Distribution of Perigastric Station 4d Lymph Nodes in Vascularized Gastroepiploic Lymph Node Transfer: An Anatomic Study and Case Series.

BACKGROUND: Vascularized gastroepiploic lymph node transfer (VGLNT) is a well-accepted surgical treatment for restoring physiological function in chronic lymphedema. However, the inclusion of substantial lymph nodes (LNs) in the flap remains uncertain. This study aimed to identify the anatomical basis for reliable flap harvest for VGLNT. PATIENTS AND METHODS: The anatomy of perigastric station 4d LNs was studied in healthy cadavers (n = 15) and patients with early gastric cancer (EGC) (n = 27). The omentum was divided into three segments: proximal, middle, and distal from the origin of the right gastroepiploic vessels. The flap dimension, number, location, size of LNs, and caliber of the vessels were reviewed. Eight patients underwent VGLNT for upper/lower limb lymphedema. RESULTS: The mean numbers of LNs in the proximal, middle, and distal segment were 2.5, 1.4, 0.5 in the cadavers, and 4.9, 2.7, 0.7 in the gastrectomy specimens, respectively. The proximal third included a significantly greater number of LNs than the distal third in the cadaveric (p = 0.024) and ECG (p = 0.016) specimens. A total of 95% of the LNs were located within proximal two-thirds of the flap from the vessel origin both in the cadavers (21.0 × 5.0 cm) and in the gastrectomy specimens (20 × 3.5 cm). In VGLNT, the transferred flap was 25.5 ± 6.9 × 4.1 + 0.7 cm in dimension, containing a mean number of 6.5 ± 1.9 LNs. At postoperative 6 months, the volumetric difference was significantly reduced by 22.8 ± 9.2% (p < 0.001). CONCLUSIONS: This study provides a distinct distribution pattern of station 4d LNs. Inclusion of the proximal two-thirds of the flap, which carries majority of the LNs, is recommended for VGLNT.

Regression analysis of nasal shape from juvenile to adult ages for forensic facial reconstruction.

The nose is a prominent feature for facial recognition and reconstruction. To investigate the relationship of the nasal shape with the piriform aperture in Korean adults and juveniles, we performed regression analysis. By regression analysis, prediction equations for nasal shape were obtained in relation to the shape of the piriform aperture considering sex and age groups. Three-dimensional skull and face models, rendered from computed tomography images, were assessed (331 males and 334 females). Juveniles (<20 years) were divided into three age groups according to the development of the dentition. Adults were divided into three age groups of two decades each, according to their age. To measure the nasal area, nine landmarks and nine measurements were chosen, while seven landmarks and five measurements were selected to measure the piriform aperture area. Four measurements were defined to explain the direct relationship between the nasal aperture and nasal shape. First, descriptive statistical analyses were performed according to sex and age groups. Subsequently, the correlation of nasal soft tissue measurements with piriform measurements was analyzed. Last, we performed a linear regression analysis of the measurements with higher correlations, considering sex and age groups as variables. Prediction equations were used to estimate the nasal bridge length, height, protrusion, and width. Equations considering sex and age groups showed better explanation ability. Measurements related to the height of the nasal bridge presented improvement. This study may assist in the more accurate approximation of nasal shape in facial reconstruction.

Greater Knee Rotatory Instability After Posterior Meniscocapsular Injury Versus Anterolateral Ligament Injury: A Proposed Mechanism of High-Grade Pivot Shift.

Background: For anterolateral rotatory instability as a result of secondary soft tissue injuries in anterior cruciate ligament (ACL)-deficient knees, there is increasing interest in secondary stabilizers to prevent internal rotation (IR) of the tibia. Purpose: To determine which secondary stabilizer is more important in anterolateral rotatory instability in ACL-deficient knees. Study Design: Controlled laboratory study. Methods: The lower extremities of 10 fresh-frozen cadavers (20 extremities) without anterior-posterior or rotational instability were included. Matched-pair randomization was performed, with each side per specimen assigned to 1 of 2 groups. In group 1, the ACL was sectioned, followed by the anterolateral ligament (ALL); in group 2, the ACL was sectioned, followed by sequential sectioning of the posterolateral meniscocapsular complex (PLMCC) and posteromedial meniscocapsular complex (PMMCC). The primary outcome was the change in relative tibial IR during a simulated pivot-shift test with 5 N·m of IR torque and 8.9 N of valgus force. The secondary outcomes were the International Knee Documentation Committee grade in the pivot-shift test and the incidence of the grade 3 pivot shift. Results: In group 1, compared with baseline, the change in relative tibial IR at 0° of knee flexion was 1.4° (95% CI, -0.1° to 2.9°; P = .052) after ALL release. In group 2, it was 2.5° (95% CI, 0.4° to 4.8°; P = .007) after PLMCC release and 4.1° (95% CI, 0.5° to 7.8°; P = .017) after combined PLMCC and PMMCC release. Combined PLMCC and PMMCC release resulted in greater change of tibial IR with statistical significance at 0°, 15°, and 30° of knee flexion (P = .008, .057, and .004, respectively) compared with ALL release. The incidence of grade 3 pivot shifts was 10% in group 1 and 90% in group 2. Conclusion: Posterior meniscocapsular laxity caused an increase in relative tibial IR as much as ALL injury in ACL-deficient knees in our simulated laboratory test, and greater anterolateral rotatory instability occurred with posterior meniscocapsular injury compared with ALL injury. Clinical Relevance: Repair of the injured posterior meniscocapsular complex may be an important treatment option for reducing anterolateral rotatory instability in the ACL-deficient knee.

Predicting the eyebrow from the orbit using three-dimensional CT imaging in the application of forensic facial reconstruction and identification.

Eyebrows are the most important facial feature in facial recognition with its shape rated to be more helpful than color or density for facial reconstruction or approximation. However, little extant research has estimated the position and morphological territory of the eyebrow from the orbit. Three-dimensional craniofacial models, produced from CT scans of 180 Koreans autopsied at the National Forensic Service Seoul Institute, were used to conduct metric analyses of subjects (125 males and 55 females) between 19 and 49 (mean 35.1) years. We employed 18 craniofacial landmarks to examine the morphometry of the eyebrow and orbit with 35 pairs of distances per subject measured between landmark and reference planes. Additionally, we used linear regression analyses to predict eyebrow shape from the orbit for every possible combination of variables. The morphology of the orbit has more influence on the position of the superior margin of the eyebrow. In addition, the middle part of the eyebrow was more predictable. The highest point of the eyebrow in female was located more medially than the male. Based on our findings, the equations for estimating the position of the eyebrow from the shape of the orbit is useful information for face reconstruction or approximation.

Statistical classification methods for estimating sex based on five skull traits: A nonmetric assessment using 3D CT models.

Five cranial nonmetric traits for sex estimation for sex estimation are classified by score according to geometry. The population of origin is one of the factors influencing cranial nonmetric traits. Moreover, among the five cranial traits, the robust traits for estimating sex varied across population. The aim of this study is to suggest the most useful method for sex estimation and demonstrate the need of a suitable method for each population. One-hundred thirty-five three-dimensional skull images from 21st century Korean autopsy cadavers were evaluated using the ordinal scoring system of five cranial nonmetric traits as outlined in Buikstra & Ubelaker (1994). All scores of each trait were analyzed by linear discriminant and decision tree analyses for sex estimation. The frequency of each trait was analyzed and compared to populations from other studies. The accuracy for both sexes was 88.1% by discriminant analysis and 90.4% by decision tree. The traits with the highest accuracy were the glabella and mastoid process in both discriminant analysis and decision tree. Sex estimation in modern Korean cadavers using the cranial nonmetric method was shown to be highly accurate by both discriminant analysis and decision tree. When comparing the pattern of frequency scores in this study with those of other populations, the pattern of trait scores for estimating sex was different for each population, even among populations in the same Asian region, which suggests the need for methods suited for specific populations.

Reappraisal of the Lymphatic Drainage System of the Distal Rectum: Functional Lymphatic Flow into the Presacral Space and Its Clinical Implication in Rectal Cancer Treatment.

Understanding the source and route of pelvic metastasis is essential to developing an optimal strategy for controlling local and systemic diseases of rectal cancer. This study aims to delineate the distribution of lymphatic channels and flow from the distal rectum. In fresh-frozen cadaveric hemipelvis specimens, the ligamentous attachment of the distal rectum to the pelvic floor muscles and the presacral fascia were evaluated. Using indocyanine green (ICG) fluorescence imaging, we simultaneously evaluated the gross anatomy of the lymphatic communication of the distal rectum. We also investigated the lymphatic flow in the pelvic cavity intraoperatively in rectal cancer patients who underwent radical rectal resection with total mesorectal excision (TME). In fresh cadavers, multiple small perforating lymphovascular branches exist in the retrorectal space, posteriorly connecting the mesorectum to the presacral fascia. The lymphatic flow from the distal rectum drains directly into the presacral space through the branches. In patients who underwent TME for rectal cancer, intraoperative ICG fluorescence signals were seen in the pelvic sidewalls and the presacral space. This anatomical study demonstrated that the lymphatic flow from the distal rectum runs directly to the pelvic lateral sidewalls and the presacral space, suggesting a possible route of metastasis in distal rectal cancer.

Revealing Joseon period People's single nucleotide polymorphism associated with lactase gene by ancient DNA analysis of human remains from archaeological sites in Korea.

Lactase non-persistence (LNP), one of the causes of lactose intolerance, is related to lactase gene associated single nucleotide polymorphisms (SNPs). Since the frequency of LNP varies by ethnic group and country, the research to reveal the presence or absence of LNP for specific people has been conducted worldwide. However, in East Asia, the study of lactase gene associated SNPs have not been sufficiently examined so far using ancient human specimens from archaeological sites. In our study of Joseon period human remains (n=14), we successfully revealed genetic information of lactase gene associated SNPs (rs1679771596, rs41525747, rs4988236, rs4988235, rs41380347, rs869051967, rs145946881 and rs182549), further confirming that as for eight SNPs, the pre-modern Korean people had a lactase non-persistent genotype. Our report contributes to the establishment of LNP associated SNP analysis technique that can be useful in forthcoming studies on human bones and mummy samples from East Asian archaeological sites.

Thickness of the Deltoid Muscle and Location of the Anterior Branch of the Axillary Nerve and the Posterior Circumflex Humeral Artery for Deltoid Injections.

This study investigated the thickness of the deltoid muscle and the location of the anterior branch of the axillary nerve (AAN) and posterior circumflex humeral artery (PCHA), with the goal of maximizing the effectiveness of deltoid injections. Forty specimens from 22 adult Korean cadavers were used. A reference line was identified, connecting the anterior point of the deltoid muscle (AP) and the posterior point of the deltoid muscle (PP) on the surface. The midpoint between the AP and PP was used as the origin point (OP). The line connecting the OP and the lowest point of the deltoid tuberosity (DP) was used as the y-axis. The mean distance of the reference line from the AP to PP was 4.7 ± 0.7 cm. The vertical mean length of the deltoid muscle from the OP and DP was 16.1 ± 1.0 cm. At the 3, 5, and 7 cm sites, the thickness of the deltoid muscle was 0.62 ± 0.9, 0.73 ± 0.7, and 1.3 ± 1.1 cm, respectively. Most of the branches of the axillary nerve were concentrated in the third section (4-6 cm, 51%), while the branches of the PCHA were predominantly found in the fourth section (6-8 cm, 69%). The peripheral branches of the AAN entering the muscle were distributed between 2.2 and 9.8 cm from the acromion. The mean number of the peripheral branches of the AAN was 9.6 ± 3.4. In the deltoid muscle, the mean number of peripheral branches of the PCHA was 8.2 ± 2.8. Administering deltoid injections 5-6 cm below the OP is recommended to avoid axillary nerve injury.

Anatomical classification of middle rectal arteries regarding detailed vasculature patterns.

This study aimed to clarify the anatomy of middle rectal artery and pelvic vasculature patterns, and to provide schematic information in a manner applicable to the total mesorectal excision. Forty sides of pelvis from 20 formalin-embalmed cadavers (10 male, 10 female) were dissected, and all the pelvic vasculatures from the internal iliac artery were investigated, focusing on the middle rectal artery. Middle rectal arteries were classified into major types depending on their vascular origins. Each type was subdivided into minor types according to variability of the pelvic vasculature. A middle rectal artery was identified in 18 out of 20 cadavers, and in 25 out of 40 pelvic sides. In most cases, the middle rectal artery originated from the internal pudendal artery or inferior gluteal artery. These two arteries arose directly from the anterior trunk of the internal iliac artery or were bifurcated from the gluteal-pudendal trunk. In rare cases, these arteries arose from the posterior trunk of the internal iliac artery. The other origins of the middle rectal artery included the gluteal pudendal trunk, inferior vesical artery, internal iliac artery, obturator artery, and the prostatic artery, and the pelvic vasculatures in these cases also presented variability. The detailed anatomical findings related to the middle rectal artery and pelvic vasculatures are noteworthy for their improved clinical applicability.

Evaluating the effectiveness of gluteal intramuscular injection sites: a cadaveric study.

The gluteal region is a frequent target for injecting high volumes. However, the safe intramuscular injection sites have been controversy in this region. This study was aimed to compare the subcutaneous fat and muscle thicknesses at the two gluteal injection sites and to determine the influence of sex and body mass index (BMI) on fat and muscle thicknesses. The ultimate purpose of this study is to suggest the most suitable intramuscular injection site among the ventrogluteal and dorsogluteal regions. Eleven fresh cadavers were injected with colored gelatin using syringes at the two gluteal injection sites. Seven variables were measured at both gluteal injection sites and analyzed relative to sex and the BMI. No variables showed statistically significant differences between the two gluteal injection sites according to sex. In a one-way analysis of variance, total length and muscle thickness had significant difference according to the BMI category. In obese cadavers, the injected gelatin core was located in the subcutaneous layer (average 109.0 percentile), and in the muscle layer (average 78.9 percentile) in the dorsogluteal region. These were found that the success rate of injection in the dorsogluteal region was higher than in the ventrogluteal region, especially when classed as obese. Also, it is suggested that nurses should use the traditional intramuscular injection method. It will also be necessary to consider expanding these findings to other ethnic groups in the Asia-Pacific region and then also education in universities and health providers on selecting the intramuscular gluteal injection site.

Morphologic classification and innervation patterns of the pectineus muscle.

The purpose of this study was to identify the frequency of pectineal hiatus and of pectineus innervations, including femoral, obturator, and/or accessory obturator nerves. Also, this study sought to detailed intramuscular nervous distributions, with a particular focus on the relationship of nerves in multi-innervated pectineus. One hundred (49 right and 51 left) thighs from 52 cadavers (25 men and 27 women) were dissected. The morphology and innervations of the pectineus were investigated. Modified Sihler's whole-mount nerve-staining method was employed for visualization of the intramuscular nerve-distribution patterns of the pectineus. Variation of the pectineus forming a hiatus was identified in 18% of the specimens. The femoral innervations to the pectineus were identified in all specimens. Additional innervation either by the obturator or the accessory obturator branch to the pectineus was identified in 10% or 2% of specimens, respectively. No case of triple innervation to the pectineus was observed. In cases of dually innervated pectineus, two nerves formed a communication system inside the muscle. Among the three nerves supplying the pectineus, the femoral nerve branched more than the other two nerves and covered the greatest area in the muscle. The pectineal hiatus appears to be a common variation. The femoral nerve branch in a dually innervated pectineus is the dominant nerve component that supplies the muscle when considering frequency, branching pattern, and area, even though cooperation between two nerve components is implied. This study serves to advance the existing anatomical knowledge about the pectineus muscle, which is of clinical value.

The ascending branch of the lateral circumflex femoral artery penetrating the posterior division of the femoral nerve.

Understanding anatomic variations in neurovascular structure inside the femoral triangle is crucial for regional anesthesiologists performing femoral nerve block. During routine dissection of a cadaver, an ascending branch of the lateral circumflex femoral artery with an anomalous course passing through the femoral nerve, specifically the posterior division, was identified inside the femoral triangle on the left thigh. The novel variation identified in this study occurred in an early stage of prenatal development. Recognition of this anatomic variation will be helpful for reducing unexpected complications during the femoral nerve block and the tensor fascia latae flap. Penetration of the posterior division of the femoral nerve by the arterial branch might cause pain or paresthesia of the medial aspect of the leg in the distribution of the saphenous nerve.

Fasting glucose level and all-cause or cause-specific mortality in Korean adults: a nationwide cohort study.

BACKGROUND/AIMS: Although people with diabetes have been shown to have higher mortality than people without diabetes, there is a lack of data on the association between fasting glucose (FG) levels and cause-specific mortality rates in the general population. METHODS: A total of 326,547 Korean adults over 20 years of age, who had received a health checkup between 2006 and 2008 were selected from the Korean National Health Insurance Service sample cohort dataset and followed until 2015. We estimated hazard ratios (HRs) of all-cause mortality and cause-specific mortality relative to various range of FG levels. All causes of death were classified according to International Classification of Diseases (ICD)-10 codes. RESULTS: During follow-up (mean, 8.5 years), a total of 13,536 deaths (mortality rate 4.89/1,000 person-year) occurred; 4,916 deaths from cancer, 2,133 from cardiovascular disease, 762 from infectious disease, 199 from renal disease, and 5,526 from other causes. The overall mortality rate increased with an increase in FG category (HR, 1.78; 95% confidence interval, 1.65 to 1.92; in the ≥ 160 mg/dL). In addition, a J-shaped associations was found between FG levels and all-cause mortality after adjustment for age, sex, smoking, drinking, physical activity, body mass index, diabetes mellitus medication, hypertension, and dyslipidemia. In particular, the risk of cancer-mortality with high FG levels was increased for men but not women. CONCLUSION: The risk of all-cause and cause-specific mortality showed the tendency to increase when the FG level was outside of the normal range, indicating a J-shaped relationship, in both men and women.

3D morphological classification of the nasolacrimal duct: Anatomical study for planning treatment of tear drainage obstruction.

BACKGROUND: The purpose of this study is to analyze and classify morphological features of the nasolacrimal duct (NLD) through 3D reconstruction to help understand the causes and treatment of NLD obstruction. METHODS: In this study, we included 63 males and 55 females who underwent autopsy without NLD obstruction with ages ranging from 20 to 78 years. The NLD was defined from the lacrimal fossa to the opening of the BNLD to the inferior meatus, and all continuous CT images showing the NLD were selected. Segmentation was performed semi-automatically, and the reconstruction and measurement of NLD was performed using the Mimics program. RESULTS: Overall NLD length, bony nasolacrimal duct (BNLD) length, anteroposterior and transverse diameters at the entrance to the BNLD, anteroposterior and transverse smallest diameters of the BNLD, BNLD volume, and lacrimal sac BNLD angle were significantly higher in males than females (p < .05). BNLD direction in the coronal plane was slightly more likely to be inward. The most common type in both sexes was cylinder type (42.0%), males were more likely to have lower-thicker types (34.1%), and females more likely to have upper-thicker types (22.7%). CONCLUSION: There were sex differences in NLD measurements, and females had significantly smaller NLDs. These results may partially explain the increased prevalence of primary acquired NLD obstruction in females. The BNLD tends toward the midline, and inclines posteriorly.

Application of nasal profile estimation methods for Korean population.

The nose is an important facial feature that affects facial reconstruction quality and its recognition. We reviewed a selection of papers that researched the nose with regression analysis and applied their regression formulae to our sample to compare the estimated value and measurements. One-hundred computed tomography (CT) scans of Korean adults were selected for this study. The subjects were patients without head trauma, severe deformities, or asymmetry at St. Mary's Hospital in Seoul, Korea. Three dimensional (3D) models of the cranium and face were remodelled and measured by Mimics 14.1 (Leuven, Belgium, Materialise). A measurement system for 3D models that referred to landmarks from previous studies was used to facilitate the comparison process. Estimation formulae were applied to the subjects and compared with the measurement results of this study's population. Corresponding measurements showed that the measurements were statistically significantly different from estimated values obtained with regression formulae. A difference in the results was expected because of the different sample population, but the age of subjects could also impact the results and cause variability. Therefore, the results of this study emphasise the necessity of basal research for a specific target population.

Assessment of nasal profiles for forensic facial approximation in a modern Korean population of known age and sex.

The nose is a valuable facial feature for facial recognition and approximation. We propose the use of regression functions to predict nasal profiles comprising the structures around the piriform aperture using CT-based 3D models. We examined craniofacial reconstruction models acquired from computed tomographic images of Korean adults (188 males and 201 females). Eighteen measurements using 16 craniometric landmarks were measured on 3D craniofacial models. We conducted a descriptive analysis with comparisons according to sex, and simple linear regression analyses to obtain regression functions. Using multiple regression analyses with sex and age as independent variables, multiple regression equations were developed with coefficient of determination R2 ranging from 0.314 to 0.724, meaning that the equations for known sex and age were better for the prediction of nasal profiles than equations that assumed only known sex. These equations are useful and practical for reconstructing nasal profiles in forensic analyses.

A historical approach to syphilis infection in Korea

From the end of the 15th century, syphilis spread worldwide, posing a serious threat to public health. Venereal syphilis has been a major research topic, not only in clinical medicine but also in paleopathology, especially because it is a disease of questionable origin and of high prevalence until the discovery of antibiotics. Syphilis in history has been studied extensively in Europe and the Americas, though less so in Asia. In this review, based on extant historical documents and available paleopathological data, we pinpoint the introduction and trace the spread of venereal syphilis in Korea to the end of the 19th century. This review provides fundamental information that will be a great help in future researches on pre-20th century syphilis in Korea.

Post-factum autopsy to confirm cardiac structures visible on computed tomography images of Korean mummies: the radiological basis of paleo-cardiology.

Accurate interpretation of radiological data is important for reliable paleopathological study of mummies. This is especially true for the mummified heart, an anatomically complicated organ that is distorted and displaced due to long-term dehydration and the action of gravity. In the present study, we compared post-factum autopsy results for mummified hearts of differing preservation statuses with corresponding radiological (computed tomography [CT]-image) findings in order to obtain information necessary for accurate radiological diagnosis. We found that the valvular apparatus (especially the aortic valve and chordae tendinae) was easily distinguishable on the CT images of mummies in which more cardiac structures were preserved. We also identified several situations that are known to incur misdiagnosis of cardiac CT images: the presence of pseudo-cavities in the cardiac wall, confusion of the valvular apparatus with cardiac-wall debris, and invisibility of cardiac structures on CT images due to collapse or adhesion. While acknowledging the merits of top-priority CT scanning in non-invasive research, post-factum autopsy also has value as a complementary and confirmatory analysis for enhanced accuracy of diagnoses in paleo-radiological studies.

Comprehensive evaluation of the greater sciatic notch for sexual estimation through three-dimensional metric analysis using computed tomography based models.

The greater sciatic notch is an effective indicator for sexual estimation, which is the initial process to identify unknown skeleton. Visual assessment is the mainstream of analysis methods; however, the subjectivity of researchers is also questioned. Metric method using three-dimensional models reconstructed from radiographic images can ensure reproducible and stable measurement of the greater sciatic notch. In this study, the greater sciatic notch was analyzed in various manners, including distances, angles, and dimensions, with the aid of an automatic measurement program and a landmark verification system. Among 28 items, 15 measurements showed more than 85% accuracy. Measurements related to the posterior part of the greater sciatic notch near the posterior inferior iliac spine particularly showed higher accuracy (93.1%). To test this observation, "arithmetic posterior angle of the greater sciatic notch", a generalized form of partial angle of the greater sciatic notch, was designed. It showed more than 90% accuracy. When the results of the three-dimensional measurements were applied to classify dry bones, it proved to be valid in contemporary Korean population. The method and results of this study can be referenced in wider use of the greater sciatic notch analysis.