The present and future of the Korean Medical Practice Review Authority

The Korean Medical Association (KMA) has been working on medical appraisals for the last 30 years. In 2019, the Korean Medical Practice Review Authority (KMPRA) was established to systematically promote medical appraisal. In addition, regulations related to medical appraisals were amended, professional committees of KMPRA established, and medical case management programs developed. This study reviews the history, present challenges, and the future of KMPRA.Current Concepts: The efforts made by KMA for the development of KMPRA have provided evidence of the excellence of medical appraisal system, with a highly professional, fast, and transparent medical practice review system. Nevertheless, KMPRA has not completely resolved the social distrust of fairness and the quickness of medical appraisals. It is necessary to identify the obstacles that exist in the current appraisal system for the continued development of KMPRA. Currently, KMPRA faces several challenges, such as lack of independence, financial constraints, dichotomized process of medical appraisal, and insufficient administrative manpower, in the process of handling thousands of requested cases. To improve the level of expertise of the professional medical appraisal system, independence, fairness, and speed of its process, KMPRA requires more attention and support from KMA and other major professional medical organizations.Discussion and Conclusion: KMPRA is committed to fulfilling the social responsibility of fair medical appraisal, and it will ultimately contribute to resolving social conflicts derived from medical services and further improving trust relationships with the public.

Medicosocial Conflict and Crisis due to Illegal Physician Assistant System in Korea

The Korean Medical Association opposes the illegal attempt to implement the physician assistant (PA) system in Korea. The exact meaning of ‘PA’ in Korea at present time is ’Unlicensed Assistant (UA)’ since it is not legally established in our healthcare system. Thus, PA in Korea refers to unlawful, unqualified, auxiliary personnel for medical practitioners. There have been several issues with the illegal PA system in Korea facing medicosocial conflicts and crisis. Patients want to be diagnosed and treated by medically-educated, licensed and professionally trained physicians not PAs. In clinical settings, PAs deprive the training and educational opportunities of trainees such as interns and residents. Recently, there have been several attempts, by CEO or directors of major hospitals in Korea, to adopt and legalize this system without general consensus from medical professional associations and societies. Without such consensus, this illegal implementation of PA system will create new and additional very serious medical crises due to unlawful medical, educational, professional conflicts and safety issues in medical practice. Before considering the implementation of the PA system, there needs to be a convincing justification by solving the fundamental problems beforehand, such as the collapsed medical delivery system, protection and provision of optimal education program and training environment of trainees, burnout from excessive workloads of physicians with very low compensational system and poor conditions for working and education, etc.

The present and future of the Korean Medical Practice Review Authority

The Korean Medical Association (KMA) has been working on medical appraisals for the last 30 years. In 2019, the Korean Medical Practice Review Authority (KMPRA) was established to systematically promote medical appraisal. In addition, regulations related to medical appraisals were amended, professional committees of KMPRA established, and medical case management programs developed. This study reviews the history, present challenges, and the future of KMPRA.Current Concepts: The efforts made by KMA for the development of KMPRA have provided evidence of the excellence of medical appraisal system, with a highly professional, fast, and transparent medical practice review system. Nevertheless, KMPRA has not completely resolved the social distrust of fairness and the quickness of medical appraisals. It is necessary to identify the obstacles that exist in the current appraisal system for the continued development of KMPRA. Currently, KMPRA faces several challenges, such as lack of independence, financial constraints, dichotomized process of medical appraisal, and insufficient administrative manpower, in the process of handling thousands of requested cases. To improve the level of expertise of the professional medical appraisal system, independence, fairness, and speed of its process, KMPRA requires more attention and support from KMA and other major professional medical organizations.Discussion and Conclusion: KMPRA is committed to fulfilling the social responsibility of fair medical appraisal, and it will ultimately contribute to resolving social conflicts derived from medical services and further improving trust relationships with the public.

Medicosocial Conflict and Crisis due to Illegal Physician Assistant System in Korea

The Korean Medical Association opposes the illegal attempt to implement the physician assistant (PA) system in Korea. The exact meaning of ‘PA’ in Korea at present time is ’Unlicensed Assistant (UA)’ since it is not legally established in our healthcare system. Thus, PA in Korea refers to unlawful, unqualified, auxiliary personnel for medical practitioners. There have been several issues with the illegal PA system in Korea facing medicosocial conflicts and crisis. Patients want to be diagnosed and treated by medically-educated, licensed and professionally trained physicians not PAs. In clinical settings, PAs deprive the training and educational opportunities of trainees such as interns and residents. Recently, there have been several attempts, by CEO or directors of major hospitals in Korea, to adopt and legalize this system without general consensus from medical professional associations and societies. Without such consensus, this illegal implementation of PA system will create new and additional very serious medical crises due to unlawful medical, educational, professional conflicts and safety issues in medical practice. Before considering the implementation of the PA system, there needs to be a convincing justification by solving the fundamental problems beforehand, such as the collapsed medical delivery system, protection and provision of optimal education program and training environment of trainees, burnout from excessive workloads of physicians with very low compensational system and poor conditions for working and education, etc.

Clinical Effects of Guardcel® Nasal Packing on Endonasal Dacryocystorhinostomy

Purpose@#To compare the clinical effects of Guardcel® (Genewel. Co, Seongnam, Korea) and Nasopore®(Polyganics, Rozenburglaan, Groningen, The Netherlands), two types of absorbable nasal packing materials after endonasal dacryocystorhinostomy. @*Methods@#A total of 41 patients (49 eyes) who underwent endonasal dacryocystorhinostomy from March 2017 to January 2019 were studied retrospectively. Twenty seven eyes were packed with Guardcel® and twenty two eyes with Nasopore®. We compared the postoperative anatomical and functional surgical success rates between the groups at 1 week, 1 month, 2 months, and 6 months , as well as the frequency of postoperative complications including bleeding. @*Results@#There was no significant difference between the Guardcel® and Nasopore® groups in the postoperative anatomical and functional surgical success rate at 1 week, 1 month, 2 months, or 6 months. Also, there was no significant group difference in the incidence of postoperative complications. @*Conclusions@#The anatomical and functional surgical success rates and incidence of postoperative complications, including bleeding, synechiae, infection, granuloma, and revision were similar between the Guardcel® and Nasopore® groups. Therefore, Guardcel® can be used safely and effectively as an absorbable nasal packing material in endonasal dacryocystorhinostomy treatment.

Present status and constitutional remedies of continuing medical education in Korea

The purpose of this study is to identify the historical background and status of continuing medical education (CME) in Korea, and to establish a method for improving CME in the future. Currently, the CME in Korea presents several problems that need to be addressed, such as the appropriateness of the annual required credits, maintenance of simple refresher training, insufficient online education, and evaluation and accreditation of educational institutions. Solutions are offered in the form of increased time for the required credits, introduction of social competency topics and education methods, improvement of online education, evaluation to improve the quality of CME, and introduction of a systematic and appropriate evaluation and accreditation system. CME and continuing professional development (CPD) are not only obligations stipulated in the medical law, but also professional requisites in terms of securing autonomy through self-development and self-regulation. It aims to enlighten the high level of professionalism required by the international community. It is an essential requirement and ultimately promotes and protects the physical, mental, and social health of people worldwide. In order to cope with the international standards of CME/CPD that ensure high quality treatment and patient safety, it is crucial to reform the continuing medical education system by securing the physicians’ professionalism. To this end, authors propose the improvement and implementation of CME system in Korea based on internal review and benchmarks of the internationally recognized CME/CPD systems that meet global standards.

Global trends in continuing medical education and continuing development: A proposal for implementation in Korea

This study is to introduce an effective and systematic accreditation and evaluation system of continuing medical education (CME) and continuing professional development (CPD) in Korea, suitable for the future development, and based on the review of the characteristics of well-recognized systems implemented in western countries such as the US and Canada. CME and CPD comprise programs that expand the clinical knowledge and skills required of physicians as well as educational activities aiming to maintain, develop, and increase knowledge, specialized skills, or performance standards for provision of better medical services. These include not only self-directed activities but also official activities, such as leadership activities, professional development, and evaluation of the practitioner’s level of knowledge and competence. Recently, continuing education for doctors has emphasized CPD, centered around learners, in a departure from CME, centered around educators. Each CME/CPD program in the US and Canada has unique features. However, they share common features of self-directed learning, competency-based education, and evaluation. Although there are remain problems, the Continuing Medical Education Accreditation and Evaluation Council of the Korean Medical Association, as a unique accreditation authority for CME, is currently developing a new CME/CPD system, which would constitute an idealistic onesystem for Korean physicians oriented toward future development, designed to fulfill standards equivalent to that of the Accreditation Council for Continuing Medical Education or any other internationally well-recognized organization.

Present status and constitutional remedies of continuing medical education in Korea

The purpose of this study is to identify the historical background and status of continuing medical education (CME) in Korea, and to establish a method for improving CME in the future. Currently, the CME in Korea presents several problems that need to be addressed, such as the appropriateness of the annual required credits, maintenance of simple refresher training, insufficient online education, and evaluation and accreditation of educational institutions. Solutions are offered in the form of increased time for the required credits, introduction of social competency topics and education methods, improvement of online education, evaluation to improve the quality of CME, and introduction of a systematic and appropriate evaluation and accreditation system. CME and continuing professional development (CPD) are not only obligations stipulated in the medical law, but also professional requisites in terms of securing autonomy through self-development and self-regulation. It aims to enlighten the high level of professionalism required by the international community. It is an essential requirement and ultimately promotes and protects the physical, mental, and social health of people worldwide. In order to cope with the international standards of CME/CPD that ensure high quality treatment and patient safety, it is crucial to reform the continuing medical education system by securing the physicians’ professionalism. To this end, authors propose the improvement and implementation of CME system in Korea based on internal review and benchmarks of the internationally recognized CME/CPD systems that meet global standards.

Global trends in continuing medical education and continuing development: A proposal for implementation in Korea

This study is to introduce an effective and systematic accreditation and evaluation system of continuing medical education (CME) and continuing professional development (CPD) in Korea, suitable for the future development, and based on the review of the characteristics of well-recognized systems implemented in western countries such as the US and Canada. CME and CPD comprise programs that expand the clinical knowledge and skills required of physicians as well as educational activities aiming to maintain, develop, and increase knowledge, specialized skills, or performance standards for provision of better medical services. These include not only self-directed activities but also official activities, such as leadership activities, professional development, and evaluation of the practitioner’s level of knowledge and competence. Recently, continuing education for doctors has emphasized CPD, centered around learners, in a departure from CME, centered around educators. Each CME/CPD program in the US and Canada has unique features. However, they share common features of self-directed learning, competency-based education, and evaluation. Although there are remain problems, the Continuing Medical Education Accreditation and Evaluation Council of the Korean Medical Association, as a unique accreditation authority for CME, is currently developing a new CME/CPD system, which would constitute an idealistic onesystem for Korean physicians oriented toward future development, designed to fulfill standards equivalent to that of the Accreditation Council for Continuing Medical Education or any other internationally well-recognized organization.

Surgery versus Nerve Blocks for Lumbar Disc Herniation : Quantitative Analysis of Radiological Factors as a Predictor for Successful Outcomes

OBJECTIVE: To assess the clinical and radiological factors as predictors for successful outcomes in lumbar disc herniation (LDH) treatment. METHODS: Two groups of patients with single level LDH (L4–5) requiring treatment were retrospectively studied. The surgery group (SG) included 34 patients, and 30 patients who initially refused the surgery were included in the nerve blocks group (NG). A visual analogue scale (VAS) for leg and back pain and motor deficit were initially evaluated before procedures, and repeated at 1, 6, and 12 months. Radiological factors including the disc herniation length, disc herniation area, canal length-occupying ratio, and canal area-occupying ratio were measured and compared. Predicting factors of successful outcomes were determined with multivariate logistic regression analysis after the optimal cut off values were established with a receiver operating characteristic curve. RESULTS: There was no significant demographic difference between two groups. A multivariate logistic regression analysis with radiological and clinical (12 months follow-up) data revealed that the high disc herniation length with cutoff value 6.31 mm [odds ratio (OR) 2.35; confidence interval (CI) 1.21–3.98] was a predictor of successful outcomes of leg pain relief in the SG. The low disc herniation length with cutoff value 6.23 mm (OR 0.05; CI 0.003–0.89) and high baseline VAS leg (OR 12.63; CI 1.64–97.45) were identified as predictors of successful outcomes of leg pain relief in the NG. CONCLUSION: The patients with the disc herniation length larger than 6.31 mm showed successful outcomes with surgery whereas the patients with the disc herniation length less than 6.23 mm showed successful outcomes with nerve block. These results could be considered as a radiological criteria in choosing optimal treatment options for LDH.

World Health Organization Grade II Oligodendroglioma Occurring after Successful Treatment for Childhood Acute Lymphoblastic Leukemia

When treating childhood acute lymphoblastic leukemia (ALL), secondary neoplasms are a significant long term problem. Radiation is generally accepted to be a major cause of the development of secondary neoplasms. Following treatment for ALL, a variety of secondary tumors, including brain tumors, hematologic malignancies, sarcomas, thyroid cancers, and skin cancers have been reported. However, oligodendroglioma as a secondary neoplasm is extremely rare. Herein we present a case of secondary oligodendroglioma occurring 13 years after the end of ALL treatment.

The Short-Term Effect of Prostaglandin Analog Monotherapy on Corneal Biomechanical Properties in Normal Tension Glaucoma Patients

PURPOSE: To evaluate the effects of short-term prostaglandin analogues treatment on the corneal biomechanics of patients with normal tension glaucoma. METHODS: This study included 52 eyes of 52 patients who were diagnosed with normal tension glaucoma. All patients were divided into two groups; one group (27 eyes) received tafluprost while the other group (25 eyes) received travoprost. Intraocular pressure, Biomechanical properties were measured by using goldmann applanation tonometer, ocular response analyzer before treatment and at 8-week after treatment. RESULTS: The mean decrease in intraocular pressure, Goldmann-correlated IOP (IOPg), corneal-compensated intraocular pressure by using Goldmann applanation tonometer, and Ocular response analyzer were statistically significant in total patients, tafluprost, and travoprost group after using prostaglandin analogues (p < 0.001, p < 0.001, p < 0.001, respectively). Corneal hysteresis showed no statistical differences after treatment in total, tafluprost and travoprost group but corneal resistance factor (CRF) showed statistically significant decrease after using prostaglandin analogues in total, tafluprost, and travoprost group (p < 0.001, p = 0.025, p < 0.001). Upon multivariate analysis, the higher initial IOPg and the lower initial CRF checked, the variation of CRF (CRF in baseline – CRF at 8 weeks) got higher (β = 0.134, p = 0.017). CONCLUSIONS: It is needed to carefully monitor and evaluate the effects of prostaglandin analogues on intraocular pressure associated with initial intraocular pressure and the changes of CRF after prostaglandin treatment in normal tension glaucoma patients. CRF is sensitive factor to short-term changes of intraocular pressure after prostaglandin analogues treatment, and it is required to consider the properties of CRF when we evaluate between progression of glaucoma and corneal biomechanical properties.

Two Cases of Acute Spontaneous Resolution in Macula-Off Rhegmatogenous Retinal Detachment

PURPOSE: To report 2 cases of acute spontaneous resolution of rhegmatogenous retinal detachment (ASRRRD). CASE SUMMARY: (Case 1) A 28-year-old male presented with acute visual loss in his left eye for 5 days. The best corrected visual acuity was 10/200 in the left eye and fovea-off retinal detachment with retinal break at the 11-o'clock location was observed. The retina was reattached after 5 days without any treatment. Prophylactic barrier photocoagulation was performed around the break and 3 months after ASRRRD visual acuity improved to 20/30. (Case 2) A 19-year-old male was referred with a history of blurry vision and visual disturbance in his right eye. He underwent a cataract surgery due to traumatic cataract in his right eye 3 years prior. The best corrected visual acuity was 10/200 in the right eye and fovea-off retinal detachment with retinal break at the 10:30-o'clock location was observed. The retina reattached spontaneously after 5 days. Prophylactic barrier photocoagulation was performed around the break and 3 months after ASRRRD visual acuity improved to 20/30. CONCLUSIONS: It would be better to check the status of fundus and the visual acuity before the surgery in the cases of rhegmatogenous retinal detachment in young age.

A Case of Joubert Syndrome Accompanied with Retinal Abnormality

PURPOSE: Joubert syndrome is a rare disorder which affects the cerebellum and the brain stem. Herein, we report a case of Joubert syndrome accompanied with retinal abnormality. CASE SUMMARY: A 9-year-old female visited our hospital with chief complaints of low vision in both eyes, nystagmus, and lack of gaze movement. The best-corrected visual acuity in her right eye was 20/80 and in the left 20/80 and heterotropia was not observed. She appeared to have incomplete total color blindness on the color vision test. The anterior segment test showed no abnormal findings other than diffuse pigmentation and degeneration of the peripheral retina, vascular attenuation, and pale optic disc in both eyes on fundus examination. The patient showed overall developmental delay and decreased muscle tension, but genetic and congenital metabolic disease tests were normal. The molar tooth sign of the midbrain, defect in the lower part of the cerebellum and dilatation of the fourth ventricle were observed on magnetic resonance imaging. CONCLUSIONS: Appropriate evaluation of retinitis pigmentosa and visual function should be performed in Joubert syndrome patients.

Cervical Stand-Alone Polyetheretherketone Cage versus Zero-Profile Anchored Spacer in Single-Level Anterior Cervical Discectomy and Fusion : Minimum 2-Year Assessment of Radiographic and Clinical Outcome

OBJECTIVE: We compared the clinical and radiographic outcomes of stand-alone polyetheretherketone (PEEK) cage and Zero-Profile anchored spacer (Zero-P) for single level anterior cervical discectomy and fusion (ACDF). METHODS: We retrospectively reviewed 121 patients who underwent single level ACDF within 2 years (Jan 2011-Jan 2013) in a single institute. Total 50 patients were included for the analysis who were evaluated more than 2-year follow-up. Twenty-nine patients were allocated to the cage group (m : f=19 : 10) and 21 for Zero-P group (m : f=12 : 9). Clinical (neck disability index, visual analogue scale arm and neck) and radiographic (Cobb angle-segmental and global cervical, disc height, vertebral height) assessments were followed at pre-operative, immediate post-operative, post-3, 6, 12, and 24 month periods. RESULTS: Demographic features and the clinical outcome showed no difference between two groups. The change between final follow-up (24 months) and immediate post-op of Cobb-segmental angle (p=0.027), disc height (p=0.002), vertebral body height (p=0.033) showed statistically better outcome for the Zero-P group than the cage group, respectively. CONCLUSION: The Zero-Profile anchored spacer has some advantage after cage for maintaining segmental lordosis and lowering subsidence rate after single level anterior cervical discectomy and fusion.

A Rare Case of Malignant Lymphoma Occurred at Spinal Epidural Space: A Case Report

The sacral spinal epidural space is an uncommon site for primary malignant lymphomas, presenting with symptoms associated with cauda equina compression. Especially, lumbo-sacral epidural lymphoma has been reported to be very rare. We present a rare case of 29-year-old male with sacral spinal epidural malignant lymphoma. The patient complained of tingling sensation in his buttocks that was radiating to his calf. The neurological examination was normal. Magnetic resonance imaging (MRI) with contrast showed a well-defined extradural mass lesion at the mid L5 to mid S2 level. The lesion was iso- to hypointense on T1 and T2 weighted images and showed homogenous enhancement and a focal enhancement in the L5 vertebral body on post-contrast images. The patient underwent a L5-S2 laminectomy and subtotal excision of the lesion. Intra-operatively, the lesion was extradural and not densely adherent to the dura; the lesion was friable, not firm, fleshy, brownish and hypervascular. The histologic diagnosis was grade 2 non-Hodgkin's follicular lymphoma. Even though the primary spinal epidural non-Hodgkin's lymphoma is a very rare disease, clinicians should take it into consideration in the differential diagnosis of patients with spinal epidural tumor.

Insulin Phosphorylates Tyrosine Residue 464 of Tub and Translocates Tubby into the Nucleus in HIRcB Cells

BACKGROUND: The tubby protein has a motif that might be relevant for its action in the insulin signaling pathway. Previous studies have indicated that tubby undergoes phosphorylation on tyrosine residues in response to several stimuli and is known to localize in the nucleus as well as in the plasma membrane. However, the relationship between phosphorylation and nuclear translocation is not well understood. Here, we report that insulin directly phosphorylates tubby, which translocates into the nucleus. METHODS: The effects of insulin on Tubby were performed with Western blot. The immunoprecipitation and confocal microscopy were performed to prove phosphorylation and nuclear translocation. RESULTS: Mutation study reveals that tyrosine residue 464 of tubby gene (Tub) is a phosphorylation site activated by insulin. In addition, major portions of tubby protein in the plasma membrane are translocated into the nucleus after insulin treatment. Tyrosine kinase inhibitor pretreatment blocked insulin-induced tubby translocation, suggesting that phosphorylation is important for nuclear translocation. Moreover, mutant tyrosine residue 464 did not translocate into the nucleus in respond to insulin. These findings demonstrate that insulin phosphorylates tyrosine residue 464 of Tub, and this event is important for insulin-induced tubby nuclear translocation. CONCLUSION: Insulin phosphorylates tyrosine residue 464 of Tub and translocates tubby into the nuclei of HIRcB cells.

A Case of Corrected Residual Refractive Error after Cataract Surgery with the Sulcoflex Piggyback IOL

PURPOSE: To report a case of corrected residual refractive error after cataract surgery with sulcoflex piggyback intraouclar lens (IOL). CASE SUMMARY: A 77-year-old man was diagnosed as having hypermature cataract in the right eye and his corrected visual acuity in the same eye was hand-motion before surgery. Refractive error was +9.0 diopter (D) 6 months after conventional cataract surgery in the right eye. The authors performed additional cataract surgery using a piggyback method inserting a +10.0 D IOL in the ciliary sulcus. Four weeks after surgery, his refractive error was -1.25 D, visual acuity increased to 120/200 and 60/200 (with and without correction, respectively). No complication was observed during follow-up time and the patient was satisfied with his results. CONCLUSIONS: Correction of residual refractive error after cataract surgery with sulcoflex piggyback IOL is safe and effective.

Risk Factors Associated with Poor Outcomes in Patients with Brain Abscesses

OBJECTIVE: The purpose of this study was to describe the clinical characteristics, treatment outcomes, and prognostic factors in patients with brain abscesses treated in a single institute during a recent 10-year period. METHODS: Fifty-one patients with brain abscesses who underwent navigation-assisted abscess aspiration with antibiotic treatment were included in this study. Variable parameters were collected from the patients' medical records and radiological data. A comparison was made between patients with favorable [Glasgow Outcome Scale (GOS) > or =4] and unfavorable (GOS or =13) and 24 patients (47%) had predisposing factors. The offending microorganisms were identified in 25 patients (49%), and Streptococcus species were the most commonly isolated bacteria (27%). The mean duration of antibiotic administration was 42 days. At discharge, 41 patients had a favorable outcome and 10 had an unfavorable outcome including 8 deaths. The decreased level of consciousness (GCS or =140 mg/dL) was an independent risk factor for prolonged antibiotic therapy (p=0.032). CONCLUSION: We found that the level of consciousness at admission was associated with treatment outcomes in patients with brain abscesses. Furthermore, initial hyperglycemia was closely related to the long-term use of antibiotic agents.

Decompressive Hemicraniectomy and Duroplasty in Toddlers and Preschool Children with Refractory Intracranial Hypertension after Unilateral Hemispheric Stroke

OBJECTIVE: Life-threatening hemispheric stroke is associated with a high mortality and morbidity. Decompressive hemicraniectomy has been regarded as an effective treatment option for refractory intracranial hypertension. Here, we reported the clinical course of 5 children with decompressive craniectomy and duroplasty after non-traumatic refractory intracranial hypertension. METHODS: Four toddlers and one preschool-girl were included in this study; there were 3 boys and 2 girls with a mean age of 34.6 months (range 17-80). Decompressive craniectomy including duroplasty was performed in cases of dilatation of pupil size after intensified standard medical therapy had proven insufficient. All children had a Pediatric Glasgow Coma Scale score <8 at pre-operation state. The mean time-point of craniectomy after stroke attack was 12 hours (range 4-19). RESULTS: During the long-term follow-up period (mean 47.6 months), no children died. One year later, when we checked their Glasgow Outcome Scale scores, only one toddler received a score of 4 (moderate disability). But the others had good recoveries although they had minor physical or mental deficits. According to the Pediatric Cerebral Performance Category Scale, 4 children received a score of 2 (mild disability). CONCLUSION: Despite our small cases, we suggest that decompressive hemicraniectomy and duroplasty is an acceptable and life-saving treatment for refractory intracranial hypertension after unilateral hemispheric stroke in toddlers and preschool children.