BackgroundChest pain is one of the common complaints for emergency and outpatient department (OPD) visits in children and adolescents. Chest pain accounts for 0.6% of pediatric emergency visits and 2.5% of pediatric outpatient consultations. The prevalence of chest pain and the etiological factors associated with children in India is unclear. The primary objective of this study was to evaluate the etiology of chest pain in children and adolescents. The secondary objective was to describe the demographic characteristics and associated symptoms with chest pain and the outcomes of children after the intervention.MethodologyA retrospective analysis of case records of 55 children aged between 5 and 15 years who attended the emergency or OPD of the hospital with the primary complaint of chest pain from July 1, 2019, to June 30, 2021, was done.ResultsThe mean age of patients in our study was 10.75 ± 2.47 years. Of 55 children, 26 were males, and 26 were females . In total, 43 (78.2%) patients had screen time of more than two hours. Palpitation was recorded in 11 (20.4%) patients, whereas only four (7.3%) children had breathing difficulties. Of 55 children, 46 (83.6%) had psychogenic causes, six (10.9%) had organic reasons, and three had no identifiable cause of chest pain. Anxiety disorder (40%) and depression (21.8%) were the leading psychogenic causes of chest pain. Overall, 13 (23.6%) children had associated smartphone and internet addiction disorder. Of 55 children, 36 (63.6%) improved following an appropriate intervention. Five children had some or no improvement in chest symptoms. Finally, 15 (27.3%) children were lost to follow-up.ConclusionsChest pain is one of the common complaints in the pediatric age group needing referral to a pediatric cardiologist. The most common etiology associated with chest pain is often non-cardiac and psychogenic. Good patient history taking, clinical examination, and fundamental investigations are sufficient to unravel the etiology in most cases. Chest pain is one of the common complaints for emergency and outpatient department (OPD) visits in children and adolescents. Although the exact prevalence of chest pain in children is unknown, it accounts for 0.6% of pediatric emergency visits and 2.5% of pediatric outpatient consultations . In adulThe prevalence of chest pain and the etiological factors associated with children in India is unclear. From a recent study involving the Western population, the most common causes of chest pain were musculoskeletal (33%) and psychogenic (28.4%) . BecauseA retrospective analysis was conducted by reviewing patients’ past medical records from the HealthWorld Hospital, Durgapur, and West Bengal, India hospital database. Children aged 5-15 years with a primary complaint of chest pain who attended the OPD or emergency department of the hospital from July 1, 2019, to June 30, 2021, were considered for inclusion in this study. Ethical clearance was obtained from the institutional ethical committee before the study. All children underwent thorough history taking, physical examination, and electrocardiography (ECG). Echocardiography was done in high-risk cases by a trained pediatric cardiologist. Any obvious abnormality in physical examination such as joint laxity, skeletal deformity (kyphoscoliosis), and chest asymmetry was noted. Any additional investigations such as complete hemogram, lipid profile, chest X-ray, exercise stress test, upper gastrointestinal endoscopy, pulmonary function test, and angiography were done as required based on the clinical scenario and examination findings. The family’s socioeconomic status was categorized into upper, middle, and lower based on the modified Kuppuswamy scale . BroadlyData were collected from the hospital records of individual patients. Baseline data such as age, sex, religion, education, anthropometry, and residence were recorded. The number of siblings, parental education, employment, and family income were noted. The child’s habits such as food habits, screen time, sleep habits, outdoor playtime, and associated symptoms such as palpitation, breathing difficulty, and abdominal pain were noted. The etiology of chest pain was recorded after a thorough evaluation. Follow-up records of patients for at least six months were reviewed when available, and details of outcomes were observed. Data collected were entered in MS Excel. Baseline variables were expressed in percentages and mean ± SD. Different etiology and factors associated with the chest were expressed in percentages. The outcome of chest pain was expressed in percentages. Fisher’s exact test compared the etiology of chest pain in males and females. P-value ≤0.05 was considered significant. Data collected were analyzed by MS Excel and GraphPad Prism 9 software.A total of 55 children and adolescents between 5 and 15 years of age met the inclusion criteria and were included in this study. The mean age of patients in our study was 10.75 ± 2.47 years. Of 55 children, 26 were males, and 26 were females . Around 73% of children belonged to Hindu families, and 28% belonged to Muslim families. Most patients (65.5%) with chest pain were from highly educated families. Both parents of these children had graduation or higher qualification. Per the modified Kuppuswamy scale, 45 (81.8%) chest pain patients belonged to upper and middle socioeconomic families. Only 18.2% of children complaining of chest pain were from families with lower socioeconomic status. The demographic profile of patients with chest pain is summarized in Table Chest pain of fewer than 48 hours, 48 hours to two weeks, and more than two weeks at presentation were found in six (10.9%), 11 20%), and 38 (60.9%) children, respectively. It was found that 43 (78.2%) patients had screen time of more than two hours. Fourteen of the 43 children were used to screen viewing for over 10 hours. It was observed that 31 (56.4%) children had sedentary habits without outdoor play or daily exercise. Associated findings noted with chest pain were palpitation and breathing difficulty. Palpitation was recorded in 11 (20.4%) patients, whereas only four (7.3%) children had breathing issues. Characteristics of chest pain and associated findings are presented in Table 0%, and 3The etiological diagnosis for chest pain was made after a thorough evaluation and was broadly classified into organic, psychogenic, and idiopathic. To our surprise, chest pain was psychogenic in 83.6% of cases. Of 46 patients with non-organic/psychogenic chest pain, anxiety disorder (40%) and depression (21.8%) were the leading causes. Acute stress disorder (9.1%), conduct disorder (5.5%), dissociative disorder (3.6%), and panic disorder (3.6%) were other psychogenic causes. It is important to note that 13 (23.6%) children had associated smartphone and internet addiction. On comparing psychogenic causes of chest pain between males and females, we found no statistically significant difference (p = 0.72). Organic causes of chest pain were musculoskeletal, respiratory, cardiac, and gastrointestinal noted in six cases. One case of asthma and acute gastritis with chest pain was found. Cardiac abnormality in the form of anomalous origin of the right coronary artery was the sole cause of chest pain in our study. No definite etiology could be established in three cases with chest pain. A summary of the causes of chest pain is described in Table Chest pain has always been considered a life-threatening symptom requiring urgent attention and referral to a pediatric cardiologist. Similarly, most patients included in our study were referred by a general practitioner or pediatrician for urgent attention. Because all patients in our study were evaluated with thorough history taking, clinical examination, and ECG by a pediatric cardiologist, there is only a small chance of any cardiac disorder being missed or misdiagnosed. Per our primary objective, we searched the etiology of these patients with chest pain. We found the cardiac cause in only one out of 55 patients. Anomalous origin of the right coronary artery was found by CT angiography of the coronary vessels in a 12-year-old boy referred to a higher center for surgical intervention. In our study, the organic cause was found in six 10.9%) patients. Among these causes, the musculoskeletal problem was found in three cases, one of asthma, and one of acute gastritis. Although the incidence of cardiac causes of chest pain is variable, it was found in 0-5% of children in previous studies % patient. RespiraAlthough the rare association of a cardiac disorder with chest pain is reassuring, psychogenic causes are a matter of concern. Psychogenic causes account for 10-30% of chest pain in children . Based oChest pain as a presenting symptom is common in adolescents ,19,20. TThe limitation of this study is that it was a retrospective analysis of patients from records and involved a small number of patients. Our study had no comparison group, and many patients were lost to follow-up.Chest pain is one of the common complaints in the pediatric age group needing referral to a pediatric cardiologist. The most common etiology associated with chest pain is often non-cardiac and psychogenic. Good history taking and clinical examination with basic investigations, if required, are often sufficient to unravel the diagnosis in primary care settings. Efforts to exclude cardiac and other organic causes must be made in all children with chest pain before labeling them psychogenic. A large prospective controlled research is needed to establish the etiology and framework for diagnosing and managing chest pain in children.


The latter was related to the greater need for rescue medication in the fentanyl group . On the other hand, fentanyl had significantly fewer non-life-threatening side effects, such as high-intensity pruritus , nausea , vomiting and dizziness upon first mobilization . It remains for future clinical trials to help establish doses that will tilt the scale to one side or the other.Perioperative analgesia for cesarean section aims to ensure the mother’s comfort, facilitate a smooth surgical experience, and promote a successful recovery. One-hundred-ninety patients were enrolled in a randomized double-blind study designed to assess the quality of perioperative analgesia, level of satisfaction, and incidence of adverse reactions in elective cesarean section under spinal anesthesia when fentanyl or morphine was added to bupivacaine. Two treatment groups comprising 173 subjects were compared in the per-protocol analysis: F  and M . Numerical pain scores were recorded perioperatively for 72 h (both at rest and on mobilization), with overall postoperative satisfaction and analgesic-related side effects. The patients in the morphine group had significantly better pain management (Mann–Whitney U test,  Cesarean section is a common surgical procedure for delivering a baby and can result in significant pain for the parturient. Postpartum pain is an important and ongoing concern for women and an important factor of maternal satisfaction ,2. AcutePain is a complex and multidimensional experience. Furthermore, pain severity scores do not consider influences by other factors, such as fear, depression, anxiety, nausea, vomiting, or functional limitations . This is1.Regional neuraxial anesthesia—includes techniques such as spinal anesthesia, epidural anesthesia, or combined spinal–epidural anesthesia. These techniques provide effective pain relief during and after the surgery, spinal anesthesia being the technique of choice.2.General anesthesia—is only used if the patient’s medical condition requires it, if it is the mother‘s choice, or in the case of an emergency with no time to perform a regional neuraxial block.There are two approaches to anesthesia for cesarean section:Most anesthetists have a multimodal analgesia approach for postoperative pain control, namely a combination of regional techniques  and systemic analgesia , sometimes combined with non-pharmacological methods, aiming to provide comprehensive pain management. So far, systemic analgesics such as opioids are the mainstay of analgesia, especially in the early postoperative hours, but the current trends aim at decreasing reliance on this class of drugs due to the high rates of adverse reactions. The choice regarding the anesthesia technique and perioperative analgesia strategy depends on several factors: patient’s medical history, type of surgery, and patient’s preference. The anesthetist and obstetrician must work together to determine the best approach for each individual patient and establish side effects management and rescue analgesia plans.Different regimens of multimodal analgesia have been tested in clinical trials. An intrathecal combination of a local anesthetic and an opioid is frequently used. Fentanyl doses of 10–25 μg) and morphine (doses of 0.1–0.2 mg) are two regularly used opioids for obstetrical pain relief, each with distinct advantages regarding the onset and duration of their effects 9). Intrathecal fentanyl used as an adjunct has many advantages: it improves the quality of spinal anesthesia by acting quickly and therefore decreasing the time to establish the block , and it . Intrath–25 μg anThe objectives of this study were (a) assessing the perioperative analgesia and the degree of patient‘s satisfaction when comparing morphine 100 μg with fentanyl 25 μg used as an adjunct to bupivacaine in spinal anesthesia for cesarean section; (b) assessing the incidence and the degree of side effects, like nausea, vomiting, dizziness, pruritus, sedation, and respiratory depression.We conducted a prospective double-blind, randomized trial, from January to December 2022 at Pelican Clinic Hospital from Oradea (Romania). The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committees of Pelican Hospital from Oradea (no. 2672/28.12.2021). Full-term parturient patients scheduled for cesarean section under spinal anesthesia were randomly distributed in two groups: group F (fentanyl) was administered hyperbaric bupivacaine 0.5% with a standard dose of 25 μg fentanyl; group M (morphine) received hyperbaric bupivacaine 0.5% with a standard dose of 100 μg morphine. The dose of hyperbaric bupivacaine 0.5% to be injected was based on the patient’s height (doses range between 7.5 mg and 11 mg).The inclusion criteria were ASA I-II patients; age 18–40 years; no medical history; unknown allergies to the used medication; no history of chronic pain or regular use of analgesics; no history of anxiety or depression; body weight ≥ 50 kg; elective cesarean section indication with a pregnancy equal to or above 37 weeks; alive and single fetus.The exclusion criteria were pregnant women with psychiatric disorders; history of drug addiction; diagnosis of acute or chronic fetal distress; contraindication to spinal anesthesia; patient refusal; preeclamptic patients; patients who developed allergic reaction after enrolling in the study; refusal of analgesia; need of surgical re-intervention in the next 72 h after cesarean section; conversion from a natural delivery with/without an epidural anesthesia in place; previous administration of opioids and/or other central nervous system depressants.During the pre-anesthetic consultation, all patients received information about the aims of the study, the choice of anesthesia, and details about the pain management and assessment using the numerical pain scale (NPS). Written consent was obtained after being assessed for inclusion criteria. Two anesthetists were needed to ensure the double-blind compliance: one randomly assigned the patient and prepared the intrathecal solution for the spinal anesthesia; another one performed the spinal anesthesia (blinded to the used solution). All drugs were from the same manufacturer.Patients’ demographics data comprised height, term weight, and age. In addition, drugs and full medical history, previous allergies, and other relevant medical data were documented . The pain assessment was carried out through an interview conducted by a member of the medical staff, namely a senior anesthesia trainee. The assessment and follow-up staff were independent of the team who provided anesthesia. Pain was assessed on an 11-point numeric rating scale (NRS) from 0 (no pain) to 10 (worst imaginable pain). Participants’ subjective pain intensity was recorded at the baseline during the surgical intervention (PS0), at the end of the cesarean section (PS1), and at 4, 6, 12, 24, 48, and 72 h after PS1. Postoperative pain scores were assessed at rest and on mobilizing.In case of required postoperative rescue medication for pain, imputation was subsequently applied: last value was carried forward within a four-hour time window. To comprehensively compare the postoperative pain in the study groups, the area under the pain scores over 72 h (AUPS72h) was employed:Adverse effects associated with anesthesia were recorded: presence and intensity of pruritus, nausea, vomiting, sedation, respiratory depression, dizziness (either constant or on first mobilization). Level of patients’ overall satisfaction was recorded on a 5-point Likert-type scale.The sample size of the two trial groups was determined for a 1:1 ratio, considering two types of outcomes: (a) the pain score on a 0 to 10 scale; (b) the proportion of symptoms associated with anesthesia. The R packages “MKpower” v. 0.5  and “webPower” v. 0.6 applying the J. Cohen theory were employed . The simThe actual dropout differed in the two groups, so they ended up having different sizes, as shown in −1, with a barbotage effect. Local anesthetic infiltration was performed with 2 mL of 1% lidocaine. After the block, the patient was placed in a supine position with a roll wedge placed under the right hip to displace the uterus to the left until fetal extraction.Preoperative venous access was obtained with an 18 G cannula, and 500 mL of Ringer lactate solution was infused prior to anesthesia. Patients were fasted and given pantoprazol 40 mg and metoclopramide 10 mg (intravenously as pre-anesthetic medication). The spinal anesthesia was performed under an aseptic technique with the patient in a sitting position, at the level of L3–L4 interspace, using a midline approach, with a 27 G Whitacre needle and an introducer. The anesthetic mixture was manually injected at a rate of 1 mL.15 s−1 hr−1) was given to optimize the volemic status. All patients had anti-embolic socks on lower limbs. Surgery started when sensory block reached the T4 dermatome level, as assessed by the cold test.Warm Ringer lactate (10–20 mL kgNon-invasive blood pressure (BP) was measured every minute until the baby was delivered and every 3–5 min afterwards. Any decrease in systolic blood pressure below the baseline level resulted in intravenous ephedrine doses of 5–15 mg, repeated every minute until the systolic blood pressure was optimally restored. At delivery, oxytocin 5 I.U. was given intravenously  and afterwards as required.Our approach to prevent the emetic syndrome involved an initial dose of 1 mg granisetron given intraoperatively and a single dose of 4 mg dexamethasone. A second dose of granisetron was administered 12 h apart. Afterwards, anti-emetic medication was given if required.Heart rate, blood pressure, and oxygen saturation measured by pulse oximetry (SpO2), requirements for supplemental analgesics and the need for conversion to general anesthesia, were recorded intraoperatively. In addition to these parameters, the level of sensory block was assessed by the cold test, and the maximum motor block score was recorded using the 4-point Bromage scale until complete motor block recovery.Postoperative pain control strategy was based on regular paracetamol 1 g every 6 h and ibuprofen 400 mg every 8 h. Doses of 50 to 100 mg of intravenous tramadol were available if required, to a maximum dose of 400 mg/day.t-test for independent samples was applied, with Levene’s test for equality of variances. For comparing distribution of non-normally distributed numerical values, the non-parametric Mann–Whitney U statistical test was applied and median (interquartile range) with Tukey’s hinges was additionally provided as a descriptive statistic.Descriptive statistics included the observed frequency counts (percentage) for categorical variables and mean ± standard deviation for numerical variables, irrespective of their distribution. Normality was tested with the Kolmogorov–Smirnov test. For comparing means in normally distributed values, the The chi-squared statistical test  was applied to check the statistical significance of the association between the categorical variables. The odds ratio (OR) values were calculated for the symptoms associated with the two anesthetics, such as nausea and dizziness.The statistical analysis was conducted at a 95% level of confidence and a 5% level of statistical significance. All reported probability values were two-tailed. Statistical analysis was performed with the statistical software IBM SPSS v. 20 and open-source R v. 4.0.5 packages.The study enrolled 190 full-term parturient patients scheduled for cesarean section under spinal anesthesia. After the randomization, seventeen patients were excluded due to various reasons: participation declining after enrollment (six patients); developing allergic reactions (four patients); pre-eclampsia development (four patients); and surgical re-intervention (three patients). Therefore, the final analysis was conducted on 173 patients: 94 in M group, and 79 in F group.p = 0.039), with a higher percentage of smokers in the M group (18.1% compared to 8.9%).The mean time from anesthesia to incision for all patients was 6.50 min. The full data regarding the time elapsed from anesthesia to sensory block and surgical incision are shown in The results for perioperative pain are presented in p < 0.001) in favor of M group. The individual characteristics of the 13 patients who required rescue analgesia are presented in Contrary to the findings regarding higher incidence of adverse side effects in M group, these patients had better perception of analgesia effectiveness and higher satisfaction levels compared to F group . The difSpinal anesthesia is a common technique in the field of obstetric anesthesia as it is accessible, safe, and easy to perform. In addition to an optimal surgical anesthesia, by using a local anesthetic agent, an adequate relaxation of the abdominal wall muscles can be induced. It is well known that mixing opioids with bupivacaine will allow a decrease in the local anesthetic dose with similar efficiency on pain control and even better hemodynamic stability, being also a simple and effective way to manage postoperative pain in cesarean section patients .In our study, 77.2% of the fentanyl group patients reported effective pain control, while all 94 patients 100%) from the morphine group reported effective analgesia and consistently rated their satisfaction as maximum. Only three patients from the morphine group needed rescue medication. In contrast, 10 patients from the fentanyl group needed additional analgesics. Our study results showed the analgesia to be more effective in the morphine group during the postoperative hours. Similar results were reported by Karaman et al. 0% from t. The latAccording to some researchers, intrathecal morphine reduces intraoperative discomfort ,19, wherConcerning the duration of effective analgesia, previous studies pointed out that the use of fentanyl in combination with a local anesthetic had about a 12 h effect, whereas the average duration of effective analgesia was 18 to 22 h in studies when morphine 100 μg was used [Regarding opioids’ side effects, previous research ,18,19,20Mild nausea and drowsiness were more frequently reported by participants receiving morphine compared to fentanyl, at 6 h and 12 h, respectively . Our patOther studies also reported problems with side effects, such as nausea and vomiting ,29. ReseOne of the most concerning and severe adverse events of spinal administration of opioids is respiratory depression. Most studies reported no respiratory adverse events due to intrathecal opioids. Our study also registered zero events. However, some other research pointed out that sufentayl and morphine were associated with a significant increase in the incidence of respiratory depression. They showed that respiratory depression was associated with spinal administration of morphine at doses higher than 1.0 mg .In our study, dizziness on first mobilization after spinal anesthesia was often encountered in the morphine group (55.3% compared to 24.1% in the fentanyl group). This dizziness reported to be associated with mobilization was transient and short-lived, with no clinical consequence and no distress for the patient. Constant dizziness was reported in only three cases (1.7%), all associated with morphine administration. Other studies reported dizziness or strange feelings occurring shortly after the spinal anesthesia and associated with hypotension .Although a study on the use of morphine and fentanyl for cesarean section might seem redundant, it is of particular interest for the female population in Eastern Europe, where the number of cesarean sections is considerably high and the reasons that underlie the decision are very diverse. Eurostat data on the percentage of cesarean births in EU countries in 2017 revealed the highest rates in Cyprus , followed by Romania (44.1%), and Bulgaria (43.1%) . A recenWe acknowledge that per-protocol analysis entails a risk of attrition bias. Even further, the outcome is influenced by factors related to adherence to treatment, and we faced different dropout rates in the two groups . To minimize the number of patients excluded from the final analysis, imputation was applied in cases of emergency pain therapy; i.e., the last observation was carried forward; this approach might have led to underestimated variability in the pain scores in F group, in which such rescue medication was required. An additional limitation concerns the dosage investigated: one standard dose was used for each of the two opioids considered in the present study.According to our findings, morphine for spinal anesthesia in cesarean section offers better postoperative analgesia compared to fentanyl. On the other hand, morphine was associated with a higher chance of non-life-threatening side effects, such as pruritus, nausea, and dizziness. Despite these analgesic-related adverse effects, patients who received morphine reported higher effectiveness of analgesia and better overall satisfaction. Future clinical trials should be conducted to evaluate the adequate doses of opioids and local anesthetics for optimal spinal anesthesia with safe side effects profiles.


The treatment group, compared to the placebo group, also showed significant statistical improvements in functional capacity  and quality of life . Conclusions: Mesotherapy treatment with diclofenac and thiocolchicoside is a safe and effective procedure in the management of neck pain in fibromyalgia patients in the short term in terms of pain reduction, functional recovery and quality of life.Background and Objectives: Fibromyalgia is a very common musculoskeletal disease. The purpose of this study is to assess, on a population of fibromyalgic patients, the clinical efficacy of antalgic mesotherapy with diclofenac and thiocolchicoside in the treatment of cervical pain reduction for improvement of the functional capacity and quality of life of these patients. Materials and Methods: We conducted an observational study of 78 fibromyalgia patients recruited using our hospital database. Based on the different types of treatment received, the patients were divided into two groups: the treatment group (TG), who received antalgic mesotherapy with diclofenac, thiococolchicoside, and mepivacaina; and the placebo group (PG), who received mesotherapy with sodium chloride solution. Patients in both groups also received the same rehabilitation protocol of 20 sessions. The primary outcome evaluated was the extent of pain. The secondary outcomes were the functional capacity and quality of life. Results: Pain improved both in the treatment group (7.4 ± 1.2 vs. 5.1 ± 1.1;  Fibromyalgia is a musculoskeletal disease of unknown etiology, which affects, on average, 2.10% of the world population; it affects 2.31% of the European population ,5.It has been hypothesized that fibromyalgia is of a multifactorial origin, with an underlying clear genetic predisposition . PossiblThe immune system and neuroinflammation therefore play a crucial role in CNS sensitization, including the activation of nociceptors. Many studies ,8,9,10 iThe stimulation of nociceptors is triggered by proinflammatory mediators such as adenosine triphosphate (ATP) and interleukin-1β (IL-1β), resulting in increased sensitivity to pain and contributing to the symptomatology of FM.Recent studies have also shown that purinergic signaling is often associated with pain and inflammatory responses . Indeed,The main clinical feature of fibromyalgia is the presence of widespread chronic pain, similar, for clinical presentation, physiopathology, and neuropharmacology, to neuropathic pain. Muscles, skin, ligaments, and tendons are affected, often accompanied by allodynia and hyperalgesia, as well as asthenia, morning stiffness, sleep disturbances, paresthesia, headache, anxiety and depression, irritable bowel syndrome, Raynaud’s phenomenon, and menstrual pain ,5.Chronic pain in these patients is often localized in the cervical spine region, making it responsible for acute and protracted episodes of cervical pain, associated with concomitant states of muscle tension of the suboccipital muscles, trapezius muscle, and shoulder blade lift muscle. This is often associated with impairment in neck movement ,15,16.Fibromyalgia is a very often underestimated and neglected condition, but over time, it strongly affects the quality of life and physical and working capacity of affected individuals .In patients with fibromyalgia, cervical pain is a very common and highly disabling multifactorial symptom, a concerning problem for modern society that is often responsible for limiting social and work activities, and although it is not the most common musculoskeletal disorder, it appears to play a certain role in the worsening of the patient’s psychological–physical–social condition, also representing an economic burden that is not to be underestimated, given both the costs of processing and any problems related to reduced working and functional productivity . Current treatment of fibromyalgia is based on a multidisciplinary and gradual approach: lifestyle and behavior changes, pharmacological treatments , and non-pharmacological treatments . The latExercise is the most appropriate non-pharmacological treatment, but the heterogeneity of the disease must be individualized according to the physical function of the patients, the severity of the pain, and other symptoms . It can Antalgic mesotherapy, an increasingly emerging approach, can be considered a valid therapeutic alternative in fibromyalgic patients . MesotheThe great advantage offered by mesotherapy consists in the amount of drug used, minimal compared to the dosage required in the conventional ways of administration; additionally, therapeutic action is “targeted”, which means that it acts in the localized painful part of the body ,28. WhenThe pharmacological combination most used for antalgic mesotherapy is the combination of NSAIDs, muscle relaxants, and local anesthetics ,28,29. TOnly a few studies have currently evaluated the efficacy of mesotherapy in the management of cervicalgia , while iThe purpose of this study is to assess, on a population of fibromyalgic patients, the clinical efficacy of antalgic mesotherapy with diclofenac and thiocolchicoside in the treatment of fibromyalgia for cervical pain reduction and the improvement of the functional capacity and quality of life of these patients.We conducted a case–control observational study at the U.O.C. of Recovery and Functional Rehabilitation of the A’O.’U. Paolo Giaccone of Palermo on patients diagnosed with neck pain suffering from fibromyalgia. The study was conducted according to the ethical guidelines of the Declaration of Helsinki; the local ethics committee “Palermo 1” approved the study, with reference number 03/2022; information and data were handled according to Good Clinical Practice (GCP) guidelines. All participants signed an informed consent form at enrollment to collect clinical data. Using our hospital database, we included a consecutive series of fibromyalgia patients.A total of 78 fibromyalgia patients met the inclusion criteria and were included in our study. Of these, 39 patients had undergone analgesic mesotherapy treatment with a combination of diclofenac fl 50 mg/2 mL, thiococolchicoside fl 4 mg/2 mL, and mepivacaine fl 10 mg/1 mL and were assigned to a treatment group (TG), while the remaining 39 patients underwent mesotherapy treatment using a placebo consisting of 9 mL of sodium chloride solution and were assigned to a placebo group (PG). The mesotherapy sessions were carried out by the same physiatrist doctor with many years of experience (D.S.) every week for a total of 7 sessions. Additionally, the patients of both groups received the same rehabilitation protocol of 20 sessions, under the supervision of a physiotherapist with many years of experience.The following inclusion criteria were used: age 18–55 years; clinical diagnosis of fibromyalgia according to the 2016 revised American College of Rheumatology (ACR) criteria ; clinicaDemographic  and clinical (comorbidity and presence of muscle tension) information was taken into consideration. The following rating scales were also administered: Numeric Rating Scales (NRS) , to asseThe NRS scale is a quantitative assessment scale whereby patients are asked to evaluate their pain on a defined scale, from 0 to 10, best reflecting the intensity of pain at that specific time . The Neck Disability Index (NDI) is a self-administered questionnaire, i.e., completed by patients with cervical pain, who assess how neck pain affects their daily life activities. The NDI consists of 10 sections, each of which investigates how pain affects different aspects of daily life . Each section contains 6 possible answers with the score varying from 0 to 5, where 0 corresponds to no difficulty or pain while 5 corresponds to inability to perform the activity or disabling pain. The complex score varies between 0 and 50, where higher scores are associated with increased disability . The Fibromyalgia Impact Questionnaire (FIQ) is a questionnaire consisting of 10 questions, divided into three parts. The first part contains 11 items related to the ability in the last week to carry out activities of daily life, with a score varying between 0  and 3 (never). In the second and third parts, the number of days of the last week in which the patient has felt well and has not been able to carry out their work (including housework) due to the symptoms of fibromyalgia is required. Questions 4 to 10 are related to the extent of fibromyalgia interference with one’s work, the intensity of pain and asthenia, the quality of night rest, the intensity of rigidity, and the presence of anxiety or depression; the answers vary from 0 (no disturbance) to 10 (very important disturbance), marked on a horizontal linear scale. The maximum FIQ score, corresponding to the highest degree of disability, is 100; in patients with fibromyalgia, the mean FIQ values are around 50, while only patients with severe clinical pictures have results above 70 .The SF-12 scale is a shortened version of the Short Form 36 Items Health Survey (SF-32) questionnaire and is a generic indicator of the patient’s quality of life and biopsychosocial well-being. Through 12 of the 36 questions of the original questionnaire, this scale investigates 8 aspects related to the state of health: physical activity, role limitations due to physical health, emotional state, physical pain, perception of the general state of health, vitality, social activities, and mental health. The synthesis of the scores totaled allows 2 synthetic indices to be built: a physical health index (PCS-12) and a mental health index (MCS-12). The lower the score of the two indices, the higher the level of disability .The mesotherapy was performed by an experienced and trained physician using a 10 mL syringe on which 4 mm and 6 mm 30 Gauge sterile disposable needles were mounted . At each treatment session, a pharmacological mixture containing 2 mL (50 mg) of diclofenac, 2 mL (2 mg) of thiocolchicoside, and 1 mL (10 mg) of mepivacaine was prepared. Then, 4 mL of sodium chloride solution was added. The operator starts with the disinfection of the skin with gauze soaked in chlorhexidine. After the application, the disinfectant was left to work for 5 min.A measure of 0.1–0.2 cc of this pharmacological mixture was administered at each injection site injected at a depth of 1–3 mm, with a distance between two injection points of about 2 cm and without causing papules. At the end of the injections, disinfection of the skin was performed again, a covering patch was applied, and the patient remained in observation for about 10 min, noting the possible appearance of adverse reactions. Patients were advised not to wet the injection area within the next 12 h . 2 laser, and 15 min of transcutaneous electric nerve stimulation (TENS) on specific tender points.The rehabilitation sessions were held three times a week with a duration of 100 min and under the supervision of an experienced physiotherapist. Each session consisted of 40 min of aerobic exercises, 30 min of COAerobic exercises promote body weight loss and help reduce the work of antigravity muscles, with muscle relaxant and analgesic effects. Aerobic exercises consisted of three parts. The first part of the 10-minute warm-up consists of breathing and stretching exercises performed at 70–80% of the maximum heart rate; patients performed segmental active muscle stretching without the assistance of the therapist. Large muscles were chosen for their role in muscle chains of the overall postural re-education method. The triceps surae, buttocks, ischiotibials, paravertebrals, latissimus dorsi, hip adductor, and pectoral were targeted. The intensity of the elongation was gradually increased to the point of moderate discomfort and the position was maintained for 30 s, according to the recommendation of the American College of Sports Medicine . The secThe low-energy laser is a widely used tool used in the treatment of musculoskeletal disorders, including fibromyalgia. It was applied to the three most painful points. It acts through an anti-inflammatory, anti-edema, and analgesic action, with short- and long-term efficacy in the treatment of fibromyalgia .TENS is a non-invasive method with analgesic action that is carried out through the excitation of the sensory nerves and the stimulation of the gate pain mechanism and/or the opioid system. It allows a reduction in pain and fatigue, improving hyperalgesia and the functional capacity in patients with fibromyalgia .The data obtained were indexed on an Excel sheet and analyzed with the statistical software R. The sample size was calculated with the formula below:ε = 0.05 is the maximum error acceptable to the researcher, and the choice of ε is arbitrary. Finally, we use the worst-case scenario of the proportion equal to 0.5. The formula gave a result equal to 69.99. Consequently, the number of 78 patients considered was sufficient to prove our thesis.The type I error is equal to 0.01 . The denominator t-test to compare means for quantitative variables, Mood’s median test to compare medians for ordinal variables, and the test for two proportions. The results were considered statistically significant with a p-value < 0.05.The descriptive analysis was performed based on the mean and standard deviation. For the statistical test, we used three different tests: the n = 71) identifying as female and the remaining 8.9% (n = 7) identifying as male.A total of 58% of patients had at least one comorbidity, among which the most common were: anxiety–depressive syndrome (24%), insomnia (21%), and headache (16%). n = 68) had states of tension on the trapezius, paravertebral, shoulder blade lift, and rhomboid muscles. In 38% of patients, these muscular tensions were present bilaterally, while in the remaining 62%, they were monolateral. A total of 73% of patients had an important limitation of the ROM of the cervical spine, with a greater involvement of the movement of flexion and left and right rotation. A total of 87% (p < 0.05).The mean value of the NRS scale was 7.3 ± 2.13, with more than 50% of patients reporting a worsening of symptoms during the night. Paresthesia in the neck and/or upper limbs was present in 33% of patients. The average score on the NDI scale was 36.2 ± 5.3, with the worst scores being highlighted for work, ability to concentrate, drive, and sleep. Finally, the average score of the FIQ scale was 55.9 ± 6.1, while the SF-12 questionnaire was 17.4 ± 8.25, with worse scores affecting the physical health. No statistically significant difference was observed between the two basal groups, except for a greater presence of comorbidity in the placebo group , while in the placebo group at T1, pain was reduced by about 1.4 points according to the NRS scale .p < 0.05) and the SF-12 scale . No statistically significant improvement was observed in the placebo group for the NDI scale  and SF-12 .The treatment group also showed statistically significant improvements at T1 in the NDI scale score  or in the placebo group .No statistically significant improvement was observed for the FIQ score, either in the treatment group  in combination with a rehabilitation protocol compared to mesotherapy with only a placebo in combination with a rehabilitation protocol in fibromyalgic patients with cervicalgia in terms of pain reduction, disability improvement, and quality of life. The results obtained at the two-month revaluation show a statistically significant improvement in pain reduction for both the control group and treatment group.Regarding the treatment group, this result could partly derive as a direct consequence of the reduction in muscle tension states induced by drugs; on the other hand, the beneficial effects of mesotherapy with associations of NSAIDs and muscle relaxants are now known in the literature ,41. ThisOther authors  have stuFerrara et al.  also anaRonconi et al.  investigMoreover, we must consider how the role of rehabilitation, therapeutic and aerobic physical exercise, is of fundamental importance for the fibromyalgic patient, as widely expressed in the literature, to obtain a reduction in and control of pain and improvement in terms of mobility and joint recovery. In fact, even the control group achieved a significant reduction in pain. Borcher et al.  report tOther authors report how bi- or tri-weekly aerobic exercises and therapeutic exercise focused on muscular strengthening has a positive impact on the reducing pain and also on mood and depression  and thatThe improvement of functional indices and quality of life is also statistically significant for the treatment group; an increase, although not statistically significant, turned out to be the overall psycho-physical impact on these patients. Few studies in the literature have investigated the application of mesotherapy in the treatment of chronic cervicalgia. Paolucci et al.  comparedIn the treatment group, along the same lines as the results of Paolucci et al. , we alsoIts main advantages are low invasiveness, easy reproducibility and speed of execution, and the possibility of administering the drug directly in the pain site while avoiding all possible complications, both systemic and non-systemic, resulting from the passage of different drugs into the gastrointestinal tract . Finally, patients in the treatment group expressed a significant and statistically significant improvement in their quality of life, with increased participation in recreational and social activities.This could be the result of the efficacy and safety of mesotherapeutic treatment and its low incidence of side effects perceived by the patient himself. Among possible side effects, we can divide complications between infectious and non-infectious complications, the first being more concerning than the latter, which can be avoided by following strict hygiene and sterility regulation. Non-infectious complications mainly include dermatological complications such as the formation of granulomas, microabscesses, and more common local skin reactions, urticarial rashes, and intolerance to the substances . The sidMesotherapeutic treatment could therefore be an alternative therapeutic solution that avoids the use of pharmacological principles with systemic action, favoring even more compliance, especially in patients with comorbidity and those fearful of taking medication. The latter category includes fibromyalgic patients, who often resort to abusing drugs with different consequences for the body and economic burdens.The main strength of our experience is the uniqueness of the project, as we were the first to consider the use of mesotherapy with and without drugs in the management of cervicalgia in fibromyalgic patients. However, our experience has some limitations, including the low sample cohort, which does not allow use to generalize the results to all of the effects shown; and the lack of a follow-up. Long-term follow-up could show the real duration of the benefits obtained and the ability to prevent further episodes of neck pain as well as the impossibility to distinguish the real effectiveness of the treatment with respect to the possible placebo effect on the psychological component.Considering our limited understanding of the etiopathogenesis of fibromyalgia, which includes a complex multifactoral system involving increased central sensitivity for nociception in which inflammation plays a fundamental role, the innovation of this study lies in the lack of literature exploring similar treatments: the comparison between a medicated intradermal treatment and a placebo for the treatment of cervicalgia in fibromyalgic patients. By acting safely, you work on multiple components of pathology, inflammation, and antalgic contractures. The clinical management of the fibromyalgic patient is still under discussion today, given the considerable mental and psychological components associated with the pathology. Our experience emphasizes the effectiveness and use of a technique such as mesotherapy, in some of its possible uses in the management of cervical pain in fibromyalgic patients. Mesotherapeutic treatment with diclofenac and thiocolchicoside has proven to be a safe and effective procedure in the management of cervicalgia in fibromyalgic patients, and superior, in the short term, to the placebo in terms of pain reduction, functional recovery, and quality of life. Moreover, thanks to its safety profile, it could be considered a first-line therapeutic approach in fibromyalgia. Of course, further studies are still needed to assess their effectiveness over time. Our goal was to create a starting point for further research developments that include conservative and/or minimally invasive treatments, such as mesotherapy, in treating cervical pain and improving the quality of life of these patients.


No significant differences were found on the VRS scale between nurse assessments and patient self-assessments of current pain intensity. The pain was described as moderate by 35% of participants, including 35.9% nurses and 35% patients. Significant positive correlations were recorded between values on the VRS and NRS scales for nurses  and patients . The results of this study may have implications for the improvement of postoperative pain management protocols, with regular use of pain assessment scales and individualization of analgesic prescriptions.Postoperative pain is the most common form of acute pain. Nurses contribute to effective pain management with their knowledge and skills. The aims of this research were to examine differences between nurses’ assessments and patients’ self-assessments of postoperative pain, differences in the mentioned (self) assessments with respect to characteristics of both groups of respondents, and the correlation between the NRS and the VRS scale. The study included 103 nurses employed at a hospital and 103 patients treated in the surgical departments after the surgical procedures. Data were collected using the standardized Numerical rating scale (NRS) and Verbal rating score (VRS). The median of patients’ self-assessments of pain intensity on the NRS scale was 4, while the nursing assessment of patients’ pain was 3, with no significant difference ( Postoperative pain has long been ignored or inadequately treated . Pain asAssessment of pain intensity level is a key component in providing effective pain treatment. The systematic process of evaluation, measurement, and re-assessment improves the ability of nurses and healthcare teams, in general, to reduce the experience of pain in patients; increase comfort and satisfaction during hospital stays; and improve physiological, psychological, and physical functions after surgery . To avoiThere are several types of instruments  to assesSubjective pain assessment includes one-dimensional and multidimensional tools. The most commonly used one-dimensional tools in the assessment of acute pain intensity are visual analogue scales; verbal, graphic, and numeric rating scales; pain flow diagrams; computer graphics; and pictorial scales ,19, as sTreatment of acute pain requires close interdisciplinary collaboration in the planning and implementation of treatment ,23. EffePain, as one of the most common patient symptoms encountered by nurses in their practice, has been analysed and described in theories by well-known nurses. The theory of unpleasant symptoms is the first midrange theory that deals with the assessment of multiple symptoms and, as such, provides a broader view of the interrelationship between symptoms and their outcomes ; this thIn this study, a quantitative research approach was applied with the use of two validated scales and measurement methods. Data were collected from respondents only once, in two different time periods, which indicates a cross-sectional design. Given that the goals of this research were primarily focused on examining differences between nursing assessments and patient self-assessments of postoperative pain and examining correlations between the two applied scales, this study can be described as a quantitative, cross-sectional correlational study.This study was conducted at the Clinical Hospital Center in the Republic of Croatia in four departments where surgical patients are treated . The study was carried out in two phases, including a preoperative examination of the patient on sociodemographic data as well as expectations and fears about pain after surgery, alongside a simultaneous assessment of pain by nurses and self-assessment of postoperative pain by patients in the mentioned health institution. The selection criteria for the healthcare institution included the following: (a) the healthcare institution in our study is the central and largest healthcare institution in this region of Croatia, (b) the healthcare institution belongs to the first category according to the Croatian classification , (c) approval of the Hospital Board of Directors to conduct the study, (d) the institution is a teaching base of the faculty within which the researchers conduct the study. The criterion for selecting the hospital departments for the study meant that 24-h service was provided.The study sample consisted of working nurses and patients who were hospitalised at the Clinical Hospital Centre. Inclusion criteria for both samples were as follows: the respondents are (a) over 18 years of age, (b) read and understand the Croatian language, and (c) voluntarily participate in the study. Of the total of 223 respondents from both samples, 206 completed the questionnaires (response rate of 91%). From the nursing staff group, the response rate was 100%, while from the patient group it was 85.8%, because 17 patients did not meet the inclusion criteria on the first postoperative day. To detect a medium effect (d = 0.5) in the difference of numerical variables between nurses and patients with a significance level of 0.05 and a power of 0.80, the minimum required sample size was 128 respondents (64 per group) (G*Power 3.1.9.4).Additional inclusion criteria for the sample of nurses were as follows: (a) respondents are nurses permanently employed at the mentioned health institution, (b) respondents provide direct healthcare to hospitalised patients; exclusion criteria included nurses employed in the outpatient clinic for day surgery and in the operating room. Additional inclusion criteria for the sample of patients were the following: (a) hospitalised patients in surgical departments after simple elective surgeries  on the first postoperative day; (b) fully conscious and communicative, without obstacles in pronunciation ; (c) respondents have a predefined dose of analgesics on the Therapy List, which they can receive “on demand”. The exclusion criteria were as follows: patients operated on in a day surgery clinic (discharged on the first day after surgery); respondents on continuous permanent analgesia, with whom verbal communication cannot be established or with obstacles in pronunciation.The questionnaire used in this study included two validated standardised scales: (a) Numerical rating scale (NRS)  and (b) Data were collected over two months through two phases. In the first phase, during admission of the patient to the surgical department, patients were asked if they wanted to participate in this anonymous study and signed an informed consent form to participate. The patients then completed the first part of the questionnaire, which included sociodemographic data. Furthermore, the researchers instructed the patients to inform the nurse of any pain on the first postoperative day using only the sentence “nurse, I am in pain”, along with the usual physical expressions of pain . This formulation was used exclusively for research purposes to assess nursing pain objectification skills with as little verbal input as possible from the patient.The surveyed nurses were also asked to anonymously participate in the study, for which they signed informed consent. In the first phase of data collection, they completed a section of the questionnaire that included sociodemographic questions. The researchers instructed them on the statement the patient would make when pain first appeared on the first postoperative day. After the surgical procedure, if the patient met the inclusion criteria, they could proceed to the second phase of the questionnaire completion. On the first postoperative day, when the patient informed the nurse for the first time that they were in pain, she assessed their pain level using the NRS and VRS scales based on the patient’s appearance and behaviour. Afterward, the patient self-assessed the intensity of their pain on the NRS and VRS scales. After completing the second phase of data collection, the patient received prescribed analgesia according to the standard pain management procedure in the hospital.Participation in the study was voluntary and anonymous. Along with the questionnaire, the respondents also received an introductory text containing information about the details of the study . Respondents confirmed their voluntary participation in the study by signing a questionnaire and completing it for the researcher. The respondents had the right to withdraw from the study without consequences. The anonymity of the respondents was guaranteed, i.e., it was not possible to determine their identity from their answers. Only researchers had access to the study data. All procedures of translation of applied NRS and VRS scales are under the jurisdiction of the Croatian Council of Nurses and approved by the Ministry of Health of the Republic of Croatia . The stu® Statistical Software version 20.100  and SPSS Statistics for Windows, Version 23.0 .The numerical data were described using basic measures of central tendency and dispersion. The normality of the distribution of the observed numerical variables was tested using the Kolmogorov–Smirnov test. Categorical variables were described using absolute and relative frequencies. The Mann–Whitney test was used to compare two independent groups when the data were not normally distributed. The Kruskal–Wallis test was used for more than two independent groups. Differences among categorical variables were tested using Fisher’s exact test. The correlation between numerical variables was measured using Spearman’s correlation coefficient (Rho). A significance level of α = 0.05 was chosen to evaluate the significance of the results. The computer software used for statistical analysis was MedCalcA total of 206 participants took part in this study, including 103 (50%) nurses and 103 (50%) patients . The samp = 0.083). The distribution of the nurse and patient respondents with respect to the assigned numerical values of the assessed and self-assessed pain on the NRS scale is shown in The overall mean value (median) of patients’ self-assessments of pain intensity on the NRS scale was 4 (interquartile range 2–5), while the nursing assessment of patient pain was 3 (interquartile range 2–5), with no significant difference  according to gender  men and 16 (27.6%) women, while strong pain was described by 8 (17.8%) men and 13 (22.4%) women, without a significant difference  and patients .Significant positive correlations were recorded between values on the VRS and NRS scales for both nurses  assessments with respect to characteristics of both groups of respondents and to examine the correlation between the NRS and VRS scales.The results of this study indicate that there is no significant difference in the overall mean value of pain assessed by nurses on the NRS scale, which is 3 (interquartile range 2–5), and the patient’s self-assessment of pain, which is 4 (interquartile range 2–5). Furthermore, there was no significant difference between nurses’ assessments and patients’ self-assessments of the current intensity of postoperative pain on the VRS scale.Similar results were reported by a research team from Norway. They conducted a scoping review of multiple published studies and showed that achieving consistent pain assessment between patients and nurses on numerical and verbal pain scales can ensure better treatment of postoperative pain due to similar levels of understanding of pain by nurses and patients . They alThe agreement between nursing assessments and postoperative pain self-assessments of postoperative pain in this study may also be the result of good preoperative preparation of patients for pain. The patient typically undergoes a structured interview with an anaesthesiologist about previous anaesthesia, allergies, and previously used methods of postoperative analgesia. The patient comes into contact with a nurse on the ward on the day before or the day of the surgical procedure. Despite the overall physical preoperative preparation and unfavourable staffing organization of the ward, the nurse usually manages to talk to the patient about the expectations and fears of pain and inform them about pain management options. Every patient has the right to be informed and educated, and with hospital accreditation, informing patients becomes a legal obligation for all employees . MoreoveIn this study, the pain was assessed as “unpleasant” on the VRS scale by 35.9% of nurses and 35% of patients. The highest agreement on the assessment of pain on the NRS scale in this study was in the selection of level 6. Choosing the “middle ground” in assessing the intensity of a patient’s pain by nurses creates a certain level of certainty in avoiding errors in assessment. When nurses deviate from the average value, they often assess and mark a lower level of pain. In descriptive scales, the occurrence of the “middle ground” is more common because data are obtained during the conversation, often without directly formulated questions about the pain. Non-verbal communication as well as many factors that affect verbal communication during the first postoperative day  can favour the assessment. The literature describes an underestimation of a patient’s pain level on surgical wards that is often a result of insufficient nursing communication with the patient about pain. Nurses do not generally enquire about a patient’s subjective experience of pain. The experience of pain should be fully examined, as well as the meaning of pain to each patient. Experience in practise indicates that nurses on surgical wards are responsible for assessing and transmitting data about a patient’s pain to the doctor. In contemporary hospital practise in Croatia, the patient has a precisely determined dose of medicine written on the so-called therapeutic list by the operating surgeon or anaesthesiologist. Regardless of the intensity of pain expressed by the patient, the nurse gives the prescribed dose of medication to the patient as needed and monitors its effects and the patient’s reactions, along with a qualitative and quantitative assessment of pain. Objective pain measurement with a pain scale and adjustment of the therapeutic dose according to the result are rarely performed.Continuous use of pain scales would improve patient understanding, safety in hospital treatment, nursing documentation, pain history tracking, standardisation of pain management procedures, and faster postoperative recovery, ultimately reducing healthcare costs. Although this study did not record significant differences in overall pain assessment between nurses and patients, differences were noted only at certain levels of pain. Constant monitoring and evaluation of pain intensity using pain scales would significantly improve the outcomes of pain management on surgical wards and contribute to positive changes in the approach of the entire healthcare team . Fletcher et al.  focused In this study, the majority of VET-educated nurse respondents rated the pain as moderate on the VRS. Master’s-degree-holding nurses rated pain with a score of 6 on the NRS, while nurses with other levels of education rated pain with a score of 3. The differences in the perception of pain by nurses based on their educational background were greater on the NRS scale and smaller on the VRS scale, indicating high consistency among nurses in their work, as well as better marking on the NRS scale. On the verbal scale, MSc nurses did not rate patients as having any pain or unbearable pain in any case. As many as 77.7% of nurses in this study work in 12-h shifts (day and night) shifts, with VET education level and without BSc- or MSc-level supervisor education. These results suggest the expertise of nurses who continuously monitor and evaluate patients throughout the postoperative recovery period, as well as the high level of empathy of nurses regardless of their level of education. MSc nurses have more formal training, training, and clinical experience in pain management than VET nurses. This experience can help better understand and assess postoperative pain in patients. In some organisations, MSc nurses may be more involved in pain management and have more opportunities to specialise in that area, while in other organisations, this may not be the case . MSc nurIn this study, male and female patients self-assess pain equally on the NRS scale, while the biggest differences in self-assessment of pain, based on sex, are on the VRS scale in the descriptions of “mild pain” and “severe pain”. However, the majority of patients on the VRS scale self-assess pain as moderate, unpleasant pain, especially men, which could be interpreted as patients objectively marking pain on the NRS scale because they can describe pain on the VRS scale. More men chose moderate pain on the VRS scale, but there are studies that describe men as more willing to endure and not express as much pain as they actually experience ,44. WiseIn this study, it was found that the higher the assessment and self-assessment of postoperative pain on the NRS, the higher the VRS values in both groups of participants. Ho-Jin Lee and colleagues  reportedIn this cross-sectional study, participants are nurses who work in direct patient care and are employed in a clinical hospital in Croatia, as well as patients hospitalised in surgical departments during the postoperative period. Therefore, the sample is not large enough to generalise the results to all healthcare professionals and surgical patients in hospital institutions at the level of the Republic of Croatia. In the future, a study is planned to be conducted with more participants from different categories of hospital institutions  from different regions in Croatia. In addition, future studies could include the results of pain assessment after different types of surgery, as pain and its assessment method may differ depending on the type of surgery. Furthermore, different pain assessment techniques could be included and the effectiveness of different interventions in reducing postoperative pain could be investigated. Ultimately, possible cultural differences in pain assessment and self-assessment could be included and taken into account in the analysis of the results. This would contribute to a higher level of objectivity and a better understanding of the patient’s postoperative pain in the hospital environment.The results of this study may have implications for the development of a higher quality treatment of patients’ pain after surgical procedures in surgical departments. Namely, the conducted study showed that nurses assess pain similarly to patients on two different one-dimensional scales. With their knowledge, empathy, and communication with patients, as well as the recognition of pain episodes in patients, nurses are ready to provide patients with an individualised approach to pain assessment and management after surgery. Based on the results of this study, hospital protocols can be established in the field of pain management related to the regular and continuous use of pain assessment scales and the individualisation of analgesic prescriptions for each patient. In addition to the abovementioned changes that the hospital could devise and implement, it is necessary to involve hospital management and physicians who are responsible for prescribing analgesia doses. The introduction of individualised pain management would contribute to meeting the needs of patients in terms of pain relief, which would ultimately significantly contribute to more effective overall patient care.The results of this study indicate that there is no significant difference between nursing assessments and patients’ self-assessments of postoperative pain. The length of nursing work experience is not related to the level of assessed pain. Differences in pain assessment between nurses and patients were found in the group of nurses with 21–30 years of work experience, where there is a stagnation in professional enthusiasm and a decrease in willingness to work and collaborate with the team. The level of training of nurses is not related to the assessment of pain in patients. VET nurses are the ones who care for patients in this study for the highest percentage of 24 h, and their work with the patient does not diminish the quality of the patient’s pain assessment and, thus, overall health care. Nurses, regardless of work experience and professional qualifications, are sufficiently educated and empathetic to work with patients during the postoperative period. Consistent use of pain assessment scales, structured patient education with written materials, and individualisation of prescribed analgesia for patients will contribute to patient safety and satisfaction, as well as improve the overall quality of healthcare.


Quadratus lumborum block is a relatively new truncal block and different approaches to this block have been described. With a recent modification to the subcostal approach to the anterior quadratus lumborum block (QLB3), the injection point was moved further cranially and medially, thereby aiming to enhance the spread of the local anesthetic into the thoracic paravertebral space. Although the level of blockade achieved with this modification seems sufficient for open nephrectomy, the modification is still for clinical evaluation. In this retrospective study, we aimed to evaluate the effects of the modified subcostal QLB3 approach on postoperative analgesia.All adult patients who received a modified subcostal QLB3 for postoperative analgesia following open nephrectomy between January 2021- 2022 were retrospectively evaluated. Accordingly, total opioid consumption and pain scores during rest/activity within the first 24 h after surgery were evaluated.A total of 14 patients underwent open nephrectomy were analyzed. Pain scores within the first 6 h postoperatively, particularly the dynamic numeric rating scale (NRS) scores (4–6.5/10), were high. The median (interquartile range) resting and dynamic NRS scores for the first 24 h were 2.75 (1.79) and 3.91 (1.67), respectively. The mean ± standard deviation IV-morphine equivalent dose for the first 24 h was 30.9 ± 10.9 mg.It was found that the modified subcostal QLB3 did not provide satisfactory analgesia in the early postoperative period. Further randomized studies that extensively investigate the postoperative analgesic efficacy are required to draw a stronger conclusion. Open nephrectomy causes a significant level of postoperative pain, and thoracic epidural analgesia is routinely used to treat this type of pain. However, the development of hypotension as a result of bilateral sympathectomy due to this technique limits its use. In addition, comorbidities and medications used in the patient population undergoing surgery, particularly anticoagulants, render the use of neuraxial techniques unfavorable .Quadratus lumborum block (QLB) is among the relatively new truncal interfascial blocks that involve different local anesthetic (LA) injection sites and therefore different levels of dermatomal blockade . AnterioInjecting the LA closer to the region where QLM attaches to the 12th vertebra makes it easier for the LA to reach the lower thoracic paravertebral space (TPVS), thereby ensuring a higher level of sensory block encompassing the mid-thoracic dermatomes. Indeed, in previous studies, dermatomal spread to T9–L1 was reported with QLB3 and to T6–L2 with the subcostal approach . HoweverA retrospective evaluation of the open nephrectomy case series was performed for the time period between January 2021 and January 2022 upon approval (2022/578) from the Clinical Trials Ethics Committee of Ondokuz Mayıs University. All adult patients who received modified subcostal QLB3 for postoperative analgesia were included in the study. The data were obtained from the medical anesthesia records of the university hospital. The data included patient descriptive characteristics and the numeric rating scale (NRS) scores during rest and activity, and heart rate and mean arterial pressure. The pain scores during rest and activity within the first 24 h postoperatively (post-anesthesia care unit [PACU]-3–6-12–18-24 h) according to NRS. Pain was managed with intravenous (IV) patient-controlled analgesia (PCA) . Patients could demand opioids from the PCA device when the NRS score was ≥ 4 during activity. Conversely, patients who still had an NRS score ≥ 4 despite opioids were administered IV tramadol 100 mg for rescue analgesia. In addition, all patients were administered IV paracetamol 15 mg/kg in 6-h intervals. Total opioid consumption within the first 24 h starting from the PACU was recorded.The patients were placed in sitting position and the relevant surgical field was prepared with povidone iodine according to the principles of asepsis/antisepsis followed by sterile draping. Convex ultrasound probe with a plastic sterile cover  was placed 6–8 cm lateral to the L1 spinous process, with the orientation marker cranially located. Here, the acoustic shadow of the 12th rib and QLM were identified. The probe was then moved medially until the edge of the L1 transverse process was visible. The apposition zone between the QLM and the diaphragm and the acoustic shadow of the 12th rib were viewed on the ultrasound. The apposition zone enables spread of the LA to the TPVS through the inferior aspect of the lateral arcuate ligament and along the sub-endothoracic space. Visualization of the QLM, LAL, ATLF, and diaphragm movements was considered necessary for optimal ultrasound imaging.For local infiltration, 1–2 ml of 1% lidocaine  was administered to the cutaneous-subcutaneous tissues where the block needle would be inserted. This was followed by moving a 21-G, 100-mm short-bevel block needle  towards the plane between the investing fascia of QLM and ATLF right under the LAL in the caudocranial direction with the in-plane technique; 1–2 ml of 0.9% normal saline was injected to confirm the location of the needle  and remifentanil (infused at a rate of 0.1–0.25 mcg/kg/min), and endotracheal intubation was performed with rocuronium (1.2 mg/kg). Maintenance anesthesia was achieved with 1 MAC  age-adjusted sevoflurane and O2/Air (fraction of inspired oxygen: 0.40) mixture, and remifentanil IV infusion (0.1–0.25 mcg/kg/min). After radial artery cannulation on the dependent side, the remifentanil infusion rate was adjusted to maintain heart rate and blood pressure within ± 20% of baseline values. At the end of the surgery, rocuronium was reversed with a combination of atropine and neostigmine, and extubation was performed. For analgesic purposes, IV tenoxicam 20 mg was administered after induction, and IV paracetamol 15 mg/kg was administered 20 min before the end of the case. For postoperative nausea and vomiting (PONV) prophylaxis, the patients were routinely administered IV dexamethasone 8 mg before induction and IV ondansetron 0.1 mg/kg 20 min before the end of the procedure. PONV was evaluated with a 4-point scale , and patients with a score > 1 were additionally administered IV ondansetron 0.1 mg/kg. If it failed, IV metoclopramide 0.15 mg/kg was added.NRS scores were calculated for two distinct conditions, that is, during rest and activity, in the first 24 h postoperatively (PACU-3–6-12–18-24 h). In addition, total opioid consumption was recorded in the first 24 h starting from the PACU and converted to IV morphine equivalent dose (MED). The data were analyzed using the Statistical Package for the Social Sciences Version 24 . The normality of the data was evaluated using the Shapiro–Wilk test. The quantitative data with a normal distribution were represented using mean ± standard deviation values, while the data with non-normal distribution were reported using median values (interquartile range). Categorical data were presented using absolute frequencies and percentages.This case series consisted of 14 patients, that is, 7 patients (50%) who underwent open radical nephrectomy and 7 patients (50%) who underwent partial nephrectomy. Patient demographics and NRS scores during rest and activity were provided in Tables In patients undergoing open nephrectomy who received modified subcostal QLB3 with a single injection in the preoperative period, pain scores within the first 6 h post-surgery, especially the dynamic NRS scores, were high (4–6.5/10). However, the total 24-h pain scores were more reasonable.p = 0.004) were lower in our patients compared to the values in the said study. Increased LA spread to the lower TPVS as a result of this modification may have led to this outcome. In the above-mentioned study, the patients had high pain scores in general and especially in the first day (4–5/10). The authors could mostly block the T8–12 dermatome . This block level could have been insufficient for the pain after nephrectomy incision. Conversely, the authors attributed the mentioned high pain scores to the fact that three patients had chronic pain. In the present study, pain scores could not be reduced to the desired level in the early postoperative period. This may have stemmed from failure of the LA to reach the TPVS in a degree that would ensure splanchnic nerve/celiac ganglion blockade which is especially required for visceral analgesia ), respectively . SimilarIn the literature, there are also case presentations that contradict our article. For instance, it was reported that a satisfactory level of analgesia was achieved with a single injection in patients undergoing nephrectomy who received QLB3, wherein one patient had 13 mg of 24-h morphine consumption and another patient did not even need additional analgesics , 12. In Although studies on QLB in laparoscopic nephrectomy are ongoing, the existing data are promising for postoperative pain control and opioid reduction in patients . CompareFirstly, the statistical value of our deductions is limited, since a small patient group was evaluated in this retrospective analysis. In addition, the present study was not a randomized but a descriptive study. Finally, the study did not include any obese patients.This modification of the subcostal QLB3 should be compared with placebo or other classic QLB approaches in prospective randomized studies to be conducted in the future. This would enable a more extensive investigation into the postoperative analgesic efficacy of this technique. Moreover, it should be investigated in cadaver and imaging studies whether this modification increases LA spread into the lower TPVS.In summary, it was found that modified subcostal QLB3 below the lateral arcuate ligament level did not provide satisfactory analgesia in the early postoperative period.


Introduction: Total knee arthroplasty (TKA) is now being performed in the outpatient setting, and often the postoperative pain is managed with opioid analgesics. Non-opioid pain management modalities are in crucial demand, and we propose a surgical technique that can potentially result in less pain and the decrease in the use of opioid analgesia following TKA. The purpose of this study was to investigate the safety and efficacy of a novel peripheral nerve block (PNB) that includes a single injection and catheter placement for a continuous regional nerve block in total knee arthroplasty.Methods: Fifty-six patients underwent TKA by a single surgeon utilizing the novel method. Patient-reported outcomes were entered into an outcomes database and compared to an aggregate of over 3,500 comparative TKA patients. A visual analog scale (VAS) evaluated perioperative pain. Patient perioperative opioid usage, expectations of pain control, the incidence of common side effects, and the average hospital length of stay (LOS) were collected.Results: Compared to the aggregate of patients in the database, the patients who received the novel surgeon-placed adductor canal block (ACB) and catheter placement reported findings that suggest this technique can possibly lead to a decrease in the severity of pain in addition to a reduction in side effects and the need for opioid analgesia. LOS for these patients was short, and patient satisfaction scores were excellent for the surgeon performing this technique.Conclusions: Using the placement technique described, surgeons can reproducibly perform a single injection of PNB and place an indwelling catheter in the adductor canal through direct visualization of the muscles that make up the borders of the adductor canal. This technique offers potential advantages over pain management modalities that can be elucidated in further studies. The power of this study is limited due to these findings having not been analyzed for statistical significance. Total knee arthroplasty (TKA) is considered one of the most painful medical procedures that a patient can undergo -3. Pain However, the optimal PNB or combination of blocks remains unclear ,2. ThereThe adductor canal is a musculoaponeurotic tunnel that originates at the apex of the femoral triangle in the mid-thigh and extends distally to the adductor hiatus . The canThe saphenous nerve travels between the muscles that comprise the adductor canal and is a pure sensory nerve carrying a large majority of sensory innervation from the knee ,11. It iManagement of post-operative pain after TKA is critically important and one of the primary reasons for the need of inpatient care after TKA. Pain control during the immediate post-operative period is also critical if patients are going to reach the rehabilitation goals required to achieve the most successful outcome . TraditiWhile surgeons have long performed local nerve blocks and joint capsular injection cocktails, regional nerve blocks have recently gained significant popularity . These rThe placement of these indwelling catheters can present challenges. Some surgeons may find that anesthesia services are either not set up to place indwelling catheters and/or not willing to provide post-operative care or monitoring of these catheters. The placement of these catheters may also present with a challenge for the anesthesia services regarding the best location for the catheter placement. If placed at the mid or low  adductor canal position, the catheter can invade the sterile surgical field, or be in jeopardy when a tourniquet is used. If the catheter is placed high  in the adductor canal to avoid the tourniquet and sterile surgical field, the risk of a motor block of the femoral nerve can be realized . The purMethodsBetween July and November of 2017, 56 consecutive patients who underwent primary total knee arthroplasty (TKA) performed by a single surgeon were entered into the study cohort. There were 31 females, and 25 males aged from 51 to 91 with a mean of 70.5. After informed consent, patients agreed to assist with collecting outcomes data by answering pre-operative and post-operative questions related to pain, use of opioid medications, and issues with nausea, emesis, constipation, dizziness, and drowsiness. The length of stay in the hospital was also collected. Patients were randomly entered into this study cohort as they presented consecutively through the clinic for TKA. Each of the patients had a 23-hour outpatient TKA performed. To remove selection bias, all patients were entered into the study group consecutively without any regard to co-morbidities, the extent of disease, or deformity.Patients agreed to be entered into an email/text-based data collection program. Staff enrolled patients pre-operatively, and patients then received email and text messages to respond to questions pre-operatively and post-operatively through post-op day seven. Patient data were collected in a prospective manner and then entered into a database to compare outcomes with a database aggregate of comparative TKA patients who received a single-shot adductor canal block, placed by anesthesia, but did not receive the novel surgeon-placed block and catheter placement as described in this study. A visual analog scale (VAS) was used to evaluate perioperative pain. Patient perioperative opioid usage, patient’s expectations of pain control, the incidence of common side effects, and the average hospital length of stay (LOS) were also analyzed. Surgeon-placed adductor canal techniqueUsing a standard parapatellar, mid-vastus, or sub-vastus approach to TKA, the surgeon can readily place a catheter between the muscles that make up the adductor canal using only blunt retraction of the vastus medialis oblique muscle (VMO) without any further significant dissection. This regional nerve block and catheter placement take less than 60 seconds to perform, adding no additional time to the surgical procedure. This can be performed while the cement is curing or during the irrigation phase prior to closing if using an uncemented prosthetic. While this placement may be a slight paradigm shift for some surgeons, the medial knee joint anatomy is very familiar to all surgeons and requires a very shallow learning curve to perform.The VMO, the adductor longus, and the sartorius are the three muscles that makeup the borders of the adductor canal. This adductor canal is easily accessed through any standard anterior surgical approach to the distal femur. The surgeon must first identify and palpate the adductor tubercle and the medial intermuscular septum, which is found as the fascia lying just anterior to the adductor longus tendon that attaches to the adductor tubercle. Two major sensory nerves, the saphenous nerve and the obturator nerve (anterior and posterior branches), are the major sensory nerves that provide sensation to the knee joint ,13,19. TPlacing an introducer needle with a peel sheath through the skin laterally at the superior pole of the patella, the needle is placed underneath the rectus femoris and brought into this potential medial space. The surgeon is then able to pass a “soaker type” catheter through this introducer needle and then grasp the catheter to bring it into the surgical wound. After removing the peel sheath, the surgeon can grasp the catheter and pass it 8-10 inches into the adductor canal from distal to proximal between the muscles that make up the borders of the adductor canal. This reproducibly and safely places the catheter along the course of the saphenous nerve within the adductor canal. The nerve and femoral vessels are protected by the fenestrated medial intermuscular septum that runs along the nerve as it courses through the adductor canal.Fifty-six patients were prospectively entered into this original study group. Each patient agreed to complete the daily survey over the first seven post-operative days. Forty-eight patients (86%) initiated the surveys during this collection period Figure . Thirty-Overall, when compared to the aggregate database, patients in this study had a 24% reduction in total opioid pills used (POD 1-7), 25% reduction in pain on the VAS 3.9 to 2.9)  into the outpatient freestanding ambulatory surgery center (ASC) arena -16. ThisPost-operative pain management remains a major concern, as adequate pain control is one of the primary reasons for the need for inpatient care. Traditionally, pain management has relied heavily on parental and oral opioid analgesics . These oSignificant improvements have been achieved over the past decade with regard to pain management. Most of these advancements have been related to multi-modal pain management protocols ,18. ThesTraditionally, these regional nerve blocks have been placed by anesthesia services using a nerve stimulator or, more recently, ultrasonic guidance ,20,21-26While the traditional single-injection regional ACBs can provide significant relief for the first 16-24 hours, patients can experience a significant rebound of pain as the block resolves . Even thThese indwelling catheters are traditionally placed pre-operatively. As noted in the introduction, if placed in the mid or low  adductor canal position, the catheter can invade the sterile surgical field or be in jeopardy when a tourniquet is used. In contrast, if the catheter is placed high  in the adductor canal to avoid the tourniquet and the sterile surgical field, the very real risk of a motor block on the femoral nerve is realized ,27-30. TKavolus et al.  publisheThe senior author of this article has been successfully placing adductor canal blocks and indwelling catheters under direct visualization, using the technique described in this paper since 2016.Limitations of this studyThis study was performed retrospectively outside the setting of a clinical trial. The results of this study have not been analyzed for statistical significance, so it is unclear if the improvements in pain, opioid use, and adverse side effects are statistically significant. The findings in this article detail less than 5% of the operations that the senior author has performed with this technique. While the technique is showing promising efficacy in the pioneering surgeon's clinical practice, this article serves the purpose of exposing the community of orthopedic surgeons performing TKA to this technique while simultaneously showing promising preliminary data associated with this method. In order to fully assess the efficacy of this method in improving pain and reducing opioid usage, a proper clinical trial with appropriate analysis is warranted for further study.Using the placement technique described in this study, surgeons can reproducibly place a single injection and an indwelling catheter for a continuous nerve block in the adductor canal under direct visualization of the muscles that make up the borders of the adductor canal. This novel technique and placement have potential advantages over anesthesia placement techniques with regard to efficacy, efficiency, and safety. When using this described novel technique in combination with a comprehensive multi-modal pain management protocol, patients may experience significantly less pain, use fewer opioids, have a shorter hospital length of stay (LOS), and have less side effects without jeopardizing quality scores and patient satisfaction. There is also the potential for significant cost reduction in a bundle payment scenario with the elimination of additional anesthesia procedures.Using the surgeon-placed adductor canal block techniques presented, in combination with a multi-modal peri-operative pain management protocol, the surgeon can address the opioid epidemic and move one step closer to establishing an outpatient total joint service. Based in part from the evidence in this study, the senior author of this paper (DEM) began a successful, same-day discharge outpatient total joint program in August 2020. At the time of submission of this manuscript, the senior author had successfully performed 403 consecutive outpatient total joint arthroplasty procedures with a mean post-operative time to discharge of 3 hours 23 minutes. To date, there have been no readmissions related to same-day discharge. At the time of submission of this manuscript, the senior author (DEM) had successfully placed indwelling catheters using this novel technique in over 1275 patients without any complications related to this placement.


Rheumatoid arthritis is a chronic systemic disease that causes joint damage. A variety of methods have been used to evaluate the general health status of these patients but few have specifically evaluated the hands. The objective of this study was to translate, perform cultural adaptation and assess the validity of the Michigan Hand Outcomes Questionnaire for Brazil.  Validation study conducted at a university hospital in Curitiba, Brazil. Firstly, the questionnaire was translated into Brazilian Portuguese and back-translated into English. The Portuguese version was tested on 30 patients with rheumatoid arthritis and proved to be understandable and culturally adapted. After that, 30 patients with rheumatoid arthritis were evaluated three times. On the first occasion, two evaluators applied the questionnaire to check inter-rater reproducibility. After 15 days, one of the evaluators reassessed the patients to verify intra rater reproducibility. To check the construct validity at the first assessment, one of the evaluators also applied other similar instruments.  There were strong inter and intra rater correlations in all the domains of the Michigan Hand Outcomes Questionnaire. Cronbach's alpha was higher than 0.90 for all the domains of the questionnaire, thus indicating excellent internal validity. Almost all domains of the questionnaire presented moderate or strong correlation with other instruments, thereby showing good construct validity. The Brazilian Portuguese version of the Michigan Hand Outcomes Questionnaire was translated and culturally adapted successfully, and it showed excellent internal consistency, reproducibility and construct validity. This was a convenience sample. The number used was chosen in accordance with the guidance of Beaton et al.,All the patients investigated were users of the public healthcare system .Two independent native speakers of Brazilian Portuguese who were fluent in English translated the original MHQ from English to Brazilian Portuguese in the manner recommended by Guillemin et al.This version of the MHQ in Brazilian Portuguese (which was considered to be the test version) was administered to 30 patients with rheumatoid arthritis, who were selected from the Rheumatology Outpatient Clinic of the Evangelical University Hospital in Curitiba, Paraná, taking into account the American College of Rheumatology (ACR) classification criteria.,,,With regard to cultural equivalence, the patients' degree of understanding was measured by a yes/no answer to the question: "Do you understand what is being asked for"? Any items that were not understood by 20% of the respondents would be revised by the expert committee and the new version would be retested on 30 patients. The proportion of 20% was defined in accordance with what had been used in previous, similar published papers.A new group of 30 patients was selected using the same inclusion and exclusion criteria, after the MHQ had been tested and semantic and cultural equivalence had been attained. These patients were evaluated three times. In the first interview, two examiners administered the questionnaire on the same day to check inter-rater reproducibility. In the second interview, which was conducted 15 days later, one of the first reviewers reapplied the MHQ with the intention of verifying the inter-assessment reproducibility. The internal consistency of the multi-item subscales was assessed.The construct validity was tested in the first interview through simultaneous application of the Disability of the Arm, Shoulder and Hand questionnaire (DASH),19 Visual Analogue Scale (VAS) of pain,We used descriptive statistical analysis showing the mean and standard deviation of the data. Intraclass correlation coefficient (ICC) evaluation and Bland-Altman analysis were used to assess the interobserver and intra-observer reproducibility. Internal consistency was assessed by means of Cronbach's alpha test. The Spearman correlation test was used to investigate the construct validity.Calculations were done with the aid of the GraphPad Prism 6.0 software  and SPSS 17.0 .Thirty patients diagnosed with RA according to the ACR criteriaThere were no losses in applying the protocol. All the patients who agreed to participate completed the whole evaluation, and the evaluator checked whether each questionnaire had been completed before releasing the patient. About 30% of the patients who were invited to participate in the study did not accept the invitation and thus were not included. s ranging from -0.41 to -0.89) were found.RA is a chronic systemic disease that causes joint damage especially in the wrist and small joints of the hands. Decreased joint mobility, reduced grip strength and deformities occur early in the disease and are some of the major determinants of the disease outcome.,,,A growing number of questionnaires for evaluating hand function and the impact of RA on patients' quality of life have been introduced.,The MHQ measures individuals' perceptions of their hands in terms of function, appearance, pain and satisfaction. These last three items provide an advantage for this questionnaire over the COCHIN Rheumatoid Hand Disability scale, which does not include them. Pain control and esthetics have been demonstrated to be important motivators for surgical interventions in RA patients.We present here a Brazilian Portuguese version for MHQ. We have followed the validation process proposed in the guidelines of the American Academy of Orthopedic Surgeons Outcome Committee.In this study, we chose a test-retest interval of two weeks. RA is a chronic disease and we believed that over a two-week period, no important changes to the disease status would occur but that this would be long enough for a patient not to recall the content of the instrument from the first interview. None of the patients had any changes in medication over this interval. Both the intraclass correlation (ranging from 0.84 to 0.96) and the interclass correlation (ranging from 0.61 to 0.92) were high, as can be seen in Concerning the construct validity, we compared the Brazilian Portuguese version of MHQ with DASH, COCHIN, VAS for pain and HAQ. We found moderate to high correlations between these instruments and most of the MHQ domains, except for the following: esthetics, which showed weak correlations with HAQ, DASH and DASH Work; ADL, which showed a weak correlation with VAS; and satisfaction, which showed a weak correlation with HAQ. Since the MHQ is the only instrument that evaluates esthetics and satisfaction, this explains the weak correlation found.One weakness of this study is that only 30 patients were included in each phase. However, this disadvantage was minimized by achieving a Cronbach's alpha for internal consistency that was higher than 0.90. Calculating Cronbach's alpha in future studies using this tool will certainly help support its validity.Another weakness to be taken into account is the lack of economic profile information for the patients in our dataset. Although this does not affect the validation of the questionnaire, it does preclude comparisons of this characteristic in future studies.We conclude that the Brazilian Portuguese version of the MHQ was successfully translated and adapted, with very good internal consistency, reliability and construct validity.