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Ramani Vijayan,1 Gauhar Afshan,2 Khalid Bashir,3 Mary Cardosa,4 Madhur Chadha,5 Pongparadee Chaudakshetrin,6 Khin Myo Hla,7 Muralidhar Joshi,8 Francis O Javier,9 Asif Gul Kayani,10 Andi Takdir Musba,11 Sasikaan Nimmaanrat,12 Dwi Pantjawibowo,13 Jocelyn C Que,14 Palanisamy Vijayanand15 1Department of Anaesthesiology, University Malaya Medical Centre, Kuala Lumpur, Malaysia; 2Department of Anaesthesiology, The Aga Khan University, Karachi, Pakistan; 3Department of Anaesthesia, Hameed Latif Hospital, Lahore, Pakistan; 4Department of Anaesthesiology, Hospital Selayang, Selangor, Malaysia; 5Department of Pain Medicine, Primus Hospital and Fortis Group of Hospitals, New Delhi, India; 6Pain Management Clinic, Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 7Department of Physical Medicine & Rehabilitation, Yangon General Hospital, University of Medicine-1, Yangon, Myanmar; 8Department of Anaesthesia & Pain Medicine, Virinchi Hospitals, Hyderabad, India; 9Pain Management Center, St Luke’s Medical Center, Metro Manila, Philippines; 10Department of Anesthesiology, Kulsum International Hospital, Islamabad, Pakistan; 11Department of Anesthesiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia; 12Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand; 13Department of Anesthesiology, Intensive Therapy, and Hospital Pain Management, Premier Bintaro Hospital, South Tangerang, Indonesia; 14Center for Pain Medicine, Department of Anesthesiology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines; 15Pain Management Department, Sri Ramakrishna Hospital, Coimbatore, Tamil Nadu, India Background: The supply of controlled drugs is limited in the Far East, despite the prevalence of health disorders that warrant their prescription. Reasons for this include strict regulatory frameworks, limited financial resources, lack of appropriate training amongst the medical profession and fear of addiction in both general practitioners and the wider population. Consequently, the weak opioid tramadol has become the analgesic most frequently used in the region to treat moderate to severe pain.Methods: To obtain a clearer picture of the current role and clinical use of tramadol in Southeast Asia, pain specialists from 7 countries in the region were invited to participate in a survey, using a questionnaire to gather information about their individual use and experience of this analgesic.Results: Fifteen completed questionnaires were returned and the responses analyzed. Tramadol is used to manage acute and chronic pain caused by a wide range of conditions. Almost all the specialists treat moderate cancer pain with tramadol, and every one considers it to be significant or highly significant in the treatment of moderate to severe non-cancer pain. The reasons for choosing tramadol include efficacy, safety and tolerability, ready availability, reasonable cost, multiple formulations and patient compliance. Its safety profile makes tramadol particularly appropriate for use in elderly patients, outpatients, and for long-term treatment. The respondents strongly agreed that tighter regulation of tramadol would reduce its medical availability and adversely affect the quality of pain management. In some countries, there would no longer be any appropriate medication for cancer pain or the long-term treatment of chronic pain.Conclusions: In Southeast Asia, tramadol plays an important part in the pharmacological management of moderate to severe pain, and may be the only available treatment option. If it were to become a controlled substance, the standard of pain management in the region would decline. Keywords: tramadol, questionnaire, indications, efficacy, safety, controlled substance

A randomized single blind clinical trial was carried out in order to compare the effectiveness of oral morphine syrup and injected morphine in premedication of postpartum tubal sterilization by local anaesthesia. A total of 200 postpartum patients were divided into two groups by systemic random sampling. The first group of 100 patients was premedicated with 30 mgs of syrup morphine orally 90 minutes before operation, and the second group of 100 patients was premedicated with 10 mgs of morphine hydrochloride via the intramuscular route 15 minutes before operation. All patients were given tubal sterilization by first- and second- year residents, using the modified Pomeroy technique. The pain experienced by each patient during the operation was evaluated by verbal and numerical rating scales. The pain scores and the operating time of both groups were analysed by the Mann Whitney U test and pair t test, respectively. The pain scores of the first and second group were 3.644 ± 1.802 and 3.570 ± 1.470, respectively, with no significant difference. The operating time was 10.300 ± 1.904 and 11.200 ± 2.543 minutes in the first and second group, respectively. The effectiveness of oral morphine syrup and intramuscular morphine in premedication for postpartum tubal sterilization was found to give the same results. The cost-effectiveness of oral morphine syrup is greater and it can therefore replace intramuscular morphine in premedication for postpartum tubal sterilization.

Objective: To evaluate the various coexisting soft tissue pathology that made up 'frozen shoulder' and the treatment outcomes. Design: Prospective case series report Methods: All patients with 'frozen shoulder from soft tissue origin were included in this study. A new assessment tool for 'frozen shoulder' was performed integrating the conventional orthopaedic approaches with myofascial pain syndrome by performing only three simple range of movement tests; abduction of shoulder joint (Painful Arch Test), external rotation with abducted shoulder joint and Hand On Scapular Blade Test. Results: Fifty percent (50%) of the patients presented with multiple pathology and sixty six percent (66%) of them revealed multiple structures involvement. Prevalence of MPS and tendinitis were equally high in 'frozen shoulder' (75%). Seventy five percents (75%) of the patients were successfully managed based on this three steps clinical evaluation. Conclusion: The key success of the 'frozen shoulder' management depends on the ability to identify the accurate diagnosis/pathology that made up this complex disorder. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the various coexisting soft tissue pathology that made up "frozen shoulder" and the treatment outcomes. Design: Prospective case series report Methods: All patients with "frozen shoulder from soft tissue origin were included in this study. A new assessment tool for "frozen shoulder" was performed integrating the conventional orthopaedic approaches with myofascial pain syndrome by performing only three simple range of movement tests; abduction of shoulder joint (Painful Arch Test), external rotation with abducted shoulder joint and Hand On Scapular Blade Test. Results: Fifty percent (50%) of the patients presented with multiple pathology and sixty six percent (66%) of them revealed multiple structures involvement. Prevalence of MPS and tendinitis were equally high in "frozen shoulder" (75%). Seventy five percents (75%) of the patients were successfully managed based on this three steps clinical evaluation. Conclusion: The key success of the "frozen shoulder" management depends on the ability to identify the accurate diagnosis/pathology that made up this complex disorder. [ABSTRACT FROM AUTHOR]

By injection of eosin dye with latex into 45 cadaveric fingers we were able to demonstrate: (1) a distinct digital pulp arch formed by the ulnar and radial digital arteries over the mid-point of the terminal phalanx in 93% of digits; (2) variations in size of the proper digital arteries to each digit; (3) numerous branches from the pulp arch to the tip of each digit and (4) a constant pattern of dorsal veins over the terminal segment in 89% of digits. [ABSTRACT FROM PUBLISHER]

Abstract: Since it was founded, the International Association for the Study of Pain (IASP) has been at the forefront of improving pain research, education, and effective pain management in both developed and developing countries. As IASP activities progressed, major differences between the practice of pain management, education, and research in developed countries compared with developing countries were identified. This led to areas of focus by IASP that included pain education to address poor knowledge of pain assessment and treatment, prioritization of pain management by governments and official national legislation and programs, and availability of pain treatments (especially potent analgesics). A few pioneering IASP members from developing countries in the early years encouraged more multidisciplinary professionals to join IASP and attend conferences. Inauguration of national and regional chapters was also encouraged, and regular continuing medical education programs were held, especially on topics from IASP conferences and global pain events. Many IASP chapters in developing countries have established collaborations with groups from developed countries, whereas IASP also implemented other innovative approaches including the developing countries working group, educational grants, pain camps, and multidisciplinary pain hubs with toolkits to develop pain experts for regions in the developing world. Thus, the influence of IASP in many developing countries has had a multiplier effect on the progress made in effective pain management, education, and research. Nonetheless, challenges remain and include better integration of pain management, education, and research in national health systems and academic programs for health professionals., (Copyright © 2023 International Association for the Study of Pain.)

Approximately 80% of the world's population lives in countries with little or no access to pain management. These countries also have 74% of the world's deaths from cancer and human immunodeficiency virus. Appropriate use of oral opioids can control 80%-90% of cancer pain. However, only 6.7% of the world's medical opioids are available in these low-resource countries. With the Lancet Commission on Global Surgery calling for a significant expansion of surgical services, postoperative pain management will need to be an increasing focus of our attention. There are multiple barriers to providing effective pain management. These include the type and funding of the health care system, the size and educational level of the workforce, the ease of access to effective medications, and the expectations and knowledge base of the community. Some barriers can be addressed by education at the undergraduate level, postgraduate level, and community level. Others will require continued advocacy at government level. Only when we tackle these problems will the considerable neglect of access to effective pain treatment in low- and middle-income countries be lessened.

Background and Purpose: Neuropathic pain (NeuP) associated with traumatic brachial plexus injury (BPI) can be severe, persistent, and resistant to treatment. Moreover, comorbidity associated with NeuP may worsen the pain and quality of life. This study compared persistent NeuP after BPI between patients with and without co-morbid conditions (psychiatric dysfunction and other painful conditions) and tramadol usage as a second-line agent in combination with an antiepileptic and/or antidepressant during a 2-year follow-up., Methods: The medical records of patients diagnosed with BPI referred to a pain center between 2006 and 2010 were reviewed for 2 years retrospectively. Data regarding patient demographics, injury and surgical profiles, characteristics of NeuP and its severity, and treatment received were compared between patients with and without manifesting co-morbid conditions. The NeuP and pain intensity assessments were based on the DN4 questionnaire and a numerical rating scale, respectively., Results: Of the 45 patients studied, 24 patients presented with one of the following co-morbid conditions: myofascial pain (21%), psychiatric disorder (17%), phantom limb pain (4%), complex regional pain syndrome (21%), and insomnia (37%). Tramadol was required by 20 patients with co-morbidity and, 9 patients without co-morbidity (p<0.001). The mean pain score after 2 years was higher in patients with co-morbidity than in those without co-morbidity (p<0.05)., Conclusions: Persistent pain following BPI was more common in patients manifesting other painful conditions or psychiatric co-morbidity. A higher proportion of the patients in the co-morbid group required tramadol as a second-line of agent for pain relief., Competing Interests: The authors have no financial conflicts of interest.

Objective: Thyroid cancer patients treated with 1-131 are potential source of radiation exposure to relatives who are knowingly and willingly exposed to ionizing radiation as a result of providing comfort to patients undergoing I-131 therapy. This study aims to determine radiation dose received by relatives who care for non self-supporting 1-131 patients at Siriraj Hospital., Material and Method: Twenty caregivers of 20 patients underwent I-131 therapy for thyroid cancer with a standard protocol were given specific instructions with regard to radiation safety and provided with electronic digital dosimeter to continuously measure radiation dose received on daily basis, three days in the hospital. On the day patient is released, thyroid uptake estimates were performed to assess internal radiation dose received by caregivers., Results: The 3-day accumulative doses to caregivers to patients receiving 150 mCi (n = 11) and 200 mCi (n = 9) of I-131 ranged from 37 to 333 uSv and 176 to 1,920 pSv respectively depending on the level of supports required. Thyroid uptake estimates in all caregivers were undetectable. Dosimeter indicated a maximum whole-body dose of1.92 mSv was more than the public dose limit of] mSv but within the dose constraint of 5 mSv for caregivers., Discussion: Radiation dose to caregivers of a non self-supporting hospitalized patient undergoing 1-131 therapy were well below the limits recommended by the ICRP. The patients can be comforted with confidence that dose to caregivers will be less than the limit., Conclusion: This study provides guidance for medical practitioners to obtain practical radiation safety concerns associated with hospitalized patients receiving I-131 therapy especially when patient needs assistance.

Thyroid cancer patients treated with high-dose radioactive iodine (3.7-7.4 GBq) are different from other people because after the administration, the radionuclide I-131 is excreted via urine, feces, saliva and breathing, and also via exposure to other patients. Caregivers of the patient may receive higher radiation doses than normal. The purposes of this study were to estimate the total effective dose equivalent from internal and external exposure to caregivers of patients treated with high dose I-131 admitted at Siriraj Hospital, and to compare the estimated dose with the dose constraint of 5 mSv per annum for caregivers. Thirteen caregivers of 13 patients who underwent radioiodine therapy for thyroid cancers following a standard protocol were given specific instructions with regard to radiation safety and were attached to an electronic personal dosimeter and a personal air sampler pump continuously to measure received radiation dose on a daily basis over three days in the hospital. On discharge day, caregivers were asked to perform an in vivo bioassay by the thyroid uptake instrument. The results from the thirteen caregivers were divided into 3 groups. The total effective dose equivalent to caregivers of patients administered 3.7 GBq (n = 1), 5.55 GBq (n = 9), and 7.4 GBq (n = 3) were 0.159 mSv, 0.123 to 0.629 mSv, and 0.631 to 0.718 mSv, respectively. There values were well below 5 mSv per episode as proposed in the IAEA Safety Reports Series No. 63 and the ICRP Publication 103.

Objective: To compare the efficacy and cost-effectiveness of high and low dose regimens of I-131 treatment in patients with hyperthyroidism., Material and Method: One hundred fifty patients with proven hyperthyroidism were randomly allocated into the high (74 patients) and low (76 patients) dose regimen of I-131 treatment. Four patients of the high dose group and one patient of the low dose group were excluded because of lost follow-up. A gland-specific dosage was calculated on the estimated weight of thyroid gland and 24-hour I-131 uptake. The high and low I-131 dose regimens were 150 microCi/gm and 100 microCi/gm, respectively. The first mean radioiodine activity administered to the high and low dose group was 10.2 and 8 mCi, respectively. Repeated treatment was given to 25 patients of the high dose group and 40 patients of the low dose group. Clinical outcome and calculated costs for outpatient attendances, and laboratory tests together with initial and subsequent treatments were evaluated for one year after I-131 treatment. Elimination of hyperthyroidism that resulted in either euthyroidism or hypothyroidism was classified as therapeutic success. The cost effectiveness was also compared., Results: At 6 months after treatment, 45 (64.3%) patients receiving high dose and 59 (78.7%) patients receiving low dose were hyperthyroidism. Clinical outcome at one year showed persistence of hyperthyroidism in 21 (30%) patients of the high dose regimen and 36 (48%) patients of the low dose regimen. At one year post treatment, it was demonstrated that the high dose regimen could eliminate hyperthyroidism in a significantly shorter time than the low dose regimen, i.e., 259.6 days and 305.5 days, respectively, p = 0.008). For the persistent hyperthyroid patients, the average total cost of treatment in the low dose group was significantly higher than that of the high dose group, i.e., 13,422.78 baht and 10,942.79 baht, respectively; p = 0.050)., Conclusion: A high dose regimen of radioactive iodine treatment is more effective than the low dose regimen. The successful outcome of a high dose regimen occurred significantly earlier than that of the low dose regimen. For the persistent hyperthyroid patients, the average total cost in the low dose group was significantly higher than that of the high dose group.

Background: Pain is one of the most frequent and deleterious symptoms for patients with advanced cancer. Pain assessment is important because it is used for detecting severity of disease and the response to treatment. To provide the adequate treatment for pain relief in cancer patients, an assessment tool should be used for pain evaluation. Moreover, suitable tools for pain evaluation should be validated in local language to obtain better pain information., Objective: The objective of the present study was to demonstrate validity and reliability of the Thai version of the Brief Pain Inventory (BPI-T), which is a simple and concise instrument for pain assessment., Material and Method: The available data were obtained from 520 patients with cancer pain. The data included pain severity, which patients reported using Thai version of Brief Pain Inventory (BPI-T). The pain severity and pain information were reported three times with 2-week intervals between each assessment time point., Results: Factor analysis of the Thai version of the Brief Pain Inventory resulted in two factors, pain severity and pain interference, showing valid structures consistent with other language versions of the instrument. Cronbach's alphas, computed for pain interference and pain severity item were 0.88 and 0.89, 0.01 and 0.92, and 0.93 and 0.94, for first, second, and third assessment time, respectively., Conclusion: Thai version of the Brief Pain Inventory is a reliable and valid instrument for cancer pain assessment in Thailand

Objective: To cross-culturally adapt the neuropathic pain diagnostic questionnaire (DN4) to Thai language, Material and Method: Phase 1: Forward and backward translation followed by assessment of semantic equivalence. Phase 2: Testing of the questionnaire in 30 neuropathic pain patients who were seen and diagnosed by experts, followed by modifications to produce a final version., Results: All the Thai translated pain descriptors except 'tingling' got high percentages of understanding among neuropathic pain patients in the first round of testing. After some adaptation of the Thai word for 'tingling' had been made, the new translated word was retested, and all subjects doing the retest understood the word very well., Conclusion: The Thai DN4 questionnaire was systematically translated and validated. This offers a simple Thai neuropathic pain diagnostic tool for clinical use.

Objective: To examine the profile and treatment pattern of patients with neuropathic pain attending Siriraj Pain Clinic., Material and Method: A 2-year retrospective study of the prevalence of neuropathic pain, characteristics of the patients and the use of medical treatment. Records of all the patients that attended Siriraj Pain Clinic from September 1, 2002 until September 30, 2004 were reviewed., Results: One thousand three hundred and thirty patients' records were reviewed. Five hundred and three patients were diagnosed as having neuropathic pain. The prevalence of neuropathic pain at Siriraj Pain Clinic during the survey period was 37.8%. The average age of neuropathic pain patients was 54 years. The most common type of neuropathic pain was peripheral type, nerve compression in particular. The most common concomitant illness was malignant tumor. The majority of patients (71.8%) had one pain location and the most common site was the lower extremity. The main descriptions of neuropathic pain were radiating, electric shock-like, burning, numbing and shooting. Oral medication was the most common method (79%) of pain-relief treatment. Almost all of the patients (93%) had received more than one type of oral medication. The most commonly used medicine was TCA (77.1%), followed by gabapentin (35%), carbamazepine (34%) and tramadol (24.3%). Most of the pain-relief medicines prescribed at this clinic were under the recommended doses for the treatment of neuropathic pain., Conclusion: Characteristics and treatment patterns of neuropathic pain at Siriraj Pain Clinic are similar to those seen in other pain clinics elsewhere in the world. The high prevalence of neuropathic pain in the clinic indicates that this type of pain syndrome is increasingly critical to our clinical practice. More educational programs on neuropathic pain and management are needed for Thai healthcare professionals.

Breakthrough pain (BKP) is a transitory flare of pain that occurs on a background of relatively well controlled baseline pain. Previous surveys have found that BKP is highly prevalent among patients with cancer pain and predicts more severe pain, pain-related distress and functional impairment, and relatively poor quality of life. An international group of investigators assembled by a task force of the International Association for the Study of Pain (IASP) evaluated the prevalence and characteristics of BKP as part of a prospective, cross-sectional survey of cancer pain. Fifty-eight clinicians in 24 countries evaluated a total of 1095 patients with cancer pain using patient-rated items from the Brief Pain Inventory (BPI) and observer-rated measures. The observer-rated information included demographic and tumor-related data, the occurrence of BKP, and responses on checklists of pain syndromes and pathophysiologies. The clinicians reported BKP in 64.8% of patients. Physicians from English-speaking countries were significantly more likely to report BKP than other physicians. BKP was associated with higher pain scores and functional interference on the BPI. Multivariate analysis showed an independent association of BKP with the presence of more than one pain, a vertebral pain syndrome, pain due to plexopathy, and English-speaking country. These data confirm the high prevalence of BKP, its association with more severe pain and functional impairment, and its relationship to specific cancer pain syndromes. Further studies are needed to characterize subtypes of BKP. The uneven distribution of BKP reporting across pain specialists from different countries suggests that more standardized methods for diagnosing BKP are needed.

Neural blockade has been used as the single method to anesthetize a part of the body or used in combination with general anesthesia to lessen perioperative pain. Currently, nerve blocks are used for diagnostic, prognostic, therapeutic and prophylactic proposes for management of chronic, acute and cancer pain in a Pain Clinic. Reviewing the records of the 3,349 patients at Siriraj Pain Clinic, we found 2,662 and 687 cases had chronic and acute pain problems respectively, and only 646 patients were treated with anesthetic interventions during 1990 to 1998. They consisted of 317 male and 329 female. The techniques included stellate ganglion block, paravertebral nerve block, celiac plexus block, hypogastric plexus block, mesenteric plexus block, sacral nerve block, epidural steroid, lumbar sympathectomy, first and second thoracic sympatholysis, facet joints injection, sacroiliac joint injection, intravenous regional block with guanethidine or ketanserin, continuous opioid infusion, intravenous lidocaine infusion, and a phentolamine test. The common problems of pain included brachial plexus injury, chronic spinal pain, herpetic neuralgia, ischemic pain, central post-stroke pain, and causalgia. This retrospective review showed that 38 per cent of them reported 50 per cent pain relief with temporary effect. 34 per cent experienced good and satisfactory pain relief while 9 per cent reported excellent pain relief. 17 per cent did not gain benefit from any technique of pain relief and about 2 per cent could not be evaluated due to they did not return for follow-up. One serious complication after thoracic sympatholysis was brachial plexus injury. The neural blockade is proven to be one of the useful adjunct in the management of chronic pain but the selection of the technique is subjected to its critical appraisal.