Acute Myocardial Infarction due to Cardiac Allograft Vasculopathy: An Autopsy Report / 대한법의학회지

After the Organ Transplant Act was enforced in 2000, the criteria for the diagnosis of brain death have been legalized, and cardiac transplantation has become a promising treatment choice for patients with chronic heart disease. Even though more than hundreds of cases have been accumulated in the national registry and the survival rates are increasing, the compliance of long-term survivors may decrease paradoxically, which can hinder the efforts to enhance the quality of the registry. The patients who are lost from the doctor's surveillance and die outside hospitals should be appropriately examined to determine the cause of death so that the influence of their medical condition, if any, on their death could be revealed. Here, we report an autopsy case of a patient who died of a complication of chronic rejection after cardiac transplantation.

Acute Myocardial Infarction due to Cardiac Allograft Vasculopathy: An Autopsy Report / 대한법의학회지

After the Organ Transplant Act was enforced in 2000, the criteria for the diagnosis of brain death have been legalized, and cardiac transplantation has become a promising treatment choice for patients with chronic heart disease. Even though more than hundreds of cases have been accumulated in the national registry and the survival rates are increasing, the compliance of long-term survivors may decrease paradoxically, which can hinder the efforts to enhance the quality of the registry. The patients who are lost from the doctor's surveillance and die outside hospitals should be appropriately examined to determine the cause of death so that the influence of their medical condition, if any, on their death could be revealed. Here, we report an autopsy case of a patient who died of a complication of chronic rejection after cardiac transplantation.

The Statistical Analysis on the Postmortem Inspection Cases of National Forensic Service Seoul Institute in 2016 / 대한법의학회지

From January 1, 2016 to December 31, 2016, a total of 1147 postmortem inspection cases in Area 8, Seoul Metropolitan Police Agency (Gangseo, Yangcheon, and Guro police stations) were statistically analyzed. Autopsies were performed in 205 cases (17.9%), and the autopsy rates were 17.6% (75/426 cases) in the Gangseo police station, 9.5% (34/357 cases) in the Yangcheon police station, and 24.3% (82/337 cases) in the Guro police station. For 288 cases with an unknown cause of death, the autopsy rates were 70.0% (60/87 cases) in the Gangseo police station, 28.6% (26/91 cases) in the Yangcheon police station, and 63.1% (65/103 cases) in the Guro police station. For 65 cases due to fall from height, the autopsy rate was 7.7% (n=5). Of the 187 cases due to hanging, 155 cases were classified as suicide at the scene with a 4.5% (n=7) autopsy rate and 32 cases were classified as an undetermined manner of death at the scene with a 15.6% (n=5) autopsy rate. The distribution of the “manner of death” was natural death, 45% (n=516); unnatural death, 29.9% (n=343); and other and undetermined, 25.1% (n=288). Proportions of dispatch times were 50.9% (584 cases) during work hours (09:00–18:00), 13.8% (n=158) during evening hours (18:00–21:00), 13.4% (n=154) at night (21:00–00:00), 11% (n=126) at dawn (00:00–06:00), and 10.9% (n=125) during morning hours (06:00–09:00). The male-to-female ratio was 1.86:1 (746:401). These statistics are valuable for the evaluation of postmortem inspections by experts.

The Statistical Analysis on the Postmortem Inspection Cases of National Forensic Service Seoul Institute in 2015 / 대한법의학회지

Since March 1, 2015, the National Forensic Service Seoul Institute has commenced postmortem inspections at the death scene in agreement with the Korean National Police Agency. Included regions were mainly Seoul Metropolitan Police Agency Wide Area 8 (Gangseo, Yangcheon, Guro police stations), and several other areas. In total, 837 postmortem inspection cases from March 1 to December 31, 2015, were analyzed statistically. Of these, 168 were autopsy cases, and the rates were 20% (67 cases) in Gangseo Police, 14.5% (30 cases) in Yangcheon Police, and 22% (57 cases) in Guro Police stations. For 269 cases of “unknown cause of death”, the autopsy rates were 44% in Gangseo Police, 36% in Yangcheon Police, and 47% in Guro Police stations. For 82 cases of fall from height, autopsy rates were 17% (n=14). Of the 133 cases of hanging, 121 cases were classified as suicide at the scene with a 2.5% (n=3) autopsy rate. Twelve cases were classified as an undetermined manner of death at the scene with a 33% (n=4) autopsy rate. The distribution of the “manner of death” was natural death for 29% (n=250), unnatural death for 38% (n=318), and other and undetermined manner of death for 32% (n=269) of cases. Proportions of dispatch times were 49.2% (412 cases) during work hours (09:00-18:00), 15.7% (n=131) during evening hours (18:00-21:00), 13% (n=110) at night (21:00-24:00), 10% (n=88) at dawn (24:00-06:00), and 11% (n=96) during morning hours (06:00-09:00). The male to female sex ratio was 1.96:1 (556:281). These statistics are valuable for evaluation of postmortem inspections by experts.

Medical ethics education in the medical school curriculum

In the past 30 years, medical ethics education has emerged as a high-priority subject in Korea. This article provides a general overview of medical ethics education in the medical school curriculum. The author supports the idea that the goal of medical ethics education should be to equip physicians with a knowledge base for analyzing and resolving ethical dilemmas as a core element of the profession. The core elements already have been delineated by the textbook of medical ethics that is in use, and can be applied in contexts including theoretical work, specific areas of application, and problematic clinical cases. This field requires a multidisciplinary approach and should be integrated throughout the entire curriculum of medical school. Ethical theory and knowledge-based approaches should be studied as a basic course, and case studies and ethical debates should incorporated into applied clinical training courses. The grade system is suitable for the knowledge-based approach, while pass-fail evaluations are suitable for small-group discussions of case studies. A team-based approach including both ethicists specializing in philosophy and physicians would be helpful in teaching medical ethics. Progress in ethics education may depend on medical schools to invest in faculty development and to allocate resources accordingly. Ethics education should be treated as a course in professionalism, and should also be incorporated into continuing medical education programs after graduation from medical school.

The Predictive Ratios of Intoxicated Deaths by Police's Death Scene Investigation and Doctor's Death Certificates in South Korea / 대한법의학회지

Forensic autopsies were performed on 1,821 cases in 2014 and 2,024 cases in 2015 at the National Forensic Service Seoul Institute. Based on the autopsy reports, 103 cases (5.7%) in 2014 and 130 cases (6.4%) in 2015 were selected as unnatural deaths caused by fatal intoxication. The cases were divided into five groups. The first group had ethanol intoxication, the second had drug intoxication, the third had agrochemical intoxication, the fourth had cyanide intoxication, and the fifth had miscellaneous intoxications. Of the 233 cases, 202 had death certificates. Of these 202 cases, 169 (83.7%) had an undetermined manner of death (MOD); 17 (8.4%) had an unnatrual MOD and intoxication was the cause of death (COD); nine (4.5%) had an unnatural MOD, but the COD was not intoxication; seven (3.5%) had a natural MOD and disease as a COD. The predictive ratios of intoxication as a COD were compared with the death certificates and the police death scene investigation results. The death certificates and the police investigation results showed predictive ratios of 8.4% and 55.2%, respectively, for intoxication as a COD. The discrepance in these predictive ratios and relatively low predictive ratio of police investigation results mean that intoxicated deaths have been underevaluated; thus, some homicides or intentional deaths were probably missed under South Korea's death investigation system. Doctors who specialize in forensic medicine need to supervise the entire postmortem examination process and emergency blood toxicological analysis should be performed in South Korea.

Medical Professionalism-on Social Responsibilities Viewed from Historical Perspective / 대한소화기학회지

What is medical professionalism and does it matter to the patients? Medical professionals take responsibility for their judgements and the consequences that ensue. Traditionally medical professionalism is defined as a set of values, behaviors, and relationships which support the trust the public has in doctors. The public is well aware that absence of professionalism is harmful to their interests. However, the exercise of medical professionalism is endangered by the political and cultural environment. The values of professionalism have been changed throughout the medical history and the meaning of it was also changed according to social theories. Traditional medical professionalism was based on the virtue of autonomy, self-regulation and competency etc. However, in the new millenium era, the meaning of professionalism has changed under the concept of responsibility which includes the classical virtues. The meaning of professionalism nowadays is only based on the structure and conflicting theories which cannot solve all the issues surrounding professionalism in medical practice. The conditions of medical practice are critical determinants for the future of professionalism. The interaction between doctor and patient is central to the medical care, and medical professionalism has roots in almost every aspect of medical care. I argue that doctors have responsibility to act according to the values which have been determined by the medical profession, history and surrounding society. The new millennium medical professionalism which based on the responsibility could initiate a public dialogue about the role of the doctor in creating a fairer society.

A Legal Framework for Improving Patient Safety in Korea / 보건행정학회지

This paper reviewed structure and current status of laws related to patient safety using patient safety law matrix to promote systematic approach in legal system of patient safety. Laws related to patient safety can be divided into three areas: laws for preventing; laws for knowing about; and laws for responding. In the case of Korea, gaps are especially prominent in the areas of laws for knowing about and responding. Patient safety law which will be enacted in July 2016 will fill the gap in the area of laws for knowing about. This law will be comprehensive law, covering the full spectrum of laws related to patient safety. However, after reviewing current patient safety law in Korea, the following drawbacks were identified: absence of code for grasping the current patient safety level; absence of code for mandatory reporting in patient safety reporting system; and absence of code for privilege about patient safety work product. Furthermore we need wider discussions about covering issues of open disclosure, apology law, coroners system, and complaint management system in patient safety law.

Histologic Estimation of Intrauterine Retention Time after Fetal Death / 대한법의학회지

The intrauterine retention time (IURT) after fetal death can be estimated from the loss of nuclear basophilia. We therefore attempted to derive an autolysis equation to estimate IURT in experimental rat fetuses and human fetal autopsy slides. The degree of loss of nuclear basophilia in various tissues was assessed by hematoxylin and eosin (H & E) staining. Fetal rat tissues showed different rates of autolysis, allowing for the construction of an experimental autolysis curve. We also reviewed the H & E stained slides obtained from 27 human fetal autopsy cases with well-documented death intervals. The degree of autolysis in various tissues was evaluated using percentile scores (PS). Using the findings from H&E staining, we derived the equation Ln (PS/[100-PS]) = 2.62716-0.02377 x IURT. However, this equation or autolysis scores showed some limitations. Owing to the inconsistency of PS, this equation is reliably applicable only within 24 hours of intrauterine fetal death. In the fetal autopsy review, fetal hydrops, local effusion, and sepsis also contributed to accelerated autolysis.

Comparison of success rates of orthodontic mini-screws by the insertion method / 대한치과교정학회지

OBJECTIVE: The aim of this study was to compare the success rates of the manual and motor-driven mini-screw insertion methods according to age, gender, length of mini-screws, and insertion sites. METHODS: We retrospectively reviewed 429 orthodontic mini-screw placements in 286 patients (102 in men and 327 in women) between 2005 and 2010 at private practice. Age, gender, mini-screw length, and insertion site were cross-tabulated against the insertion methods. The Cochran-Mantel-Haenszel test was performed to compare the success rates of the 2 insertion methods. RESULTS: The motor-driven method was used for 228 mini-screws and the manual method for the remaining 201 mini-screws. The success rates were similar in both men and women irrespective of the insertion method used. With respect to mini-screw length, no difference in success rates was found between motor and hand drivers for the 6-mm-long mini-screws (68.1% and 69.5% with the engine driver and hand driver, respectively). However, the 8-mm-long mini-screws exhibited significantly higher success rates (90.4%, p < 0.01) than did the 6-mm-long mini-screws when placed with the engine driver. The overall success rate was also significantly higher in the maxilla (p < 0.05) when the engine driver was used. Success rates were similar among all age groups regardless of the insertion method used. CONCLUSIONS: Taken together, the motor-driven insertion method can be helpful to get a higher success rate of orthodontic mini-screw placement.

Court decisions on withdrawal of life sustaining treatment and related problems associated with legalization

The development of life sustaining treatment technology including artificial ventilation has given us the moral problem, considering the human dignity and futility of medical treatment, until when these treatments could be given to terminally ill patients. In Korea, there were two supreme court decisions a significant impacts on the withdrawal of life sustaining treatment. After these decisions, Korean medical society has developed a guideline for advance directives and has also established a voluntary hospital ethics committee. The patient's right of self- determination right and the paternalistic approach of medicine should be balanced at an optimal level, because benefits of medical advances should be adjusted to take into account the burden of life prolongations. Decision making always has been difficult because related to ethical values, and there a broad spectrum of value-laden attitudes within Korean society. The legalization of end-of-life care should be from the respect of the professional autonomy of medical society. Under these considerations, we should supply alternative methods like hospice care, which can help to manage the withdrawal of life support appropriately, and also make an effort to relieve the economical burden of patients.

The Toxicological Studies and Autopsy Findings of Aconitine Poisoning / 대한법의학회지

BACKGROUND: Aconitium species have been used for a material of oriental herb medicine for analgesic and anti-inflammatory effects. But Aconitium species were known to have the potent poisons like aconitine, mesaconitine and hypaconitine which are of C19 diterpenoid alkaloids. The intoxication symptoms are nausea, vomiting, discomfort and cardiac arrhythmias which are well known as a main cause of death. METHOD AND MATERIALS: We obtained the specimens from the five poisoned cases and analyzed those specimens by GC/MS-SIM for 2002-2004. These cases were divided into two groups. The first group was the victims who ingested raw Aconitium roots and leaves and were all dead. The second was those who ingested processed Aconitium roots. One of them drank Aconitium root-submersed alcohol (root wine) and died. Another victim had ingested some liquid extract of herb medicine for three months but the person's symptom was manifested by jaundice and hematuria without fatality. RESULTS: Autopsy pathology on the cases of raw Aconitium ingestion and root wine drinking revealed similar gross and microscopic feature. The benzoylaconine analogues were detected in root wine (dead case) and hypaconitine, benzoylmesaconine and benzoylhypaconine were detected in herb liquid (living case). The aconitine analogues are hydrolyzed to make less toxic benzoylaconine analogues but the toxicity of hydrolyzed products and the methods of detoxification are still in controversy. CONCLUSION: We could conclude that benzoylaconine is relatively more toxic than benzoylmesaconine and benzoylhypaconitine. And the hypaconitine is relatively less toxic than aconitine and mesaconitine.

Development of Specific Primer for Tricholoma matsutake

In this study, in an effort to develop a method for the molecular detection of Tricholoma matsutake in Korea from other closely related Tricholomataceae, a species-specific PCR primer pair, TmF and TmR, was designed using nuclear ribosomal intertranscribed spacer (ITS) sequences. The DTmF and DTmR sequences were 5'-CCTGACGCCAATCTTTTCA-3' and 5'-GGAGAGCAGACTTGTGAGCA-3', respectively. The PCR primers reliably amplified only the ITS sequences of T. matsutake, and not those of other species used in this study.

Tuberculous Meningoencephalitis Complicated by Subarachnoid Hemorrhage

Tuberculous meningoencephalitis (TBM) is often complicated by various neurologic manifestations including ischemic infarctions. However, intracerebral hemorrhage in TBM has rarely been described. We report a 30-year-old woman with TBM who developed subarachnoid, intraventricular, and intracerebral hemorrhage, and finally died in spite of treatment with antituberculous and steroid therapy. Autopsy findings revealed multifocal thrombotic occlusion of the arteries and thinning of the vessel walls secondary to tuberculous vasculitis.

The Withdrawal of Life-sustaining Management for Dying Patients: A Study in Judicial Precedents Worldwide

The decision to withdrawal of life-sustaining management for dying patients is one of the most difficult challenges in modern medical ethics. Due to the advances in medical science and technology, terminally ill patients can survive longer than ever expected before. More specifically, artificial ventilation, nutrition, and recently developed drugs constitute the cores of life -sustaining management for dying patients. The issues of patients' autonomy, medical paternalism and sanctity of life are related with this particular problem. Korean Supreme Court recently approved the request of a permanent vegetative status patients' family to terminate the artificial ventilation and allow the patient to die. Korean Medical Association is currently seeking to establish the guideline. Korean government and parliament are also looking for a way to enact the law. However, religious sector including Catholic Church and a significant proportion of the population have opposed the legalization of euthanasia. A careful study in other countries' legislations related to the care for dying patients would help to establish the consensus in the nation.

Cost-Effectiveness of Donor Screening Strategies for Acitretin Medication / 대한수혈학회지

BACKGROUND: Donors with acitretin medication history are deferred for three years in Korea, because acitretin has teratogenic effect. Authors tried to evaluate the cost-effectiveness of the donor screening measures for acitretin medication. METHODS: From January 2006 to May 2007, the numbers of screened donors and accepted donors were 10,098,868 and 7,867,019, respectively. Although there was no single case of reported congenital malformation due to transfusion of blood donated by donors on acitretin medication, we assumed one case had occurred to contect the cost-effectiveness analysis. Also, the quality of life (QOL) of fetus with congenital malformation was assumed to be 0. The expected life-span of average Korean people was 78.6 years. RESULTS: The cost-effectiveness of electronic inquiry of computer database and blood test for acitretin were calculated to be 173,453,840 won/QALY and 8,780,333,865/QALY, respectively. They equaled $188,537/QALY and $9,543,841/QALY, respectively. CONCLUSION: The cost-effectiveness of electronic inquiry of computer database and blood test for acitretin were 3.8 and 190 times of $50,000/QALY, which is usually accepted to be reasonable in medical field. Electronic inquiry of computer database could be reasonable measure, if we deal with the problem protecting donor privacy, while blood test for acitretin could not be enforced because of unacceptably expensive cost.

Cost-Effectiveness of Donor Screening Strategies for Acitretin Medication / 대한수혈학회지

BACKGROUND: Donors with acitretin medication history are deferred for three years in Korea, because acitretin has teratogenic effect. Authors tried to evaluate the cost-effectiveness of the donor screening measures for acitretin medication. METHODS: From January 2006 to May 2007, the numbers of screened donors and accepted donors were 10,098,868 and 7,867,019, respectively. Although there was no single case of reported congenital malformation due to transfusion of blood donated by donors on acitretin medication, we assumed one case had occurred to contect the cost-effectiveness analysis. Also, the quality of life (QOL) of fetus with congenital malformation was assumed to be 0. The expected life-span of average Korean people was 78.6 years. RESULTS: The cost-effectiveness of electronic inquiry of computer database and blood test for acitretin were calculated to be 173,453,840 won/QALY and 8,780,333,865/QALY, respectively. They equaled $188,537/QALY and $9,543,841/QALY, respectively. CONCLUSION: The cost-effectiveness of electronic inquiry of computer database and blood test for acitretin were 3.8 and 190 times of $50,000/QALY, which is usually accepted to be reasonable in medical field. Electronic inquiry of computer database could be reasonable measure, if we deal with the problem protecting donor privacy, while blood test for acitretin could not be enforced because of unacceptably expensive cost.

Bioethics and privacy right on genetic epidemiology / 한국역학회지

Unlike the classical genetic study which dealt with the mendelian inheritances of relatively small number of patients, the genetic epidemiology study needs the large scaled genetic data base. The main ethical and legal problems of these kinds of studies are research design, informed consent, long term follow-up of research subjects, data sharing and benefit sharing. Classically, the informed consent was an important right but if these kinds of large scaled and long period studies were involved, the newly developing rights should be more stressed. The bioethics and biosafety act and governmental regulations for the genetic study and gene bank also shows those considerations. In EU, the general consent is considered acceptable if the approval of all future projects is fulfilled by a research ethics committee and the participants' right to withdraw samples at any times. In U.S.A., strict restriction is required for future experiments, but if the research involves no more than minimal risk to the subject, the waiver or alternation will not affect adversely the rights and welfare of subjects and the research could not be practicably carried out without the waiver or alteration, the specific future consents could be exempted. Long term follow up of research patients is needed to provide the newly developed information which would be helpful for the patients. Data sharing is needed to prevent the exclusive possession of genetic information. Benefit sharing is the newly coming up debates on how to manage the conflicts of interests between tissue-donors and scientific researchers. The context and inventory of human rights for the research is changing and still under construction.

The Ethical and Legal Considerations on Preimplantation Genetic Diagnosis and Prenatal Diagnosis / 대한산부인과학회지

OBJECTIVE: After 'Bioethics & biosafety act' has been enacted since 2005, Preimplantation genetic diagnosis (PGD) for embryo and Prenatal diagnosis (PD) for fetus are regulated by this law. This article will discuss the problem and revision of that law. METHODS: From the medical point of view, we consider the developmental stages of human embryo, genetic disease and PGD. According to the documentary records, we discuss the PGD allowance of European countries and USA and requisites for that allowance. We also discuss the PD in association with the 'Motherhood act' and a related judicial decision. RESULTS: On PGD, the attitude of quality of European countries is in the nature of variable spectrum and USA doesn't have explicit federal regulations. PGD permission is based on the individual institution and the genetic disease. The genetic conditions for legitimate abortion of 'Motherhood act are not included in Bioethics & biosafety act'. So The purpose and criteria of PD is now in a state of confusion. CONCLUSION: PGD should be regulated within the title of embryo in 'Bioethics & biosafety act' not within the title of genetic test. Each PGD should be permitted individually on the basis of each institution and genetic disease and then the criteria could be more broadened. The provision for PD should include the legitimate abortion conditions of 'Motherhood act'. To diagnose the sex linked genetic disease, the punishment for sex detection should be excepted to the 'Medicine act'.

Selection of Autopsy Method Depending on Situation / 대한법의학회지

Traditionally autopsy has been classified as legal autopsy and pathology autopsy. For this classification, the purpose of the autopsy was the criteria. That is under what condition autopsy was performed decided the nature of the autopsy. From the point of MD who actually perform the autopsy, there seems little difference between legal and pathology autopsy. Our society expands as time goes on, and it has become more complex. With this there have been many situations that does not coincide with the conventional way of thinking. Under these circumstances there have been some situations that conventional way for the autopsy classification bears problem. System for the postmortem investigation in Korea are deeply linked with these. Authors report these cases with the review of our postmortem investigation system and discuss what MD can do right now.