Background/Aims: Biliary tract cancer (BTC) is a rare malignancy with poor prognosis. We investigated genomic determinants of clinical benefit from gemcitabine, cisplatin, and nab-paclitaxel (GAP) versus gemcitabine and cisplatin (GC) in advanced BTC. Methods: Clinical and genomic data using TruSight Oncology 500 were analyzed from patients treated with GAP (N=198) or GC (N=89) as first-line therapy. Results: With a median follow-up of 33.0 months, GAP modestly improved progression-free survival (PFS) (hazard ratio [HR] 0.764; 95% confidence interval [CI] 0.591–0.989) without significant overall survival (OS) difference compared to GC. Genomic profiling revealed frequent alterations in TP53 (35.2%), KRAS (16.4%), SMAD4 (10.5%), and TNFRSF14 (10.5%), involving RTK/RAS (44.3%), TP53 (41.8%), and PI3K (20.2%) pathways. Single-gene mutations did not predict treatment benefit. However, pathway-level analysis identified PI3K pathway activation as significantly associated with inferior PFS (HR 2.148; 95% CI 1.478–3.124) and OS (HR 2.096; 95% CI 1.413–3.109) in patients receiving GAP, an effect not observed with GC. Importantly, GAP conferred clinical benefit only in patients without PI3K pathway activation, while no survival advantage was seen in those with such alterations (Pinteraction=0.023 for PFS, Pinteraction=0.003 for OS). Similar results were obtained in the independent validation cohort treated with GAP (N=103) or GC (N=64) for BTC. Conclusions Genomic profiling using next-generation sequencing identified PI3K pathway activation as key molecular determinant that differentiates patient outcomes between GAP and GC treatments in advanced BTC.

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.

This study aimed to evaluate anatomical factors influencing the palatal approach for endodontic microsurgery in maxillary molars using cone-beam computed tomography (CBCT). Understanding the spatial relationship between the palatal root apex and surrounding anatomical structures is essential for effective surgical planning. CBCT scans of 100 patients, comprising 200 maxillary first molars and 200 maxillary second molars with 3 separate roots, were retrospectively analyzed. Measurements included palatal bone thickness at the root apex and at a simulated 3-mm resection level, buccolingual root width, palatal soft-tissue thickness, the angle between the palatal root axis and the palatal soft-tissue surface, and the vertical relationship between the palatal root apex and the maxillary sinus floor. Palatal bone thickness at the apex was significantly greater in maxillary first molars than in second molars (4.01 mm vs. 3.39 mm; p<0.05). Palatal bone thickness at the 3-mm level and buccolingual root width did not differ significantly. Palatal soft tissue was significantly thicker in maxillary second molars at both measurement levels (p<0.05). The angle representing the surgical trajectory showed no significant difference between tooth types. Regarding the sinus relationship, type II (apex contacting the sinus floor) was most frequently observed in first molars, whereas type I (sinus floor above the apex) predominated in second molars. No significant difference was found in the mean apex-to-sinus distance between groups. These findings highlight the importance of CBCTbased evaluation of palatal bone, soft tissue, and sinus proximity when evaluating the feasibility and complexity of the palatal approach in endodontic microsurgery.

Purpose: Acute sagittal injury in boxer’s knuckle causes extensor tendon subluxation. We analyzed anatomical measurements for posture-related hand parts and measured the force generated when striking the fingers. Methods: In 120 healthy adults (55 males, 65 females), the palm area, finger length, finger length, finger circumference, and wrist circumference were measured. Using a digital force gauge, the force generated by striking with finger flexion (FFF) performed by the middle finger was measured. The forces generated during extension flicking (FEFs) by the index and ring fingers were also measured. The forces exerted by the hand and fingers was measured using a grip force meter. The relationships of measured values with sex and age were statistically analyzed. Results: The FFF of the middle finger was 12.9±7.0 N, and the FEFs of the index and ring fingers were 6.8±2.5 N and 5.8±2.3 N, respectively. The grip force was 343.3±134.7 N in the four fingers excluding the thumb, 108.4±41.6 N in the index finger, 110.5±45.4 N in the middle finger, and 83.6±36.5 N in the ring finger. Males had higher FFF for the middle finger (17.9±6.6 N) than females (8.6±3.9 N) (p<0.001), and greater FEFs for the index (8.5±2.0 N) and ring fingers (7.1±2.2 N) compared to females (5.3±1.7 N and 4.7±.8 N, respectively) (p<0.001). Cross-analysis results showed differences by sex and age. The circumference of the index finger exceeded that of the ring finger. Conclusion The study findings shed light on the relationship between the forces generated in the process of finger flicking.

In stroke patients, upper extremity deep vein thrombosis (UEDVT) is uncommon compared with lower extremity. Unlike the blood stasis in lower extremity, UEDVT has been developed by secondary cause. We reported a case of stroke patient with repeated UEDVT, presenting superficial venous congestion, who was finally diagnosed with pulmonary adenocarcinoma. The cause of stroke was non-bacterial thromboembolism formed at the mitral valve. Our case shows that unexpected UEDVT should be closely evaluated for higher coagulable status such as a malignancy.

Background: There has been no comparison of the determinants of admission route between acute ischemic stroke (AIS) and acute myocardial infarction (AMI). We examined whether factors associated with direct versus transferred-in admission to regional cardiocerebrovascular centers (RCVCs) differed between AIS and AMI. Methods: Using a nationwide RCVC registry, we identified consecutive patients presenting with AMI and AIS between July 2016 and December 2018. We explored factors associated with direct admission to RCVCs in patients with AIS and AMI and examined whether those associations differed between AIS and AMI, including interaction terms between each factor and disease type in multivariable models. To explore the influence of emergency medical service (EMS) paramedics on hospital selection, stratified analyses according to use of EMS were also performed. Results: Among the 17,897 and 8,927 AIS and AMI patients, 66.6% and 48.2% were directly admitted to RCVCs, respectively. Multivariable analysis showed that previous coronary heart disease, prehospital awareness, higher education level, and EMS use increased the odds of direct admission to RCVCs, but the odds ratio (OR) was different between AIS and AMI (for the first 3 factors, AMI > AIS; for EMS use, AMI < AIS). EMS use was the single most important factor for both AIS and AMI (OR, 4.72 vs. 3.90). Hypertension and hyperlipidemia increased, while living alone decreased the odds of direct admission only in AMI;additionally, age (65–74 years), previous stroke, and presentation during non-working hours increased the odds only in AIS. EMS use weakened the associations between direct admission and most factors in both AIS and AMI. Conclusions Various patient factors were differentially associated with direct admission to RCVCs between AIS and AMI. Public education for symptom awareness and use of EMS is essential in optimizing the transportation and hospitalization of patients with AMI and AIS.

In acute stroke, emboli are mostly composed of thrombi from artery, cardiac chamber, valve and vein. Non-thrombotic emboli are sometimes difficult to identify the origin. According to the increased number of cancer patients, now 10% of stroke patients have a cancer. However, the potential mechanisms of stroke in patients with cancer are various. We presented a case of serious acute arterial occlusion with a tumor embolus, which was revealed by histopathologic analysis of retrieved emboli during mechanical thrombectomy.

Methods: The electronic databases MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Web of Science, and Scopus were searched for relevant articles comparing the outcomes of SB-ACLR versus DB-ACLR that were published until November 2019. Results: Seventeen biomechanical studies were included. The anterior laxity measured using the anterior drawer test showed significantly better results in DB-ACLR when compared with SB-ACLR. In addition, outcomes of the anterior tibial translation test under a simulated pivot shift presented with better results at low flexion and 30° in DB-ACLR, compared with SB-ACLR. However, there were no significant biomechanical differences between the groups in internal rotation. Conclusions The present study demonstrated that both techniques for ACLR are associated with restoration of normal knee kinematics. DB-ACLR is superior to SB-ACLR in terms of restoration of anteroposterior stability.However, which technique yields better improvement in internal rotation laxity, and internal rotation laxity under a simulated pivot shift at a specific angle, remains unclear.Level of evidence: This is a level II meta-analysis.

This report describes osteotomy and iliac bone graft for malunion caused by failed mandibular fracture reduction. A 27-year-old man was referred 3 months after a motor vehicle accident. At another hospital, two operations had been performed for symphyseal fracture using two resorbable plates. Malocclusion was noted, and panoramic radiography and computed tomography revealed a misaligned dental arch, with a 9.37-mm gap between the central and the lateral incisor of the left mandible. A wafer was made from the patient’s dental model, and a maxillary arch bar was applied. Through a lower gingivolabial incision, osteotomy was performed between the malunited symphyseal fracture segments. Both segments were reduced to their original position using the wafer and fixed with titanium miniplates via intermaxillary fixation (IMF). The intersegmental gap was filled with cancellous bone from the iliac crest. The gingival defect was covered with a mucosal transposition flap from the gingivolabial sulcus. IMF and the wafer were maintained for 5 and 9 weeks, respectively. At postoperative week 13, the screws were removed from the mandible and satisfactory occlusion was noted. His mouth opening improved from 2.5 to 3 finger breadths (40 mm). This case demonstrates the need for sufficient IMF when using resorbable plates.

The authors regret that one co-author (Kyung-Hyo Kim) was missing in the article.