The lack of clear definition and classification for “moderate ulcerative colitis (UC)” creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

The lack of clear definition and classification for “moderate ulcerative colitis (UC)” creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

The lack of clear definition and classification for “moderate ulcerative colitis (UC)” creates ambiguity regarding the suitability of step-up versus top-down treatment approaches. In this paper, experts address crucial gaps in assessing and managing moderate UC. The Asia-Pacific, Middle East, and Africa Inflammatory Bowel Disease Coalition comprised 24 experts who convened to share, discuss and vote electronically on management recommendations for moderate UC. Experts emphasized that the goal of treating UC is to attain clinical, biomarker, and endoscopic remission using cost-effective strategies such as 5-aminosalicylates (5-ASAs), well-tolerated therapy that can be optimized to improve outcomes. Experts agreed that 5-ASA therapy could be optimized by maximizing dosage (4 g/day for induction of remission), combining oral and topical administration, extending treatment duration beyond 8 weeks, and enhancing patient adherence through personalized counselling and reduced pill burden. Treatment escalation should ideally be reserved for patients with predictors of aggressive disease or those who do not respond to 5-ASA optimization. Premature treatment escalation to advanced therapies (including biologics and oral small molecules) may have long-term health and financial consequences. This paper provides consensus-based expert recommendations and a treatment algorithm, based on current evidence and practices, to assist decision-making in real-world settings.

Purpose::Tibial stress fracture associated with knee osteoarthritis is an unusual and difficult clinical scenario. There is no clear existing treatment guideline for this uncommon clinical disease. The aim of this study is to review the impact of various treatment options for patients with advanced knee osteoarthritis associated with proximal tibial stress fracture.Methods::The study was performed using the databases of PubMed and Scopus. Methodological index for non-randomized studies score was used to evaluate the included studies’ bias. The concluded data included the treatment approach, reported outcome measure, and time to fracture union. The literature search was started in December 2021 and accomplished in January 2022. A narrative description of the different methods and comparison of their results were done.Results::Out of total assessed 69 studies, 9 studies were included in our review. The commonest treatment approach used was total knee arthroplasty by long tibial stem extension. The mean preoperative knee society score and knee functional score were 30.62 and 23.17, respectively. The mean postoperative knee society knee score was 86.87, while the functional score was 83.52. The average reported time to achieve fracture union was 4 months (a range of 2.07 - 5.50 months).Conclusion::The optimal clinical outcome for treating either acute or mobile tibial stress fracture in patients with advanced knee osteoarthritis can be achieved with long stem total knee arthroplasty. However, due to heterogeneity of data, comparison of different treatment options for chronic proximal tibial stress fracture mal-union/non-union coexisting with knee osteoarthritic and such inferences need to be judged cautiously.

Malignant hyperthermia (MH) is a rare, potentially fatal genetic disorder characterized by an unexplained elevation of expired carbon dioxide despite increased minute ventilation, muscle rigidity, and rhabdomyolysis, hyperthermia, tachycardia, acidosis, and hyperkalemia. It can be triggered by many pharmacological agents such as potent inhalation agents (halothane/ isoflurane/ sevoflurane/ desflurane), the depolarizing muscle relaxant (succinylcholine), and extreme physiological conditions such as vigorous exercise and working excessively in a hot and dry environment. Prompt and early recognition of the condition and rapid initiation of treatment measures are necessary to salvage the patient. Since MH is commonly encountered in the operating room or early postoperative period, anesthetists and surgeons need to keep themselves updated regarding the same. This review article aims to summarize our understanding of MH's pathophysiology, current diagnostics, management, and treatment strategies, along with a brief review of literature of published cases in Indian Subcontinent.

INTRODUCTION: There has been a global decrease in operative vaginal deliveries, with a marked shift towards the vacuum extractor. However, little is known about the trends in operative vaginal delivery in Singapore. METHODS: A retrospective study was conducted on all operative vaginal deliveries performed from 2012 to 2017 at Singapore General Hospital (SGH). Maternal outcomes in terms of postpartum haemorrhage and obstetric anal sphincter injuries were compared between forceps- and vacuum-assisted deliveries. Neonatal outcomes in terms of neonatal intensive care unit (NICU) admission and clinically significant neonatal events were compared. The instrument preference of obstetricians was analysed. RESULTS: A total of 906 consecutive operative vaginal deliveries were included in the study, comprising 461 forceps- and 445 vacuum-assisted deliveries. The rate of operative vaginal delivery was maintained at approximately 10% from 2012 to 2017. Neonatal cephalohematomas were more common after vacuum-assisted deliveries. Other maternal and neonatal outcomes did not differ significantly between the two groups. Clinically significant neonatal events were mostly due to shoulder dystocia, whereas all cases of NICU admissions were not directly related to the mode of delivery. Obstetricians' choice of instrument appeared to reflect personal preference and was not affected by the year of graduation. CONCLUSION The rates of neonatal and maternal morbidity were low at SGH. Overall instrument use of forceps and vacuum was balanced, and proficiency in both was demonstrated by all operators. Operative vaginal delivery remains an essential skill in facilitating safe vaginal delivery, which should be maintained to keep Caesarean section rates in check.
Infant, Newborn ; Pregnancy ; Humans ; Female ; Cesarean Section ; Retrospective Studies ; Vacuum Extraction, Obstetrical/adverse effects* ; Hospitals, General ; Obstetrical Forceps/adverse effects* ; Delivery, Obstetric

Background: Pain control is a crucial aspect of pediatric dentistry for patient management. Thermo-mechanical devices (Buzzy TM Pain Care Labs, USA) work on the concept of vibration and cooling and have shown promising results in pain control during local anesthesia in pediatric dentistry. On the other hand, audio distraction has also been used for pain management. The amount of pain endured is determined by the patient's perception and attentiveness. Thus, if audio function is added to the thermomechanical device it might increase its efficiency. Hence, the present study aimed to compare pain on injection using a thermo-mechanical device with and without audio during inferior alveolar nerve block (IANB) injection in children aged 5-10 years old. Methods: Twenty-eight children aged between 5 and 10 indicated for IANB were included in this randomized study. Children who were undergoing the dental procedure were divided into 2 groups, with 14 children in each group. The study group was the thermo-mechanical device with audio distraction; the control group was the thermo-mechanical device without audio distraction. IANB was administered. Subjective pain evaluation was performed using the Wong–Baker Faces Pain Rating Scale (WBFPR) and objective pain evaluation was done using the Faces, Leg, Activity, Consolability, Cry (FLACC) scale. Results: The outcome depicted a significant reduction in pain on injection for both objective and subjective evaluations in the thermo-mechanical device with an audio distraction group. Conclusions Less pain on injection was observed, when a thermo-mechanical device was used with audio distraction for IANB procedures.

Anterior cervical corpectomy and fusion is considered the mainstay of surgical treatment in cervical pathology. Expandable and nonexpandable cages are preferred over autogenous bone graft because of donor-related morbidity. However, the choice of the cage type remains a debatable topic as studies report conflicting results. Thus, we evaluated the outcomes of expandable and non-expandable cages following cervical corpectomy. Studies were searched in various electronic databases (MEDLINE, PubMed, EMBASE, CINAHL, Scopus, and Cochrane) between 2011 and 2021. Forest plot was made to compare the radiological and clinical outcomes between expandable and non-expandable cages following cervical corpectomy. Altogether, 26 studies (1,170 patients) were included in the metaanalysis. The mean change in segmental angle was significantly greater in the expandable cage group than in the non-expandable cage group (6.7° vs. 3.0°, p <0.001). The mean subsidence rate was lower in the expandable cage group (6% vs. 41%, p <0.001). The mean fusion rate was lower (93% vs. 98%, p =0.06) and the mean displacement rate was significantly higher in the expandable cage group (29% vs. 5%, p <0.05). The mean reoperation rate was higher in the expandable cage group (16% vs. 2%, p >0.05). The improvement in segmental angle is better with expandable cages. Higher subsidence is a major problem with non-expandable cages, but it seems to be beneficial as evidenced by the high fusion rate and minimal effect on clinical outcome in patients with this cage.

Background/Aims: Primary sclerosing cholangitis (PSC) represents the most common hepatobiliary extraintestinal manifestation of inflammatory bowel disease (IBD), including ulcerative colitis (UC) and Crohn’s disease (CD). Limited data exist on PSC in patients with IBD from India. We aimed to assess the prevalence and disease spectrum of PSC in Indian patients with IBD. Methods: Database of IBD patients at 5 tertiary care IBD centers in India were analyzed retrospectively. Data were extracted and the prevalence of PSC-IBD was calculated. Results: Forty-eight patients out of 12,216 patients with IBD (9,231 UC, 2,939 CD, and 46 IBD unclassified) were identified to have PSC, resulting in a prevalence of 0.39%. The UC to CD ratio was 7:1. Male sex and pancolitis (UC) or colonic CD were more commonly associated with PSC-IBD. The diagnosis of IBD preceded the diagnosis of PSC in most of the patients. Majority of the patients were symptomatic for liver disease at diagnosis. Eight patients (16.66%) developed cirrhosis, 5 patients (10.41%), all UC, developed malignancies (3 colorectal cancer [6.25%] and 2 cholangiocarcinoma [4.16%]), and 3 patients died (2 decompensated liver disease [4.16%] and 1 cholangiocarcinoma [2.08%]) on follow-up. None of the patients mandated surgical therapy for IBD. Conclusions Concomitant PSC in patients with IBD is uncommon in India and is associated with lower rates of development of malignancies.

Background: Dental pain management is an important aspect of patient management in pediatric dentistry. Articaine is considered the most successful anesthetic agent for infiltration anesthesia. Buffered articaine has been observed to have faster onset and longer duration of action with less pain on injection. The aim of this study was to evaluate and compare pain on injection, onset of action, and pain during extraction using buffered (using Sodium bicarbonate (NaHCO 3 )) and non-buffered 4% articaine (with 1:100000 adrenaline) infiltrations for primary maxillary molar extractions in 4–10-year-old children. Methods: Seventy children who required extraction of maxillary primary molars were enrolled in this triple-blind randomized study. Children undergoing extraction were randomly divided into two groups, with 35 in each group. The study group was the buffered articaine group; the control group was the non-buffered articaine group. Buccal and palatal infiltrations were administered with either buffered or non-buffered articaine. Subjective evaluation was done for pain on injection, pain during extraction using Wong–Baker Faces Pain Rating Scale (WBFPR) and onset of anesthesia in seconds. Pain on injection, pain during extraction were objectively evaluated using Sound Eye Motor (SEM) scale and onset of anesthesia was also evaluated objectively by pricking with sharp dental probe. Results: The outcome was, significantly less pain on injection and significantly faster onset of anesthesia with significantly less pain during extraction for both subjective and objective evaluations in the buffered articaine group. Subgroup analysis was also performed and it showed variable results, with only significant difference for WBFPR scores in age subgroup 4–7 years for palatal infiltration. Conclusion Less pain on injection, faster onset of anesthesia, and less pain during extraction were observed when buffered articaine was used for maxillary primary molar extraction.