Opioids are effective analgesics, but they are often difficult to use properly, due mainly to adverse events, such as constipation, respiratory depression, addiction, tolerance, and opioid induced hyperalgesia. In the past, the problem of opioids around the world was usually caused by drugs traded illegally, so there was no need for medical and social attention in Korea. On the other hand, with the dramatic increase in the therapeutic use of opioids, which commenced more than a decade ago, problems caused by legally prescribed drugs have emerged, and now a more serious opioid crisis is being experienced than in the days of illegal drugs. A growing number of patients are chronically prescribed opioids, and a growing number of health care providers and hospitals suffer from problems related to chronic prescription. Currently, in Korea, it is the time to pay serious attention to achieve the safe and effective use of prescribed opioids. This paper consists of the following parts. 1) A summary of the issues related to chronic pain, opioids, and problems associated with the use of opioids. 2) Some case examples the authors' experienced. 3) Simple guidelines on the use of opioids in the treatment of chronic non-cancer pain are proposed based on the author's experience and existing literature. These guidelines are by no means comprehensive, and hopefully in the future, related experts will join forces to develop better guidelines.
Analgesics ; Analgesics, Opioid ; Chronic Pain ; Constipation ; Hand ; Health Personnel ; Humans ; Hyperalgesia ; Korea ; Prescriptions ; Respiratory Insufficiency

The need for a short-acting non-depolarizing neuromuscular blocking agent to replace succinylcholine chloride(succinylcholine) is recognized widely and attempts to find such a drug have been numerous. Atracurium besylate(atracurium) is one of the new series of neuromuscular blocking agents with little cardiovascular effect and is not dependent on hepatic and renal function for terminating its action because of its self-destroying mechanism. Because succinylchline may occasionally be contraindieated for intubation in parturients we studied the use of atracurium in 23 patients having cesarean section. All patients received 0. 5 mg/kg atracurium for intubation and neuromuscular relaxation. Hemodynamic changes, the time from the injection of atracurium to maximal twitch suppression, the time between atracurium administration and the return to 10% of control twitch height were recorded and observed the degree of vocal cord relaxation and conditions of intubation and evaluated the Apgar scores. 1) Mean arterial pressure and heart rate increased significantly after intubation compared with that of control and just before intubation but there were no significant changes in 5 minutes after intubation. 2) The 90% twitch suppression following atracurium administration was 75.6+/-20.9 seconds. 3) The return of 10% of control twitch height was 2449.3+/-1114.0 seconds. 4) Intubation conditions were excellent for 19 patients. 5) The Apgar scores of 20 neonates were high. These data suggest that the use of atracurium may be a useful alternative for induction for Cesarean section when succinylcholine is contraindicated.
Arterial Pressure ; Atracurium* ; Cesarean Section* ; Female ; Heart Rate ; Hemodynamics ; Humans ; Infant, Newborn ; Intubation ; Intubation, Intratracheal* ; Neuromuscular Blockade ; Neuromuscular Blocking Agents ; Pregnancy ; Relaxation ; Succinylcholine ; Vocal Cords

OBJECTIVE: The objective of this study was to compare maxillary soft tissue changes and their relative ratios to hard tissue changes after anterior segmental osteotomy (ASO)/bilateral sagittal split ramus osteotomy (BSSRO) and Le Fort I/BSSRO in skeletal Class III malocclusion with upper lip protrusion. METHODS: The study sample comprised the ASO/BSSRO group (n = 14) and the Le Fort I/BSSRO group (n = 15). The Le Fort I/BSSRO group included cases of maxillary posterior impaction only. Lateral cephalograms were taken 2 months before and 6 months after surgery. Linear and angular measurements were performed. RESULTS: The anterior maxilla moved backward in both groups after surgery, however the amount of change was significantly larger in the ASO/BSSRO group (p < 0.01). The ratios of hard to soft tissue change were 79% (SLS to A point), 80% (LS to A point) in the ASO/BSSRO group, and 15% (SLS to A point), 68% (LS to A point) in the Le fort I/BSSRO group. In addition, there was a 3.23degrees increase of the occlusal plane in the Le Fort I/BSSRO group. CONCLUSIONS: When two-jaw surgery is indicated in skeletal Class III patients with protrusive lips, ASO may be a treatment of choice for cases with more severe upper lip protrusion, while Le Fort I with posterior impaction may be considered if an increase of occlusal plane angle is required.
Dental Occlusion ; Humans ; Lip ; Malocclusion ; Maxilla ; Osteotomy ; Osteotomy, Sagittal Split Ramus

We report a case of free flap deterioration which may have been induced by pressure gradient resulting from cranial defect overlying a ventriculoperitoneal shunt (VP shunt). The patient, male and aged 78, had a VP shunt operation for progressive hydrocephalus. Afterwards, the scalp skin flap surrounding the VP shunt collapsed and showed signs of necrosis, exposing part of the shunt catheter. After covering the defect with a radial forearm free flap, the free flap site showed signs of gradual sinking while the vascularity of the flap remained unimpaired. An agreement was reached to remove the shunt device and observe the patient for any neurological symptoms, and after the shunt was removed and the previous cranial opening filled with fibrin glue by Neurosurgery, we debrided the deteriorated flap and provided coverage with 2 large opposing rotational flaps. During 2 months' outpatient follow-up no neurological symptoms appeared, and the new scalp flap displayed slight depression but remained intact. The patient has declined from any further follow-up since.
Catheters ; Decompressive Craniectomy ; Depression ; Fibrin Tissue Adhesive ; Follow-Up Studies ; Forearm ; Free Tissue Flaps* ; Humans ; Hydrocephalus ; Male ; Necrosis ; Neurosurgery ; Outpatients ; Scalp ; Skin ; Ventriculoperitoneal Shunt*

Kasabach-Merritt phenomenon does not occur with common hemangioma, rather it is associated with the more aggressive Kaposiform hemangioendothelioma and rarely with other vascular neoplasm. We report the case of an adult who was diagnosed as Kaposiform hemangioendothelioma complicated by Kasabach-Memtt phenomenon. This is the first report in Korea of an adult with Kasabach-Merritt phenomenon who has osteolytic changes of femur, pelvic bone, and lumbar spine.
Adult* ; Femur ; Hemangioendothelioma* ; Hemangioma ; Humans ; Kasabach-Merritt Syndrome ; Korea ; Pelvic Bones ; Spine ; Vascular Neoplasms

Sunken upper eyelids are one of the common and complicated problems that occur with an aging process or after double eyelidplasty. Autologous microfat grafting is a technique that has frequently been used for sunken eyelids. The traditional blind method of microfat grafting has a some complications. Therefore, we performed the open method with incisional double eyelidplasty. Between June, 2005 and February, 2008, we performed incisional double eyelidplasty and autologous microfat grafting into orbital septum in 63 patients(124 cases) with sunken upper eyelids. The fat was harvested from periumbilical regionand centrifuged at 3000 rpm for 3 minutes. After the middle fat layer was obtained by 1cc syringe, we made skin incision and separated orbital septum(inner layer) and levator aponeurosis. And then, we injected the microfat into orbital septum with 0.9 mm blunt cannula. At this time, one of the important things was to make the patient gaze upward during the fat injection. All the patients were satisfied, except 5 cases which were 3 cases of undercorrection and 2 cases of asymmetry. Surgical revision was required for only the above 5 cases(4%). Patients with some transient complications of ptosis (13 cases), overcorrection(4 cases) and nodular appearance(2 cases) were self-improved. We found that the method using incisional double eyelidplasty and autologous microfat grafting into orbital septum has many advantages which include less traumatic, less complication rate, less absorption rate of fat. and less burden of patients.
Absorption ; Aging ; Catheters ; Eyelids ; Humans ; Orbit ; Reoperation ; Skin ; Syringes ; Transplants

BACKGROUND: Patent foramen ovale (PFO) is increasingly being recognized in stroke patients. The capability of transcranial Doppler (TCD) to detect a PFO has been established. We studied the frequency of PFO in patients with ischemic stroke. METHODS: Eighty-nine patients with ischemic stroke (62 men, mean age: 56.5) consecutively underwent a contrast-enhanced TCD with monitoring of the bilateral middle cerebral arteries (MCA). The contrast solution, which consisted of 8 ml of normal saline, 1 ml of air, and 0.2 ml of patient's blood, was injected twice during normal breathing and the Valsalva maneuver. High intensity transient signals (HITS) were counted for 30 seconds after the injection. RESULTS: Patent foramen ovale was detected in 19 patients (21%). The mean age was similar in those with (55 years) and those without (57 years) PFO. Patent foramen ovale was more frequent among men (26%) than women (11%). There were no differences in the frequency of PFO among stroke subtypes (large artery atherosclerosis, 18%; small artery occlusion, 27%; cardioembolic, 27%; undetermined cause, 11%). CONCLUSIONS: Patent foramen ovale is common in patients with ischemic stroke of all subtypes.
Arteries ; Atherosclerosis ; Female ; Foramen Ovale, Patent* ; Humans ; Incidence* ; Male ; Middle Cerebral Artery ; Respiration ; Stroke* ; Valsalva Maneuver

PURPOSE: The purpose of this study is to assess patient attitudes towards anti-glaucoma medication and their association with adherence, visual quality of life, and personality traits. MATERIALS AND METHODS: One hundred and forty-seven glaucoma patients were enrolled this study. The participants were divided into 'pharmacophobic' and 'pharmacophilic' groups according to their scores on the Modified Glaucoma Drug Attitude Inventory (MG-DAI). To establish a correlation with patient drug attitude, each group had their subjective drug adherence, visual quality of life, and personality traits examined. For personality traits, the Myers-Briggs Type Indicator (MBTI) was used to sub-classify each group. RESULTS: Among the patients analyzed, 91 (72.80%) patients showed a 'pharmacophobic' attitude and 34 (27.20%) patients showed a 'pharmacophilic' attitude. The pharmacophobic group tended to have worse adherence than the pharmacophilic group. Personality dichotomies from the MBTI also showed different patterns for each group. CONCLUSION: In glaucoma patients, pharmacological adherence was influenced by their attitude towards drugs; an association might exist between drug attitude and underlying personality traits.
Adult ; Aged ; Attitude ; Female ; Glaucoma/*drug therapy ; Humans ; Male ; Middle Aged ; Patient Compliance/*psychology ; Personality Inventory ; Questionnaires

Objective: The purpose of this study is to investigate an association between sex-hormone exposure during fetal period and the development of Alzheimer’s disease (AD). Methods: Twenty four AD patients and 25 normal controls were included from Memory Impairment Clinic of Pusan National University Hospital in Korea. Subjects are measured the ratio of the length of the second to the fourth digit (2D/4D) to estimate fetal sex-hormone exposure. Analysis of covariance was used to investigate an association between fetal sex-hormone exposure and the development of AD after adjusting age, education level, Korean Mini-Mental Status Examination and head circumference. Results: We found that the females with AD had significantly lower 2D/4D ratios than the female controls. In the females withAD, the 2D/4D ratios in the left hand was 0.021 and 0.017 in the right hand compared with the controls. Conclusion Our findings suggest that the development of AD in female may be related with higher testosterone and lower es-trogen exposure during fetal period.

PURPOSE: The purpose of this study is to evaluate the perioperative and long-term oncologic outcomes of hand-assisted laparoscopic surgery (HALS) and standard laparoscopic surgery (SLS) and assess the role of HALS in the management of right-sided colon cancer. METHODS: The study group included 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer between April 2002 and December 2008. RESULTS: The patients in each group were similar in age, American Society of Anesthesiologist (ASA) score, body mass index, and history of previous abdominal surgeries. Eight patients in the HALS group and no patient in the SLS group exhibited signs of tumor invasion into adjacent structures. No differences were noted in the time to return of normal bowel function, time to toleration of diet, lengths of hospital stay and narcotic usage, and rate of postoperative complications. The median incision length was longer in the HALS group (HALS: 7.0 cm vs. SLS: 4.8 cm, P < 0.001). The HALS group had a significantly higher pathologic TNM stage and significantly larger tumor size (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001). The 5-year overall, disease-free, and cancer-specific survival rates of the HALS and the SLS groups were 87.3%, 75.2%, and 93.9% and 86.4%, 78.0%, and 90.7%, respectively (P = 0.826, P = 0.574, and P = 0.826). CONCLUSION: Although patients in the HALS group had more advanced disease and underwent more complex procedures than those in the SLS group, the short-term benefits and the oncologic outcomes between the two groups were comparable. HALS can, therefore, be considered an alternative to SLS for bulky and fixed right-sided colon cancer.
Body Mass Index ; Colon* ; Colonic Neoplasms* ; Diet ; Hand-Assisted Laparoscopy* ; Humans ; Laparoscopy ; Length of Stay ; Postoperative Complications ; Survival Rate