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.

Multidisciplinary pain centers (MPC) provide benefits to patients, healthcare professionals (HCP) and the community in general but are not yet established in Indonesia and other developing countries. Before establishing a MPC, the problem in pain, HCP's perceptions, expectations and challenges in MPC establishment need to be identified. From the national survey on 1058 HCP, almost all respondents (99.0%) had met patients with pain as the primary complaint and acute pain as the most common complaint (51.2%). Insufficient pain management in Indonesian healthcare, insufficient pain epidemiological data and unaware HCP about MPC have become problems in pain management in Indonesia. However, most HCP agreed that health facilities should have pain centers as well as a center for the study of pain and recommended 'pain that requires intervention' should be referred to a MPC. Financial issues such as insufficient patient insurance was considered the most important barrier for referring patients to MPCs in Indonesia. The high incidence of pain, insufficient pain management in health facilities and insufficient data on pain have become the core problem that underlies the need for MPC establishment in Indonesia. Overall, HCPs have positive perceptions and expectations regarding MPCs. Financial barriers are thought to be a potential burden in the development of MPCs. By understanding the pain problem, HCP perceptions, expectations and potential challenges on the MPC establishment, strategic planning in MPC establishment is expected to be achieved especially in developing countries.

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.

Combination of vitamin A and D supplementation for ischemic stroke: effects on interleukin-1ß and clinical outcome.

Aim Accumulated evidence suggests that vitamin A and D agonists can alleviate the development of atherosclerosis. Therefore, the aim of this study was to determine the effect of vitamin A and D combination supplement on interleukin-1ß (IL-1ß) and clinical outcome in ischemic stroke. Methods A single-blind, randomized controlled trial was conducted on ischemic stroke patients at Adam Malik Hospital between March 2018 to February 2019. The patients were randomized into 4 groups of the treatment consisting of supplementation using vitamin A or D only, combination of vitamin A and D, and placebo group, all given for 12 weeks. Clinical outcome was determined using the National Institute of Health Stroke Scale (NIHSS). At the time of admission and after the treatment was completed, all patients were measured for vitamin A, vitamin D, and IL-1ß serum level, and NIHSS score. Results From the total of 120 patients, in the combination group there were significant increments on both vitamin A (p=0.04) and vitamin D (p=0.01) serum level after 12 weeks of the treatment, compared to the other groups. In conjunction, IL-1ß serum level showed a significant decrement in the combination group (p<0.001). Lastly, the biggest improvement of NIHSS could be seen in the combination group, which was marked by the highest decrement of NIHSS score (p<0.001). Conclusion Administration of combination of vitamin A and D supplementation can significantly increase vitamin A and D serum level, decrease IL-1ß serum level, and ultimately improve clinical outcome in ischemic stroke 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.

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.