Identifying pain problems, healthcare professional perceptions, expectations and challenges in multidisciplinary pain center establishment

Aim: Before establishing a multidisciplinary pain center (MPC), the pain problem, healthcare professionals (HCP) perceptions, expectations and the potential challenges of MPC establishment need to be identified. Methods: A quantitative survey study of 1058 Indonesian HCPs. The study uses a national inquiry sent by the International Association for the Study of Pain (IASP) chapter for pain. Results: 99.0% of respondents had met patients with pain as the primary complaint and acute pain as the most common complaint. Insufficient pain management in Indonesian healthcare, insufficient pain epidemiological data and unaware HCP about MPC become problems of pain management in Indonesia. However, most HCP agreed that health facilities should have MPC. Financial issues (insufficient patient insurance) were considered the most important barrier for referring patients to MPC. Conclusion: The identified core problem, HCP perceptions, expectations and challenges of MPC establishment should become a consideration in the strategic planning of MPC establishment.

The Effect of Flunarizine Prophylactic Treatment on Headache Frequency and Plasma Glutamate Levels in Chronic Tension-type Headache Patients

Background: Previous research has shown that flunarizine may be used for the prophylactic treatment of migraine and that plasma glutamate level monitoring in patients with migraine can serve as a biomarker of response to treatment. Our aim was to assess the efficacy of flunarizine and the correlation of glutamate levels in Chronic Tension-type Headache (CTTH) with response to medication. Methods: We studied 19 patients with diagnosis of CTTH according to International Classification of Headache Disorder, 2nd edition criteria. The level of plasma glutamate was measured before and after 8-weeks prophylactic treatments. Subjects were randomized into three interventional groups (flunarizine 5 mg, flunarizine 10 mg and placebo). Glutamate levels were measured by means of Glutamate ELISA Kit KA1909 Abnova.        Results: Flunarizine 5 mg group had lower mean plasma glutamate levels significantly compared to placebo (p < 0.00; 95% CI: 0.40-1.07). Flunarizine 10 mg group had lower mean of plasma glutamate levels significantly compared to placebo (p< 0.00; 95% CI: 0.53-1.27). However, there were no significant differences of mean plasma glutamate levels between flunarizine 5 mg group and flunarizine 10 mg group (p < 0.37; 95% CI: -(0.54) - 0.21). There were no significant differences in headache frequency reduction among the three interventional groups. Conclusions: The usage of flunarizine as prophylactic treatment can reduce plasma glutamate levels significantly in CTTH patients. Either flunarizine or placebo showed no significant difference in reducing headache frequency in CTTH patients.

The Effect of Ophiocephalus striatus sp. Extract on Nitric Oxide in Ischemic Stroke Model

BACKGROUND: One of alternative medicine in stroke therapy is Ophiocephalus striatus sp. extract. The nutrients contained in the O. striatus sp. extract, namely amino acids, fatty acids, cuprum, and zinc, are useful for the process of angiogenesis in poststroke patients through increased endothelial nitric oxide synthase. AIM: We hypothesized that there was an effect of giving O. striatus sp. extract to cerebral angiogenesis process of Sprague Dawley rats ischemic stroke models through the level of NO. METHODS: This was evidenced by conducting experimental studies on rats ischemic stroke models which were divided into five groups, (a) K (−) group (no ligation, no treatment), (b) K (+) group (ligation, no treatment), (c) P1 group (ligation, 200 mg extract), (d) P2 group (ligation, 400 mg extract), and (e) P3 group (ligation, 800 mg extract). Then blood sample was taken on day 3 to assess levels of NO. RESULTS: There was increased level of NO in P1 (p = 0.001), P2 (p < 0.001), and P3 (p < 0.001) groups compared to K (+) group. The level of NO increases along with the increasing dose of O. striatus sp. extract. Histological examination revealed that there was formation of new blood vessel in the P1, P2, and P3 groups compared to K (+) group. CONCLUSION: Our study showed that O. striatus sp. extract improves cerebral angiogenesis in rat models of ischemic stroke.

Modulation of Interleukin-8 Production by Vitamin D Supplementation in Indonesian Patients with Diabetic Polyneuropathy: A Randomized Clinical Trial

Objectives

We sought to assess the modulation of interleukin-8 (IL-8) production by vitamin D supplementation in Indonesian patients with diabetic polyneuropathy (DPN).

Methods

We conducted a cohort prospective, randomized, placebo-controlled, double-blind trial. This study was approved by the Local Ethical Committee and conducted from July 2018 to February 2019. We recruited 50 subjects with type 2 diabetes mellitus attending Haji Adam Malik General Hospital Medan, and divided them into two groups. The groups were treated for 10 weeks, either with placebo or vitamin D (D₃) supplementation of 50 000 IU/week. They were evaluated by routine nerve conduction study (NCS) in the upper and lower limbs, and their serum vitamin 25-hydroxyvitamin D (25(OH)D) and IL-8 levels before and 10 weeks after placebo or vitamin D supplementation were measured. The role of IL-8 and vitamin D supplementation on the NCS was analyzed using linear regression.

Results

There was a significant difference between the mean vitamin 25(OH)D (p = 0.001) and IL-8 levels (p = 0.002) before and after vitamin D supplementation. There was no significant correlation between changes in vitamin 25(OH)D and IL-8 levels (p = 0.743). There was significant role of IL-8 on amplitude of the sensory sural nerve (p = 0.047; B = -0.009) and the nerve conduction velocity (NCV) of the motor tibial nerve (p = 0.007; B = -0.027). There was a significant role of vitamin D supplementation on NCSs.

Conclusions

Higher IL-8 levels were correlated with poorer amplitude of the sensory sural nerve and the NCV of motor tibial nerves. Lower vitamin 25(OH)D levels were correlated with poorer distal latencies, amplitudes, and NCVs. There was no significant correlation between vitamin 25(OH)D and IL-8 levels. Thus, no sufficient evidence that vitamin D supplementation modulates IL–8 in Indonesian patients with DPN. Vitamin D₃ improved NCSs in diabetic patients.

Snakehead fish extract as an enhancer of vascular endothelial growth factor and nitric oxide levels in cerebral angiogenesis: an insight of stroke therapy

Aim To assess the effect of snakehead fish extract administration in angiogenesis focusing on the level of vascular endothelial growth factor (VEGF), nitric oxide (NO) and VEGF receptor 2(R2) expression is ischemic stroke models. Methods An experimental study was conducted on 5 groups of ischemic stroke rats models: Group K- without carotid artery ligation, Group K+ with artery ligation, Group P1 with artery ligation and administration of 200 mg/day extract, Group P2 with artery ligation and 400 mg/day extract, and Group P3 with artery ligation and 800 mg/day extract. The VEGF expression and NO levels were assessed on day 3. Results Snakehead fish extract significantly increased VEGF levels along with increasing doses, in which the highest VEGF level was observed in P3 group (361.7±40.2; p<0.001). The NO level also increased along with an increasing dose of snakehead fish extract, in which the highest NO level was found in P3 group(59.43±0.88 μmol/gr; p<0.001). The VEGFR2 expression also increased significantly after snakehead extract administration along with increasing doses (p<0.001) in which administration of 800mg extract yielded the highest VEGFR2 expression compared with lower doses (17.7 vs. 15.6; p<0.001) Conclusion Snakehead fish extract administration increased angiogenesis process marked by an increased level of VEGF, NO and VEGFR2 expression in ischemic stroke rat models.

Correlation between Serum Vitamin A and D Levels in Acute Phase Ischemic Stroke and Clinical Outcome

Background:

In the last decade, a number of studies have examined the relationship between serum vitamin D concentration and the risk of cerebrovascular events. Besides vitamin D, the latest evidence shows that vitamin A is also a risk factor for cerebrovascular disease. Vitamin A and its derivatives act biologically via specific nuclear receptors that regulate gene transcription. Vitamin A receptors can also interact with other nuclear receptors that have neuroprotective effects such as vitamin D, against stroke. Although many studies suggested the synergism of vitamin A and D, there is still no study that evaluates their levels simultaneously in acute phase ischemic stroke, and the relationship to outcome.

Objective:

The objective of this study was to analyze the correlation between serum vitamin A and D levels on admission in Acute Ischemic Stroke patients and clinical outcome by using the National Institutes of Health Stroke Scale (NIHSS).

Methods:

A prospective cohort study was conducted, and samples were followed since the diagnosis of acute-phase Ischemic Stroke was established until the clinical outcome of day 14 after stroke onset. A total of 50 subjects enrolled for this study would be examined for serum levels of vitamins A and D on admission, and on the 14th day were assessed for NIHSS as a clinical outcome.

Results:

From 50 research subjects, the mean of vitamin A and D level in the acute phase of Ischemic Stroke was 463.35 ± 116.97 µg/L and 21.65 ± 6.51 ng/mL, respectively. By using the Spearman’s correlation test, it was found that the acute phase vitamin A level and NIHSS on day 14 had a significant and strong correlation with p = 0.045 (r = -0.672). Along with it, vitamin D serum levels and NIHSS also had a significant and strong correlation with p = 0.026 (r = -0.754). Both of these results showed that vitamin A and D had an inverse association with NIHSS, meaning that the higher vitamin A and D serum levels, the better the clinical outcome would be.

Conclusion:

Both serum vitamin A and D levels in the acute phase of Ischemic Stroke was correlated strongly with short time clinical outcome. The higher vitamin A and D serum levels in the acute phase, the better the clinical outcome would be for Ischemic Stroke patients.

Predictive Model of Diabetic Polyneuropathy Severity Based on Vitamin D Level

BACKGROUND:

Type 2 Diabetes Mellitus is one of the most common metabolic diseases worldwide. The most common complication of DM is diabetic neuropathy (DN), especially diabetic polyneuropathy (DPN). Vitamin D plays an important role in the pathogenesis of DN, thus affecting its severity which can be assessed using nerve conduction study (NCS).

AIM:

This study aimed to develop a predictive model of DPN severity based on vitamin D level.

METHODS:

This was a prospective cohort study involving 50 subjects with DM which was conducted in Haji Adam Malik General Hospital Medan. All subjects were fulfilling inclusion criteria underwent laboratory examination to determine HbA1c and 25 (OH) D levels. Predictive variables were sex, age, duration of DM, smoking status, type and number of anti-diabetic drugs, the presence of metabolic syndrome, HbA1c and vitamin D levels. A scoring system was developed to determine a predictive model. The DPN severity was assessed using NCS and was re-evaluated after 3 months.

RESULTS:

Most of the subjects were female (60%), belonged to ≥ 50 years old age-group (88%), with DM duration < 5 years (56%), were non-smoker (90%), we’re using one anti-diabetic drug (60%), were using insulin (50%), had metabolic syndrome (68%), had HbA1c level > 6.5% (94%), and had vitamin D level < 20 ng/ml (56%). A score of > 4 on this predictive model of DPN severity had a relative risk (RR) of 2.70. The predictive model had a sensitivity of 82.8% and specificity of 61.9%.

CONCLUSION:

A score of higher than 4 on this predictive model showed a 2.7 times higher risk of severe DPN. A predictive model of DPN severity based on vitamin D level had high sensitivity and specificity.

The Alteration of Plasma Matrix Metalloproteinase-9 Level after the Addition of Bromelin 500 mg to Standard Therapy of Acute Ischemic Stroke and Its Correlation with Outcome

BACKGROUND

Matrix metalloproteinase-9 (MMP9) expression due to ischemic cause spreading of brain damage. Previous studies have reported that Bromelin was beneficial as anti-inflammation and prevent brain tissue damage.

AIM

This study aimed to determine the alteration of plasma MMP9 level after addition of Bromelin 500 mg to Standard therapy and its correlation with outcome in acute ischemic stroke.

METHODS

This was a preliminary report of a prospective randomised, double-blind study with pre and post-test design, forty-six acute ischemic stroke patients were randomly allocated with Bromelin and Standard groups. Measurement of MMP9 and outcome were performed before and after 14-days treatment.

RESULT

The Bromelin group showed a significant decrement of MMP9 level, from 6.02 ± 0.32 ng/ml before treatment to 5.50 ± 0.94 ng/ml after treatment (p = 0.028). There was a negative correlation between MMP9 level and mRS (r= -0.03; p = 0.905) and a positive correlation toward BI (r = 0.039; p = 0.859), while the Standard group showed increased MMP9 level from 5.82 ± 0.71 ng/ml to 5.91 ± 0.83 ng/ml (p = 0.616) which was correlated insignificantly to outcome.

CONCLUSION

We concluded that the addition of 500 mg Bromelin to standard ischemic stroke therapy reduced MMP9 level significantly and correlated to outcome improvement. However, there is a tight statistical correlation.

Effect of Flunarizine on Serum Glutamate Levels and its Correlation with Headache Intensity in Chronic Tension-Type Headache Patients

BACKGROUND

Some of the excitatory neurotransmitters including glutamate have been suggested to be involved in headache pathophysiology. To our knowledge, there is a lack of publication about flunarizine efficacy in chronic tension-type headache (CTTH) treatments and the roles of glutamate in CTTH pathophysiology.

AIM

This study aimed to investigate the flunarizine effect on serum levels of glutamate and its correlation with headache intensity based on the Numeric Rating Scale for pain (NRS) scores in CTTH patients.

METHOD

In a prospective randomised, double-blind study with pre and post-test design, seventy-three CTTH patients were randomly allocated with flunarizine 5 mg, flunarizine 10 mg and amitriptyline 12.5 mg groups. The serum levels of glutamate and NRS scores were measured before and after 15-day treatment.

RESULTS

Flunarizine 5 mg was more effective than flunarizine 10 mg and amitriptyline 12.5 mg in reducing serum glutamate levels, whereas amitriptyline 12.5 mg was the most effective in reducing headache intensity. There was found nonsignificant, but very weak negative correlation between headache intensity and serum glutamate levels after flunarizine 5 mg administration (r = -0.062; P = 0.385), nonsignificant very weak negative correlation after flunarizine 10 mg administration (r = -0.007; P = 0.488) and there was found a significant moderate positive correlation (r = 0.508; P = 0.007) between headache intensity and serum glutamate levels after amitriptyline 12.5 mg administration.

CONCLUSION

Since there was no significant correlation found between serum glutamate and headache intensity after treatment with flunarizine, it is suggested that decreasing of headache intensity after flunarizine treatment occurred not through glutamate pathways in CTTH patients.

Tumour Necrosis Factor-Α, Interleukin-1 and Interleukin-6 Serum Levels and Its Correlation with Pain Severity in Chronic Tension-Type Headache Patients: Analysing Effect of Dexketoprofen Administration

AIM:

The purpose of this study is to see the effect of Dexketoprofen on TNF-α, IL-1, and IL-6 serum levels in Chronic Tension-Type Headache (CTTH) patients and its correlation with pain severity.

METHOD:

The study subjects were recruited consecutively from the study population. Venous blood was taken at baseline to measure serum levels of TNF-α, IL-1, and IL-6 and after ten consecutive days of Dexketoprofen 25 mg once daily.

RESULTS:

Twenty three subjects participated in this study, 3 male (13.0%) and 20 female (87%). A significant difference between NRS score at baseline and after treatment (4.86 ± 1.82 vs. 1.96 ± 1.40, p = 0.001) was found. No significant difference found between baseline and after treatment TNF-α (1.48 ± 0.65 pg/dl vs. 1.48 ± 0.63 pg/dl, p = 0.963), IL-1 (0.16 ± 0.80 pg/dl vs. 0.26 ± 0.31 pg/dl, p = 0.168) nor IL-6 serum levels (1.06 ± 0.83 pg/dl vs. 1.04 ± 0.81 pg/dl, p = 0.915). A weak negative (R = -0.266) non significant correlation (p = 0.219) was found between NRS score and TNF-α. A positive weak negative (R = 0.221) non significant correlation (p = 0.311) between NRS score and IL-1. NRS score and IL-6 had a negative very weak (R = -0.019) non significant negative correlation (p = 0.931).

CONCLUSIONS:

Dexketoprofen decreased pain intensity significantly (p = 0.001), but had no effect on TNF-α IL-1 nor IL-6 serum levels. NRS score had a weak and non significant negative correlation with TNF-α, a weak and non significant positive correlation with IL-1, and a very weak and non significant negative correlation with IL-6 serum levels.