Background/Aims: Atezolizumab plus bevacizumab (ATE+BEV) therapy has become the recommended first-line therapy for patients with unresectable hepatocellular carcinoma (HCC) because of favorable treatment responses. However, there is a lack of data on sequential regimens after ATE+BEV treatment failure. We aimed to investigate the clinical outcomes of patients with advanced HCC who received subsequent systemic therapy for disease progression after ATE+BEV. Methods: This multicenter, retrospective study included patients who started second-line systemic treatment with sorafenib or lenvatinib after HCC progressed on ATE+BEV between August 2019 and December 2022. Treatment response was assessed using the Response Evaluation Criteria in Solid Tumors (version 1.1.). Clinical features of the two groups were balanced through propensity score (PS) matching. Results: This study enrolled 126 patients, 40 (31.7%) in the lenvatinib group, and 86 (68.3%) in the sorafenib group. The median age was 63 years, and males were predominant (88.1%). In PS-matched cohorts (36 patients in each group), the objective response rate was similar between the lenvatinib- and sorafenib-treated groups (5.6% vs. 8.3%; P=0.643), but the disease control rate was superior in the lenvatinib group (66.7% vs. 22.2%; P<0.001). Despite the superior progression- free survival (PFS) in the lenvatinib group (3.5 vs. 1.8 months, P=0.001), the overall survival (OS, 10.3 vs. 7.5 months, P=0.353) did not differ between the two PS-matched treatment groups. Conclusions In second-line therapy for unresectable HCC after ATE+BEV failure, lenvatinib showed better PFS and comparable OS to sorafenib in a real-world setting. Future studies with larger sample sizes and longer follow-ups are needed to optimize second-line treatment.

Purpose: The original eCura system was designed to stratify the risk of lymph node metastasis (LNM) after endoscopic resection (ER) in patients with early gastric cancer (EGC).We assessed the effectiveness of a modified eCura system for reflecting the characteristics of undifferentiated-type (UD)-EGC. Materials and Methods: Six hundred thirty-four patients who underwent non-curative ER for UD-EGC and received either additional surgery (radical surgery group; n=270) or no further treatment (no additional treatment group; n=364) from 18 institutions between 2005 and 2015 were retrospectively included in this study. The eCuraU system assigned 1 point each for tumors >20 mm in size, ulceration, positive vertical margin, and submucosal invasion <500 µm; 2 points for submucosal invasion ≥500 µm; and 3 points for lymphovascular invasion. Results: LNM rates in the radical surgery group were 1.1%, 5.4%, and 13.3% for the low-(0–1 point), intermediate- (2–3 points), and high-risk (4–8 points), respectively (P-fortrend<0.001). The eCuraU system showed a significantly higher probability of identifying patients with LNM as high-risk than the eCura system (66.7% vs. 22.2%; McNemar P<0.001).In the no additional treatment group, overall survival (93.4%, 87.2%, and 67.6% at 5 years) and cancer-specific survival (99.6%, 98.9%, and 92.9% at 5 years) differed significantly among the low-, intermediate-, and high-risk categories, respectively (both P<0.001). In the high-risk category, surgery outperformed no treatment in terms of overall mortality (hazard ratio, 3.26; P=0.015). Conclusions The eCuraU system stratified the risk of LNM in patients with UD-EGC after ER. It is strongly recommended that high-risk patients undergo additional surgery.

The modified Phemister technique, which fixes the acromioclavicular joint with a k-wire and fixes the coronoid process and clavicle with a sling, has often been used as surgical treatment for dislocation of the acromioclavicular joint. This technique has the advantage of allowing early rehabilitation exercises with accurate anatomical reduction and firm fixation. On the other hand, some complications have been reported, such as infection, deformation recurrence, fixation complications, erosion of the distal clavicle or fracture of the sling, and secondary arthritis. This study presents a patient who experienced shoulder pain and functional impairment after conservative treatment for a sling area insufficiency fracture that arose from using the modified Phemister technique. Locking screw plate fixation with tricortical iliac bone grafting and matchstick-shaped cancellous bone grafting were used, and successful outcomes were achieved. This paper reports this case with a review of the relevant literature.

Background/Aims: The eCura system, a scoring model for stratifying the lymph node metastasis risk after noncurative endoscopic resection for early gastric cancer (EGC), has been internally validated, primarily for differentiated-type EGC. We aimed to externally validate this model for undifferentiated-type EGC. Methods: This multicenter, retrospective cohort study included 634 patients who underwent additional surgery (radical surgery group, n=270) or were followed up without additional treatment (no additional treatment group, n=364) after noncurative endoscopic resection for undifferentiated-type EGC between 2005 and 2015. The lymph node metastasis and survival rates were compared according to the risk categories. Results: For the radical surgery group, the lymph node metastasis rates were 2.6%, 10.9%, and 14.8% for the low-, intermediate-, and high-risk eCura categories, respectively (p for trend=0.003). For the low-, intermediate-, and high-risk categories in the no additional treatment group, the overall survival (92.7%, 68.9%, and 80.0% at 5 years, respectively, p<0.001) and cancer-specific survival rates (99.7%, 94.7%, and 80.0% at 5 years, respectively, p<0.001) differed significantly. In the multivariate analysis, the hazard ratios (95% confidence interval) in the no additional treatment group relative to the radical surgery group were 3.18 (1.41 to 7.17; p=0.005) for overall mortality and 2.60 (0.46 to 14.66; p=0.280) for cancer-specific mortality in the intermediate-tohigh risk category. No such differences were noted in the low-risk category. Conclusions The eCura system can be applied to undifferentiated-type EGC. Close follow-up without additional treatment might be considered for low-risk patients, while additional surgery is recommended for intermediate- and high-risk patients.

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Objective: Electroconvulsive seizure (ECS) is a potent treatment modality for various neuropsychiatric diseases, including Parkinson disease (PD). Recent animal studies showed that repeated ECS activates autophagy signaling, the impairment of which is known to be involved in PD. However, the effectiveness of ECS on PD and its therapeutic mechanisms have not yet been investigated in detail. Methods: Systemic injection of a neurotoxin 1-Methyl-4-phenyl-1,2,3,6-tetrahydropyridine hydrochloride (MPTP), which destroys dopaminergic neurons in the substantia nigra compacta (SNc), in mice was utilized to induce an animal model of PD. Mice were treated with ECS 3 times per week for 2 weeks. Behavioral changes were measured with a rotarod test. Molecular changes related to autophagy signaling in midbrain including SNc, striatum, and prefrontal cortex were analyzed with immunohistochemistry and immunoblot analyses. Results: Repeated ECS treatments normalized the motor deficits and the loss of dopamiergic neurons in SNc of the MPTP PD mouse model. In the mouse model, LC3-II, an autophagy marker, was increased in midbrain while decreased in prefrontal cortex, both of which were reversed by repeated ECS treatments. In the prefrontal cortex, ECS-induced LC3-II increase was accompanied with AMP-activated protein kinase (AMPK)-Unc-51-like kinase 1-Beclin1 pathway activation and inhibition of mamalian target of rapamycin signaling which promotes autophagy initiation. Conclusion The findings revealed the therapeutic effects of repeated ECS treatments on PD, which could be attributed to the neuroprotective effect of ECS mediated by AMPK-autophagy signaling.

Objectives: During the initial clozapine titration, it is crucial to monitor for inflammatory reactions to ensure safe and effective administration. Clozapine metabolism varies by ancestry, particularly among Asians, warranting lower dosage. Recently, Dr. De Leon introduced guidelines based on ancestral differences. We aimed to provide a Korean translation, focusing on illustrating the necessity through clinical cases. Methods: The Korean translation of the guidelines, approved by Dr. De Leon, involved two psychiatrists who reviewed and revised each other’s work. An additional board-certified psychiatrist conducted an independent review. We examined two clinical cases from our institution’s database, where clozapine titration faced challenges due to fever and pneumonia, assessing guideline applicability. Results: The guidelines recommend a target clozapine dose of 175-300 mg/day for Asians with average metabolism and a slower titration rate compared to other ancestries. In both cases, CRP elevation was detected either before or simultaneously with the onset of fever, with a concentration-to-dose ratio ranging from 3.06 to 6.97. Conclusion The initial clozapine titration process should consider metabolic differences by ancestry and monitor for inflammation. Further research is needed to optimize the titration process for Koreans, considering metabolic rates, usage patterns, and side effects.

Background: This study aimed to investigate the prevalence of Clostridium difficile colitis (CDC) in elderly patients with hip fractures using a nationwide cohort database and to analyze the effect of CDC on the all-cause mortality rate after hip fracture. Methods: This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Senior cohort. The subjects of this study were patients who were over 65 years old and underwent surgical treatment for hip fractures from January 1, 2002, to December 31, 2015. The total number of patients included in this study was 10,158. The diagnostic code used in this study was A047 of the International Classification of Diseases, 10th revision for identifying CDC. Procedure codes for C. difficile culture or toxin assay were BY021 and BY022. CDC patients were defined as follows: patients treated with oral vancomycin or metronidazole over 10 days and patients with procedure codes BY021 and BY022 or diagnostic code A047 after hip fracture. Incidence date (index date, time zero) of hip fracture for analyzing risk of all-cause mortality was defined as the date of discharge.A generalized estimating equation model with Poisson distribution and logarithmic link function was used for estimating adjusted risk ratios and 95% confidence intervals to assess the association between CDC and cumulative mortality risk. Results: The prevalence of CDC during the hospitalization period in the elderly patients with hip fractures was 1.43%. Compared to the non-CDC group, the CDC group had a 2.57-fold risk of 30-day mortality after discharge, and a 1.50-fold risk of 1-year mortality after discharge (p < 0.05). Conclusions The prevalence of CDC after hip fracture surgery in elderly patients was 1.43%. CDC after hip fracture in the elderly patients significantly increased the all-cause mortality rate after discharge.