Pre-procedural ultrasound scanning has been used to facilitate spinal anaesthesia in patients with difficult anatomical landmarks and shown to improve first-attempt success rates in some studies. We studied whether pre-procedural ultrasound scanning improved first-attempt success rate and decreased time taken for the procedure in the general adult population. In this prospective, randomised controlled trial, 170 American Society of Anesthesiologists physical status 1 to 3 patients aged between 21 and 80 years were recruited. Informed consent was obtained. Patients were randomised into two groups, ultrasound-guided identification of landmarks (Ultrasound Group) and manual palpation of landmarks (Manual Palpation Group). The primary outcome was first-attempt success rate and secondary outcomes were time taken to perform procedure, number of needle redirections, patient satisfaction and complications. The first-attempt success rate was 64% in the Ultrasound Group and 52% in the Manual Palpation Group (P=0.16). Time taken for procedure was shorter in the Ultrasound Group compared to the Manual Palpation Group (2.9±3.6 minutes versus 3.9±3.7 minutes, P= 0.007). Patient satisfaction was higher in the Ultrasound Group. There were no differences in complications. As there was no statistically significant difference in first-attempt success rates between the two groups, existing evidence for routine pre-procedural scanning for all patients is inadequate. The current use of pre-procedural ultrasound scanning will probably be limited to selected patients where spinal anaesthesia may be technically challenging with conventional methods.

SummaryThe Laryngeal Mask Airway Flexible TM (LMA Flexible) has been widely utilised for dental, ophthalmology and otorhinolaryngology-related procedures. Our study evaluates two different techniques of inserting the LMA Flexible for patients undergoing day-case dental surgery. One hundred and eight patients were randomly assigned into two groups based on the LMA Flexible insertion technique -either laryngoscopy-guided (n = 54) or digital manipulation (standard technique; n = 54). Patient and airway characteristics were recorded before induction of anaesthesia. The primary outcome was success rate at first insertion. Other outcomes assessed included fibreoptic assessment of laryngeal mask airway placement, haemodynamic changes, need for airway adjustment during surgery and sore throat. The success rate of insertion on the first attempt was higher for the laryngoscopy-assisted technique compared with the standard technique (96.3% vs 81.5%, respectively, p < 0.05). Fibreoptic assessment showed that the former group had better placement of the laryngeal mask airway than the latter (59.3% vs 37% p < 0.05). There were no significant differences between the two groups for haemodynamic changes. Sore throat was more common in the group with the standard technique (35.2% vs 16.7%, p < 0.05). Our study suggests the use of the laryngoscope to guide insertion of the LMA Flexible for dental surgery is a better option compared with the standard technique of digital manipulation. Laryngeal Mask Co. Limited, Mahe, Seychelles) has been widely used for dental, head and neck-related surgery [1][2][3]. The cuff portion is identical to the classic version of the LMA, but the LMA Flexible has a long and nonrigid flexometallic tube, which may make insertion more challenging. This unique design allows greater movement of the tube without displacement of the cuff or loss of seal. The head and neck may be turned with a decreased risk of airway dislodgement during surgery. Studies have detailed its usefulness compared with tracheal intubation in dental day surgery patients [4,5], but few studies have examined different techniques of insertion. Therefore, we evaluated the use of a laryngoscopy-guided technique as an alternative to the standard technique of digital manipulation for insertion of the LMA Flexible, in adult patients presenting for day-case dental surgery.

Findings from the published ACHEON study revealed inadequate pain relief for chronic non-cancer pain (CNCP) across 10 Asian countries/regions. Hence, we performed additional analyses on the survey data to understand management practices for relieving CNCP and treatment-related adverse events (AEs). Descriptive statistics were used to summarize patients' profile, prescribed treatments, and associated AEs. Two-sample t test was used to compare pain levels between treatment groups. Univariate analyses were conducted to identify factors associated with pain intensity, presence of any common AEs, perceived treatment adequacy, patient-physician interaction, and employment status. Of 1305 patients surveyed, the median duration of CNCP was 24 (interquartile range, 39) months. The majority of patients (89.3%) reported having moderate (44.4%) or severe pain (44.9%). Most patients (80.1%) were prescribed non-opioids, while 16.2% of patients were untreated for pain. Although over half of the treated patients (53.8%) experienced AEs while receiving pain treatment, two-fifths were prescribed medications to manage these AEs. High pain levels, presence of AEs, and employment status influenced patients' perception of treatment adequacy. Patients were more willing to inform their physicians when pain levels were higher and when they perceived sufficient time with physicians. These findings revealed inadequate treatment of CNCP in patients from the participating countries/regions. CNCP management may be improved through increased physician-patient interaction time and adopting a biopsychosocial model for treatment. A proactive and multidimensional approach is required to manage CNCP and potential treatment-related AEs so as to provide optimal care for patients experiencing CNCP.

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Introduction: While opioids are effective in carefully selected patients with chronic non-cancer pain (CNCP), they are associated with potential risks. Therefore, treatment recommendations for the safe and effective use of opioids in this patient population are needed. Materials and Methods: A multidisciplinary expert panel was convened by the Pain Association of Singapore to develop practical evidence-based recommendations on the use of opioids in the management of CNCP in the local population. This article discusses specific recommendations for various common CNCP conditions. Results: Available data demonstrate weak evidence for the long-term use of opioids. There is moderate evidence for the short-term benefit of opioids in certain CNCP conditions. Patients should be carefully screened and assessed prior to starting opioids. An opioid treatment agreement must be established, and urine drug testing may form part of this agreement. A trial duration of up to 2 months is necessary to determine efficacy, not only in terms of pain relief, but also to document improvement in function and quality of life. Regular reviews are essential with appropriate dose adjustments, if necessary, and routine assessment of analgesic efficacy, aberrant behaviour and adverse effects. The reasons for discontinuation of opioid therapy include side effects, lack of efficacy and aberrant drug behaviour. Conclusion: Due to insufficient evidence, the task force does not recommend the use of opioids as first-line treatment for various CNCP. They can be used as second- or third-line treatment, preferably as part of a multimodal approach. Additional studies conducted over extended periods are required. Key words: Chronic pain, Consensus statement, Guidelines, Non-cancer pain, Opioids