substantial relative decreases in opioids for treatment of back, joint, limb, and neck pain allow for selective prescribing of opioids for treatment of acute, self-limited pain seen with musculoskeletal trauma and kidney stones, while continuing to reduce overall opioid prescribing within an ED. Studies should continue to elucidate situations in which opioid and nonopioid analgesic therapy is indicated and associated with good clinical outcomes.The goal in the pharmacotherapy of pain relief is to use the drugs available as appropriately as possible. Although opioids are effective and may still have a place in treating severely painful conditions with a self-limited, short-term time course, studies have indicated that nonsteroidal anti-inflammatory drugs are also effective in treating certain pain.


In light of the superior analgesia and opioid sparing effects provided by transversus abdominis plane (TAP) blocks, numerous new techniques and applications have evolved. However, TAP blocks are still underutilized in the critical care setting, and PubMed‑listed reports on the relevance of TAP integrity for TAP block efficacy are lacking. Here, we report bilateral TAP blocks delivering quick, potent and durable pain relief to a patient with open abdomen (OA) after prior management with opioids and epidural anesthesia had failed. Extending TAP block application to OA patients even in the post‑operative setting might hence reduce opioid consumption and quicken reconvalescence. Transversus abdominis plane (TAP) blocks are increasingly used as an effective and safe component of multimodal pain management concepts following both laparoscopy or laparotomy . As a reIn this case, we describe the application of bilateral TAP blocks at bedside in a patient with open abdomen (OA) status post emergency laparotomy after prior attempts to deliver sufficient pain control with opioids and epidural anesthesia had failed. According to our PubMed search, this is the first time in the last 20 years a TAP block has been described as delivering rapid, potent and durable postoperative pain relief in an OA patient.A 71-year-old, multimorbid male patient presented with right-sided abdominal pain to the emergency department; a CT scan of his abdomen was significant for superior mesenteric artery (SMA) stenosis, severe stenosis of the inferior mesenteric artery (IMA), pneumatosis coli of the ascending colon, portal venous gas, as well as a 50% bilateral stenosis of the renal arteries.The patient was therefore taken immediately to the operating room for exploratory laparotomy with resection of the necrotic bowel, a right-sided hemicolectomy with cecectomy. At the end of the operation, it was decided to leave the abdomen open given the lack of Doppler vascular signal in the transverse colon, which otherwise appeared macroscopically viable. The patient was taken to the intensive care unit (ICU) and postoperatively intubated for his OA with eventual return to the operating room for definitive closure.Postoperative pain was initially managed by a continuous epidural catheter infusion of bupivacaine 0.125% at 6 ml/h, as well as by intravenous fentanyl infusion. However, pain control still remained insufficient, such that concerns arose as to whether the epidural catheter was dislocated. It was consequently removed and a second epidural was performed at the thoracic level (T8-9) in a standard fashion without complication. Yet, even with a bolus of 3 ml of 2% lidocaine through the epidural, the patient's pain remained intolerable. At this point, he extubated himself, which we classified rather as a sign of pain excess than of post-operative delirium, as the patient appeared to be orientated during his entire course and expressed clearly that his pain level was 9 out of 10 on a visual rating scale. Increasing the patient’s analgesic doses did not seem like a feasible option given his advanced age and the already exhibited signs of somnolence and respiratory depression from escalating doses of his continuous fentanyl infusions. Another neuraxial approach seemed promising, but the patient was started on therapeutic anticoagulation for his critical SMA stenosis and severe stenosis of the proximal IMA. Against this background, it was decided to proceed with a TAP block. A 5 cm, 21 g x 100 mm Pajunk Sonoplex Stim Cannula  needle was applied in standard fashion and under ultrasound guidance using a Sonosite US M-Turbo  with an L25 Linear Probe for visualization of fascial plane sonoanatomy  in the anatomical space between the internal oblique and transversus abdominis muscles (TAP), where the anterior rami of the lower six thoracic nerves (T7-T12) as well as of the first lumbar nerve (L1) penetrate the plane and arborize, providing somatic sensibility to the anterolateral abdominal wall ,5. HowevEqually, the precise method of TAP block delivery varies widely. After initial reports on landmark based techniques, ultrasound-guided methods began to evolve . To dateThe posterior technique consists of an injection in the lumbar triangle of Petit, which is bordered caudally by the iliac crest, posteriorly by the latissimus dorsi muscle, and anteriorly by the external oblique muscle . It resuAdditional variations of the presented approaches for TAP blocks can be achieved by multi-injection or catheter-based continuous infusion techniques, or by performing intra-operative blocks under direct vision instead of ultrasound-guidance .Although the analgesic potential of TAP blocks is constantly being refined, it has already proven itself as a potent option in multimodal post-operative pain management. In a prospective double-blinded, randomized controlled trial, Bharti et al. observed significant reduction in morphine consumption, lower pain scores, and reduced incidence of sedation in the TAP group after laparotomy . In addiHence, TAP blocks might bear the potential to supplement or even surrogate at least two, up to now still important, elements of modern multimodal pain management concepts: opioids and epidural analgesia.Since most frequent opioid side effects are dose-dependent, the reduction of opioid consumption decreases the likelihood of postoperative nausea and vomiting, pruritus, urinary retention, ileus, sedation, and respiratory depression ,15. In aConventional epidural anesthesia is resource-consuming, limits patient mobility, and bears the risk of negatively affecting the cardiovascular and gastrointestinal tract. Nevertheless, it is an elaborate means of reducing opioid consumption. It has been shown that acute post-operative pain management via peridural anesthesia improves patient outcome far more than via opioids in terms of a better post-operative bowel function, a reduction in the incidence of post-operative myocardial infarction or pneumonia, and when weaning patients off artificial respiration ,18. It is precisely because of their positive impact on pain reduction, morphine consumption, and patient mobility that TAP blocks might come into play as an ideal alternative to epidural anesthesia, compared to which they carry a lower risk of vasoparesis, hypotension, splanchnic hypoperfusion, and prolonged and unwanted motor blockade . Moreover, TAP blocks can also be carried out when an epidural analgesia is contraindicated, e.g. in coagulopathic or septic conditions, and might even reduce chronic post-operative pain by preventing pain memory formation in more deeply sedated patients ,20.Despite the increasing use of TAP blocks and encouraging results, the essentials of TAP block efficacy still remain under investigation. As an example, the question of whether TAP blocks can also provide pain relief in patients whose abdomen has had to be kept open, and who were hence left with a disrupted TAP integrity, had thus far remained unanswered. In this case report, we present a patient in strong need of pain relief after prior attempts to control pain with opioids and epidural anesthesia had failed. Increasing the opioid dose was not possible given the patient’s advanced age and beginning signs of somnolence in addition to respiratory depression. The anticoagulation therapy that the patient received for his critical SMA and IMA stenosis precluded a second neuraxial approach. Although our PubMed search for the time between June 2000 and December 2019 did not provide any clarification as to its applicability to patients with OA, a TAP block was employed in this case. The most prevalent concern was that LA would not be sufficiently conserved nor evenly distributed within the TAP when the abdominal anatomy was abrogated, limiting postsurgical applicability of TAP blocks on patients with a closed abdominal midline incision. However, 15 minutes after placement of the TAP block, the pain level had already improved from 9 out 10 on the numeric rating scale to 6, and to 4 after a subsequent 15 minutes. The pain level remained stable and opioid consumption could gradually be reduced until the abdomen was closed on the following day. As, in this case, only single shots of submaximal doses of the LA were applied, even greater efficacy might be achieved by escalating the dose of LA and using catheter-based injection methods. Moreover, additional research to identify the LA with the strongest effects might increase the potency of this method even further. In conclusion, we endorse the expanded application of TAP blocks in the critical care setting and particularly to OA patients, where they can improve pain control, reduce opioid consumption, increase patient mobility and ultimately speed up patient reconvalescence.


Fibromyalgia syndrome (FMS) is a chronic condition of widespread pain. In 2010, the American College of Rheumatology (ACR) proposed new diagnostic criteria for FMS based on two scales: the Widespread Pain Index (WPI) and Symptoms Severity (SS) scale. This study evaluated the reliability, factor structure and predictive validity of WPI and SS. In total, 102 women with FMS and 68 women with rheumatoid arthritis (RA) completed the WPI, SS, McGill Pain Questionnaire, Trait Anxiety Inventory, Fatigue Severity Scale, Oviedo Quality of Sleep Questionnaire, and Beck Depression Inventory. Pain threshold and tolerance and a measure of central sensitization to pain were obtained by pressure algometry. Values on WPI and SS showed negative-skewed frequency distributions in FMS patients, with most of the observations concentrated at the upper end of the scale. Factor analysis did not reveal single-factor models for either scale; instead, the WPI was composed of nine pain-localization factors and the SS of four factors. The Cronbach’s α  was 0.34 for the WPI,0.83 for the SS and 0.82 for the combination of WPI and SS. Scores on both scales correlated positively with measures of clinical pain, fatigue, insomnia, depression, and anxiety but were unrelated to pain threshold and tolerance or central pain sensitization. The 2010 ACR criteria showed 100% sensitivity and 81% specificity in the discrimination between FMS and RA patients, where discrimination was better for WPI than SS. In conclusion, despite their limited reliability, both scales allow for highly accurate identification and differentiation of FMS patients. The inclusion of more painful areas in the WPI and of additional symptoms in the SS may reduce ceiling effects and improve the discrimination between patients differing in disease severity. In addition, the use of higher cut-off values on both scales may increase the diagnostic specificity in Spanish samples. Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread and persistent musculoskeletal pain, accompanied by symptoms including fatigue, insomnia, depression, anxiety, and cognitive impairments . While tAn important problem in FMS research and its clinical management is the lack of objective markers of the disease and of reliable clinical measures for its diagnosis ,11. The In 2010, the ACR proposed new criteria, based on the Widespread Pain Index (WPI) and Symptom Severity (SS) scale . The WPIThe present study evaluated the reliability and predictive validity of the WPI and SS in a sample of FMS patients recruited with the 1990 ACR criteria. Its objectives were as follows: (1) estimation of the frequency distribution of WPI and SS scores in FMS patients and a sample of patients with rheumatoid arthritis (RA), as a chronic pain syndrome of peripheral origin. 2) Evaluation of the factor structure of WPI and SS. To the best of our knowledge, no previous studies have analyzed the underlying factorial structure of these scales. Based on their aims and composition , we hypo EvaluatiIn total, 102 women with FMS, recruited from the Fibromyalgia Association of Jaén (Spain), participated in this study. All patients were examined by a rheumatologist and met the 1990 ACR criteria of FMS. The control group was comprised of 68 patients with RA who met the American Rheumatology Association (ARA) criteria for RA , with noThe patients´ clinical history and demographic data were obtained during a semi-structured interview. The Structured Clinical Interview for Axis I Disorders of the Diagnostic and Statistical Manual for Mental Disorders  was usedThe Spanish version  of 2010 The Spanish version of  McGill PThe Spanish version  of StateThe Spanish version  of Beck The Spanish version  of FatigOviedo Quality of Sleep Questionnaire (COS) . The InsThe Spanish version  of CopinPressure algometry was used for pain evocation. While pain sensitivity was assessed by the traditional static measures of pain threshold and tolerance, central nervous pain sensitization was estimated using a dynamic pain protocol. For this purpose, sensitization to slowly repeated evoked pain (SREP) was used. SREP sensitization was reliably observed in FMS patients but not in healthy controls or RA patients ,6. Furth2 was used to measure pain threshold and tolerance and to elicit SREP sensitization [A pressure algometer Tracker Freedom  with a surface stimulation area of 1 cmtization ,6. To asThe pressure used for the SREP protocol was calculated individually for each participant using the following equation: SREP Intensity = Threshold + 1.25*(DF/4), where DF = Tolerance − Threshold . ParticiThe study was conducted over two sessions that took place on the same day. During the first session, clinical histories and socio-demographic data were obtained. It was confirmed that there were no violations of the exclusion criteria. Then, the SCID-I interviews were completed, and self-report instruments were administered. During the second session (laboratory), pain threshold and tolerance were obtained, and the SREP protocol was presented. Participants were asked not to take analgesics drugs for 24 h before the study. No instructions were provided regarding anxiolytics and antidepressants, which could be taken as usual. All participants signed an informed consent form. The study protocol was approved by the Ethics Committee of the University of Jaén (CEIH 160715).p < 0.05.Exploratory factor analysis (EFA) (main component method) was used to explore latent constructs, and confirmatory factor analysis (CFA) (varimax rotation) was employed to confirm the hypothesized factor structure. Eigenvalues > 1 were used to determine significant factors, and a minimum of 2% of explained variance was used as criteria to include a factor in the CFA. The cut-off value for assignment of an item to a factor was set at 0.30 . Items tp < 0.001; for SS = 0.18, p < 0.001) or the RA patients . In FMS patients, scores were negatively skewed , with most of the observations being towards the upper end of the scale (19 for WPI and 12 for SS). In RA patients, scores were positively skewed , with most of the observations being towards the lower end of the scale. On the SS scale, most FMS patients reported fatigue, cognitive symptoms and waking unrefreshed. In addition, large proportions of FMS patients (53.9%) marked the 19 possible painful areas on the WPI and were assigned to the highest category of 25 or more symptoms on the SS2b (64.7%). In contrast, the majority of the RA patients did not report fatigue, cognitive symptoms, or waking unrefreshed; 60.3% of them indicated between 0 and 4 painful areas on the WPI and 81.6% between 1 and 10 symptoms on the SS2b.Firstly, we tested the hypothesis of a single-factor structure of the WPI and SS. For this purpose, all items of both scales were subjected to CFA assuming a two-factor solution, i.e., painful body-parts and pain-severity. This hypothesis was not supported, as most of the WPI and SS items did not load onto any of these factors (factor loading cutoff = 0.30). Factor 1 exhibited loads of 2 WPI items and 18 SS items; factor 2 exhibited loads of 1 WPI item and 8 SS items. An EFA of the items of both scales together revealed 22 factors fulfilling the Eigenvalue > 1 criterion, which explained 79.18% of the variance. The WPI and SS items loaded onto different factors without any overlap.Based on these results, further factor analyses were performed separately for the WPI and SS. The EFA for the WPI item revealed nine factors fulfilling the Eigenvalue > 1 criterion and a minimum of 2% of explained variance, explaining 77.44% of the variance. This 9-factor solution was confirmed by CFA. The nine factors were as follows: (1) shoulder girdle left, shoulder girdle right, and upper arm left; (2) lower arm left and upper and lower back); (3) jaw right and upper leg left; (4) lower arm right and hip buttock left; (5)  upper leg right and lower leg left; (7) jaw left and neck; (8) upper arm right; and (9) lower leg right. The EFA for the SS revealed 12 factors fulfilling the Eigenvalue > 1 criterion, explaining 70.28% of the variance. Analyzing the scree plot of the sedimentation graph and using the criteria of a minimum of 2% of the variance explained, a 4-factor solution was chosen. The CFA using these four factors explained 41.21% of variance; two items were excluded (vomiting and painful urination). The four factors included were as follows: (1) muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking about or remembering problems, muscle weakness, headache, pain/cramps in abdomen, numbness /tingling, and hair loss; (2) dizziness, insomnia, depression, constipation, pain in upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, and dry mouth; (3) Raynaud’s symptoms, ringing in ears, heartburn, loss/change in taste, shortness of breath, loss of appetite, rash, hearing difficulties, easy bruising, frequent urination, and bladder spasms; and (4) itching, wheezing, hives/welts, oral ulcers, seizures, dry eyes, and sun sensitivity. r = 0.40, p < 0.001) but not in the RA patients .The Cronbach’s α  was 0.34 for the WPI, 0.83 for the SS and 0.82 for both scales combined (WPI + SS). The WPI and SS scores were correlated in the FMS patients  and Depression (BDI) , and SS correlated positively with Fatigue (FSS)  and Depression (BDI) . After controlling for Fatigue (FSS) and Depression (BDI), SREP sensitization no longer correlated with Total Symptoms (SS2b) , Range of Symptoms (SS2b) , or Total Symptom Severity (SS) .Only the severity of waking unrefreshed (SS2a) was related to evoked pain, with a negative correlation seen with pain threshold. Total Symptoms (SS2b), Range of Symptoms (SS2b) and Total Symptom Severity (SS) correlated negatively with SREP sensitization. The latter associations were contrary to our predictions. We computed partial correlations to identify possible variables mediating the relationship between SREP sensitization and SS scores. SREP correlated negatively with Fatigue (FSS)  fulfilled the 2010 ACR criteria , resulting in a sensitivity of 100%, specificity of 81%, and overall diagnostic accuracy of 92.4%. The positive predictive value was 88.69%, and the negative predictive value was 100%.p < 0.001) and SS  scores discriminated between the two groups. When the two scales were jointly included as predictors using the forward selection method, the WPI score was selected in the first model. When the scores of both scales were used, discrimination accuracy reached 100%. The logistic regression analyses showed that both the WPI . Furthermore, diagnostic accuracy was greater for WPI than for SS .The Fisher’s Z statistic indicated an increase in diagnostic accuracy between the models for WPI and WPI + SS  and SS (10.05) scores of our FMS patients were higher than those previously reported. In the 2010 Wolfe et al. study , mean scWPI and SS did not follow a normal distribution. In our FMS patients, the scores were concentrated towards the upper end of the scales ; the scores of RA patients were concentrated towards the lower end of the scales . Thus, a strong ceiling effect was observed for the WPI and SS scores in our FMS patients. In accordance with their aim, the scales correctly differentiated between FMS patients and those with AR. The FMS patients indicated more painful areas, increased fatigue, a stronger tendency to wake unrefreshed, more severe cognitive symptoms, and a higher total number of symptoms than those with RA .One of the reasons for developing the 2010 ACR criteria was to devise an instrument differentiating between individual patients or patient groups according to symptom severity . HoweverContrary to our prediction, neither the WPI nor the SS exhibited a single-factor structure. The WPI items were spread across nine factors covering all painful areas represented in the scale. Most of the factors include two body areas except for Factors 1, 2, and 5, which include three body areas, and Factors 8 and 9, which only include one body area. While it is difficult to explain the loads of different body areas on the same factor, the finding challenges the validity of aggregating pain in different body areas to a single symptom scale. The factor structure of the SS was more intuitive; it involved four factors related to (1) the main clinical FMS symptoms , (2) emotional-nervousness symptoms , (3) somatic symptoms , and (4) symptoms associated with the skin and sensory sensitivity .The internal consistency of the WPI was poor, which accords with the high number of factors revealed by the EFA and reflects the low co-variation of the item on the instrument (where feeling pain in one body area does not necessarily relate to feeling pain in another body area). In addition, the internal consistency of the scale may be limited by the binary response mode and the small number of items . The SS The WPI and SS demonstrated acceptable predictive validity, as indexed by their associations with clinical symptoms. Despite the skewness of their distributions, making it more difficult to obtain significant correlations, the WPI and the Total Symptoms SS scores correlated positively with the Total Clinical Pain, Current Pain Intensity, Emotional Pain, and Sensorial Pain subscale scores of the MPQ. Similarly, correlations of WPI and SS scores with pain intensity measured by a VAS were demonstrated in previous research . An impoAnalysis of associations of WPI and SS scores with indicators of central nervous sensitization to pain is a relevant question, as this is considered the core pathological mechanism of FMS ,3. For tPatients diagnosed with FMS, compared to RA patients, exhibited higher levels of clinical pain, fatigue, anxiety, depression, insomnia and catastrophizing, a lower pain threshold, lower tolerance of pain, and stronger central pain sensitization, which is coherent with current evidence . RegardiThe results of our logistic regression analysis showed that WPI and SS also achieved good group discrimination when used separately. However, the WPI was a better predictor than the SS, reflecting the central role of pain in FMS. This is in accordance with previous research , which sArnold et al.  have recAs limitation of the study, although we have specially care in excluding patients with RA who showed FMS features, it is difficult to completely discard the possibility of the inclusion in the study sample of some cases with dual RA-FMS pathology ,60. BesiTo sum up, the precision of the WPI and SS for assessing FMS symptoms seems to be limited, as they showed skewed distributions with strong ceiling effects and did not exhibit a single-factor structure. In addition, the internal consistency of the WPI is poor. Nonetheless, the associations of the scales with measures of clinical pain, fatigue, insomnia, depression, and anxiety support their predictive validity with respect to the main symptoms of FMS. In contrast, the scores of both scales were virtually unrelated to sensitivity to evoked pain and central pain sensitization. Finally, both scales exhibited high predictive validity (with respect to discrimination of patient groups), showing very good ability to differentiate between FMS and RA patients. However, at least regarding their application to Spanish samples, it may be necessary to add more painful areas to the WPI and more symptoms to the SS, to reduce ceiling effects and improve discrimination between patients who differ in disease severity. In addition, application of higher cut-off values on both scales may increase the specificity of the diagnoses in Spanish samples.


Emerging evidence highlights the importance of preoperative expectations in predicting patient-reported outcomes of orthopedic surgeries. To date, it is still a matter of controversy whether patient satisfaction can be maximized by promoting either optimistic or realistic outcome expectations before surgery. Adjusting overly optimistic outcome expectancies in favor of a more realistic outlook on the limitations of total hip arthroplasty could reduce the risk of disappointment and lead to greater satisfaction with surgery outcomes. Our prospective cohort study was aimed at comparing the relative predictive influence of baseline expectations, expectation fulfillment and symptomatic improvement on the global effectiveness of total hip arthroplasty.Ninety patients  fulfilled inclusion criteria and completed a comprehensive preoperative assessment comprising sociodemographic, clinical, functional and psychological phenotypes. Moreover, the strengths of preoperative expectations for improvements in eight pain-related and functional domains were recorded on a 5-point Likert-scale. At 12 months after surgery, patients were asked to rate perceived improvements in each of these domains as well as the global effectiveness of the total hip replacement on a 5-point Likert-scale. To evaluate the relative impact of preoperative expectations, symptom improvement and the fulfillment of expectations on the global effectiveness of surgery, a sequential multiple regression analysis was performed.Compared with the actual improvement at 12-months follow-up, prior expectations had been overly optimistic in about 28% of patients for hip pain, in about 45% for walking ability and around 60% for back pain, independence in everyday life, physical exercise, general function social interactions and mental well-being. An optimistic hip pain expectation, walking ability at baseline and the fulfillment of expectations for walking ability, general function and independence in everyday life were found to independently predict global effectiveness ratings.Positive expectation about pain and the fulfillment of expectations concerning functional domains predicted higher global effectiveness ratings. In line with many authors investigating the relationship between the fulfillment of expectations and satisfaction with medical interventions, we suggest that professionals should explicitly address their patients’ expectations during the preoperative education and consultation.The online version contains supplementary material available at 10.1186/s12891-021-04040-y. Osteoarthritis is the most common degenerative joint disease among the elderly worldwide –3. OwingTHA is indicated in patients suffering from end-stage osteoarthritis of the hip, inflammatory arthritis, fracture or dysplasia who do not respond to conservative therapies . It is rPatients’ expectations of treatment are increasingly acknowledged as an important determinant of the patient-rated effectiveness of the treatment outcome . If not Evidently, it is crucial for surgeons to know whether to promote optimistic attitudes in their patients or whether to correct those in favor of a more realistic perspective on potential postoperative outcomes, given the individual constellation of risk factors present , 21. UnfConsequently, there is a strong need for prospective investigations simultaneously addressing symptomatic improvement, expectations, and expectation fulfillment in multivariate models. Applying a sequential multiple regression model, Mannion et al. , among oBy translating the methodological approach of Mannion et al. to the field of total hip arthroplasty , this obThe study complies with the Declaration of Helsinki and the STROBE guidelines . The EthN = 172 consecutive patients scheduled to undergo total hip arthroplasty at the Orthopedic Clinic of the Hannover Medical School were screened for eligibility. Inclusion criteria were: (a) age ≥ 19, (b) fluent German literacy skills, (c) the mental and legal ability to give written consent and (d) the agreement to participate in the 12-month follow-up survey and to provide contact details. Patients suffering from dementia, planned spinal anesthesia , drug addiction and post-surgical delirium syndrome were not eligible. We further excluded patients suffering from peri- and postoperative complications  from the 12-month follow-up analysis  Lumbar Spine Questionnaire . PatientThe single most important individual outcome occurring after the surgery in order for patients to judge the THA as successful was also recorded before surgery. Answer possibilities were: Improvements in hip pain, back pain, walking capacity, independence, physical exercise, everyday functioning, social interaction and mental well-being  .Patients were asked to choose their 3 most important reasons for undergoing THA from the following options: Other therapies were ineffective, something must be done, fear of worsening of my situation, to retain my independence, to improve everyday functioning, to improve walking capacity, to reduce pain, my physician recommended the surgery.The average hip pain intensity in the last 3 months before surgery was assessed on an 11-point Numeric Rating Scale  . The sevPain chronicity stages  were derived using the validated Mainz Pain Staging System (MPSS) , 43. The2) was applied to each site. Patients were advised to indicate when first perceiving pain during pressure stimulation with slowly increasing intensity (50 kPa/s). Pressure stimulation stopped at the patients’ report of pain or when maximum pressure intensity (1000 kPa) was reached. Analyses are based on the average threshold (kPa) over all 10 testing sites.As a measure of overall pain sensitivity, the pressure pain threshold (PPT) was recorded using an electronic pressure algometer  bilaterally over five sites  , 45. TheIn order to measure the patients’ individual mobilization ability, the psychometrically well evaluated Timed up and Go test was employed . The timTo evaluate the functional capacity of the patients, the German version of the „Western Ontario and McMaster Universities Osteoarthritis Index” (WOMAC) was employed . The WOMHealth-related quality of life was assessed using the German version of the Short-Form Health Survey (SF-12) including physical  and mental health  , 47. SumPsychological distress in terms of depression, anxiety and stress was measured employing the German version of the Depression, Anxiety, Stress Scales (DASS) , 49, 50.Somatization has previously been associated with substantial functional impairment and healthcare utilization , 52. In Movement-related fear (“kinesiophobia”) has been increasingly recognized as a crucial predictor of the maintenance of pain and disability , 54. We The cognitive appraisal of pain was assessed using the Kiel Pain Inventory (KPI) . It contAt 12 months after surgery, average hip pain intensity in the last 3 months (NRS), overall severity of chronic pain (CPG), functional capacity (WOMAC) and psychological outcome variables  were recorded again using the respective standardized questionnaires  in a telephone interview. In addition, the following outcome parameters were assessed according to a standardized protocol:At follow-up, patients rated the global effectiveness of the surgery  on a 5-point scale .Patients were additionally asked to state the single most important positive outcome they experienced as a result of the THA  .Patients were asked to rate the actual improvements regarding the 8 outcome parameters asked for in the preoperative examination booklet  on a 5-point scale .The fulfillment of expectations was obtained by subtracting the preoperative expectation score for each outcome parameter from the respective postoperative outcome score. The resulting expectations-actuality discrepancy scores ranged from − 5 to 5 points. A negative expectations-actuality discrepancy score indicated less improvement than expected and was termed “expectations not met”. A score of zero indicates an outcome as expected and was termed “expectations met”. A positive expectations-actuality discrepancy represents a greater improvement than expected and was named “expectations exceeded” Fig. .Fig. 2Cp-values are two-sided and the level of significance was set to p < 0.05. Continuous variables were described by mean and standard deviation. Discrete variables were presented as frequencies  or median with first and third quartiles . The distribution of continuous data was tested for normality using the Kolmogorov-Smirnov-Test.Statistical analyses were carried out using SPSS software . All reported Symptom change scores for pain characteristics, functional capacity and psychological variables were obtained by dividing the outcome measures at 12-months follow-up by the preoperative scores. Associations of baseline characteristics, preoperative expectations, symptom change scores and the fulfillment of expectations with the patient-rated global effectiveness of surgery, were explored by correlation analyses (Supplementary Tables 2) from one step to the next is reported.To evaluate the relative predictive influence of preoperative expectations, symptom change scores and the fulfillment of expectations on the patient-rated global effectiveness of surgery (dependent variable) a multiple regression analysis was performed adjusting for multiple baseline characteristics, performing both a complete case analysis  were entered into the model. In a fourth step, expectations-actuality scores were added.N = 85).Due to varying numbers of missing data for the different predictor variables, the sample size decreased with increasing number of variables included. As this may reduce statistical power and lead to biased results, we replicated the sequential multiple regression analysis following multiple imputation of missing values Table . In prep2) across the 10 imputed complete data sets and the pooled beta regression coefficients for the statistically significant predictors are presented  which is based on the MAR (missing at random) assumption. As White et al.  suggest ed Table .N = 36) of the study participants had at least one missing value on a variable, so that 6% of the 1260 values (cases × variables) were missing and had to be imputed. The results from the complete case analysis could be replicated in the 10 imputed data sets with comparably high goodness-of-fit according to Cohen [The missing values analysis revealed that for 93% of the predictors included at step 4 of the regression model at least 1 value is missing. Moreover, 40% . The most frequent indication for surgery was primary osteoarthritis of the hip , followed by hip dysplasia , femoral head necrosis  and posttraumatic osteoarthritis . On average, patients reported moderate pain intensities. Only one third of patients were classified as patients with a high level of chronicity. The majority of the cohort still had independent mobility skills. Symptom load for psychological parameters such as depression, somatization, kinesiophobia, catastrophizing, helplessness and fear of surgery or pain was rather low . For a comprehensive sociodemographic and clinical characterization, see Table Data analyses were based on 90 patients admitted to the hospital for total hip replacement surgery (right side: N = 63), followed by “to reduce pain” , “to retain my independence” , to “improve everyday functioning” , “other treatments were ineffective” , “fear of worsening of my situation”  and “my physician recommended it” .The most common reason for deciding to undergo surgery was “to improve walking capacities”  of the participants found improvement in hip pain to be the most important expected positive outcome , general function: 14%(N = 12), independence in everyday life: 7% (N = 6), back pain: 1% (N = 1) and physical exercise: 1% (N = 1). This preoperative rating correlated significantly  with the patients’ follow-up rating of the most important positive outcome that had occurred after the surgery (hip pain: 59% (N = 53), walking ability: 24% (N = 21), general function: 7% (N = 6), independence in everyday life: 6% (N = 5), back pain: 3% (N = 3) and physical exercise: 1% (N = 1).To evaluate the surgery as a success, 47% (N = 56) of the participants.The domain-specific preoperative expectations and respective postoperative outcomes after 12 months are shown in Table N = 53) of patients reported having met their expectations, in 10% (N = 9) actual improvement exceeded their preoperative expectations. Similarly, 48% (N = 41) of patients reported meeting their expectations concerning walking ability while 7% (N = 6) exceeded their expectations. More than 50% of patients were overly optimistic in their expectations of actual improvement concerning back pain (N = 45), independence in everyday life (N = 44), physical exercise (N = 46), general function (N = 51), social interactions (N = 48) and mental well-being (N = 48) 12-months after surgery , helped: 38% (N = 34), helped somewhat: 1% (N = 1), did not help: 1% (N = 1). No one thought that the surgery “made it worse”.When asked for the degree to which the total hip arthroplasty helped overall, responses were as follows: Helped a lot: 60% , a sequential multiple regression was performed. The multiple regression analysis was carried out based on the multiple imputation of missing data Table  to accouThe present study was designed with the aim to delineate to which extent patient self-ratings of treatment effectiveness were explained by preoperative outcome expectations, the fulfillment of these expectations or the improvement in core symptoms of hip osteoarthritis. Our analysis shows that patients undergoing total hip replacement surgery base their global effectiveness ratings mostly on the fulfillment of their preoperative outcome expectations. Interestingly, in our study, this was only observed for functional parameters like walking ability, general function and independence in everyday life. Additionally, we found the preoperative expectation of hip pain and walking ability at baseline to significantly predict the patient-rated global effectiveness of surgery. The improvement in core symptoms of hip osteoarthritis was not found to be an independent predictor of the global effectiveness of THA, however.Our findings concur with a recent review on the role of expectation fulfillment in knee and hip arthroplasty . It concInterestingly, while for more complex functional constructs like walking ability, general function and independence in everyday life, the fulfillment of expectations was found to be crucial, for hip pain, an optimistic expectations per se appeared to be most beneficial for evaluating the surgery as a success - independent of its fulfillment. This finding gives reason to assume that expectancy effects work differently for non-volitional, sensory-affective experiences like pain and more complex functions. Experimental research on placebo effects has contributed convincing evidence for non-volitional responses being mostly modulated by the expectancy of their occurrence . Thus, pDespite many salient features like the prospective nature, the use of standardized outcome measures and the comprehensive clinical characterization of the sample, the results of the present study have to be interpreted in the light of some limitations.N = 85 individuals does not comply with the generally accepted recommendation to ensure sufficient statistical power (the number of observations should be 10 times the number of independent variables) [First of all, the varying numbers of missing data for the different predictors included in the sequential multiple regression analysis has to be mentioned as a key limitation of our study. Upon stepwise addition of increasing amounts of potential predictors, the number of observations decreased which limits the external validity of the predictor selection by potentially introducing biases and power issues. The model at step 4 (containing 14 independent variables) relying on complete case analysis was only based on 54 individuals and might have been underpowered for detecting small effects. Therefore, we provided a sensitivity analysis essentially replicating the results of the complete case multiple regression analysis following multiple imputation of missing values. Importantly, however, to run models with 14 predictors on riables) .A central limitation in our and likely other investigations concerns more general aspects of the assessment of preoperative outcome expectations, mostly independent from the actual type of orthopedic surgery. Between 2012 and 2020 several review articles summarizing the available evidence on the predictive influence of preoperative expectations on patient satisfaction with THA have been published , 67. AllMoreover, we adapted the expectation scale of the NASS Lumbar Spine Questionnaire  for patients undergoing hip arthroplasty . The adaLikewise, for the assessment of the patient-rated global effectiveness, we used a question that had not been previously validated which limits the internal validity of our results.Additionally, some methodological issues have to be acknowledged. We lost 8% of the study cohort to follow-up for unknown reasons. Compared to other prospective cohort studies, the drop-out rate in our case was rather low . Still, The improvement of patient satisfaction with surgery outcomes has important economic implications. Thus, paying more attention to the refinement of the preoperative patient education is indispensable , 75. In While the intricacies of the underlying mechanisms still need further research, expectations and the fulfillment of expectations are clearly pivotal factors in predicting the effectiveness of an intervention in a clinical setting. It is therefore critical for medical professionals to not only give detailed information about the process, results and risks of a medical intervention, but also to explicitly address expectations. Our data provide evidence for the beneficial effect of promoting an attitude of realistic optimism during the shared decision-making process before surgery.Additional file 1: Supplementary Figure 1. Missing value analysis of the primary outcome measure and the 14 predictor variables included sequentially into the multiple regression analysis. A. The table displays the descriptives (mean and standard deviation), the percentage of missing values per variable, the number of imputed values  and the type of model used for multiple imputation. For the dependent variable “global effectiveness of total hip arthroplasty” the data set was complete. More than 10% missing values were identified for the rating instrument measuring hip function and mobility (WOMAC), its symptom change score (quotient of postoperative and preoperative WOMAC score) and the calculated expectations-actuality discrepancy scores (fulfillment of expectations) of physical exercise and social interactions. B. The variable chart shows that for 93% of the predictors included at step 4 of the regression model at least 1 value is missing. The cases chart shows that 40% (N = 36) of the study participants has at least one missing value on a variable. The values chart shows that 6% of the 1260 values (cases × variables) are missing. C. The bar graph displays the percentage of study participants having none to six missing predictors. Subjects with more than three missing predictors were excluded from the analysis on the imputed data set.Additional file 2: Supplementary Table 1. Correlations between baseline variables and patient-rated global effectiveness of THA.Additional file 3: Supplementary Table 2. Correlations between preoperative expectations, change in symptoms and calculated expectations-actuality discrepancy scores with the patient-rated global effectiveness of THA.Additional file 4: Supplementary Table 3. Results of the sequential multiple regression analysis: Variance explained in the global effectiveness of total hip arthroplasty at 12 months follow-up by sociodemographic and medical variables, preoperative expectations, change in symptoms and the fulfilment of expectations .


Long after surgical treatment, chronic pain continues to afflict many patients with pancreatic cancer. Multimodal pain management is the current approach to managing these complex patients. In patients with refractory pain, a celiac plexus block is a commonly used adjunct to optimize pain control. The sclerosing agents used in a celiac plexus block are known to cause local tissue necrosis as a rare complication. We present a case of extensive retroperitoneal necrosis following celiac plexus neurolysis. To our knowledge, this is the first report of extensive retroperitoneal necrosis after a celiac plexus block requiring operative management. A celiac plexus block is indicated for the treatment of intractable abdominal pain in the setting of malignant and benign neoplasms involving the pancreas, the biliary tree, the retroperitoneum, and other abdominal organs. The most common indication is for patients with pancreatic cancer. Many patients with pancreatic cancer have debilitating chronic pain that is difficult to manage with medication alone. Celiac plexus block is an adjunct to oral analgesics, which involves the injection of steroids, long-acting local anesthetic agents, epinephrine, clonidine, and other agents to the celiac plexus. Neurolysis with alcohol or phenol agents has a more permanent effect. Complications from celiac plexus block are rare with the most common being diarrhea and orthostatic hypotension. This is reported in 34% and 44% of patients respectively . There hThe celiac plexus is located at the level of L1, anterior to the aorta and posterior to the pancreas. The greater, lesser, and least splanchnic nerves, arising from T5 to T12, provide the preganglionic innervation to the celiac plexus. Postganglionic fibers leave the celiac plexus and innervate the embryonic foregut .There are different techniques to perform neurolysis of the celiac plexus. The “classic technique” is the retrocrural technique. With the patient positioned prone, a needle is directed just lateral to the vertebral body and is gradually advanced until pulsations from the aorta are felt. For a diagnostic or prognostic block, a local anesthetic such as lidocaine is used. For therapeutic neurolysis, 10-25 cc of 50% ethyl alcohol or 6.0% aqueous phenol is used.Image-guided trans-aortic celiac plexus block is now being recognized as a safer alternative to the classic retrocrural technique. The patient is again positioned prone and a scout film is used to determine the level of T12-L1 interspace and to review any distorted anatomy that may be due to malignancy or previous surgery. A stylet needle is advanced until the posterior wall of the aorta is encountered. The stylet is removed and the needle hub will show arterial blood. A saline-filled glass syringe is attached and the needle is advanced using a loss-of-resistance technique. Contrast medium is injected once the loss of resistance occurs and a CT scan is taken and reviewed for proper needle placement and spread of contrast. Once proper placement in the pre-aortic space is ensured, the neurolytic agent is injected.Our patient is an otherwise healthy 29-year-old who had been previously diagnosed with Ewing’s sarcoma of the pancreas and underwent a distal pancreatectomy with splenectomy. He had undergone 10 cycles of vincristine, doxorubicin, cyclophosphamide alternating with ifosfamide, etoposide (VDC/IE) chemotherapy. He had significant postoperative abdominal pain, nausea, and vomiting refractory to oral pain agents. Chronic constipation also likely contributed to his symptoms. Due to persistent pain, the patient was referred for celiac plexus block.A trans-aortic L1 celiac plexus block was performed under fluoroscopic guidance. 5 cc of 2% lidocaine with 80 mg of methylprednisolone was injected into the pre-aortic space, which was followed by 30 cc of 50% alcohol. There were no immediate post-procedural complications, and the patient was discharged home with a short course of oral opioids, anti-emetics, and a bowel regimen.Two days later, the patient returned to a local hospital with severe abdominal pain and was found to have peritonitis on exam. The initial workup was significant for leukocytosis, and CT imaging showed retroperitoneal free air with suspicion of retroperitoneal duodenal perforation Figure . The patHis postoperative course was complicated by prolonged ileus and a low-volume pancreatic leak well controlled with the operative drain. He had persistent leukocytosis postoperatively, which was most likely from the residual necrotic tissue, and resolved by discharge. There were no signs of ongoing sepsis. The patient was evaluated by the acute pain service and started on high-dose morphine patient-controlled analgesia (PCA) that was transitioned to oral morphine and slowly tapered over the course of his hospitalization. The patient was eventually started on a diet with continued low output from the pancreatic leak. He was discharged home on hospital day 24 and instructed to follow up with his medical oncologist for chronic pain management. Chronic pain is a well-established clinical challenge in patients with pancreatic malignancy. Patients often require long-term pain medication regimen, including adjunct analgesic procedures such as the celiac plexus block. Pain due to pancreatic malignancy was proposed by Lahoud et al. to be a combination of three physiologic pathways: visceral, somatic, and neuropathic , each ofSimilarly, 5-fluorouracil, leucovorin, irinotecan, and oxaliplatin (FOLFIRINOX) showed improved pain control and quality of life in metastatic pancreatic cancer patients . RadiatiThe celiac plexus block and neurolysis are used as adjuncts to medical regimens when patients still experience significant pain. Common complications include hypotension and diarrhea. Hypotension occurs due to regional vasodilation. This can be mitigated by initiating a 500 cc to 1 liter bolus of crystalloids prior to the procedure. Self-limited diarrhea occurs due to unopposed parasympathetic activity after the block.Additional severe complications have been reported, including intravascular injection, epidural or subarachnoid injection, renal injury, inadvertent neurolysis of the lumbar somatic nerves, peritonitis, abscess, retroperitoneal hematoma, injection of the psoas muscle, pneumothorax, bilateral diaphragmatic paralysis, and ejaculatory failure ,8. ThereIn the early 1990s, a retrospective study looked at the rates of permanent paraplegia following celiac plexus block in England and Wales during the years 1986-1990. There was a total number of four cases of paraplegia out of 2730 blocks (0.14%) that were performed over those years . In 2009Optimizing pain control in patients with pancreatic malignancy continues to be a complex and elusive moving target. Adjuncts to oral analgesics are frequently required, including celiac plexus block/neurolysis. The use of sclerosing agents likely causes local inflammation and necrosis which remains clinically occult most of the time. However, our case presentation is one example of a severe complication that can be better understood with future studies on this commonly performed procedure.Our patient experienced a rare case of extensive retroperitoneal necrosis necessitating operative intervention after a celiac plexus block. As a frequently used adjunctive pain control modality in palliative care, the celiac plexus block warrants additional research to ensure safety and adequate post-procedural monitoring.


The mean administered dose of remifentanil was 1977.7 ± 722.5 μg in the TIVA group, which was approximately 0.268 ± 0.118 μg/min/kg during surgery. Pain scores based on a numeric rating scale (NRS) and the need for rescue analgesics were compared between groups at the postoperative anesthetic care unit (PACU). The immediate postoperative NRS values of the TIVA and VA groups were 5.7 ± 1.7 and 4.7 ± 2.3, respectively (P = 0.034). Postoperative morphine equianalgesic doses in the PACU were higher in the TIVA group than in the VA group . The incidence of immediate postanesthetic complications did not differ significantly between groups. In conclusion, more rescue analgesics were required in the TIVA group than in the VA group to adequately manage postoperative pain while staying in the PACU after thyroidectomy.While the postoperative outcome is favorable, post-thyroidectomy pain is considerable. Reducing the postoperative acute pain, therefore, is considered important. This study investigated whether the pain intensity and need for rescue analgesics during the immediate postoperative period after thyroidectomy differ according to the methods of anesthesia. Seventy-two patients undergoing total thyroidectomy under general anesthesia were examined. Patients were randomly assigned to undergo either total intravenous anesthesia with remifentanil and propofol (TIVA,  Thyroid surgeries are considered to be safe operations with a relatively low level of morbidity and mortality –3. NeverThe previous propensity-score matching analysis, which we retrospectively conducted on 7,511 thyroidectomy patients , showed Total intravenous anesthesia (TIVA) refers to an anesthetic method in which general anesthesia is maintained by intravenous drug infusion rather than by inhalant agents. The hypnotic agent commonly used in TIVA is propofol, and opioids are added for an analgesic effect. TIVA is particularly useful in some situations where inhalational anesthesia is contraindicated or may interfere with the operation. Several recent studies also showed that TIVA leads to better outcomes and even relieves postoperative pain compared with inhalant anesthesia , 8. NeveTherefore, in this current randomized controlled study, we aimed to investigate the degree of postoperative pain in two methods of anesthesia: TIVA with continuous infusion of propofol and remifentanil and VA with only inhalant agents. Furthermore, other postanesthetic complications were also evaluated as secondary outcomes.We obtained approval from the Institutional Review Board of Asan Medical Centre, Seoul, Korea (2016–0463), and registered this study at cris.nih.go.kr (KCT0005047). All participants gave a written informed consent. We included 80 patients. The inclusion criteria were as follows: an age range of 20 to 79 years, either sex, having an American Society of Anesthesiologists Physical Status I–III, and undergoing an elective thyroid surgery by the same surgeon. The exclusion criteria were as follows: allergy or contraindication to opioids or nonsteroidal anti-inflammatory agents (NSAIDs); severe renal dysfunction with limited use of NSAIDs; bronchial asthma; psychiatric disease; intake of opioids within one month before surgery or any analgesics 6 h before surgery; reoperation on thyroid; or simultaneous radical neck lymph node dissection or other surgeries.This study was a prospective, assessor-blinded, randomized controlled study. Because of the significant differences between the two anesthetic techniques, the attending anesthesiologist could not be blinded to group identity. However, the patient and outcome assessors were blinded to group identity.http://www.randomization.com). Randomization was done the day before surgery, and each patient was randomly assigned to the TIVA or VA group. Standard monitoring included noninvasive blood pressure, heart rate, electrocardiogram, and a bispectral index (BIS) monitor .Subjects were randomly assigned in a 1 : 1 ratio to two groups using an online randomization program  in oxygen, and the concentration of desflurane was controlled to maintain the patient's baseline blood pressure within 20%, which was approximately 1 minimum alveolar concentration of desflurane. At the end of surgery, the anesthetic agents were immediately discontinued. After enough oral suctioning, the inhaled oxygen fraction and fresh gas flow rate were increased to 100% and 8 L, respectively, in order to facilitate emergence. Neuromuscular blocking was reversed with 0.4 mg glycopyrrolate and 15 mg pyridostigmine and confirmed by a train-of-four monitor. Endotracheal tubes were removed when patients regained consciousness with spontaneous respiration. Patients were then transferred to the postoperative anesthetic care unit (PACU) and scored for pain.Regardless of the assigned group, all patients were induced with general anesthesia with 1.5∼2.5 mg/kg propofol and 0.6 mg/kg rocuronium. Patients assigned to the TIVA group were maintained on anesthesia with an effect-site target-controlled infusion (TCI) of propofol and remifentanil using a commercial TCI pump . The effect-site concentration of propofol was controlled between 2.0 and 2.5 μg fentanyl if the pain score was still over 5. At 30 min after entering the PACU, the pain score was evaluated again, and when exceeding 5, the previously administered opioid was readministered in the same amount.Pain management at the PACU was performed in the same manner in both groups. If the pain score was over 5, the anesthesiologists ordered intravenous rescue analgesics. The first rescue analgesic was an NSAID, which was 30 mg ketorolac. After 15 min, the pain score was reevaluated, and the second rescue analgesic medication administered was 50 The primary outcome was the pain intensity assessed at the PACU at predefined time points: upon arrival to PACU, 30 min after surgery, and 60 min after surgery. This was assessed by experienced nurses who were blinded and independent of the study based on numeric rating scales (NRS) at the PACU. The NRS scale was an 11-point numerical rating scale . Simultaneously, the amount of rescue analgesics administered to manage postoperative pain was recorded. Morphine equianalgesic doses (MED) were used to quantitatively compare the effects of the sum of various rescue analgesics (fentanyl or ketorolac) administered to each group. The conversion to morphine-equivalent consumption in mg was based on the following scale: 1 : 100 for fentanyl; 1 : 0.4 for ketorolac , 10.From the induction of general anesthesia to skin incision, the patient's blood pressure, heart rate, and BIS were recorded at five predefined time points: before induction of general anesthesia (T1), before intubation (T2), 1 min after intubation (T3), before skin incision (T4), and 1 min after skin incision (T5). Incidences of postanesthetic complications such as postoperative nausea and vomiting (PONV), itching or urticaria, shivering, and desaturation due to respiratory depression were also evaluated as secondary outcomes.∗ Power 3.1.9.4. According to a previous retrospective study, the difference of the NRS score immediately after surgery was 1.58 between two groups with or without remifentanil during thyroidectomy, and the standard deviations of these groups were 2.610 and 1.706, respectively [t-test at a significance level of 0.05. Finally, a total of 80 subjects (40 in each group) were needed assuming a 20% dropout rate.To calculate sample size, we used G t-test was used for continuous variables, and a chi-squared test was used for categorical variables. Data manipulation and statistical analysis were performed using SPSS Statistics for Windows, Version 21.0 . All reported P values are two-sided, and P values < 0.05 were considered statistically significant.All continuous variables are expressed as means ± standard deviations and categorical variables are expressed as frequencies and percentages. To compare perioperative data, an unpaired, two-tailed During the entire trial, a total of 124 patients were planned to undergo thyroidectomy, but 14 were excluded because they did not meet the inclusion criteria, and 30 refused to participate in the trial. Finally, 80 patients were enrolled . One patP = 0.776). The mean administered dose of remifentanil was 1977.7 ± 722.5 μg in the TIVA group, which was approximately 0.268 ± 0.118 μg/min/kg during surgery. The comparison of pain intensity over time evaluated at the PACU is shown in P = 0.034). The second and third assessed pain intensities in both groups did not show statistically significant differences. The second and third NRS scores in the TIVA group were 5.9 ± 1.7 and 3.5 ± 1.4, and those in the VA group were 6.0 ± 1.5 and 3.2 ± 1.2 . The mean NRS scores of maximal pain intensity, while staying at the PACU, of the TIVA and VA groups were 6.8 ± 1.0 and 6.5 ± 1.4, respectively (P = 0.187). As shown in P = 0.044), but the administered dose of fentanyl between groups was not significantly different (P = 0.111). The sum of rescue analgesics administered to the TIVA group after conversion to MED was significantly higher than that of the VA group .During induction and before and after skin incision, the BIS of both groups was maintained between 30 and 60, but that of the TIVA group was sustained at a higher level than that of the VA group . The TIVThe main finding in this prospective, assessor-blind, randomized controlled study was that the intensity of immediate postoperative pain was higher in the TIVA group than the VA group before any analgesics were administered. Furthermore, the demand for rescue analgesics, during PACU stay, in the TIVA group was higher than that in the VA group for effectively managing postoperative pain. In addition, there was no difference in the incidence of complications immediately after surgery.Rapid recovery and emergence from general anesthesia are important in cases of ambulatory surgery or enhanced recovery after surgery. Both TIVA and VA are popular and reasonable for relatively simple surgeries, which are usually performed as ambulatory surgeries. Volatile agents have become more popular in general anesthesia since sevoflurane and desflurane were introduced because they allow for faster recovery . Propofo2O and desflurane. Meanwhile, remifentanil was the only drug that gave an analgesic effect in the TIVA group. Although we did not check the sedative level during the recovery phase, residual VA could result in lower NRS scores in the VA group. Other possible causes for higher NRS scores in the TIVA group might include opioid-induced hyperalgesia (OIH) or acute opioid tolerance (AOT). The exact mechanisms of these two phenomena are unclear, and some cellular- and molecular-level explanations have been suggested [μg/kg/min with continuous infusion of remifentanil could lead to OIH and AOT [The pain assessment was performed three times every 30 min. The first one is differentiated from the others because enough rescue analgesics were administered during PACU stay. The first NRS score represents analgesic effects depending on the anesthetic method, and the others show the degree of controlled immediate postoperative pain. According to the protocol, NSAIDs were first administered as a rescue analgesic agent at the PACU, and opioids were administered additionally. In order to analyze the demands of the two groups in maintaining adequate pain control, the sum of MED rescue analgesics, including both NSAIDs and opioids, was compared. Although the difference was not obvious, patients in the TIVA group complained of a more immediate postoperative pain compared with patients in the VA group. Moreover, the TIVA group needed more rescue analgesics than the VA group during the recovery period in order to maintain sufficient pain control. These results contradict those of a meta-analysis of randomized controlled studies , 14. Moruggested . Accordiuggested , the inc and AOT –24. We uRemifentanil has the advantage of controlling vital signs with an ultrashort action time. Despite its relatively high cost and the need to set up a special machine for TCI, many clinicians prefer anesthesia by remifentanil infusion in order to maintain hemodynamic stability during surgery , 26. We In this randomized controlled study, we did not observe differences in the incidence of postoperative complications including PONV, shivering, itching, or respiratory complications between the groups. This is inconsistent with a meta-analysis by Schraag et al.  that shoThere are several limitations in this study. First, we cannot explain the hyperalgesia after surgery which was induced only by intraoperative continuous infusion of remifentanil. In this study, propofol in the TIVA group and desflurane in the VA group were used as sedatives. The perception of postoperative pain intensity could be affected by the different sedatives in each group. To confirm that remifentanil induced OIH, the study should have been conducted with the same sedative in both groups. However, in this study, we aimed to compare the two anesthetic methods using the same sedatives which do not have any analgesic effect. In addition, we did not focus on chronic pain transition. The intensity and duration of acute postoperative pain is known to be a predictor of chronic postsurgical pain . If patiGeneral anesthesia with TIVA could lead to a higher but clinically acceptable intensity of immediate postoperative pain with more rescue analgesics for proper pain control. Moreover, there was no difference in the incidence of postoperative complications between the two methods. Therefore, in the case of minor surgery, with relatively little pain involved and no major bleeding expected, anesthesiologists may choose between TIVA and VA depending on the level of technical expertise and availability of resources at each institution.