World Congress on Pain Medicine and Management September 9-10, 2019 Singapore

Rajni Kaushik has completed her PhD from National University of Singapore and postdoctoral studies from Singapore-MIT alliance for Reseach and Technology. She is currently Principal Microbiologist at TUV SUD Water services. Dr. Kaushik has previous stints in UNILEVER R&D, involving designing and testing water purifier piloting, verification and performance optimization against Bacterial, Viral and Protozoan pathogens. She has also authored multiple high-impact air and water microbiology themed papers and book chapter. She successfully provided educational mentorship and coaching during her doctorate and post doctorate studies to final year projects on Microbial diagnostics. In TUV SUD, Dr Kaushik is primarily focusing on technical consultancy on Environmental microbiology, Sanitation, and product testing against microbial pathogens.

Waterborne diseases are responsible for 1.5 million child deaths annually due to poor sanitation and unsafe water. Over 2 billion people use toilets connected to septic tanks that are either not safely emptied or discharged into open drains or surface waters resulting in increased prevalence of diseases and pollution of the environment.Decentralized, energy‐efficient wastewater treatment technologies enabling water reuse are needed to sustainably address sanitation needs in water and energy‐scarce environments. These innovative technologies will face challenges in terms of technological reliability and social acceptability in the market with respect to their performance against microbial pathogens. The conservative way of wastewater treatment plants relies mostly on bacterial indicators. These coliform bacteria are unreliable indicators of wastewater sanitary quality as helminth ova are very resistant to those environmental factors that reduce the numbers of bacterial indicators or viruses in sludge. Thus, coliform bacteria testing may not adequately predict the presence of viruses, protozoa or helminths. When decentralised wastewater treatment is the primary mechanism to protect the public from infectious diseases, a comprehensive microbiological quality testing becomes crucial. In this paper, we describe how technical performance standards can help in the evaluation and adoption of innovative technologies in non- sewered sanitation. Here, we also demonstrate how the two new ISO standards (ISO 30500 and DIS 31800) on non-sewered technologies systematically and proactively addresses laboratory and field tests for testing of all key infectious agents (Bacteria, Virus, Protozoa and Helminths) with practical and reliable surrogates for future technologies. Both the ISO standards address stringent requirements towards microbial log removal using these surrogates paving the way towards unbias evaluations of innovative technologies.

Keywords: Microbial Pathogens, Non-sewered sanitation technologies, Infectious agents

Linka Matos Rivera is an anesthesiologist in San Juan, Puerto Rico. She received her medical degree from University of Puerto Rico School of Medicine and has been in practice between 11-20 years.

This is a case report of 62 year old male with history of lumbar and cervical pain, with a laminectomy in 2014. The patient also had a history of hypertension and diabetes mellitus. Three years ago he had stroke with right side weakness which improved over time with physical therapy. A year ago during evaluation he had cramps and pain in the upper and lower extremities. He also had poor sleep hygiene, difficulties writing and typing. He was diagnosed with central post stroke pain syndrome as a sequela of his stroke. The pain symptoms have been refractory to multiple medications and were limiting his activities of daily living for the past 3 years. Mesenchymal Stem Cells from Umbilical Cord (MSC UC) were used to treat his pain. Mesenchymal stem cells are multipotent cells that can differentiate in different types of tissue. They can both self-renewand differentiate into mature tissues such as heart, lung, liver, bone, nerve, muscle and cartilage, among others. They have the ability to migrate and target specific tissues, this is called homing. They also have a paracrine effect, releasing growth factors and proteins to communicate using exosomes and cytokines. An intrathecal injection at C1-C2 was done with 5 Million MSCUC was done with also a 30 Million MSC UC in an intravenous infusion. The patient was follow up for a year after the injection. He had complete resolution of his cervical and lumbar pain 2 months after the injection and 6 months after the procedure 80% of his central post stroke pain resolved. A year later the patient continues with the benefits of the MSC UC and his insulin requirements have decreased by a 60%.

You-Jin Choi has completed his PhD from Yonsei University College of Dentistry and Post-doctoral studies from Yonsei University College of Medicine. He has published more than 18 papers in reputed journals and has been serving as a Regular Member of Korean Association of Anatomists.

The paravertebral spread that occurs after erector spinae plane block may be volume-dependent. This cadaveric study was undertaken to compare the extent of paravertebral spread in erector spinae plane block using different dye volumes. After randomization, fourteen erector spinae plane blocks were performed bilaterally with either 10 ml or 30 ml dye at the level of  T5 in seven un-embalmed cadavers. Direct visualization of paravertebral space by endoscopy was performed immediately after injections. The back regions were also dissected and dye spread and nerve involvements were investigated. A total of five 10 ml injections and seven 30 ml injections were completed for both endoscopic and anatomical evaluations. No paravertebral spread was observed by endoscopy after any of the 10 ml injections. Dye spread to spinal nerves at intervertebral foramen was identified by endoscopy at adjacent levels of T5 (median: three levels) in all 30 ml injections. Upon anatomical dissection, all blocks were consistently associated with posterior and lateral spread to back muscles and fascial layers, especially in 30 ml injections, which showed greater dye expansion. In one 30 ml injection, sympathetic nerve involvement and epidural spread was observed at injection site level. Although paravertebral spread following erector spinae plane block increased in a volumedependent manner, this increase was variable and not pronounced. As injectate volume increased for erector spinae block, injectate spread to the back muscles and fascial layers seemed to be more predominantly increased, rather than the extent of paravertebral spread.

Ashutosh Joshi is an Associate Consultant in the Department of Anaesthesia in Khoo Teck Puat Hospital, Singapore. He subspecializes in Pain Management. Dr Joshi completed his post graduate training in Anaesthesia in Singapore and underwent subspecialty training in Chronic Pain Management in University of Toronto, Canada. He is a certified ‘Pain and MSK Interventional Untrasound’ physician by American Society of Regional Anesthesia and Pain Medicine (ASRA).His research interest and publications are on the role of ultrasound guidance for spinal procedures, peripheral nerves and joint injections to relieve pain. He also perform fluoroscopic guided pain relieving procedures like radiofrequency ablation of neuraxial and peripheral structures.

Neuropathic pain is a very common component of a wide range of pain states,usually resulting from neural damage,including acute and chronic post-operative pain and pain secondary to advanced malignancy. It is a complex condition. Which often has profound negative physical, psychological and social impacts. Management is universally acknowledged asextremely challenging and there is a lack of clear and specific treatment guidelines. The principal aim is to improve the patient’s quality of life by attaining pain relief whilst minimising adverse drug effects and improving physical function. The three broad categories of pain management include medications, interventional therapies, and physical or psychosocial therapies. Research indicates on average, only half of patients treated with any one modality achieve a clinically significant reduction in pain, and this is not always accompanied by improvement in function. Integrating a combination of treatment modalities is recommended. Many of the drugs used to treat neuropathic pain, including tricyclic antidepressants, gabapentin, pregabalin, duloxetine and opioids are associated with adverse effects that patients find burdensome. These include somnolence, dizziness, motor imbalance and cognitive impairment. These adverse effects may significantly restrict the patient’s independent living activities, increasing the risk of falls, limiting the ability to drive a car or be actively involved in daily living. Patients who do not show adequate response to medications may benefit from interventional treatments such as nerve blocks, modulation of specific neural structures and intravenous ketamine infusions. Spinal cord stimulation is ideal for patients not responding to other treatments, as it was shown to be relatively safe, reversible, cost-effective, and long-lasting (with results lasting a minimum of 24 months in several studies). The presentation is about interventional treatment algorithm of neuropathic pain and current evidence regarding use of perineural/ sympathetic plexus injections, intravenous ketamine infusion and spinal cord stimulator.

The significant mean CD4 count fall had been observed both in HIV positive patients as well as even with the patients of severe tuberculosis without HIV infections. But it has been observed that generally, the patients with tuberculosis does not seem to suffer that much from any secondary or opportunistic microbial infections, while in contrast, the HIV patients with same mean CD4 count suffer from plenty of opportunistic or secondary infections. The objective of this study deals with emphasizing the pivotal role of CD4 count in TB/HIV patients in maintaining their immune system effective (by maintaining CD4 count) and thus decreasing MDR/XDR, morbidity and mortality among these patients, calculating average mean CD4 count for Indian scenario in cART (Combined Antiretroviral Treatment) era and discussing and suggesting new scope of treating HIV patients for prevention of secondary infections. Method: All the 961 HIV infected patients early morning sputa were screened for AFB and few of the samples were even cultured on LJ medium. All patients’ CD4 count was also evaluated by flow cytometry method within one week of sputa collection. Seven other published work of HIV/TB patients were analyzed in relation to CD4 count. Moreover other five published research on CD4 in TB+ve/HIV-ve patients were also discussed in this article. Results: Out of 961 patients with HIV/RTI, 308(32.06%) found positive for tuberculosis with mean CD4 count found to be 198.5 and 105.9 cells/μl for pulmonary TB and for extra pulmonary TB respectively in present study. The average mean CD4 count from seven research studies from India were found to be 169.75 and 145.3 cells/μl for pulmonary and extra-pulmonary TB respectively, in TB/HIV co-infected patients on cART. Brenda et al., (1997) and other four found that in advanced/sever TB but HIV-negative patients mean CD4 count found to be 341+116. It means in severe tuberculosis patients CD4 count may reduce up to 198 cells/μl but in TB patients. But the difference between HIV and TB patients found by researchers was the CD4: CD8 ratio which always almost maintained in TB patients only but not in HIV patients. Even some researchers like MA Hauman, Fiske CT et al., (2015) could not find increased Intracellular Bacterial Infections (ICBIs) in only TB patients (HIV-ve). Conclusion: HAART and ATT (Anti Tubercle Treatment) both are equally important in maintaining immune system (maintaining CD4 count) of TB/HIV co-infected patients. In India, clinician should more suspect for TB at around mean CD4 count of 169.75 even if found negative by AFB staining for, but should be confirmed by culture on LJ medium, PCR or by any other latest technique in HIV-positive patients. It is not only reduced CD4 count responsible for secondary infections seen in HIV patients but it might be spoiled CD4:CD8 ratio, or in other world increased CD8 cells in comparison with CD4 cells might be responsible for secondary infections seen in HIV patients to confirm this further research should be done. If it is due to only this reason in severe TB with CD4 count below 200 cells/μl also secondary infections are usually not seen, then if we maintain CD4:CD8 ratio in HIV patients, by giving anti-antibodies to CD8 appropriately or by any other methods, it should theoretically reduce/stop secondary or opportunistic infections in HIV patients also. Further intensive practical research is required to find out new scope to reduce/stop secondary infections in HIV patients in this direction

Suchi is an experienced International Pre School Principal/Manager who picked up laughter exercises from many coaches around the world. She then designed laughter therapy which is being used in many places such as Hospitals and Senior Activity Centers. She provides individual and group therapy in educational and home settings. She is currently working as a Former Manager/Trainer who engages in building social awareness about Holistic approach for recovery. Her aim is to encourage people to seek help early and get on the path to recovery.

There is a lack of awareness about what happy hormones are how to use positive words to feel energetic and what can be done to get happy hormones. People tend to feel unhappy for multiple reasons and neuropathic pain adds on stress levels of not only the patient but the caregivers as well being in pains leads to feeling depressed and anxious in some cases. Review of books and research shows that getting a dosage of happy hormones will not only ease slight pain of the patient but feeling happy will also have a positive impact on the recovery of the patient. Adopting laughter therapy and getting hormones which makes one feel good will help many to recover from neuropathic pain/long term sadness caused by having grief, anger or resentment, depression and anxiety. One needs to work on his/her energies using laughter therapy which is a positive approach for not having depression and anxiety caused by neuropathic pain. The therapy can be used as a holistic way to recovery. The laughter therapy which includes ways to get the dosage of happy hormones promotes overcoming depression and anxiety caused by neuropathic pain is a fun way to manage pain. Repeated sessions to be conducted to remind patients that life while having pain or during the recovery should go beyond just seeking medical and counseling help and also include rebuilding spiritual, physical, emotional, relational and mental health. The model has been put together for testing in many settings including hospitals, elderly homes and senior citizen centers. It is just an effort to demystify the help available for depression and anxiety caused by pain. It is an attempt to motivate and encourage people to seek help and take a simple approach to remember and work on all aspects of their recovery.

Susan Jain is currently pursuing her PhD at University of New South Wales, Australia and her current research interests lie in the misuse, or over use of nonsterile gloves in healthcare settings. She is also working for the Clinical Excellence Commission’s Healthcare Associated Infections Program as a Project Officer in Sydney Australia.

Hand hygiene is well established as an effective measure for reducing the spread of microorganisms. However, there are several challenges surrounding compliance with adequate hand hygiene, especially in the context of contact precautions and the World Health Organizations’ recommendation of My Five Moments for Hand Hygiene. The foremost concern for Healthcare Workers (HCWs) is the integration of the practice of glove use into the principles of My Five Moments of Hand Hygiene despite the lack of clarity around when, and how often, gloves should be removed or changed. The indiscriminate use of gloves for contact precautions, when there is no exposure to body substances is raising confusion, gives the impression that hand hygiene is not reliable and HCWs need another layer of skin to protect them. Furthermore, HCWs lack of autonomy in conducting a knowledge-based risk assessment on deciding whether ‘to glove or not to glove’ before each episode of care to differentiate the tasks as safe without gloves and the benefits of hand hygiene over glove use, is detrimental for both healthcare worker and patient safety. As a result, the need for a modified approach and cultural shift to improve hand hygiene and patient safety led to the development and trial of contact precautions modified guidelines in multiple healthcare facilities with great success. This study highlighted the acceptance of a new and modified approach to appropriate no glove use by HCWs expecting dry contact while caring for patients colonized or infected with a multidrug resistant organism. The results of this multistage study reinforces the need for a selective approach to glove use for dry contact and the proposed modification is practical, encourages clinical judgment and, most importantly, promotes hand hygiene.