Endodontic microsurgery in mandibular molars is often challenging because of limited surgical access and the presence of thick buccal cortical bone. This case report presents two cases in which a simplified digital surgical guide was used to facilitate precise osteotomy and localization of the root apex in mandibular molars with intact buccal cortical bone. Both patients presented with symptomatic apical periodontitis associated with previously treated mandibular first molars. Radiographic and cone-beam computed tomography (CBCT) examinations identified periapical lesions involving the mesial roots, with intact buccal cortical plate. A surgical guide was digitally designed by integrating intraoral scan data with CBCT images using implant planning software and was fabricated via 3D printing. The guide enabled accurate determination of the initial osteotomy position. Guided osteotomy allowed precise localization of the root apex with minimal bone removal, and both cases demonstrated favorable clinical and radiographic healing during follow-up.

Purpose: The aim of this study is to compare the detection ability of quality of life (QoL) changes and responsiveness of the KOrean QUality of life in Stomach cancer patients Study group (KOQUSS)-40 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ). Materials and Methods: A multicenter prospective observational study was conducted to evaluate QoL changes after various gastrectomies between January 2021 and April 2022. Participants were instructed to complete the KOQUSS-40 and EORTC QLQ-C30/STO22 preoperatively and at 1, 3, 6, and 12 months postoperatively. QoL changes over time and QoL responsiveness were assessed for each questionnaire. Results: Data from 491 patients who underwent curative gastrectomy for gastric cancer at 22 institutions were analyzed. The summary scores of the KOQUSS-40 and EORTC QLQ-STO22 showed significant differences between the total and proximal gastrectomy groups (p=0.044 and p=0.038, respectively), but no difference was observed for the EORTC QLQ-C30. Dysphagia on the KOQUSS-40 was significantly different between the total and proximal gastrectomy groups (p=0.031); however, dysphagia on the EORTC QLQ-STO22 did not differ. The responsiveness of the KOQUSS-40 was similar to that of the EORTC QLQ in patients who experienced ≥ 10% body weight loss, but approximately 10% less in patients receiving adjuvant chemotherapy than the EORTC QLQ. Conclusion KOQUSS-40 has several advantages over EORTC QLQ-C30/STO22 when comparing QoL between the total and proximal gastrectomy groups. The findings provide information for researchers investigating the QoL of patients who have undergone curative gastrectomy for gastric cancer.

Purpose: The male predominance in the incidence of gastric cancer (GC) is established; however, sex differences in the prognosis of GC remain controversial. As such, this study analyzed the prognosis of patients with GC based on age and sex. Materials and Methods: Data from 14,739 patients diagnosed with GC at Seoul National University Bundang Hospital between 2003 and 2023 were analyzed. Baseline characteristics, histological types of GC, overall and GC-specific survival rates (age and stage stratification), and associated risk factors were analyzed. Results: Females were significantly younger (p < 0.001) and exhibited more gastric body cancers (p < 0.001) and tumors with diffuse-type or poorly differentiated histology (p < 0.001) than males. Females exhibited an advantage over males in terms of overall survival (p=0.004), but not in GC-specific survival. However, age stratification revealed significant sex differences, that females < 50 years of age exhibited survival disadvantages (p < 0.001); however, this trend was reversed with age, and females > 60 years exhibited survival advantages (p < 0.001) for both overall and GC-specific survival. This may be explained by the lower ratio of diffuse-type GC as females age. Furthermore, in the analysis according to stage, females with stage IV disease exhibited significant survival disadvantages, with significantly younger age and a higher proportion of diffuse-type GC which exhibits aggressive features, resulting in poorer survival than in males. Conclusion Age and stage stratification revealed significant differences in survival between the sexes, which can be helpful for public health strategies.

Background: Autosomal dominant giant platelet syndrome (GPS) is characterized by thrombocytopenia, giant platelets, and Döhle-like inclusion bodies in leukocytes.Previous studies suggest relatively preserved platelet structure and function, implicating impaired megakaryocyte fragmentation. This study aimed to identify myosin heavy chain 9 (MYH9) mutations in Korean patients with GPS and to define the associated clinical, molecular and functional characteristics. Methods: After detailed personal and family history taking, peripheral blood smears were reviewed for platelet size, count, and leukocyte inclusions. MYH9 mutations were analyzed in peripheral blood mononuclear cells by direct sequencing of selected exons or complementary DNA (cDNA). Computer-assisted structural modeling was performed to evaluate the functional consequences of identified mutations. Results: Twenty-two affected individuals from six unrelated families were diagnosed with hereditary macrothrombocytopenia consistent with GPS. The median platelet count was 59,000/L, and the mean platelet volume was markedly increased (17.8 fL). Platelets ranged from approximately half to 1.5 times the size of red blood cells.Döhle-like inclusions were observed in 25-33% of leukocytes in four families. Extrahematologic manifestations included hearing impairment (family with Ile1816Val) and renal involvement, ranging from mild proteinuria to chronic renal failure requiring renal transplantation (family with Lys373Asn). Five families harbored MYH9 mutations—Arg1933Ter, Trp33Cys (novel), Lys373Asn, Ile1816Val, and Arg1165Cys—located in exons 40, 1, 10, 37, and 26, respectively; mutations segregated with affected status.Biochemical analysis revealed decreased MYH9 in soluble fractions with increased insoluble pellets; Trp33Cys and Lys373Asn produced aberrant approximately 140 kDa bands in addition to the normal 224 kDa band. Modeling localized Trp33Cys to the proximal myosin head region implicated in actin interaction. Conclusion Five GPS-associated MYH9 mutations were identified, including a novel Trp33Cys variant. Altered MYH9 solubility and disturbed protein–protein interactions may contribute to disease pathogenesis.

Subarachnoid hemorrhage (SAH) is a stroke subtype with high mortality and poor functional outcomes. Prompt occlusion of a ruptured aneurysm at an early stage is crucial to prevent rebleeding, which can result in even higher mortality and more severe disabilities. The most critical initial decision in SAH management is the choice of treatment method with surgical clipping or endovascular coiling. We aimed to develop an evidence-based clinical guideline to select the optimal initial treatment in patients with SAH. We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer two population, intervention, comparison, outcome questions comparing clipping and coiling. The risk of bias was assessed using ROB 2.0 and the Newcastle-Ottawa Scale. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcome and mortality. We included six randomized control trials (RCTs) and 58 observational studies. Meta-analysis of RCTs showed that coiling improved functional outcomes compared to clipping (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.86–0.97). No significant mortality difference was observed in RCTs (OR, 1.38; 95% CI, 0.91–2.09), but non-RCTs favored clipping for reduced mortality (OR, 0.77; 95% CI, 0.69–0.86). However, it is difficult to generalize these findings to all clinical situations, as patients with SAH have a highly variable clinical course. Final treatment decision should be tailored to the individual patient’s status, including aneurysm location, morphology, and the expertise available at the treatment center. Such decisions are best made by specialists such as a board-certified physician and should be explained to the patient and their caregivers, along with the rationale for selecting the most appropriate treatment at the given hospital. Korea has many certified endovascular neurosurgeons, cerebrovascular surgeons, and certified cerebrovascular centers. Proper selection of the most suitable treatment method by certified physicians and centers would greatly benefit patient outcomes and healthcare professionals.

Accurate and early identification of stroke and large vessel occlusion (LVO) in emergency settings is essential for improving patient outcomes and ensuring the efficient allocation of medical resources. This clinical practice guideline systematically reviews domestic and international literature and conducts meta-analyses to evaluate the utility and diagnostic accuracy of stroke assessment tools used in prehospital emergency medical services (EMS). We developed a guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted to evaluate the usefulness of diagnostic EMS assessment tools for diagnosing stroke and LVO. Overall, 70 non-randomized control studies were selected for this study. A meta-analysis was conducted with a subgroup analysis to distinguish between patients with stroke and those with LVO. EMS tools demonstrated high sensitivity but low specificity for diagnosing stroke. In the prehospital setting, using validated EMS stroke assessment tools is recommended for the early identification of stroke and LVO. Upon hospital arrival, stroke specialists should conduct further evaluation and triage to confirm the diagnosis and guide appropriate management. Delays in diagnosing LVO are frequently unacceptable. While experts advocate for the use of EMS assessment tools to facilitate early identification of LVO, these tools alone lack adequate sensitivity. Therefore, further diagnostic evaluations and consultation with stroke specialists upon hospital arrival are recommended.

The mothership (MS) model, where patients are directly transferred to a thrombectomy-capable center, and the drip-and-ship (DS) model, where thrombolysis is initiated at the nearest primary stroke center before transfer for thrombectomy, are the primary transport modes for patients with stroke. We aimed to establish guidelines for selecting the appropriate transfer strategy based on emergent large vessel occlusion (LVO). We developed this guideline based on evidence from systematic reviews and meta-analyses via a de novo process. A systematic literature review was conducted across four databases (MEDLINE, Embase, Cochrane, and KoreaMed) to answer three Population, Intervention, Comparison, and Outcome questions comparing MS and DS models. The risk of bias was assessed using the Newcastle-Ottawa Scale. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagrams and meta-analyses were generated for functional outcomes, mortality, and successful recanalization. Twenty-six non-randomized controlled studies showed that the MS model improved good functional outcomes by approximately 14% compared with the DS model (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.00–1.30). Fifteen studies reported that mortality in the MS and DS models showed no significant differences (OR, 0.97; 95% CI, 0.84–1.11). Twenty-four studies revealed no significant difference in successful recanalization between the MS and DS models (OR, 0.87; 95% CI, 0.68–1.10). The MS model should be considered first to improve the functional outcome of patients with LVO. However, if thrombectomy cannot be performed immediately after thrombolysis, or if a thrombectomy-enabled hospital is not nearby, the DS model should be considered by stroke specialists depending on transportation time and regional factors. We suggest a mixed approach with the DS model based on specific circumstances or regions to ensure the optimum treatment of patients with acute ischemic stroke (AIS). Appropriate transport for patients with LVO improves the prognosis of AIS.

Purpose: This study compared the efficacy of different irrigation methods for the removal of Ca(OH)2 paste from the root canal. Materials and Methods: The root canals of 75 human mandibular premolars with standardized 15-mm canal lengths were prepared using nickel-titanium rotary files. After drying, the canals were filled with Ca(OH)2 paste. The teeth were divided into five groups: Control group (Group C), conventional irrigation; Group EA, sonic activation (EndoActivator); Groups EQA and EQB, sonic activation (EQ-S with metal tips A and B, respectively); and Group EU, ultrasonic activation (EndoUltra).The Ca(OH)2 paste volume before and after irrigation was measured using micro-computed tomography (CT) images. One specimen from each group was bisected along the long axis, and the canal walls were evaluated at 100× magnification using a scanning electron microscope. Statistical analyses were performed using Kruskal-Wallis and Mann-Whitney U tests. Results: Overall, Ca(OH)2 paste removal was higher in Group EQA than in Group C. In the coronal third, removal rate was higher in Group EQA than in Group C. In the middle third, Groups EQB and EU outperformed Group C. Removal from the apical third was higher in Group EQA than in Group C. All groups showed greater removal from the coronal and middle thirds than from the apical third. Conclusion Sonic and ultrasonic irrigation methods demonstrated higher efficacy than conventional irrigation method for the removal of Ca(OH)2 paste from the root canal. All groups demonstrated better effectiveness in removal from the coronal and middle thirds than from the apical third.

Background: This study aimed to investigate changes in gene expression related to matrix synthesis in individuals with fullthickness rotator cuff tears (RCTs) and normal tendon tissues. The study also aimed to examine the differences in gene expression according to 4 distinct tear sizes. Methods: A total of 12 patients with full-thickness RCTs were included in the study, all of whom underwent arthroscopic rotator cuff repair. The RCTs were stratified by size into small, medium, large, and massive. Tendon samples were harvested from the midpoint between the lateral end of the torn tendon and the musculotendinous junction. Subsequent analysis of the tissue samples revealed the mRNA expression levels of 11 collagen types, 6 proteoglycans, and 8 glycoproteins through real-time polymerase chain reaction techniques. For control purposes, supraspinatus tendon tissue was sourced from 3 patients who had proximal humerus fractures but did not present with RCTs. Results: Among the 11 collagens and 14 non-collagenous protein (NCP) genes examined in this study, COL3A1 and COL10A1 showed a significant increase, whereas COL4A1 and COL14A1 showed a tendency to decrease compared to those in the normal group. ACAN significantly increased by 8.92-fold (p < 0.001) compared to that in the normal group, whereas DCN and LUM showed a tendency to decrease. FN1 and TNC increased significantly by 3.47-fold (p = 0.003) and 5.38-fold (p = 0.005), respectively, and the genes ELN, LAMA2, and THBS1 were all significantly reduced compared to those in the normal group. In the NCPs, almost all the genes with increased expression levels had the highest level in small size RCTs, and gene expression decreased as the size increased. The 3 proteoglycans (ACAN, BGN, and FMOD) showed the highest levels of expression in small size RCTs compared to those in the normal group, and 5 glycoproteins (COMP, FBN1, FN1, HAPLN1, and TNC) also showed the highest expression in small size RCTs. Conclusions We confirmed that most of the detected extracellular matrix gene expression changes were related to the size of the full-thickness RCTs. In NCPs, gene expression was increased in small-size tears, and gene expression levels were significantly reduced when the size increased.

Environmental damage affects many aspects of healthcare, from extreme weather events to evolving population disease. Singapore's healthcare sector has the world's second highest healthcare emissions per capita, hampering the nation's pledge to reduce emissions by 2030 and achieve net zero emissions by 2050. In this review, we provide an overview of the impact environmental damage has on healthcare, including facilities, supply chain and human health, and examine measures to address healthcare's impact on the environment. Utilising the 'R's of sustainability - rethinking, reducing/refusing, reusing/repurposing/reprocessing, repairing, recycling and research - we have summarised the opportunities and challenges across medical disciplines. Awareness and advocacy to adopt strategies at institutional and individual levels is needed to revolutionise our environmental footprint and improve healthcare sustainability. By leveraging evidence from ongoing trials and integrating sustainable practices, our healthcare system can remain resilient against environment-driven challenges and evolving healthcare demands while minimising further impacts of environmental destruction.
Humans ; Climate Change ; Delivery of Health Care ; Singapore ; Conservation of Natural Resources ; Sustainable Development ; Environment