Objective Endometriosis is a complex disease, and pain is an important component of the syndrome. One of the most used methods to assess pain is the visual analogue scale (VAS). The aim of the present research was to study the pain experienced by patients who referred to our unit for endometriosis, using the VAS to understand the variables that could influence it.Methods We have conducted a prospective study from February 2012 to December 2016, enrolling 388 patients who referred to a university hospital, in Florence, Italy. We have included in the present study patients during their follow-up for endometriosis; we have also included patients who underwent surgery with a histological diagnosis of endometriosis. We have collected sociodemographic and clinical information regarding age, body mass index (BMI), smoking habit, number of pregnancies, and endometriosis staging. Finally, we have administered the VAS for several symptoms.Results Dysmenorrhea was the symptom associated with the highest perception of pain (mean VAS score of 5.76). The logistic regression showed that the stage of endometriosis could influence the pain associated to constipation and to dysuria. The linear regression showed that age could influence the pain associated to constipation, to dyspareunia, and to dysmenorrhea. A positive correlation was found between dysmenorrhea and chronic pelvic pain (CPP), between dysmenorrhea and dyspareunia, and between constipation and dysuria.Conclusion Using a validated method, the VAS, we have studied the pain experienced by a group of patients with a history of endometriosis and observed that smoking habit and BMI did not influence the VAS scores, and that dysmenorrhea was associated with the highest perception of pain. Endometriosis could be defined as the presence of endometrial-type mucosa outside the uterine cavity, and its standard diagnosis is performed through a direct visualization and histological examination of the lesions.In particular, CPP causes neurological changes in the dorsal horn of the spine, resulting in neurogenic inflammation of multiple pelvic viscera, hyperalgesia, dysreflexia, a lower sensory threshold and, therefore, a greater perception of pain. Endometriosis is observed in between 71–87% of the women with CPP.The aim of the present research was to study the pain experienced by a group of patients who referred to our unit with a history of endometriosis. Our primary objectives were: 1) to use the VAS, to measure the pain related to the following symptoms: dyschezia, dysuria, chronic pelvic pain, dyspareunia, and dysmenorrhea; 2) to use the VAS score to evaluate the impact of age, body mass index (BMI), smoking habit, and stage of the disease on pain; 3) to detect possible correlations among the symptoms in terms of VAS scores.We have conducted a prospective study from February 2012 to December 2016, enrolling patients who referred to our tertiary university hospital, in Florence.The present study was approved and data were collected in a totally anonymous way: the patients signed an informed consent form for the clinical investigations and for the disposition of the results for scientific analysis according to privacy laws and to human rights before being enrolled.We have included in the present study patients during their follow-up for endometriosis; we have also included patients who underwent surgery with a histological diagnosis of endometriosis. The histological diagnosis was performed by evaluating the presence of endometrial tissue outside the uterine cavity, according to the current guidelines.Sociodemographic and clinical information regarding age, BMI, smoking habit, and number of pregnancies were only available when the study started; afterwards, we interviewed the patients by administering the VAS: we have used this score to describe the pain associated with dyschezia, dysuria, CPP, dyspareunia, and dysmenorrhea.p < 0.05.Data were collected in a database and processed using the software Stata 12 . The Shapiro-Wilk test was used to assess the non-normal distribution of the examined variables. Although not normally distributed, we have calculated means, medians, and standard deviations (SDs) for each variable. We have used logistic regression and the Spearman correlation test to analyze the relationship between the independent variables  and the VAS scores of each type of pain. A multiple regression was used to understand a possible correlation between the pain with the highest VAS score and the other types of pain. The level of significance was set at 2 . Out of the total sample, 30.67% of the women declared to be smokers, 27.84% declared to have had at least one previous pregnancy; 80.36% of the women declared that they presented with symptoms of endometriosis. In 334 women, a histological analysis was performed to classify the stage of the disease . The mean BMI was 22.5 kg/m disease .The VAS was administered to evaluate the pain associated with the five most frequent symptoms associated to endometriosis .Dysmenorrhea was associated with the highest perception of pain (mean VAS score of 5.76).The impact of independent variables on pain is described in Stage – The logistic regression showed that the stage of endometriosis could influence the pain associated to dyschezia , and to dysuria . The multiple regression, which included age among the independent variables, showed that the ORs were 1.83 for dyschezia, and 2.30 for dysuria.Age – The linear regression showed that age could influence the pain associated to dyschezia , to dyspareunia , and to dysmenorrhea .Other variables – The logistic regression showed that smoking habit did not influence the VAS scores . Similarly, the linear regression showed that BMI did not influence the VAS scores .Finally, we have tried to understand if there could be an association between dysmenorrhea (chosen as the reference variable because of its greater pain score) and the other symptoms, using a multiple linear regression model  and 5.p < 0.01; Spearman correlation coefficient [Rho] = 0.20); a positive correlation could also be found between dysmenorrhea and dyspareunia . Moreover, dyschezia and dysuria are positively correlated .Dysmenorrhea is strictly associated with CCP and dyspareunia, but adding age as an independent variable, it was strictly associated only with CPP. Completing the analysis with the Spearman correlation test , it was Endometriosis is a complex disease, and pain is an important component of the syndrome, but not the only one.Previous studies have shown that there is not an optimal scale to evaluate (and therefore treat) pain related to endometriosis, as pain is a complex and subjective domain. The VAS seems to be the scale with a better balance between strong and weak points.In the present study, dysmenorrhea was the symptom with the highest VAS score. Previous studies have shown a causal association between severe dysmenorrhea and endometriosis, and this association seems to be independent of the macroscopic type of the lesions or of their anatomical locations, and may be related to recurrent cyclic microbleeding in the implants. Endometriosis-related adhesions may also cause severe dysmenorrhea.As for CPP, it could be considered nowadays a notable health problem that challenges physicians all over the world. This is due to its etiology, which is still unclear, and to the disease itself, which could have a very different presentation (in terms of time onset and severity) among different patients, and the response to treatments is not always successful.In particular, DIE is the only macroscopic type of endometriosis for which the relationship with CPP symptoms appears to be well understood.In severe pelvic endometriosis, the involvement of the urinary tract is quite common, with subsequent dysuria. Dyschezia, on the other hand, could be considered as a useful predictor for posterior DIE, whose severity is related to the involvement of the posterior vaginal wall, of the rectovaginal septum, and of anterior rectal wall DIE.In the present research, the logistic regression showed the influence of the stage of endometriosis on dyschezia and on dysuria. This is an interesting result because, in previous studies, authors found no association between the type of pain and the stage of the disease.As for the age variable, other studies showed that endometriosis is more frequent among young women.Other studies in the literature demonstrated that the pain caused by endometriosis has been shown to reduce sexual satisfaction and may also lead to a significant impairment in health-related quality of life (QOL) when compared with the general population.The most important limitations of the present study were: 1) the selection bias of the sample, which could make the sample non-representative and, therefore, render the results ungeneralizable; 2) the type of the study, which did not allow for the temporal and therefore potential causal relation between the variables; 3) the small effect sizes that should be taken in consideration when examining the findings .As suggested by the scientific literature, it would be interesting to complete the present study by also analyzing the QOL of the patient by using the validated 36-item short form survey (SF-36) questionnaire, which, although it is not disease specific, could be used to add further information, allowing us to measure at the same time both the mental and physical health of the enrolled sample.Concluding, using a validated method, the VAS, we have provided a picture of pain perception of women suffering from endometriosis. We have observed that dysmenorrhea was associated with the highest perception of pain; moreover, it is strictly associated with CCP and dyspareunia. Smoking habit and BMI did not influence the VAS scores. The stage of endometriosis, contrariwise, could influence the pain associated to dyschezia and to dysuria. The age of the patient could influence the pain associated to dyschezia, to dyspareunia, and to dysmenorrhea. One of the most interesting results of the present study was the influence of the stage of endometriosis on dyschezia and on dysuria, which calls into question previous evidence.


The goal of this narrative review is to describe the current understanding of the pathology of Complex Regional Pain Syndrome (CRPS), as well as diagnostic standards and therapeutic options. We will then make the case for early recognition and management.CRPS remains an enigmatic pain syndrome, comprising several subtypes. Recent recommendations clarify diagnostic ambiguities and emphasize the importance of standardized assessment and therapy.Awareness of CRPS should be raised to promote prevention, early detection, and rapid escalation of therapy in refractory cases. Comorbidities and health costs  must also be addressed early to prevent negative consequences for patients. Among “mysterious” posttraumatic pain phenomena, complex regional pain syndrome (CRPS) is certainly one of the greatest challenges clinicians face in their daily practice. It is considered a rare but severe complication of injuries to the extremities that can progress into a debilitating form of persistent pain. Early diagnosis and treatment are deemed crucial to avoid worse outcomes. In this review, we will outline the pathophysiology and examine recent developments in diagnosis and standard treatment of the condition. Further, we will lay out the importance of early detection and care.The two most cited, population-based studies place the incidence of CRPS between 5.5 and 26.2 per 100.000 person years . Trauma Risk factors are female sex, immobilization, nerve damage, (open) fractures, asthma, migraine, osteoporosis, rheumatoid arthritis, ACE inhibitors, and a tight cast after fracture •, 13–19.Emotional distress due pain and/or interference with activities of daily living and social participation are often present ••. As a In the beginning, a drop in norepinephrine levels in the circulation of the affected limb can cause the typical presentation with hyperthermia and redness . AfterwaIt is crucial to remember that the CRPS characteristics can occur in a variety of combinations and only continuous, disproportionate pain is mandatory. Further, it should be noted that none of the CRPS characteristics are pathognomonic. Therefore, clinicians must first rule out other differential diagnoses Table , before “Technical” examinations are primarily performed to rule out potential differential diagnoses and to confirm CRPS. Unfortunately, there is no gold standard test to rule out other pathologies, and a multitude of efforts have resulted in mixed results for many apparative procedures. For instance, there has been a negative study for Quantitative sudomoter axon reflex test (QSART) , and smaThe most important treatment of CRPS is early recognition and initiation of comprehensive care. Therapy itself is similarly complex to the diagnostic process and must be adapted to the patient. Precisely because treatment can be extensive and sometimes complicated, patients need to be educated and informed about the condition and the possible course of the disease. Cases that do not show a rapid improvement within 2 months after the onset of symptoms must be referred to specialized centers . AlthougThere is no data supporting the use of non-steroidal anti-inflammatory drugs for CRPS specifically; however, these drugs are often given to interrupt the initial inflammatory phase. Drug treatment follows that for neuropathic pain with a few exceptions. In general, medications are classified as off-label use, which should be communicated to patients. For the classical antineuropathic drugs, there is one RCT each for amitriptyline  and gabaAs in other inflammatory processes, free oxygen radicals play an important role in CRPS. They are supposed to be treated by the administration of vitamin C. One RCT proved the prophylactic benefit of the drug , and thiBecause of the possible side effects and the necessary monitoring during the application, these therapy forms belong in specialized centers. Ketamine is a substance of interest, best known for its NMDA antagonism but also for modulation of cholinergic neurotransmission and enhancement of descending modulatory pathways. When used, ketamine produces very rapid pain relief, especially in neuropathic pain, and is also thought to counteract central pain sensitization, although this effect has not been well studied. For ketamine, there are two RCTs (one with a continuous infusion over 24 h for 4 days and one with an infusion for 4 h over 10 days), which resulted in a pain reduction for up to 12 weeks , 66. In Physiotherapy should not only prevent pathological movement patterns and “learned non-use” of the affected limb, but also train behavioral aspects. Including active physiotherapy is essential, as passive measures alone are unsuitable to treat CRPS. Immobilization and restriction should be avoided if possible . A speciPsychotherapy aims at treating psychiatric comorbidities, reduce anxiety, and promote relaxation and imagination techniques. Further goals are to improve body perception and self-awareness. Since CRPS is “complex” in nature, patients  can feel overwhelmed with diagnosis and treatment. It is important to emphasize that the illness is not psychogenic, but that educational aspects and self-empowerment must be addressed . It is cBecause of the early onset of CRPS symptoms and signs in the vast majority of cases, one would expect a rapid diagnosis. In clinical reality, however, much longer latencies between injury and diagnosis are observed, depending on the study. For example, a prospective analysis found that after removal of the cast , it took an additional 21.7 ± 23.7 days  for the diagnosis of CRPS in conservatively treated radius fractures . AnotherComplicating matters further, many practitioners struggle with diagnosis and treatment. For example, a 2016 international survey showed that 50% of CRPS specialists surveyed reported at least “some” difficulty in recognizing symptoms and signs of CRPS . ExtrapoThere are several strategies to mitigate negative patient outcomes and prevent unfavorable socioeconomic impacts:Prevention of CRPSEarly recognition of the first signs of CRPS can prevent a fully developed CRPS and reduce the severity and duration. In a cohort of patients with conservatively treated distal radius fractures, there were significantly fewer cases of CRPS after staff training on symptoms/signs of a beginning CRPS and cast management were implemented . As mentRapid Escalation of Therapy in Refractory CasesThe greatest therapeutic success can be expected within the first months of the disease , 86, yetPrevention of Somatic and Psychological ComorbiditiesThe likelihood of somatic or psychological comorbidities increases with the duration of untreated CRPS . SomaticPrevention of Reoccurring CRPSReoccurence in a patient with a history of CRPS is an understudied topic, but the risk seems to be substantial. In one investigation, 13% (6 of 47 patients) developed another CRPS postoperatively, although only one case was serious and persistent . FurtherHealth and Economic CostsAccording to one prospective study, no significant improvements in the disability or work status were recorded after 6 months  and in aIn the last decade, significant advances have been made to streamline the diagnosis of CRPS and coordinating research. The “Budapest criteria” are now a standardized assessment and are being applied in clinical and research settings worldwide. Moreover, the Valencia Consensus has provided clarity in their application. However, the suspected CRPS subtypes and the role of the autoimmune system need further research to finally provide tailored therapy for subgroups of patients. In the meantime, the greatest challenge in the clinical context is to create an awareness of the risk of CRPS, to detect the disease early using standardized diagnostic processes, and to rapidly expand therapy in refractory cases. In addition, comorbidities and socioeconomic factors must be addressed early to prevent negative consequences for patients.


Chronic pain and migraines often go untreated despite patient- and economic-related burdens . Understanding the reasons for non-treatment is important to enable interventions aimed at improving care-seeking behaviors. However, reports on disease-specific justifications for nontreatment in Japan are limited. We aimed to determine the barriers to healthcare access in untreated patients with chronic pain or migraines.This was a non-interventional, cross-sectional, internet questionnaire survey of patients with chronic pain or migraines. The primary endpoint was to identify the reasons for untreated chronic pain or migraines. Secondary endpoints included factors associated with healthcare access, including patient background, patient-reported outcomes, and awareness of generic or authorized generic drugs (AG).We surveyed 1,089 patients with chronic pain [605 (55.6%) untreated] and 932 patients with migraines [695 (74.6%) untreated] in 2021. The main reasons for not seeking treatment for chronic pain was “my pain is tolerable” and for migraine, “I can manage my pain with over-the-counter drugs.” Background factors significantly associated with untreated chronic pain were younger age, less time required to access the nearest medical institution, less pain, higher activities of daily living (ADL) scores, and lower awareness of generic drugs and AG. Among patients with migraine, notable characteristics included being female, having shorter travel times to the nearest medical facility, residing in municipalities with populations under 50,000, experiencing moderate to severe pain, having higher ADL scores, and displaying lower awareness of AG. The AG awareness rate was 2-fold higher in treated patients than in untreated patients.Educating patients regarding the risks associated with pain and its underlying causes, availability of inexpensive treatment options, and location of appropriate treatment facilities may increase treatment rates. Pain isIn Japan in 2013, the prevalence of chronic pain was 16.6% according to a survey among 10,000 randomly selected individuals aged ≥20 years . The oveMigraine is associated with symptoms such as sensitivity to light, sound, and nausea . The mosAlthough pain may be a common reason for seeking medical treatment, more than half of individuals with preexisting pain remain untreated , who administered a large general population questionnaire panel in Japan, and coding was conducted by QLife Inc. . Prior to the main study, a preliminary survey was conducted to determine the reasons for untreated chronic pain or migraines. The responses to the open-ended questions obtained in the pre-survey were collated using QLife and used as the closed-ended answer choices in the main survey.The questionnaires in the main survey were distributed on the Cross Marketing internet site under the heading “Questionnaire about you,” so that the content of the questionnaire could not be identified from the title. People who accessed the site then read an explanatory document about the study (stating that the survey was about chronic pain and migraines and that questions would be asked to ascertain pain and patient status). Those who decided to participate in the study then clicked on the “I agree (to participate in the study)” button to provide informed consent and proceed. Participants answered screening questions to determine their eligibility for the study. Those who fulfilled the eligibility criteria responded to a follow-up questionnaire, and the survey agency collected participants' information from the forms.To improve the generalizability of the results of this study, both the pre-survey and the main survey were designed based on the results of the 2020 Japanese national census . QuestioThe study protocol was approved by the Takahashi Clinic Ethics Committee, a third-party ethics review committee unaffiliated with Viatris Pharmaceuticals. The study was conducted in compliance with the legal and regulatory requirements and the Ethical Guidelines for Medical and Health Research Involving Human Subjects established by the Ministry of Health, Labour and Welfare and the Ministry of Education, Culture, Sports, Science and Technology. All the study participants provided informed consent.2.2.The inclusion criteria for patients with chronic pain were: aged ≥20 years with chronic pain that had persisted for ≥3 months, had been present within the last month, and was rated 5–10 on the pain Numerical Rating Scale (NRS). “Treated” or “untreated” was determined by whether or not the patient had received any kind of treatment for chronic pain in the past year. Patients were excluded if their pain was caused by migraines or cancer.The inclusion criteria for patients with potential migraine were: aged ≥20 years who answered “sometimes” or “more than half the time” to at least two items on the simple migraine questionnaire . “Treate2.3.The questionnaires used in this study are shown in 2.4.The primary endpoint was the reason for not seeking treatment in untreated patients with chronic pain or migraines. The selection and order of answers were decided based on the preliminary survey outcomes to mitigate bias prior to the implementation of the main survey. Secondary endpoints included factors associated with barriers to healthcare access, reasons for healthcare visits in treated patients, and awareness of generic drugs/AG between treated and untreated patients.2.5.n (%) for categorical variables. For patients with untreated chronic pain or migraines, the reasons for remaining untreated were summarized using descriptive statistics, and the background factors associated with nontreatment were evaluated using logistic regression analysis. For the two variables, with Spearman's correlation coefficient of 0.4 or higher in the univariate analysis, logistic regression analysis was conducted, leaving only the representative variable and excluding the rest. The potential impact of awareness of generic drugs and AG on healthcare visits was also summarized using descriptive statistics.For demographic and clinical characteristics, data were summarized using descriptive statistics, including mean ± standard deviation (SD), median, quartile [Q]1, and Q3, for continuous variables and The stratification by age  used in the univariate and multivariate analysis was based on the definitions from the “Act on Promotion of Development and Support for Children and Young People,” the Cabinet Office Survey, and the World Health Organization –27. All 3.3.1.3.1.1.A flowchart of patients with chronic pain is shown in 3.1.2.A flowchart of the patients with migraines is shown in 3.2.3.2.1.The most common reason for patients with chronic pain not seeking treatment was “my pain is tolerable”   , followed by “anticipated treatment effect” (39.5%) and “superior expertise” (30.2%) when multiple reasons were allowed, and “reaching the institution seems easy” (28.7%), “anticipated treatment effect” (27.3%), and “superior expertise” (16.3%) when only one reason was allowed , less time required to access the nearest medical institution , population of municipality of residence <50,000 , moderate/severe pain , higher ADL , and lower awareness of AG  .The main reasons for seeking treatment in the treated group were “anticipated treatment effect” (37.6%), “reaching the institution seems easy” (37.1%), and “healthcare professionals were kind and nice during my consultation” (30.0%) when multiple reasons were allowed, and “anticipated treatment effect” (23.6%), “reaching the institution seems easy” (19.8%), and “superior expertise” (16.0%) when only one reason was allowed  is a pharmaceutical product that is identical to a brand name drug but marketed as a generic version without the brand label. Untreated patients with chronic pain tended to be less aware of generic drugs than treated patients. It is possible that the treated patients were more familiar with generic drugs than the untreated patients because they obtained information during their healthcare visits. Regarding awareness of AG, there was a 2-fold difference in overall recognition between treated and untreated patients with chronic pain or migraine. The awareness of AG was much lower than that of generic drugs. Based on this, we consider that the concept of AG as a drug product that is unbranded but is otherwise identical to the brand-name drug product  is not wInterestingly, in the present study, the time required to access the nearest medical institution was shorter in untreated patients. The reason for this is unclear, but information about appropriate treatment facilities for pain is important for improving treatment access. In the migraine group, factors associated with non-treatment included female sex and living in a municipality with a population of <50,000 people. Although it is assumed that women are generally more likely than men to consult general practitioners for all symptoms and conditions, the difference is less clear for headache and back pain . MunicipHealth problems among workers have a negative impact on society. Previous studies have investigated the economic burden of presenteeism due to various health problems –39, and 4.1.This study has some limitations, including those inherent to the survey design, such as the possibility of recall bias. In the population with potential migraine, the diagnosis was not made by a physician but was based on simple migraine questionnaire results. Therefore, patients with potential migraine in this study did not have a confirmed migraine diagnosis; thus, some patients may not have met the criteria for migraines and instead may have suffered from headaches or diseases other than migraines. As this study used an internet questionnaire survey, it was difficult to determine whether the participants answered truthfully. Therefore, the data entered in the questionnaire may not have been reliable. Finally, the questionnaire survey targeted a panel maintained by the survey agency, which may have led to bias; therefore, the population analyzed may not be representative of the general population.5.The current study revealed the reasons for and factors associated with barriers to healthcare access in patients with chronic pain or migraines. Our findings suggest that to improve healthcare access in patients with chronic pain or migraines, it is necessary to educate patients about the risks associated with their pain and underlying disease, the availability of inexpensive treatment options, and the location of appropriate treatment facilities.


In separate multiple logistic regression analysis, US-guided intra-articular steroid injection was the only predictor of improved joint pain at follow-up visit . Conclusions: Musculoskeletal US can be an effective modality to detect inflammatory arthritis as well as to guide targeted intra-articular steroid injection to alleviate joint pain in SLE patients with or without FM.Background: Systemic lupus erythematosus (SLE) is a complex autoimmune condition with varied clinical presentations, and musculoskeletal pain is one of the most commonly associated symptoms. However, fibromyalgia (FM) is a prevalent co-existing condition in SLE patients that can also cause widespread pain, and in patients with both conditions, it is often difficult to distinguish the underlying cause of musculoskeletal pain and provide optimal therapy. Methods: A retrospective cohort study was conducted including all adult SLE patients who received musculoskeletal ultrasound (US) examinations for joint pain at the Ohio State University Wexner Medical Center between 1 July 2012, and 30 June 2022. Binary and multiple logistic regression analyses were performed to determine predictors of US-detected inflammatory arthritis as well as improved musculoskeletal pain. Results: A total of 31 of 72 SLE patients (43.1%) had a co-existing diagnosis of FM. In binary logistic regression, a co-existing diagnosis of FM was not significantly associated with US-detected inflammatory arthritis. In multiple logistic regression analysis, clinically detected synovitis was significantly associated with US-detected inflammatory arthritis (aOR, 142.35,  Systemic lupus erythematosus (SLE) is a complex autoimmune condition characterized by autoantibodies and aberrant immune responses involving one or more organ systems that affects more than 3 million people worldwide . MusculoThe heterogeneous clinical presentation of SLE has led various international working groups and organizations to construct classification criteria to improve characterization of affected patients for research studies, while also updating these criteria to incorporate the adoption of immunologic laboratory tests in clinical practice and to reflect the improved understanding of the observed patterns of organ involvement. Two of the most widely recognized among these, the 2019 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) classification criteria and the 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria, both include measures of joint tenderness among the clinical criteria for SLE . HoweverAmong these other causes of musculoskeletal pain, fibromyalgia (FM) is a condition characterized by chronic and widespread pain that affects 1–2% of the general adult population ,8, with It has previously been reported that SLE patients without co-existing FM who have sonographic features of inflammatory arthritis in the hands and wrists are more likely to respond to systemic glucocorticoid therapy . While tMusculoskeletal US examination of the joints allows further diagnostic examination of the synovial membrane and intra-articular space as well as adjacent bone cortices to assess for the presence of synovitis and erosive changes associated with inflammatory arthritis from any cause, including rheumatoid arthritis and psoriatic arthritis as well as SLE. The sonographic features associated with inflammatory arthritis are well described in consensus definitions from the Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT) US special interest group and include gray-scale changes detected in B-mode indicating synovial hypertrophy ; joint effusion ; tenosynovitis ; and bone erosion  . Power DParticularly among SLE patients without detectable radiographic changes associated with arthritis, such as bone erosions, previous studies have demonstrated that musculoskeletal US can be a useful tool to detect subclinical synovitis, or early joint inflammation, as well as to confirm the presence of clinically detected synovitis ,29,30,31Study design. A retrospective cohort study was conducted including all adult patients  with a documented diagnosis of SLE from a rheumatologist who received musculoskeletal US examinations for joint pain in an outpatient setting at The Ohio State University Wexner Medical Center between 1 July 2012, and 30 June 2022. Of note, musculoskeletal US examinations were performed in a dedicated clinic by a rheumatologist or sports medicine physician with privileges to perform US-guided arthrocentesis at the Medical Center (US practitioner) separately from the patient’s routine clinic visits with his or her managing rheumatologist. Musculoskeletal US practitioners were required to complete a minimum of 16 h of musculoskeletal US-specific continuing medical education (CME) including didactics and hands-on training, as well as a minimum of 25 supervised US examinations. Musculoskeletal US examinations and intra-articular steroid injections, when performed, were targeted to the single joint where the patient reported the greatest pain. If a patient was examined more than once in the study period, the first US examination was included to maintain independence of observations within the study sample. Exclusion criteria included the following: patients < 18 years of age, those who did not have a diagnosis of SLE prior to the time of musculoskeletal US examination, and those with prior surgical instrumentation of the joint examined by US. Patient medical records fulfilling the above criteria were requested through The Ohio State University Wexner Medical Center Information Warehouse, which were then manually reviewed to confirm study eligibility. Study data were recorded in a de-identified manner to protect patient confidentiality.Clinical and Laboratory Data. Medical records of eligible patients were reviewed, and demographic  data were recorded. Documentation produced by the patient’s managing rheumatologist preceding the musculoskeletal US examination was then reviewed to determine if there was clinically detected inflammatory arthritis  , as wellp-value ≤ 0.20), which were then fitted into multiple logistic regression models using the backward elimination method. Predictor variables with p-values less than 0.05 in multiple logistic regression were considered statistically significant, and the strengths of association were interpreted using the adjusted odds ratio (aOR) and 95% confidence interval (CI).Data Analyses. Data were analyzed using SPSS version 28 . Descriptive statistics summaries including frequencies and cross-tabulations were used to characterize the data. Correlation matrices were reviewed for statistically significant  associations among potential predictor variables, and significantly correlated variables were excluded to avoid multicollinearity. Binary logistic regression analysis was then used to identify predictor variables associated with the outcome variable (2 (±SD 9.4 kg/m2). Prior to the musculoskeletal US examination, 6 (8.3%) of the patients were found to have clinically detected synovitis based on the previously described criteria. A summary of the demographic characteristics of SLE patients who had or did not have a co-existing diagnosis of FM is shown in A total of 72 adult SLE patients  received musculoskeletal US examinations for joint pain in the study period, with a median age of 50 years (interquartile range [IQR]: 40–63 years). Of these patients, 31 (43.1%) had a co-existing diagnosis of FM preceding the musculoskeletal US. The patients self-reported their race as the following: 30 (41.7%) were White/Caucasian, 33 (45.8%) were Black/African American, 4 (5.6%) were Asian American, and 4 (5.6%) were Other, with 1 (1.4%) declining to answer. The mean BMI was 32.3 kg/mNearly all SLE patients were on hydroxychloroquine prior to the musculoskeletal US examination, including 29 (93.5%) of the patients with co-existing FM and 37 (90.2%) of those without co-existing FM. Those who were not on hydroxychloroquine were noted to have previously discontinued this medication due to side effects. Additionally, a greater proportion of patients with co-existing FM were on systemic steroids prior to the US examination , while relatively more patients without co-existing FM were on steroid-sparing immunosuppression (51.2% vs. 32.3%), with mycophenolate and methotrexate being the most common immunosuppressants used .Laboratory measures for this cohort of SLE patients with joint pain prior to the US examination included (medians and IQRs): anti-dsDNA , C3 , C4 , ESR , and CRP . Stratification of these laboratory measures according to whether the patient had FM is presented in Musculoskeletal US examinations were most often performed on a knee joint . Twelve patients (16.7%) each had an US examination of a shoulder or hip joint. Eight patients (11.1%) had an US examination of a joint of the hand. Five patients (6.9%) each had an US examination of a wrist or ankle joint. The remaining patients had an US examination of an elbow joint  or a foot or sacroiliac joint (3 patients or 4.2% each).On musculoskeletal US examination, the US practitioners detected the presence of inflammatory arthritis in 8 patients, 5 (62.5%) of whom had synovitis detected on clinical examination. The reported sonographic features of inflammatory arthritis included gray-scale changes indicating both synovial hypertrophy and joint effusion in 7 (87.5%) of these patients and tenosynovitis in 2 patients (25.0%), with PD signal detected in the joints of 3 patients (37.5%). Bone erosions were not detected in any of these patients. Of these SLE patients with US-detected inflammatory arthritis, 3 (37.5%) also had a diagnosis of FM.During the musculoskeletal US examination, 58 patients (80.6%) received an intra-articular steroid injection, and 9 patients (12.5%) had an aspiration of a joint effusion. Eight patients (11.1%) received additional systemic steroids and/or immunosuppression from their managing rheumatologist upon receiving the US examination report. The median time to follow-up visit with the managing rheumatologist after the US examination was 77 days (IQR: 44–132.5 days).r = 0.34, p < 0.01), and CRP  was found, as has been previously described in patients with inflammatory arthritis [r = 0.61, p < 0.001), ESR , and CRP  were noted; therefore, C3 was also excluded and C4 was retained for further regression analysis. Similarly, race was also excluded, as it was significantly associated with ESR based on analysis of variance .Descriptive statistics summaries revealed significant correlations among several potential predictor variables. A significant correlation between BMI and both ESR (p = 0.002), as well as a borderline significant association with ESR levels .On binary logistic regression, age, sex, and co-existing diagnosis of FM were not found to be associated with US-detected inflammatory arthritis . Multiplp < 0.001).The results of additional binary logistic regression analyses to identify significant predictors of reported improvement in joint pain at the follow-up visit with the managing rheumatologist after musculoskeletal US examination are shown in As reported in the United States and globally, SLE patients are predominantly (>85%) female ,35, whicThe results of this study support the association of the sonographic features of inflammatory arthritis with the clinical assessment of synovitis, which remains a well-recognized parameter in both the clinical diagnosis and classification criteria of SLE ,6. Care Musculoskeletal US as an imaging modality to improve detection of pre-clinical synovitis in SLE has been well described ,29,30,31Among SLE patients with joint pain, use of musculoskeletal US has the additional benefit of providing image guidance for intra-articular steroid injections, which can ensure accurate medication delivery based on real-time anatomic visualization. The targeted delivery of an intra-articular injection into a specific joint has the additional appeal of lower or less rapid systemic absorption compared to oral, intramuscular, or intravenous formulations, as peak serum steroid levels appear to be affected more by the number of joints injected rather than by the dose alone, though individual variability can be observed ,39. AddiIn cases where joint pain reported by SLE patients is localized to a specific joint, the presented findings suggest that there may be an additional role for more targeted US assessments of the joints involved, which can provide confirmatory findings of inflammatory arthritis in cases complicated by multiple other potential causes of joint pain and inform decisions on adjustments to systemic therapies. Moreover, during the US examination, accurate image-guided administration of intra-articular steroid medications can provide therapeutic benefit to alleviate the pain experienced by these patients. Furthermore, SLE patients with FM who do not have US-detected features of inflammatory arthritis may also benefit from intra-articular steroid injections to improve joint pain from other causes, as these patients have been shown to have higher perceived pain from other joint pathology such as osteoarthritis .Limitations of this study include the retrospective design of the study and that all patients were treated at a single academic healthcare institution. Due to the retrospective nature of the study, the presence or absence of US-detected inflammatory arthritis was recorded as binary data from the text of the musculoskeletal US examination notes, as the US practitioners did not document standardized scores and for the patients who received intra-articular steroid injections, the corresponding pre-injection US images were not consistently available for review. Outcomes such as patient-reported improvement in musculoskeletal pain were similarly limited to binary data based on the medical documentation. The median follow-up in this study was between 2 and 3 months, which aligns with the reported duration of pain alleviation following intra-articular steroid injections for conditions such as osteoarthritis . Future Furthermore, as a lack of association between conventional SLE disease activity indices such as the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and the European Consensus Lupus Activity Measurement (ECLAM) and sonographic features of inflammatory arthritis has previously been demonstrated, these indices were not included in this study . It has Musculoskeletal US can be an effective modality to distinguish inflammatory arthritis from other causes of musculoskeletal pain in SLE patients, as well as to guide targeted intra-articular steroid injection for the alleviation of joint pain, regardless of whether these patients have a co-existing diagnosis of FM.


Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. The “Critical Care Pain Observation Tool (CPOT)” is a reliable and validated objective assessment tool for those patients who cannot self-report pain in ICU. The objectives of the educational course were to assess the baseline knowledge, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test.The educational course of six hours of contact time on the use of CPOT for pain assessment in ICU patients was designed and conducted by the authors after approval from the Ethics Review Committee, Aga Khan University. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan. A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge, and practice of participants regarding pain assessment in critically ill patients and the same test was taken at the end of the course.A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belong to the metropolitan city (p = 0.010). In multivariate analysis, participants from non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038).The participating physicians and nurses showed a positive impact on the knowledge and clinical skills regarding pain assessment in CIPs. The participants from hospitals in metropolitan cities showed a significant improvement over those who were from non-metropolitan cities.The online version contains supplementary material available at 10.1186/s12909-023-04523-7. Pain in patients admitted to intensive care units (ICU) is a silent reality. Patients admitted to ICU usually have moderate-to-severe pain at rest and during care-related activities. A recent study showed that around 33% of the patients admitted to ICU experience pain at rest and about 10% experience moderate to severe pain .Literature reported that chronic diseases, associated wounds and drains, the presence of endotracheal tube, and routine nursing care procedures e.g., patient positioning, and airway suctioning are the usual reasons for pain in critically ill patients (CIPs) , 4. ReguNurses are the first responders for admitted patients and are closely involved in the care of CIPs. They face numerous challenges in assessing pain in patients who are unable to self-report due to altered levels of consciousness, sedation, and mechanical ventilation. Physicians covering ICUs are responsible for prescribing analgesics for effective pain relief which has to be ensured by regular pain assessment. Inappropriate pain management has health-related and financial consequences .Literature showed that nurses working in ICU perform pain assessments of patients, but their practice is sub-optimal. So, there is a need for on-job teaching, training, and continuous assessment of nurses about how and when to assess pain in ICU patients. All stakeholders, like healthcare professionals, Institutions, nursing schools, and policymakers should collaborate to improve nurse’s knowledge and practices of pain assessment and treatment . There iThe Critical Care Pain Observation Tool (CPOT) is an objective means of pain assessment and proved effective in improving the performance of ICU nurses in the assessment and appropriate treatment of pain. COPT is a validated and useful tool for pain assessment, and it is recommended to be used in all ICUs . In thisCritically ill patients (CIPs) are neglected in terms of objective pain assessment. So, this educational course would help in creating a better understanding among physicians and nursing staff regarding the importance of pain assessment and its documentation. This would improve pain treatment, patient care, and the overall outcome of patients. This educational course would act as a resource for the regular teaching and training of ICU physicians and nursing staff in developing countries like Pakistan.The objectives of these educational courses were to assess the baseline knowledge, skills, and practice of pain assessment in critically ill patients and reassess the same in all participants of the course by comparing the results of pre and post-test.A course of six hours of contact time on the use of CPOT for pain assessment in CIPs was designed by the authors. This educational course was delivered at five different tertiary care hospitals in the Sindh province of Pakistan over a period of one year. Approval for the project was granted by the Ethics Review Committee of Aga Khan University. Informed and written consent was taken from the Head of the Department of all five relevant Institutions and verbal consent was taken from all participants included in this course.To design the course, a group was formed that consists of five faculty members responsible for the provision of acute and chronic pain services and one faculty from the ICU, at Aga Khan University. Regular meetings were held with the group members to determine the specific objectives of the educational course and topics to be included in the curriculum for achieving these objectives. Subject experts were invited from other specialties, including nursing services and the critical care unit.Teaching methods included didactic lectures, small group tutorials, problem-based interactive sessions using case scenarios, hands-on workshops using locally developed videos, and simulated patients. A uniform evaluation method comprising pre and post-MCQ tests was developed for the course. In addition, a five-point Likert scale form was developed to observe clinical skills, and course attendees were signed off at the end of the course. Finally, at the end of each educational course, a debriefing session was held with the participants and verbal feedback on the course was obtained.The authors conducted a total of five education courses to train critical care physicians and nursing staff in the use of the Critical Care Pain Observation Tool (CPOT) to assess pain in unconscious, critically ill patients. This course was conducted by experienced anesthesiologists, critical care physicians, and pain physicians. Five tertiary care hospitals were identified , Peoples University (Nawabshah), and Shaheed Mohtarma Benazir Bhutto Medical University (Larkana) where critical care units are well-established. The target participants included physicians and nursing staff working in intensive care units of major tertiary care hospitals. To get official consent to participate in this educational activity, the head of anaesthesia/ICU departments in the above-mentioned five tertiary care hospitals were contacted via phone/email. Coordinators were identified from every hospital to make the necessary arrangements required for the conduct of the course. Coordinators of respective hospitals nominated and enrolled the candidates for the course. Both physicians and nurses were invited to attend the course with the eventual aim of implementing the objective pain assessment tool (CPOT) in the critical care units of their hospitals to improve pain assessment and relief. The educational course details are as follows: Informed and written consent were taken from the Head of the department of all 5 relevant institutions.A pre-test consisting of 25 true/false multiple-choice questions was conducted at the beginning of the course to assess the baseline knowledge and practice of participants regarding pain assessment in critically ill patients. The post-test, consisting of the same questions, was administered at the end of the course to re-assess the knowledge after attending the basic level course on the use of the behavioral pain scale (CPOT) to assess the impact of the course by comparing the results of pre and post-test. A five-point Likert scale was used to observe the clinical skills required to use the CPOT, and all course attendees were signed off at the end of the course. (Appendix)Statistical analyses were performed with Statistical Package for Social Sciences . Mean and standard deviation was computed for quantitative variables and frequency and percentage for qualitative variables. Pre and post-test score difference was compared by paired t-test and pre and post-test score means were reported in the error bar with a 95% confidence interval. Analysis of covariance was applied to observe the effect of training in terms of the pre-post score by using a general linear model, in which pre and post-test score difference was considered as outcome and gender, city, and workplace was used as fixed factors and pre-test score as a control variable. Unadjusted and adjusted beta coefficients and 95% confidence interval were reported in the model.A total of 205 critical care physicians and nursing staff attended the courses. Both pre-test and post-test were completed by 149 (72.6%) participants, of which 53 (35.6%) were female and 96 (64.4%) were male. A total of 69 (46.3%) physicians and 80 (53.7%) nursing staff successfully completed the course. Participants from the metropolitan city were 80 (53.7%) while 69 (46.3%) belonged to non-metropolitan cities. Participants from public sector hospitals were 93 (62.4%) while 56 (37.6%) worked in private sector hospitals.The mean pre-test score of participants was 57.83 ± 11.86 and the mean post-test score of participants was 67.43 ± 12.96 and this was statistically significant (p = < 0.01). The overall gain in knowledge after the educational session was statistically significant (p = < 0.01)  and in those participants, who belonged to the metropolitan city p = 0.010). Participants from public sector hospitals showed less improvement in knowledge and understanding as compared to the private sector, but this difference was not statistically significant. In multivariate analysis, the adjusted regression coefficient for non-metropolitan cities showed less improvement in post-test scores compared to those who come from the metropolitan city (p = 0.038) Table 0. ParticThe authors designed a course on the use of critical care pain observation tool (CPOT) for pain assessment in patients admitted to the ICU. The course was delivered to critical care physicians and nurses at five major tertiary care hospitals in the Sindh province of Pakistan. The effectiveness of the course was demonstrated by the significant increase in knowledge of the participants after attending the course as per the scores of pre and post-tests.Patients admitted to ICU suffer from considerable pain due to various causes , 4. It iRababa et al. identified various barriers to pain assessment and management as perceived by critical care nursing staff. They categorized the barriers into four groups: patient-related, nurse-related, doctor-related, and system-related. Lack of knowledge regarding pain assessment tools on part of the nurses were among the most frequently reported barriers along with difficulty in communication with critically ill patients (CIPs), analgesic prescriptions being written without considering the pain scores, and unavailability of guidelines for pain assessment and management , 14. TheBehavioral pain scales were developed to overcome the difficulty faced in pain assessment of patients unable to communicate, including mechanically ventilated patients in ICU , 15, 16.Educational sessions and workshops on pain assessment tools in critically ill intubated patients create awareness and help to develop skills among healthcare staff working in ICU. Literature shows that a simple audit or even pilot study may help in the decision to implement the CPOT in certain ICUs that may promote better goal-directed management of pain , 21. MenIn an informal telephonic inquiry of consultants of forty-three intensive care units (ICUs) in both government and private sector hospitals of our country, it was revealed that less than 10% of ICUs were using validated pain assessment tools. Barriers to the use of assessment tools, identified by the responders included a lack of awareness and knowledge of the usefulness of pain assessment tools based on behavioral indicators, lack of training, shortage of staff, and increased workload. This informal inquiry led to the identification of the need for training the physicians and nurses working in ICUs in this important aspect of the management of CIPs.To the best of the authors’ knowledge, this was the first education course on pain assessment in CIPs developed and conducted for physicians and nursing staff of critical care units in Pakistan. Significant improvement in knowledge after attending the course is a promising sign for improvement in pain assessment in CIPs, which is an essential prerequisite for effective pain relief. If the knowledge and skills gained by the participants are effectively utilized by the respective hospitals, the participants can act as peer trainers in the use of CPOT for pain assessment for facilitating the routine use of CPOT in the ICUs of the participants’ hospitals.All participants signed off on a structured checklist with a 5-point Likert scale in a simulated environment. Thus, successful attainment of knowledge and skills was achieved, as evidenced by the improvement in knowledge shown by the improved scores in the post-test and successful sign-off on practical skills using the simulated scenario. The authors recommend the conduct of more courses for critical care nurses and physicians. An important aspect of evaluating the effectiveness of an educational intervention is to assess the retention of knowledge and skills after a reasonable interval following the intervention. The interval assessment could not be carried out after these courses due to logistic issues and lack of funds. The authors further commend that each course should be followed for three months by an interval assessment for retention of knowledge and skills, in addition to the pre and post-test and sign-off on the day of the course.Although improvement in knowledge and attainment of skills were achieved in the participants through these courses, we did not assess the attitude and practice of critical care physicians and nurses regarding pain assessment in CIPs. A useful exercise for future courses would be the administration of a short questionnaire before the course and three months later, to assess the baseline attitude and practice of critical care physicians and nurses regarding pain assessment in CIPs and the change in attitude and practice achieved after attending the course.This was the first ever course developed and conducted in Pakistan, an LMIC. This course not only assesses the baseline knowledge of participants but also assessed the change in knowledge and clinical skills of participants after signing off from the educational course.In this study, there was no control group which may limit the ability to conclude the observed intervention effect. In this study, knowledge was tested soon after the course which may not ensure long-term retention of knowledge. Conducting workshop-based training will hopefully be the beginning of a practice change in pain assessment that may lead to appropriate pain treatment for ICU patients.Critical care nursing staff and physicians involved in the management of ICU patients should undergo regular training sessions in the use of objective pain assessment tools like BPS and CPOT. Regular pain assessment and its documentation is recommended for optimal care and a better outcome for critically ill patients. Such educational courses should be regularly conducted for better understanding and its implementation in ICUs.Regular assessment and documentation of pain are imperative to ensure effective pain relief in critically ill patients (CIPs). The participating physicians and nurses showed a positive impact on the knowledge, and clinical skills regarding pain assessment in CIPs. The overall gain in knowledge after the educational session was statistically significant (p = < 0.01). In univariate analysis, the effect of training was significantly higher in the female gender (p = 0.0005) and in those participants, who belonged to the metropolitan city (p = 0.010). In multivariate analysis, participants from the metropolitan city showed significant improvement in post-test scores compared to non-metropolitan cities (p = 0.038).Below is the link to the electronic supplementary material.Supplementary Material 1: CPOT Sign off Likert scaleSupplementary Material 2: Program of basic certificate course on objective pain assessment of critically Ill patients


Despite various pain management methods, chronic pain is still a challenging issue after thoracotomy. This retrospective study was designed to determine the possible factors affecting the development of chronic pain following open thoracotomy.The study included patients who underwent elective open thoracotomy at Ankara University İbni Sina Hospital, between 01.01.2016 and 31.12.2020. The medical files and electronic records of the patients were scanned from the system. Patient history, analgesic methods, and surgical details were recorded. The need for and usage analgesic drugs after the surgery were also recorded.A total of 229 patients who underwent thoracotomy were included in the study, and 83 (36.2%) patients had chronic pain. Duration of surgery, doses of remifentanil, fentanyl or NSAI drugs, duration or number of chest tubes , diabetes, or PCEA usage were found as variables affecting pain. Logistic Regression, Multilayer Perceptron, Naive Bayes, AdaBoost, and Random Forest methods were used to evaluate the prediction performances. According to the model created with logistic regression, the rate of the correct classification was 90.8%. The duration of surgery, remifentanil administration, chest tube for more than 4 days, and diabetes were found to be risk factors for developing chronic pain. Fentanyl bolus, PCEA-bupivacaine, and NSAID bolus were determined as preventive factors.A careful analysis of risk factors should be performed for each patient to prevent chronic pain after thoracotomy, and preemptive effective analgesia methods should be performed. The tissue around the surgical incision in thoracotomy is formed by musculoskeletal and nerve damage. It develops in two different periods: acute and chronic. If acute and severe pain that develops immediately after surgery is not adequately controlled or treated, the risk of developing chronic pain is high.2Chronic pain lasts longer than the course of the disease and may persist for 3 to 6 months after recovery. It can be nociceptive, neuropathic, or mixed.3Direct activation of nociceptors after surgery causes pain in and around the surgical site due to inflammation and nerve damage. Pain is associated with touch, movement, respiratory movements, or coughing. Additionally, it is thought that neuropathic components due to nerve damage develop after surgery, and thus pain may develop even in the absence of inflammation or peripheral nociception. Symptoms related to nerve damage are seen. Chronic pain that develops after surgery limits the daily activities of patients and adversely affects their quality of life.This retrospective study was designed to determine the factors influencing the development of chronic pain in patients undergoing thoracotomy at our center.This retrospective single-center study was conducted in Ankara University after ethical approval was obtained from the Human Research Ethics Committee of the Ankara University (Number: İ6-481-21). The clinical trial number for the study is NCT05501977. The study, initiated after the approval of the ethics committee dated 18.08.2021, was completed on 25.07.2022.Patients with ASA I-III who were over 18 years of age and planned and scheduled for elective thoracotomy between 01.01.2016 and 31.12.2020 at Ankara University İbni Sina Hospital were included in the study. Patients with ASA IV and V, emergency or trauma thoracotomy, malignancy infiltrating the chest wall, more than one thoracotomy performed, cardiovascular, cerebrovascular, or musculoskeletal system affected at a level that would affect their daily activities after surgery, and patients with insufficient data for various reasons were excluded.All patients’ medical files and electronic records were obtained from the hospital medical record system. Patients who presented to the pain clinic and reported pain at 3 and 6 months in the thoracic surgery outpatient clinic controls were classified as chronic pain group. Patients without pain at 3 and 6 months were classified as the non-chronic pain group. Age, sex, weight, ASA score, smoking, comorbidities, intraoperative and postoperative analgesia method, duration of acute pain, type of surgery, duration of surgery, duration of anaesthesia, rib resection, number and duration of chest tubes, time to apply to the pain clinic, and the analgesic method applied were recorded.t-test was used if normal distribution assumptions were met, and the Mann-Whitney U test was used if assumptions were not met. Chi-square and Fisher's exact tests were used to examine the relationship between two qualitative variables. Risk factors affecting pain were examined using univariate logistic regression analysis. The statistical significance level was taken as 0.05. Logistic Regression, Multilayer Perceptron, Naive Bayes, AdaBoost, and Random Forest techniques were used for the machine learning classification. The dataset was tested using 10-fold cross validation. Accuracy, F-measure, Matthews correlation coefficient (MCC), ROC curve, and precision recall curve (PRC) were used as performance criteria. All analysis were made using the R programming language, and the RWeka and e1071 packages in the language were used with this program.SPSS 11.5 was used in the analysis of retrospectively collected data. The mean ± standard deviation for quantitative variables and the number of patients (percentage) for qualitative variables were used as descriptors. To determine whether there is a difference between the categories of the qualitative variable with two categories in terms of quantitative variables, Student’s Between 01.01.2016 and 31.12.2020, a total of 326 patients who underwent thoracotomy at İbn-i Sina Hospital were initially examined. Of the patients examined, thirty-one patients were excluded because of missing data, nineteen patients due to ASA IV and V, seventeen patients due to death, twelve patients under the age of 18, and 8 patients due to emergency trauma surgery. A total of 229 patients who underwent thoracotomy was included in the study.While 146 (63.8%) patients had no complaints of chronic pain, 83 (36.2%) patients had chronic pain. When examining whether there was a difference between chronic pain categories in terms of demographic and clinical data, a significant difference was found in terms of hypertension and diabetes; 45.8% of patients with hypertension and 59.6% of patients with diabetes had chronic pain .We examined whether there was a difference in the development of chronic pain in terms of the variables of the intraoperative and postoperative medical analgesia methods. While 64.6% of patients who were administered remifentanil had chronic pain, this rate was 21.3% of patients who received fentanyl. Chronic pain was present in 23.6% of patients who were administered lidocaine infusion. A total of 44.2% of the patients who underwent IV fentanyl-PCA had chronic pain, and it was determined that 29.5% of the patients who were treated with non-steroidal anti-inflammatory drugs (NSAIDs) had chronic pain. The patients (9.1%) who received epidural bupivacaine-PCA had chronic pain, while this rate was 44.8% in patients who did not receive epidural bupivacaine-PCA .The mean duration of surgery was significantly higher in patients with chronic pain. Rib resection is an important factor for chronic pain, 85.7% of patients with rib resection have chronic pain. Number of chest tube and chest tube duration time were found to be significantly higher in patients with chronic pain. The mean duration of acute pain was 4.29±1.60 days in patients with chronic pain and 3.71±1.34 days in patients without chronic pain .The risk factors affecting chronic pain were examined by logistic regression analysis, and hypertension and diabetes were found to be significant risk factors. The presence of hypertension increases the risk of chronic pain by 1.895 times, and the presence of diabetes increases the risk of chronic pain by 3.403 times.The risk of chronic pain increases by 6,717 times in patients not using fentanyl. The risk of chronic pain increases by 2.175 times in patients who do not use lidocaine infusion. While the risk of chronic pain increases by 8.125 times in patients not using epidural bupivacaine-PCA. The use of NSAIDs also effects chronic pain. Increasing the duration of acute pain by one day increases the risk of chronic pain by 1,312 times, while increasing the duration of surgery by one minute increases the risk of chronic pain by 1,058 times. The presence of rib resection increases the risk of chronic pain by 11,299 times. Increasing the number of chest tubes by one increases the risk of pain by 4,742 times, and an increase in the duration of the chest tube by one day increases the risk of chronic pain by 1.747 times .As to decide the importance of the variable and the effect of the variables on pain were examined more tests performed (the gain ratio and information gain variable significance tests) . When thLogistic regression, multilayer perceptron, naive Bayes, AdaBoost and random forest methods were used to evaluate the prediction performances, and the results of these methods are given in According to the model created with logistic regression, the rate of correct classification was 90.8%. With this model, when we made a general estimation of no/has pain for the patient, the accuracy rate of this estimation was 90.8%. In other words, with this model, the prediction result of about 90 out of 100 people was correct. In addition, the correct classification rate of the patients who said they had no pain in this model was 93.8%, and the rate of accurate classification of the patients who said they had pain was 85.5% .5 In our study, the incidence of CPAT was 36.2%, which was consistent with the literature.The incidence of CPAT is high. In different studies, the prevalence of chronic pain developing after thoracotomy varies between 25% and 68%.6 The higher risk in younger patients is thought to be due to stronger inflammatory and immune responses. In our study, age was not found to be one of the risk factors for CPAT because the majority of patients included in the study were elderly.Advanced age is considered a risk factor for many diseases, but many studies have shown that patients who develop CPAT are at least 10 years younger than patients who do not develop pain and that the risk of developing pain is higher in patients under 60 years of age.7 In our study, CPAT developed in 45.8% of patients with hypertension, and hypertension increased the risk of pain development by 1.9 times.Different experimental studies have shown that there is a relationship between pain and hypertension. In studies, different mechanisms come into play to prevent and regulate blood pressure in hypertensive patients who develop pain. One of these mechanisms is the excessive release of endogenous opioids to control pain. Because endogenous opioid secretion is higher in hypertensive patients than in healthy individuals, tolerance develops after a certain period, and it is thought that an increase in pain sensitivity can be observed.8 ASA I-IV patients over the age of eighteen who had undergone thoracotomy at Peking Union Medical College Hospital between 2009 and 2020 were examined. They found that the risk of developing chronic pain in patients with diabetes was significantly higher than that in patients without diabetes.9 In our study, the results were similar, and the risk of developing CPAT was found to be 3,403 times higher in patients with diabetes.Polyneuropathy causing severe pain is seen in patients with diabetes. Complex mechanisms involving inflammation, microvascular, and immune responses contribute to the development of neuropathic pain in diabetic patients. Neuropathic pain developing before surgery is thought to trigger the development of chronic pain in the postoperative period together with surgical stress.10 126 patients were included, and the rate of chronic pain development at the third month after surgery was found to be significantly higher in the remifentanil group compared to the fentanyl group. In our study, chronic pain was observed in 21.3% of the patients who received fentanyl, whereas the rate was found to be 64.5% in patients who used remifentanil. Intraoperative use of remifentanil increased the risk of chronic pain by 6.7 times.It is thought that the use of intraoperative remifentanil causes the development of hyperalgesia in the postoperative period and pain that develops in the acute period affects the development of chronic pain. In this study, the effect of intraoperative remifentanil and fentanyl use on chronic pain after cardiac surgery was investigated. A randomized controlled study by de Hoogd et al.,11 which included sixty-one patients who underwent mastectomy, the patients were divided into two groups: placebo was administered to one group and intraoperative lidocaine infusion was administered to the other group. Because of the study, chronic pain developed in 30% of patients who received placebo at the 6th month after surgery, but this rate was found to be significantly lower in patients who received lidocaine infusion (12%).11 Our results were similar; chronic pain developed in 23.6% of patients who received lidocaine infusion, but chronic pain developed in 40.3% of patients who did not receive lidocaine infusion.Lidocaine infusion, which is used in multimodal analgesia, prevents chronic pain that develops after surgery by different mechanisms. Its ability to prevent chronic pain is due to its sodium channel blockade in neurons, its ability to prevent inflammation, and its antihyperalgesic effects. In the study by Terkawi et al.,12 compared IV-PCA and epidural-PCA methods. Ninety-six patients who had undergone thoracotomy were included in the study, and the patients were divided into two groups: intravenous and continuous epidural analgesia. Because of the study, the rate of development of chronic pain in the third month was 55.2% in patients who received IV analgesia and 28.6% in patients who received continuous epidural analgesia.12 In our study, it was determined that chronic pain developed in 44.2% of patients who received IV fentanyl-PCA chronic pain developed in 9.1% of patients who received epidural bupivacaine-PCA.Different treatment methods are used for pain control after thoracotomy. Among the multimodal treatment methods, intravenous and epidural patient-controlled analgesia methods are frequently and widely used. Li et al.13 in 1992 for the first time. The development of acute postoperative pain is a risk factor for postoperative chronic pain.13 Wang et al.9 investigated the risk factors affecting the development of chronic pain after thoracotomy. A total of 466 patients who underwent thoracotomy between 2009 and 2010 were included in the study, and it was found that each additional day of acute pain duration increased the risk of developing chronic pain by 1.2 times.9 Similar results were obtained in our study. It was determined that increasing the duration of acute pain for one day increased the risk of chronic pain by 1,312 times, and more research is needed on this subject.There are many studies on the relationship between acute postoperative pain and chronic postoperative pain. This relationship was shown in the study of Kalso et al.14 In the study of Maguire et al.,15 it was determined that patients who did not undergo rib resection were exposed to more intercostal nerve damage during rib resection. Although the effect of rib resection on the development of postoperative chronic pain is controversial, there are studies with different results. In a study that retrospectively investigated the risk factors affecting the development of chronic pain after thoracotomy and included 208 patients, it was found that the risk of developing chronic pain increased by 9.8 times in patients who underwent rib resection.16 In our study, rib resection increased the risk of chronic pain after surgery by 11.8 times.Neurological damage during surgery is thought to be the source of postoperative chronic pain. Rib resection and suturing techniques increase the risk of nerve damage.17 it was determined that intercostal nerve damage developed during chest tube insertion, with the risk increasing as the number of procedures increases. Mongardon et al.6 included sixty-eight patients who underwent posterolateral thoracotomy between 2007 and 2008, in which 48% of the patients developed chronic pain. It was determined that the risk of developing chronic pain increased as the number of chest tubes increased.6 The results of this study were similar, the risk of developing CPAT increased by 4.7 times in patients with two chest tubes compared with patients with one chest tube.The number of chest tubes placed after surgery is believed to influence the development of chronic pain. As the number of tissue damage increases, the risk of developing chronic pain after surgery also increases. In the study of Miyazaki et al.,16 that included 208 patients in which the risk factors affecting the development of chronic pain after thoracotomy were investigated, it was found that the risk of developing CPAT increased as the duration of chest tube thrusting increased. In another study, risk factors affecting the development of chronic pain after thoracotomy was investigated. A total of 466 patients who had undergone thoracotomy between 2009 and 2010 were included in the study, and it was found that the risk of developing CPAT increased by 1.3 times as the duration of chest tube stay increased.14 Similar results were obtained in our study, and it was determined that the risk of chronic pain increased by 1.747 times with each additional day of chest tube insertion.The risk of developing CPAT increases as the duration of the chest tube increases because of continuous exposure to tissue damage. In a retrospective study by Kar et al.After more detailed analysis of the statistics for related factors, the duration of surgery, remifentanil administration, chest tube existence for more than 4 days, and the presence of diabetes were found to be more related risk factors for the development of chronic pain than the others that were evaluated. The administration of a fentanyl bolus, PCEA-bupivacaine, and a NSAID bolus were determined as preventive factors.18 evaluated 3200 patients after thoracic surgery, which covers a 10-year period. They concluded that the duration of surgery is a factor that relates to chronic pain, which is consistent with our results. The continuous and prolonged surgical impulses may explain these findings.18The duration of surgery was found to be the most related factor to the development of chronic pain. Yoon et al.A limitation of the study is that as this is a retrospective study, it is not possible for us to form groups and compare methods. This study may guide us to establish a new prospective comparative study to determine an effective approach in the preventing of chronic pain in thoracotomy patients.The development of chronic pain after thoracotomy is an important health problem influenced by multiple factors rather than a single cause. Because of our research, hypertension, diabetes, intraoperative intravenous remifentanil infusion, rib resection, prolongation of acute pain duration, number of chest tubes and prolonged chest tube duration were determined to be risk factors for the development of chronic pain after thoracotomy. Intraoperative fentanyl and lidocaine infusion, postoperative epidural bupivacaine-PCA, and NSAID uses have been found to significantly reduce the development of chronic pain after thoracotomy. Duration of surgery, remifentanil administration, chest tube existence for more than 4 days, and diabetes were found to be more related to chronic pain after thoracotomy. By identifying these factors, we applied the necessary treatments to prevent the development of chronic pain and improve patient outcomes.


The purpose of this study was to assess patient satisfaction and identify risk factors for dissatisfaction after anterior stabilised conventional total knee arthroplasty (TKA) without patellar resurfacing, using the Goodman score.We conducted a cross-sectional study using data from our institutional database from 1 January 2018 to 1 March 2021. Patients who underwent TKA with the Vanguard® Cruciate Retaining Anterior Stabilized Knee System  without patellar replacement were included. Patients with other bearing surfaces  or diagnosed with infection or instability were excluded. Patients' reported outcomes, body mass index (BMI), passive range of motion, the timed up-and-go test, sit-up test, and algometry were assessed. Patients were also asked if they had anterior knee pain. Satisfaction was assessed using the Goodman scale, and logistic multivariate regression was used to identify variables associated with dissatisfaction and perceived improvement in quality of life.A total of 131 TKA patients were included in the study. The median satisfaction score was 100 , with the 75-point threshold at the 90th percentile according to Section A of Goodman. Section B of Goodman showed that 113 TKA patients (86.26%) reported "great improvement" or "more than I ever dreamed." Multivariate logistic regression revealed that anterior knee pain , the sit-up test , and BMI  were significantly associated with patient dissatisfaction and a worse perceived improvement in quality of life. The receiver operating characteristics curve for the models had areas under the curve of 0.83 (95% CI 0.69 to 0.97) and 0.82 (95% CI 0.70 to 0.94), respectively.Anterior stabilised TKA without patellar resurfacing can achieve 90% satisfaction and 86% improvement in quality of life. To improve these results, it is essential to prevent and treat anterior knee pain and enhance quadriceps strength.Level III (retrospective cohort study). Total knee arthroplasty (TKA) is a common procedure aiming to restore function and alleviate pain in patients with end-stage knee osteoarthritis . The impPatient satisfaction and improvement in quality of life are the primary outcomes to be achieved after TKA. Recently, Goodman et al. developed a reliable scale to objectively measure both outcomes, which has been validated and adapted for Spanish speakers , 18. HisCurrently, numerous technical controversies exist, such as the choice of polyethylene insert and the necessity of performing patella resurfacing . Many stOur institution is a university hospital that led the TKA volume in our country from 2004 to 2019  complicaA cross-sectional study was designed and approved by our local ethics committee and was conducted in accordance with the declaration of Helsinki. The institutional database was reviewed from 1 January 2018 to 1 March 2021. Patients were invited to participate in the study if they had undergone TKA using the Vanguard® Cruciate Retaining Anterior Stabilised Knee System  without patellar replacement. Patients were excluded if another bearing surface was used  or if they had a diagnosis of infection or instability. TKA was performed using a medial parapatellar approach and eversion of the patella. Neither a tourniquet nor wound drainage was used. Extra or intramedullary guidance for tibial alignment was used according to the surgeon's preference, while intramedullary guidance for femoral alignment was used in all cases. The epicondylar axis and the Whiteside line were used for rotational alignment on the femoral component; conversely, the posterior cruciate ligament to tibial tubercle axis and the anterior cortex were used as reference points for rotation on the tibia. The surgeons in this study never replaced the patella and always performed patellar denervation.A total of 345 TKAs were identified. The four surgeons who participated in the study carried out 253 of them (73%). Twenty-six of the 253 10%) were unicompartmental arthroplasties, and 61 (24%) TKAs were not included because they were revision surgeries, or a PS bearing was used. One hundred sixty-six TKAs were identified for recruitment, of which one patient was excluded for acute infection (0.6%) and one (0.6%) for medial instability. Finally, 123 of 164 TKAs (75%), corresponding to 105 patients, were successfully contacted and agreed to participate in the study. All of them received counselling and then signed written informed consent to participate. If a patient had a contralateral TKA performed before the time frame of this study at our institution using the same model, both TKAs were recruited. This occurred in eight patients , totalling 131 recruited TKAs in 105 patients  from March 2022 to September 2022. The assessment included patients' reported outcomes, body mass index (BMI), passive ROM, the timed up-and-go (TUG) test, sit-up test, and algometry. Additionally, all patients were asked if they experienced AKP during their daily activities, regardless of intensity and frequency (daily or weekly). The response was recorded as either yes or no.The principal outcome of the study was satisfaction and patients' perceived improvement in their quality of life after TKA, using the Goodman scale, which has been validated for TKA and adapted for Spanish speakers , 18, 56.The passive ROM was assessed with the participant in the supine position, with hips in the neutral position. A 360° universal plastic goniometer with a 30-cm movable arm and a scale of 1° increments  was used for all measurements. The stationary arm was placed along the femur to the greater trochanter. The movement arm was placed along the fibula to the lateral malleolus. The fulcrum was visually positioned at the trans epicondylar axis of the knee joint. For knee flexion, the heel of the foot was required to be in contact with the examination couch during the assessment. For passive knee extension, a cylindrical roll was placed underneath the heel of the foot to allow the knee to extend as much as possible. Both knees were assessed .The TUG test corresponds to the time it takes for a patient to get up from a chair, walk 1.5 m in a straight line, turn around, and return . The time was recorded in seconds . For theContinuous variables were summarised as median (50th percentile), range, and IQR (25th percentile to 75th percentile). Categorical variables were summarised using frequency and percentages. A comparison was performed for all variables between patients with one-sided TKA and those with bilateral TKA.The Goodman scale was the primary outcome . A quantSection "B" was dichotomised into two categories for analysis purposes: answers from 1 to 4 were classified as "Same or Worse", and answers from 5 to 6 as "Much better". Then, a logistic regression was estimated to determine risk factors for "Same or Worse". For those variables with a significant odds ratio (OR), the area under the receiver operating characteristic (ROC) curve was estimated to evaluate the ability to discriminate. A bootstrapped multivariate logistic regression (MLR) with 200 repetitions using stepwise was performed. After the MLR, the goodness of fit test, with a maximum of 10 group covariances, was conducted to determine if the model was adequately estimated.A total of 131 TKAs were recruited from 105 patients, of whom 46 were men (43.81%). The median age at surgery was 66 years , 78 TKAs were on the right side (59.54%), and 13 patients underwent bilateral TKA. The median follow-up was 2.74 years .No clinically relevant difference in functional evaluation was found between patients with one-sided TKA and bilateral TKA Table ; thus, n2, with 55 patients (42%) between 30 to 35 kg/m2 and 20 patients (15%) above 35 kg/m2 , according to Section A of the Goodman scale Table . The 75-PGoodmanA = 88.14103 + (-1.602564 * WOMAC A) + (-2.350427 * WOMAC B) + , reaching a pseudo-R2 of 0.32. The scatter plot . Anterior knee pain and gender showed a significant coefficient but with a low pseudo R2. Conversely, patient-reported outcomes demonstrated a significant coefficient with pseudo-R2 ranging from 0.18 to 0.26. Multivariate bootstrapped quantile regression indicated that the best-predicted model was the pain and stiffness WOMAC and the Kujala score Table . The preLogistic regression showed a significant association between the perceived improvement by patients (Goodman B) and patient-reported outcomes, anterior knee pain, years at follow-up, BMI at follow-up, sit-up, and TUG tests Table . MLR indThe main finding of this study was that 86% of patients reported significant improvement, and 90% reported at least 75 points out of 100 in satisfaction after TKA with anterior stabilisation insert and no patellar resurfacing. Dissatisfaction after TKA has been historically documented to be around 20% . NeverthThe main reasons for improved satisfaction after TKA are better implant design, increased understanding of TKA biomechanics and patellar tracking, and advancements in perioperative pain management , 42, 54.Knee anterior pain and performance in the sit-up test were significantly associated with satisfaction and the improvement perceived by patients. This is consistent with other studies, as patients' expectations before surgery are a well-documented risk factor for dissatisfaction . These eWe report a relatively high incidence of anterior knee pain after AS TKA, but within the range found in the literature , 43. A sAdditionally, the type of bearing surface seems to be related to anterior knee pain, with secondary patellar replacement being performed more frequently on PS cases, according to the German registry . NeverthA recent study comparing TKA with patellar resurfacing and TKA with patellar denervation found that denervation decreased the intensity of anterior knee pain the most, with similar satisfaction among groups at 24-month follow-ups . AnotherInfection and malalignment should be ruled out in cases of anterior knee pain after surgery. Subsequently, an interdisciplinary approach must be taken for pain management , 41. RadPerformance in TUG, muscular force, and the sit-up test were significantly associated with the patient's perception of improvement. The latter was also significant in the multivariate analysis for both sections of the Goodman scale. All these tests indirectly assess quadriceps strength, which is impaired after TKA compared to age-matched controls. Furthermore, low quadriceps strength before surgery has been associated with a longer period of recovery after TKA . No specQuadriceps strength and anterior knee pain are well-known related problems as well . AnterioAnother finding in our report was that patients with greater BMI had a significant trend to self-perceive a more remarkable improvement after TKA, but similar satisfaction. Contradictory statements are found in the literature on this topic . Our resFinally, WOMAC, Kujala, and KOOS quality of life were strongly related to the Goodman scale, which makes our results more reliable and not biased by one patient-reported outcome. Also, it could help other surgeons to estimate their patients' satisfaction.The main limitation of our study is the low sample size compared to other studies. Nevertheless, the findings consistently show that the same variables—anterior knee pain and sit-up test—were related to satisfaction and patients' improvement, and the bootstrapped regression accounts for this limitation. Also, these findings cannot be instantaneously extrapolated to other types of insert or patellar resurfacing. Additionally, this study did not use radiological assessment, which may bias the results. A further step in our research is determining which radiological parameters predict anterior knee pain in TKA without patellar resurfacing.Anterior stabilised TKA without patellar resurfacing can achieve 90% satisfaction and 86% improvement in quality of life. To improve these results, it is essential to prevent and treat anterior knee pain and enhance quadriceps strength.