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2010 Nagoya-Yonsei University
Research Exchange Meetings on Health Sciences

October 23, 2010
Auditorium at East building
Daiko Campus
Nagoya University
Nagoya, Japan!

Preface
It is my great pleasure to host the 2010 Nagoya-Yonsei University Research Exchange
Meeting on Health Sciences (October 22-23, 2010) at the Daiko Campus in Nagoya University.

2010 Nagoya-Yonsei University
Research Exchange Meetings on Health Sciences

This is the first meeting that is held to promote academic exchanges between Nagoya University,
School of Health Sciences and Yonsei University, College of Health Sciences and College ofNursing in Korea.
This booklet shows presentation contents of the research activities of the graduate
students and faculty members of both universities in the research exchange meeting. Each ofthese presentations expresses the high research activities in health sciences.
Needless to say, the recent globalization progresses very fast in every field, and ouractivities, the scientific research and the education in the university, have also undergone a big

Organizing Committee
Chair:
Hisataka Sakakibarachange. Although health sciences are still in a relatively young science fields, it will be a chancefor us to create and develop new health sciences with the advance of the globalization. We,

Members:

academics in the fields of the health sciences, need to challenge to create a future-oriented

Sumio Yamada

healthcare research for the future society.

Yoshie Kodera

Nagoya University is one of the leading universities in Japan and Yonsei University is theYoung-Joon Seo

oldest private university and a leading institution of higher education and research in Korea. As

Tetsuhito Kojima

a leading University, we are convinced that this research exchange meeting will make great

Kunufumi Suzuki

contribution for the development of both universities in the future.

Midori Asano

Next research exchange meeting will be held at the Yonsei University in 2011 in Korea.

Tsutomu Kawabe

We hope that the interchange between both universities of the research and education activities

Mitsuru Ikeda

will develop more in the near future.

Susumu Ota
Chiyo Kawaura
Jun Ueyama
Jun-ichi Uemura
Kazuteru Niinomi
Naoko Ito
Hisataka Sakakibara
Director
Nagoya University, School of Health Sciences

CONFERENCE SCHEDULE
Symposium Venue: Nagoya University School of Health Science
Banquet: Soleil in Nagoya University Hospital

DATE
14:20
16:30
Oct. 22 (Fri.) 17:45 ~ 18:45
19:00 ~ 22:30
21:00
9:45 ~ 10:00
10:00 ~ 11:20
11:30 ~ 12:10
12:10 ~ 13:30
13:30 ~ 16:00
Oct. 23 (Sat.)

Oct. 24 (Sun.)

10:00 ~
15:20

SCHEDULE
Arrival at Centrair Airport
Hotel Check-in
Nagoya University Hospital Tour
Banquet (Soleil in Nagoya University Hospital)
Back to Hotel
Opening Remarks (Auditorium in East Building)Keynote Address (Auditorium in East Building)Session in Health Administration (Auditorium in East Building)
Lunch (Large Meeting Room in Main Building)
Subcommittee Sessions
Medical Technology (THP Seminar Room in Main Building)Radiological Technology (Room2 in Main Building)Physical Therapy (Room3 in Main Building)Occupational Therapy (Room4 in Main Building)Nursing (Room1 in Main Building)Dinner (in each major )Sightseeing
Departure for Seoul!"#$%&#"$Keynote Address (10:00 ~ 11:20 Auditorium of East Building)Session chairs: Prof. Sumio Yamada, Prof. Tetsuhito Kojima
KA-1 “Present and Future of Health Science Research in Japan”
Gentleman

OfficeProf. Yoshie Kodera, Univ. of Nagoya, JAPANRest Room(Ladies)

Gate

Large Meeting
Room (Lunch)KA-2 “The Present and Future of Korean Healthcare Industy”

EV

Prof. Youngjoon Seo, Univ. of Yonsei, KOREA
THP Seminar
Room

Main Building 1F

Session chair: Prof. Takaaki Kondo
kondo

Rest Room(Ladies)

Lecture Room 2

Session-Health Administration (11:30 ~ 12:10 Auditorium of East Building)

Lecture Room 1
 East Building

EV

LectureRoom 3

LectureRoom 4

HA-1. “Quality Assessment of Stroke Treatment and Pay-for- Performence in Japan and Korea”
Seungwon Jeong (Health Scientist)
HA-2. “Total Health Expenditure and Its Structure in Two Asian OECD Countries, Japan and Korea”
Jung-Woo Shin (D)South
Building

Main Building 2F
Session-Nursing (13:30 ~ 16:00 Lecture Room 1)
Gentleman

Session chairs: Prof. Makoto Hirai, Prof Midori Asano

Rest Room(Ladies)EV

Auditorium

N-1. “Health Status and Health Care Utilization by Marriage-based Women Immigrants in Korea andPolicy Directions: Focus on Mental Health”
Yang-Heui Ahn (Professor)
N-2. “Association of Underweight with Low Lymphocyte Count and Prealbumin as Indicators ofMalnutrition in Japanese Women”

East Building 4F

Tomoko Nishida (Aichi Health Plaza), Yukiko Okamura, Hisataka Sakakibara
N-3. “Comparison of Salivary Cortisol, Heart Rate, and Oxygen Saturation between Early
Mother-Infant Skin-to-skin Contact Methods with Different Initiation and Duration Times in
Healthy, Full-term Infants.”
Yuki Takahashi (D), Koji Tamakoshi

N-4. “Evidence-Based Nursing Strategy for Acute Ischemic Stroke Patients Management in the

Session-Medical Technology (13:30 ~ 16:00 THP Seminar Room)
Session chairs: Prof. Shinya Wakusawa, Prof. Tsutomu Kawabe

Emergency Department”
Ji-Eun Baek (M)N-5. “Development of a Japanese Functional Health Literacy Test”
Katsuyuki Nakagami (D), Toyoaki Yamauchi
N-6. “Related Factors of Self-Efficacy in Cancer Outpatients Receiving Chemotherapy in the
National University Hospital”
Akiko Hayashi (Konan Kosei Hospital), Shoko Ando

MT-1. “Sleep Disorder and Sleep-disordered Breathing in the Elderly”
Chie Nakazaki (M), Akiko Noda, Nobuko Fujita, Sumio Yamada, Yasuo Koike, Shinya
Wakusawa
MT-2. “Mycobacterium Tuberculosis-induced Expression of Granulocyte-Macrophage Colony
Stimulating Factor is Mediated by Erk1/2 MAPK or PI3-K/Akt Signaling Pathway”
Sung-Jung Park (D), Hye-Young Lee
MT-3. “Molecular Basis of Decrease of Protein S in Pregnancy: 17-estradiol Down-regulates
Protein S (PS) Expression Recruiting Co-repressor Complex to the PS Promoter”

Session-Radiological Technology (13:30 ~ 16:10 Lecture Room 2)
Session chairs: Prof. Yoshie Kodera (RT1-4), Associate Prof. Masatoshi Tsuzaka (RT5-8)

Atsuo Suzuki (D), Yuhri Miyawaki, Junko Fujita, Asuka Maki, Yuta Fujimori, Akira Takagi,
Takashi Murate, Hidehiko Saito, Tetsuhito Kojima
MT-4. “Comparison of REBA HPV-ID with DNA Chip Based Assay for HPV Genotyping”

RT-1. “Educational system for radiological technologists in Japan- As the self-introduction of our department and Japan -”Megumi Watanabe (M)RT-2. “Advancement of Medical Imaging and Instrumentation in Radiological Science”
Hee-Joung Kim (Professor)
RT-3. “Noninvasive Estimation of Regional Cerebral Blood Flow using 123I-IMP Acquisition Data”

Sung-Hyun Kim (D)MT-5. “Morphometric and FISH Analyses of Adenocarcinoma and Mesothelial Cells Using
Liquid-Based Cytology”
Ayumi Morimoto (D), Tetsurou Nagasaka, Katsunori Hashimoto, Toyoharu Yokoi
MT-6. “Molecular Mechanism of Ceramide Kinase Gene Repression on ATRA-induced Neuronal
Differentiation”

Shinji Abe (D), Katsuhiko Kato, Yoshitake Takahashi, Masato Yamashita, Naotoshi Fujita,

Masashi Murakami (PD), Hiromi Ito, Kazumi Hagiwara, Noriko Sasaki, Misa Kobayashi, Asuka

Naotoshi Ohta, Yasukazu Kajita, Shinji Naganawa

Hoshikawa, Akira Takagi, Tetsuhito Kojima, Keiko Tamiya-Koizumi, Yoshiko Banno, Yoshinori

RT-4. “An Influence of the Beam Quality on the Noise of the Image in Digital Mammography”

Nozawa, Takashi Murate

Maki Yamada (M), Yuri Kato, Naotoshi Fujita, Yoshie Kodera
Imaging in the Photon Counting Detector”
RT-5. “Multi-material Decomposition Imajing

Hyo-Min Cho (D), Yu-Na Choi, Hee-Joung Kim
RT-6. “Dosimetric Characterization of Flattening Filter Free Linac using Monte Carlo Simulation”

Session-Physical Therapy (13:30 ~ 16:00 Lecture Room 3)
Chaired by the academic adviser of each presenter

Takuma Matsunaga (M), Tomohiro Shimozato, Yuichi Aoyama, Hiroshi Fukuma, Ryuichi Yada,
Hiraku Fuse, Yusuke Oribe, Masataka Komori, Yasunori Obata
RT-7. “Estimation of Radiation Doses from x-ray CT using Monte Carlo Simulation”
Yuki Morishita (M), Shuji Koyama
RT-8. “Evaluation of the Distribution of Intracranial Navigation Accuracy in Image-guided
Neurosurgery”
Takashi Mitsui (M), Masatoshi Tsuzaka, Yuichiro Hayashi, Yoshinori Asahina,
Kentaro Sugiura, Masazumi Fujii, Toshihiko Wakabayashi

PT-1. “Development of an Instrument for Measuring Patellar Mobility and its Clinical Application”
Susumu Ota (Assistant Professor), Morio Kawamura
PT-2. “CD105 Positive Mesenchymal Stem Cells from Mouse ES Cells Show High Potential for
Differentiation”
Nana Ninagawa (D), Eri Isobe, Rumi Murakami, Shigeko Torihashi
PT-3. “Effects of Forced Impaired Forelimb Use on Central Nervous System after Small Internal
Capsule Hemorrhage in Rats”

Akimasa Ishida (D), Keigo Tamakoshi, Michiru Hamakawa, Hiroki Nakashima, Haruka Shimada,
Hideki Hida, Kazuto IshidaPT-4. “Recurrent Risks after Mild Ischemic Stroke in a Japanese Population”
Yuji Kono (D), Sumio Yamada, Kenta Kamisaka, Amane Araki, Yusuke Fujioka, Keizo Yasui,
Yasuhiro Hasegawa, Yasuo Koike
PT-5. “Locomotor Imagery Training Improves Gait Performance in People with Chronic Hemiparetic
Stroke”
Hye-Seon Jeon (Professor)
PT-6. “The Effects of an Isometric Knee Extension with Hip Adduction (KEWHA) Exercise on
Selective VMO Muscle Strengthening”
Bo-ram Choi

Session-Occupational Therapy (13:30 ~ 16:00 Lecture Room 4)
Session chair: Prof. Yuji Sawada

Invited LectureIL-1. “Occupational Therapy in Japan”
Emi Ito (Associate Prof.)

IL-2. “The Beginning and Development in the Field of Occupational Therapy in Korea”
Eun Young Yoo (Professor)
Research Presentation

Session chairs: Prof. Eun Young Yoo, Prof. Kunifumi Suzuki

OT-1. “Biological Observation during the Daytime of Elderly Patients with Advanced Dementia”
Kaori Yamaguchi (D)OT-2. “Occupational Therapy as a Career: Korean Undergraduate OT Students' Preferences andConcerns Regarding Their Future as Occupational Therapists”
Joo-Hyun Lee (M), Eun-Young Yoo
OT-3. “Alteration of Time-perception in Young and Elderly People during Tasks”
Yuko Iwamoto (D)OT-4. “Use of Scheduled Exercise Program Along With Forced Use to Increase the Function of Upper
Extremity in Individuals with Hemiplegia”
Hae-Yean Park (D)THE PRESENT AND FUTURE OF KOREAN HEALTHCARE INDUSTY

Keynote Address (10:00 11:20 Auditorium of East Building)Session chairs: Prof. Sumio YamadaProf. Tetsuhito Kojima

K
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Young-Joon Seo1)
1) Department of Health administration, College of Health Sciences, Yonsei University, Kangwon-do, Korea

The present of Korean healthcare industry
Healthcare industry has been understood as a broad concept
which includes pharmacy and healthcare appliances as well as
healthcare services together with a narrow idea which refers to
only healthcare service industry. When healthcare industry isdefined as healthcare service industry, the recent argument ofhealthcare industry advancement in Korea has been mainly
focused on changing the healthcare paradigm from a regulated
healthcare system to a free market system such as deregulation,
allowing for-profit hospital corporations and vitalization of a
private health insurance market without having a clear goal or
seeking the ideal model. Advancement of healthcare industry
from the stance of the hospital which is playing an importantrole specially in the healthcare provider group has implicatedthat the health-related systems and policies should beestablished to contribute to the national economy throughattracting overseas patients and creating employment as ahighly profitable industry by developing an advanced
healthcare technology and human resources. Furthermore, theindividual hospitals internally feel they need to enhancecompetitiveness by improving all of the hardware and softwaresystems as a world-class.
Competitiveness of Korean healthcare industry has been
told to be weak compared to the international competitors eventhough clinical technology reaches world class in many areas.
We can find the reason in the following several aspects. First,
Korean healthcare industry have difficulties in marketing
because there are a lot of limitations such as price control,
regulation of advertising, etc. Second, by serving the large
number of patients for a low margin of profit due to low
medical fee, it is difficult for hospitals to care each patientdelicately to meet their personal needs. Third, because financial
resources of the healthcare industry mainly consist of publichealth insurance, supplementary private insurance and out-ofpocket money, the scale of domestic healthcare market islimited and it is difficult for healthcare providers to invest
boldly in the clinical research and high-tech medical services(market scale of current domestic healthcare service industry is
5.6% in GDP, compared to about 10% of the advanced
countries). Fourth, because the scale of medical-related support
industry such as pharmaceutical and life sciences is small andits quality is not high, it does not exert a synergistic effect asneighbor industries.
The prospects of Korean healthcare industry
There are several factors that can have a significant effecton future Korean healthcare industry. First, due to rapid aging
population, demands for health and aged care, and healthpromotion (estimated $70billion market in 2010) will
dramatically increase and result in heavy financial burden to
the individual household as well as the government. Second,the development of information technology and life sciences
will bring the emergence of medical complex combined with
BT, IT, pharmacy, and also make it easier to access to the Uhealthcare. Third, the change of reimbursement system fromfee-for-service to capitation and prospective payment system
will drive hospital administrators to emphasizing more costeffective
management.
Fourth,demandsfortheenvironmentally-friendly healthcare will be grown in the caredelivery process as well as hospital construction due to theglobal warming, resources depletion, air pollution, etc. Fifth,
the quality assessment of healthcare that eventually converts
into accreditation system will be more reinforced, and most of
the hospital information will be released to the consumers andinsurers to use as a selection criteria. Finally, facing a turbulent
environment caused by kin competition among healthcare
institutions, introduction of for-profit hospital corporations,
growth of private health insurance market, and performancebased payment from third part payers, healthcare institutions
will try to recruit and maintain high quality staff and to
implement diverse management strategy.
Future strategies of Korean hospitals
Korean hospitals have made various efforts so far in orderto survive under the turbulent environment of healthcare
market. However, it is true that many hospitals have still
followed physician-centered traditional hospital management,
and that operating systems of the hospitals are also far fromthose of advanced countries. In order for the Korean healthcare
system and hospitals to be advanced, there are some nationaltasks to be solved. First, the government has to build advanced
healthcare system that all the people can receive good qualityof care without worrying about medical bills by increasing
public insurance coverage dramatically from the current 65% to
90% level. Second, the government should change theparadigm that has focused on disease treatment to the disease
prevention and health promotion. Third, Integrated Delivery
System (IDS) which is defined as a network of organizations
that provides a coordinated continuum of care to a defined
population should be established in order to deliver appropriate
care to the people at right time at right place. Fourth, thegovernment should actively foster the complex healthcare
industry which bundles up BT, IT, pharmacy, and business.
Fifth, the government should free unnecessary regulation thathas restrained the hospital's autonomy and creativity, while
intensify the hospital's responsibility for patient's safety andenvironmentally-friendly care. In addition to the governmentrole, hospitals themselves also have to make efforts to improvetheir internal effectiveness. First, hospitals should build
customer-oriented care delivery system through restructuring
and reengineering of the hospital. Second, hospitals should
generate synergy effect through networking with other
healthcare institutions - vertical and horizontal integration, andintegration of oriental-western medicines, etc. Third, customercentered marketing should be strengthened. To do this,
hospitals build customer database and should strengthen theformal and informal contacts with target customer groups.
Fourth, hospitals should establish the culture of labormanagement cooperation by improving the quality of workers’
life and open management. Fifth, hospitals should provide a
personalized patient-centered care through case management
system. Finally, hospitals should strengthen the relationshipwith the local communities through formal and informal
communication and economic contribution to the community.
Conclusion
The advancement of the healthcare industry in Korea could
be accomplished when government, consumers and providers

KA-2

agree on what the most desirable healthcare system in Korea
should be in the future and how it is achieved. It means that thetrue advanced health care system will be created when all the
stakeholders in healthcare market clearly recognize their rights
and responsibility, and extend mutual understanding andcooperation with sharing the goal of ‘Healthy and WelfareState of Korea’.

KA-2

Health Administration (11:30 12:10 Auditorium of East Building)Session chair: Prof. Takaaki Kondo

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Quality Assessment of Stroke Treatment and Pay-for- Performence in Japan and
Korea
S. Jeong1)
1) Center for Well-being and Society, Nihon Fukushi University, Nagoya, Japan

Introduction
P4P (Pay for Performance) is considered to be a tool thatcan enhance health care quality and improvement. Reports
show that P4P has been increasingly used in developed
countries such the United States1 and the United Kingdom.2
Nevertheless there is a lack of reports on formal evaluation of
hospital P4P in the literature. Systematic evaluation of hospital
P4P is needed to understand the effect and benefits of investingin P4P.3
Similar P4P programs are under way in Korea and Japan,
too. This study reviews the status and examines theperformance in the two countries.
P4P in Korea
In Korea, The cause-specific death rate by stroke andcerebrovascular diseases in recent years has been on the decline,
but stroke is still ranked the number one disease killer,
accounting for the highest percentage of the global burden of
disease such as disability combined and therefore causing
incrased medical costs. In consideration of this, an acute strokeassessment tool that has been developed to provide data to care
hospitals for promoting their voultary quality improvement
acitvities has been used since 2005. Also, the 2006 survey on
the status on the medical services for stroke patients was
conducted for the similar purpose. Based on these results, apilot P4P project for acute stroke was undertaken from 2007
throughout 2010.
Amomg the assessment criteria were Documentation ofsmoking history, Neurologic exam.rate, Screen for dysphasia
by end of hospital day two, brain scan within 24 hours ofadmission, Lipid Profile, T-PA considered, Autithrombotic
medication within 48 hours of admission, Discharged on
Antithrombotic, Patients with Atrial Fibrillation Receiving
Anticoagulation therapy.

>30% of patients under the P4P program should demonstrate an
improvement in their daily living functions or functional
recovery at the time of hospital discharge.
ResultKorea
The follow-up assessment for the two treatment periods, in2005 and October to December of 2008, in the categories of 1)
promptness in initial diagnosis, 2) responsiveness in initial
treatment, 3) secondary preventive measures, and 4) initialassessment of patient conditions, revealed that there wereoverall improvement in quality compared to the results on 2005,
but significant variations in treatment practices across types
and care hospitals were observed (Figure1 and 2).
Following this, the third assessment was conducted on thetreatment period of January to March of 2010 with a goal of
seeking for ways to reduce the discrepancies between hospitals
and ensuring enhanced medical service quality for stroke
patients. The numbers of subject hospitals were 187 for 2005,
194 for 2008, and 313 for 2010.

P4P in Japan
There have been growing concerns and requirements forhealth care quality in Japan. The introduction andimplementation of P4P (Pay for performance) programs forrehabilitation and recovery in 2008 was a significant
advancement in the area of health care service. However, there
still remains a gap involving a need for close examination ofwhat factors may critically influence the rehabilitation medical
service quality and the degree to which hospitals have made or
will make efforts in achieving best practice in rehabilitation. To
begin with, the assessment criteria for P4P set forth by theJapanese government are summarized as follows.
In Japan, P4P inpatient rehabilitation among stroke
survivors began in 2008 with a primary objective to provide theservices needed and improve post stroke patient functional
recovery. Despite concerns over the effectiveness and qualityof P4P by some stakeholders of the program in Japan,1 threestandards were developed for the P4P inpatient rehabilitation
program. They included: (1) >60% of participating stroke
survivors should be discharged to the community; (2) >15% of
newly hospitalized patients should have severe stroke; and (3)HA-1

Figure 1. Improvement in quality measures

Figure 2. Decrease in variance among hospitals in Korea
Japan
The comparison of the data before and after the
introduction of P4P showed that for FIM during hospital stay,the score after P4P (68.85) was slightly higher than that before
P4P (65.82) without any statistical significance. On the other
hand, the Rankin Scale score was found to be lower after P4P(3.28) than before P4P (3.78), showing higher scores forpatients with light disability (p<.001). With respect to FIM at
hospital discharge, the scores were not significantly different
between before (90.46) and after (91.86) P4P. Also, in the caseof patients whose actual FIM was deteriorated from estimatedFIM, the percentages were about the same with 34.8% and34.4% for before and after P4P, respectively. The home return
rate was 80.0% after P4P, compared to 73.0% before P4P,
showing an increase of 7.0% point (p<. 05) (table 1).
Also the therapeutic results were compared between
hospitals. We estimated the expected value of levels of ADL atdischarge for rehabilitation patients using regression analysis.
Furthermore, we identified the distribution of the expected
improvement levels in ADL by hospitals.
The results showed large differences between hospitals(Figure 3).
Table 1. State of patients before and after P4P in Japanof the P4P pilot project implemented in Korea. However the
judgment of the quality of medical services can vary dependingon which criteria are used or which compound values are taken
into account 4. This holds for the case of Japan.
The study in Japan focused on patients in recovery in the
rehabilitation ward using a sample of 680 patients from 12
different hospitals after adjusting for triage at admission
obtained from the databank (issued in September, 2009) inJapan and compared the therapeutic results between hospitals.
The comparison found that there were statistically significant
differences in the results of therapeutic achievement in eachhospital.
Thanks to advances in the assessment of health care quality
and wider publication of results from studies conducted in a
number of first world countries such as the US and the UK, it isexpected that health care providers will put a voluntary effort toimprove their future health care services. Nonetheless, prior tosuch efforts of medical providers, it is essential to develop
appropriate criteria for assessing health care quality andverifying the validity.
Conclusion
Donabedian (1980)5 mentions that those who have noexperience with the complicated system of medical practice,
are likely to think that assessing the quality of medical services
would be as easy as weighing a bag of potato chips, but in theactual settings the task is not so easy as it appears. In quality
assessment of medical services quality, there are not a few
elements involved. Indeed, it should be insured that indesigning the structure and process for targeted outcomes, therelevance to the therapeutic objective, the validity of thecausality, the sensibility, the appropriateness of timing, costs,
and the patient satisfaction, among others, are properly taken
into consideration. Since these requirements are also applied to
P4P, putting P4P in right place will be a rewarding but also
challenging task.
References[1]Jeong S, Kondo K, Inoue Y. Pay for performance in USA
and suggestion to Japan. Shakai Hoken Jyunpo.
2009;2397:20–25.
[2]Doran T, Fullwood C, Gravelle H, et al. Pay-forperformance programs in family practices in the United
Kingdom. N Engl J Med. 2006;355(4):375–384.
[3]Mehrotra A, Damberg CL, Sorbero ME, Teleki SS. Pay for
performance in the hospital setting: what is the state of theevidence? Am J Med Qual. 2009;24(1):19–28.
[4]S. Jeong, K. Kondo, N. Shiraishi, Y. Inoue#An evaluationof the quality of post-stroke rehabilitation in Japan. ClinicalAudit 2:59-66, 2010[5]A.Donabedian # Exploration in Quality Assessment andMonitoring: The definition of Quality and Approaches to Its
Management. 1!"Health Administration Press, 1980.
Author address
E-Mail: k-jeong@n-fukushi.ac.jp

Figure 3. Decrease in variance among hospitals in Japan
Discussion
Many reports suggest that improvement in Korean medical
services has been confirmed over the course of the three years

HA-1

Total Health Expenditure and its structure in two Asian OECD countries, Japan and
Korea
Jeong-Woo Shin1)1) Department of Health Administration, School of Health Sciences, Yonsei University, Wonju, Rep of Korea.

Introduction
Improvement of economic and progress of aging increase
not only a personal concern but also social interest about health.
Beyond this, it is required to make a rational policy for
operating a health care system efficiently and allocating theresources at the national level. However, to fulfill those needs,
it is necessary to build a statistical infrastructure and healthspending is regarded as one of the most important statistics.
Total Health Expenditure(hereafter THE) is a core index
showing health spending and a National Health Accounts(hereafter NHA) gives us clear information of tendency of THE.
The NHA does clearly organize the flow of health spendingby tri-axial(Health care functions, Health care service provider
industries and Sources of financing health care). The NHA is
proceeding according to the SHA(System of Health Accounts,
hereafter SHA) guideline published by Organisation for
Economic Co-operation and Development (hereafter OECD) in2000. Each economy collects the data and implements SHA inorder to develop comprehensive and enhance a consistency.
Moreover, this concept is based on the consensus on what
element should be included or not, so the result is to ensure thecomparability of health care expenditure estimated by different
nation.
Those three kinds of element(Comprehensiveness,
Comparability and Consistency) could be a strength and a main
goal of SHA. Recently, OECD, EROSTAT and WHO havecollaborated in the joint OECD-EROSTAT-WHO Health
Accounts Data collection, they have also been engaged inprojects to develop a methodology. Nevertheless, there are lotsof problems harmonizing the criteria in several aspects such as
an experience, a limitation of data and a cultural difference.
The paper begins by presenting the meaning of the SHA
briefly which is used for collecting a data internationally, andexamining the structure of THE in two countries, Japan and
Korea. Additionally, this paper aims to provide a detailed
review of THE in both countries comparing with other OECDeconomies.
A concepts and development of SHA
As noted above, The System of Health Accounts(SHA)
proposes an integrated system of comprehensive andinternationally comparable accounts and provides a uniform
framework of basic accounting rules and a set of standard
tables for reporting health expenditure data(Orosz and Morgan,2004). It proposed in three dimensions, ICHA-HF, ICHA-HC
and ICHA-HP. Firstly, ICHA-HF is related to financing
sources. THE mainly comprises public financing(HF.1.) andprivate financing(HF.2.), and its composition determines thecharacteristics of health care system. Secondly, ICHA-HC is aclassification of Function (e.g. Inpatient, Outpatient) which isthe crucial element of the SHA. Consequently, health policymaking refers to it on the national level. Lastly, ICHA-HP
shows information of providers; hospitals, nursing andresidential care facilities etc.
The SHA has two major aims; one is to provide aframework for international data collection and the other is tosuggest a possible model for redesigning and complementing

NHA to aid policy-makers(Jeong, 2010). To achieve this, a lotof health accounts expert meeting have been holding since
1990s and ‘A system of Health Accounts’ (version 1.0) was
published by OECD in 2000. During the last decade, most of
the OECD economies are able to implement basic triaxial(ICHA-HF, ICHA-HC, ICHA-HP) according to thismanual. There was a demand for systemizing accounting
system among developing countries, and the World HealthOrganization(WHO) published NHA Producers Guide toresponse those needs in 2003. Since then, a number of OECDand non-OECD countries have undergone SHA framework andhave provide a data regarding health spending. In 2004, threeinternational organizations build a cooperative system forharmonizing National Health Accounts and collecting astandardized health statistics. Such interests in Health Accounts
are also spreading to across Asian-Pacific countries like Sri
Lanka, India and China etc. Recently, the 6th APNHAN (AsiaPacific National Health Account Network) expert meeting washeld in Korea in last July 2010 and more than 50 experts
participated from approximately 20 economies. As a result, theSHA manual(OECD, 2000) is used in a large and growing
number of OECD and non-OECD countries as the standard
accounting framework for statistics on health expenditure andfinancing.
A structure of THE in Japan and Korea
Prior to comparing the major findings of THE, it is required
to close look at the characteristics of the structure of healthspending and the data sources. Although many OECD and nonOECD economies are currently undertaking the OECD/SHA
manual, some countries(including Japan) continuously use
domestic standard. However, this makes lots of confusions.
In Japan, there are two types of representative index
showing health spending statistics, one is Japanese National
MedicalExpenditure(KokuminIryohi,
hereafter
NME)
publishedby‘Departmentof
Statistics
andInformation(Japanese Ministry of Health, Labor and Welfare)’,and the other is OECD’s Total Health Expenditure(THE)estimated by ‘Institute for Health Economics and Policy(Japan,
IHEP)’.(Jeong, 2001) The former is the total medical payment
limiting its scope to medical service covered by the healthinsurance scheme, while the latter includes not only NME
statistics but also other items like OTC drugs, health promotion
services, Japanese long-term insurance(Kaigo Hoken),administrative finances and capital formation etc. In otherwords, the NME is a subset of THE. In considering the healthspending to GDP ratio, there is a 2.6%p gap between
THE(8.1%) and NME(6.5%) in 2007. In the case of THE, it isbased on the number of statistics(around 40 kinds of statisticaldata) including NME statistics.(Mitsutake, 2010)
In Korea, estimation of health expenditure was attempted
since 1976. Initially, many scholars tried various methods, butOECD’s concept was accepted right after joining the OECDin the late 1996. Eventually, SHA-based health accounts havebeen reported annually by Jeong(focal point designated ofOECD-WHO-EUROSTAT) since 2004. Recently, a Health
Accounts Forum was organized to spread its concepts and toHA-2

develop a method. For calculating THE, a variety of sources
can be used individually or in combination.
A comparative analysis of THE in Japan and Korea
Total Health Expenditure accounted for 8.1% of GDP in
Japan, slightly less than the OECD average(8.6%) in 2007.
Although it increased 15.7% in the past 10 years, that is still
below the OECD level. Meanwhile, Korea increased
53.7%(annually 10.4%) at the same period and it reached to
6.3% of GDP in 2007, even though it ranks(28th) at the bottomof OECD members. The United States is the country which
spends tremendous amount of money on healthcare with 15.7%
of GDP in 2007. Besides, 6 countries like France, Switzerland,
Germany, Austria, Canada and Belgium followed with morethan 10% of their GDP. Overall, health spending as a share of
GDP has been increased during this period, but both of two
countries level is significantly lower than the OECDaverage.(Figure1)

15.7% in Japan, notably higher than Korea(1.7%) where caretend to be provided in informal sector such as family.
In terms of hospital expenditure, out-patient care is around
27.5% of current health expenditure in Korea where hospitals
maintain large out-patient department.(excluding a tablebecause of restricted paper)
Table1. Total public and private health expenditure byfunction (US$ PPP Per capita)
Japan(2006)

In-patient Ser.
Out-patient Ser.
Other Ser.
Medical goods
Prevention
Health Admin.
Etc.
Total

US$PPP

987
823
52
548
60
61
49
2,580

(%)

(38.3)(31.9)(2.0)(21.3)
(2.3)
(2.3)
(1.9)
(100)

Korea(2008)

US$PPP

530
593
10
463
42
56
107
1,801

(%)

(29.4)(32.9)(0.6)(25.7)
(2.4)
(3.1)
(5.9)
(100)

OECD*

US$PPP

1,663
373
123
537
76
143
75
2,991

(%)

(55.6)(12.5)(4.1)(18.0)
(2.5)
(4.8)
(2.5)
(100)

1) * Source: Jeong, Lee, Shin and Song(2008) , 17 Countries average including
AUS, CAN, USA, ESP, PRT, DNK, NOR, CHE, NLD, KOR, JPN, DEU,
FRA, LUX, CZE, SVK and POL.

Figure1. Total Health Expenditure in Japan and Korea as ashare of GDP

Discussion & Conclusions
The major goal of SHA is to provide a set of international
standard aggregating NHA. Estimating THE using common
boundary such as OECD/SHA makes it possible to compare thelevel of health spending, as well as health care system. The
SHA manual(ver. 1.0) is scheduled to be revised in several year
for further development.

1) Source: OECD Health Data 2010(2010)
2) Excluding Luxembourg and Portugal.(2007 not available data)

As shown by Figure2, most of the OECD countries, there
is generally close agreement on the THE mainly financed bypublic sector with 71.2%. In Japan, 81.9% of THE is funded bypublic side in 2007 and this figure is almost similar to 10 years
ago(81.5%). On the other hand, the share of public spending in
Korea is obviously lower than that of OECD economies except
the USA and Mexico. Although Social security scheme andgovernment(public part) play an important role in Japan and
Korea, there is a big different composition in financing sources.
Figure2. Share of THE by financing agent

1) Source: OECD Health Data 2010(2010)
2) Excluding Luxembourg and Portugal.( 2007 not available data)

Table1 gives details of health spending by Function in
Japan and Korea. The allocation of health spending across thevarious service and medical goods shows the characteristics ofhealth care system. The table shows that Korea and Japan
report a relatively low proportion of expenditure for in-patient
services(29.4%, 38.3% respectively) comparing to OECDaverage level(55.6%). On the other hand, spending for Inpatient and Medical goods is high. Furthermore, large
differences remain between Korea and Japan in Long-term
nursing care. The ratio of Long-term nursing care accounted toThis paper explained about a concept of internationalclassification named OECD/SHA and examined total
health expenditure in two Asian countries. Although bothof them are based on a same prototype (NHI), it presents
the variations in terms of financing sources andallocation of resources. However, the analysis using
international data like this is expected to provide someevidence to assess health system performance and to aid
policy making.

References[1]Eva Orosz, David Morgan. SHA-Based National Health
Accounts in Thirteen OECD Countries: A Comparative
Analysis. OECD Health Working Papers No.16. Paris:
OECD. 2004.
[2]Jeong HS, Korean National Health Accounts and Total
Health Expenditure in 2008. Seoul: Ministry of Health andWelfare. 2010.(Korean)[3]Jeong HS, Jeremy Hurst. An Assessment of the performanceof the Japanese Health Care System. Labour Market andSocial Policy Occasional Papers No.56. Paris: OECD. 2001.
[4]Jeong HS, Lee JH, Shin JW, Song YM. Scale and structureof 2006 Total health expenditure in Korea constructedaccording to OECD/WHO/EUROSTAT’s SHA. The Korean
Journal of Health Economics and Policy. 2008;14(1):151169.(Korean)[5]Mitsutake Naohiro.  -OECDSHA  . .
2010;80:11-23.(Japanese)[6]OECD, OECD Health Data 2010. 2010.
[7]OECD. System of Health Accounts. Paris: Organization for
Economic Cooperation and Development. 2000.
Author address
E-Mail: jwshin@ymail.com

HA-2

Nursing (13:30 16:00 Lecture Room 1)
Session chairs: Prof. Makoto Hirai
Prof. Midori Asano

N
u
r
s
i
n
g

Health Status and Health Care Utilization by Marriage-based Women Immigrants in
Korea and Policy Directions: Focus on Mental HealthYang-Heui Ahn1)
1) Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea
providers. Cultural competence including cultural behaviour
and cultural sensitivity was measured using the CulturalCompetence Scale. Scores on cultural behaviour for Public
Health Nurses were lower than for care providers at multicultural family centres. However scores for cultural sensitivity
were not significantly different between the two groups. Public
Health Nurses have no educational experience on culture incaring for multi-cultural families.
Acculturation, mental health status, and health careutilization by marriage-based immigrant women: Demographic
characteristics of marriage-based immigrant women were as
follows. The average age of the first marriage for immigrant
women was older compared to Korean women (33.3 years ofage for immigrant women, 28.7 for Korean women). The
average age difference between immigrant women and theirpartners was 9.9 years, while for Korean couples it was 2.7. In
terms of nationality, immigrant women in their twenties at thefirst marriage came from Vietnam or Cambodia. The averageage difference between them and their partners was 17~18 years.
Most immigrant women were high school graduates, but 2030% of women coming from Vietnam or Cambodia had lessthan elementary school graduation. Regarding length ofresidence, 90% of women coming from Vietnam or Cambodia
had under 5 years and 21.5% of immigrant women’s household
monthly income was under 1,000,000won (about 73,800 ).
Medical aid benefits were received by 7.9% of immigrant
women, which is higher than the rate for Korean people (3.7%).
Regarding of their acculturation, the greatest difficulty waslanguage difference. The overall level of acculturation stress
was moderate, and cultural shock had the highest score. Taking
their health into account, 52.1%~53.8% of the women had aperceived general health status as good which is higher than the
38.7%, rate for Korean women who are over 19 years of age.
The prevalence rate for depression was 26.5%~40.6%, also
higher than the 18.9%, prevalence rate of depression among
Korean women of the same age. The rate of alcohol
consumption and smoking was lower than for Korean womenof this age. The rate of visits to clinics or hospitals when theyfelt ill was 73.3~78.6%, while to Public Health Centres was
3.3~8.7%.

Introduction
One of the challenges of the 21st century is providing
care to increasingly multicultural societies. Foreigners living
in Korea have increased since 1990s. As of December 31,
2009, 2.4% (1,268,477 persons) of the total Korean
population were foreigners. Of importance is the rate ofincrease every year. Korean society is becoming a
multicultural society. The rate of international marriage
increased in 2005 compared to 2000, but the number ofinternational marriages decreased in 2006 compared to 2005.
However it has stood at over 10% of total marriages.
Marriage-based women make up 75.5% of couples, whichmeans there are 3 times more foreign women than men ininterracial marriages. Most come from China, Vietnam,
Philippines. The Ministry of Justice and the Ministry of
Gender Equality and Family have a central part in making
policies to support marriage-based immigrants. Various
services including Korean language, culture, and otherservices for marriage-based immigrants have been delivered
through multi-cultural family centres based on the“Multicultural Families Support Act”. However health carepolicies for these women are relatively scarce. This everincreasing multicultural population in Korea poses a
significant challenge to nurses offering individualized care to
their clients. The author reviewed articles and reports related
to health status, behaviours, and health care service
utilization by marriage-based immigrant women in Korea,
and proposed policy directions.
Conceptual framework and Methods
Conceptual framework of this research: 1) National
policies and the health care system related to marriage-based
immigrants; 2) cultural competence of nurses; 3) cultural
adaptation and mental health of marriage-based immigrant
women were reviewed based on health determinants of WHO(2005), and behavioural model of Anderson (2008).
Methods: Narrative review was done through 3 nationwide reports and 10 research studies published since 2005.
Results
National policies and health care system related tomarriage-based immigrants: In 2006 the government
instituted a plan consisting of multicultural policies for
immigrants to facilitate integration into their communities.
First 38 Marriage Immigrant and Family Support Centres
were established across the country in 2007, and increased to
171 centres as of 2010. The name was changed tomulticultural family support centres according to the“Multicultural Families Support Act [MFSA]” which wasenacted on March 21, 2008 by the Ministry of Justice.
Maternal and child care are delivered for immigrant womenand their children based on MFSA. Examples are provisionof helpers after delivery, health screening, and interpreters
for health examinations, and medical expenses when awoman delivers a premature baby. These services aresupported by the Public Health Centres (PHCs) in 2010.
Cultural competence of nurses: There was only one
research study on cultural competencies of nurses and care

Policy directions
Based on these results, four policy directions are proposed.
A health care system integrated with language, culture, andhealth literacy is needed: Language is a body of words andsystems of meaning for the use of the words that is common to apeople who are of the same cultural tradition or nation. Limited
Korean proficiency is to be restricted in the ability to read,
speak, write, or understand Korean, so that language difference
can cause difficulty in interrelationships among people. The
language differences themselves are barriers to effective
communication. The inability to communicate with a healthcare provider not only limits access to health care but also
affects the quality of medical care received and appropriatenessof follow-up. Culture refers to the learned, shared andtransmitted knowledge of values, beliefs and life ways of aparticular ethnic group that are generally transmitted intergenerationally and influence thinking, decisions and actions in

N-1

!
patterns or in certain ways (Leininger, 1991). This pattern ofbeliefs influences how symptoms are recognized and how
they are interpreted and affects how and when health services
are sought. The level of acculturation results in differences in
the use of health care services. One’s culture affects one’s
understanding of a word or sentence and even one’s
perception of the world. Cultural differences, which are often
associated with language differences, are barriers tocommunication with health care providers. Health literacy isdefined as the degree to which individuals have the capacity
to obtain, process, and understand basic health informationand services needed to make appropriate health caredecisions (IOM, 2004). Language and culture provide theexperiential context for comprehension of health information.
The culturally bound beliefs, values, and preferences aperson holds influence how a person interprets health careinformation. Knowing about a client’s language and culture
is a key to assessing the health literacy of the client in a given
situation. Reducing unnecessary diagnostic testing or
inappropriate use of services by providing culturally andlinguistically appropriate care through improvements inhealth literacy leads to efficiency of care. Therefore a healthcare system integrated with culture and linguistics and giving
consideration to health literacy is necessary for quality ofcare and improvement in the health of immigrant women.
Development of national standards on culturally andlinguistically appropriate services & in-service education on
culturally competent health care for public health nurses(PHNs): Cultural competence is important considering PHNs
diverse cultural backgrounds. PHNs often serve as advocatesfor multicultural families through health promotion
interventions and community-based disease control andprevention activities. Being culturally competent allows
PHNs to more effectively engage in practice, advocacy
activities, and to decrease of health disparities. Nurses areaccountable for considering cultural differences whendeveloping care approaches specific to these multicultural
individuals and families. Cultural awareness reflects
knowledge of the differences among individuals and families.
Cultural sensitivity includes one’s attitudes towards others
and one’s openness to knowledge within multiple culturaldimensions. Cultural competence includes actions taken in
response to cultural awareness and sensitivity. It involves theability of individualized care for multicultural women’s
health. Therefore, local and national public health caresystems have to be mandated to provide culturally andlinguistically appropriate services through the developmentof national standards. PHNs and other hospital nurses need to
be offered in-service education programs on culturalcompetency skills. Furthermore, nursing education needs toinclude trans-cultural nursing in the curriculum. The
curriculum in trans-cultural nursing should teach theknowledge and skills needed to provide culturally competentnursing care.
Development of an assessment instrument for high-risk
immigrant women & provision of individualized intervention
programs: The development of an accurate assessment
instrument for immigrant women within the community isessential to culturally competent care. An assessment
instrument needs to develop to discriminate primarily what is
high-risk or not. The instrument including language, culture
and health literacy and should be valid and reliable. Basedon the literature review, immigrant women’s health andhealth behaviour were found to differ by demographic
characteristics, nationality, length of stay in Korea, Korean

language proficiency, and the level of acculturation. Therefore
individualized care is needed.
Vitalizing functions of the Public Health Centres (PHCs):
PHCs provide primary health care. This care is very importantfor immigrant women. Resolution of the three policies above
must precede providing cultural and linguistic competent carewith health literacy at PHCs. Health care of marriage-based
immigrant women is needed at PHCs including care from thetime of entry into Korea, and by life cycle, and according tolevel of acculturation. PHCs need to play a key role with the
network of multi-cultural family centres and other community
resources to enhance the health of these women.
Conclusions
In an increasingly multilingual, multicultural society,providing high-quality health care requires overcoming barriers
such as language, culture, and low health literacy. For the
implementation of high-quality health care practices, there isneed for redesign in the health care delivery system. The
government should also support an integrated health caresystem that is effective, reliable, and sustainable.
References[1]Yang OK, & Kim, YS. A study on the effects ofdepressiveness among foreign wives through marriage
migration. Mental Health & Social Work 2007; 26: 79-110.
[2]Yang SJ, Kim JA, Kim SN, Choi HY, Park CS, & Dan HJ.
Health Concept, Health Status and Health Service Utilizationof Marital Immigrant Women in Urban and Rural Areas in
Korea. Ministry of Health and Welfare  Ewha Womans
University: 2009.
[3]Park, HS, Bae, KE, Kim, DH, Yoon, YR. A survey on healthrelated status of marriage-based immigrant women. Korean J
Fundamentals Nurs 2008; 15: 80-88.
[4]WHO Europe, European Health Report 2005 - Public Health
Action for Healthier Children and Population, 2005.
[5]Anderson, RM. National health surveys and the behavioral
model of health services use. Medi Care 2008; 46: 647-653.
[6]Ahn, YH, Park, MJ, & Lee EJ. Development of Family
Health Guide for Service Providers. Research Institute for
Gangwon  Yonsei University: 2009.
[7]Seol, DH, Kim, YT, Kim YM, Yoon HS, Lee HK, Lim KT etal. A Survey on Marriage-based Immigrant Women in Korea
and Policy measures. Ministry of Health and Welfare: 2005.
[8]Kim, SK, Kim, YK, Cho, AJ, Kim, HR, Lee, HK, Seol, DH
et al.. A Nation-wide Survey on Multi-cultural Family.
Ministry of Health and Welfare  Ministry ofJustice  Ministry of Gender & Equality  Korea Institutefor Health and Social Affairs: 2010.
[9]Kim, HJ. A study of social support, the demand for healtheducation, and quality of life for married female immigrants.
Korean J Women Health Nurs 2008; 14: 5-11.
[10]Jeong NO. A prediction model of health-promoting
behavior in married immigrant women[Unpublisheddoctoral dissertation]. Jeonju: Jeonbuk National University;
2008.
[11]Noh, HN. A study on acculturative stress of the Chinese
women who got married to Korean men and sellted down in
Korea[Unpublished master's thesis]. Seoul; Ewha Womans
University; 2007.
[12]Korean Center for Disease Control and Promotion. 2008
National Health Statistics: The 4th national survey on
health and nutrition. Seoul: Author: 2008.
Author address

E-Mail: ahn57@yonsei.ac.kr

N-1"

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References

Discussion"'9!@29&9A;!&;1(F!&'?J9(!;');!1A(92J9%E';!J?09A!J929!:%/9:F!
;?! ')B9! :?J92! :F0@'?8F;9! 8?1A;&#! "'9! @29B):9A89! ?D! )! :?J!
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J'?! :?&;! J9%E';! ?D! ?B92! 3! /E#! <2?;9%AP9A92EF! 0):A1;2%;%?A!
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N-2

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Skin-to-Skin Contact Methods with Different Initiation and Duration Times in Healthy,
Full-Term Infants"#!$%&%'%(')*+,!-#!$%.%&/(')*+!
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Introduction?&)5I4/I(&)5! @/54%@4! J??F+! )(! %! E1AAI&5/E5! @%3)59!
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Materials and Methods!
Subjects:! `1! @/5>8@41>! %5! /H(13<%4)/5%A! (48>:! /6! *NO!
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4'1! )56%54(! 6/3! E'/.! 4'1! (%A)<%3:! @/34)(/A! A1<1A(! E131!
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'1%A4':!68AAI413.!)56%54(,!eT!6/3!E'/.!>%4%!E131!/H4%)51>!/5!
H/4'! '1%34! 3%41! %5>! /[:915! (%483%4)/5J6)9831*+#! $')(! (48>:!
23/4/@/A! E%(! %223/<1>! H:! 4'1! U4')@(! L1<)1E! F/..)4411! /6!
4'1!7%9/:%!;5)<13()4:!?@'//A!/6!B1>)@)51,!7%9/:%,!C%2%5#!
Salivary Cortisol:?%A)<%!(21@).15(!E131!@/AA1@41>!%!4/4%A!
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.1%(831.154(! E131! @%33)1>! /84! 8()59! %! 7UXXFML!
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N-3

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Data analysis: ]5! (48>:! *,! (48>:! )56%54(! E131! >)<)>1>! )54/!
4E/! 93/82(D! 4'/(1! E'/! H19%5! ??F! S! .)5! /3! A1((! JnQYG+! %6413!
H)34'!%5>!4'/(1!E'/!>)>!(/!./31!4'%5!S!.)5!JnQYe+!%6413!H)34'#!
]5!4'1!231(154!(48>:,!4'1!6/3.13!93/82!E%(!>16)51>!%(!iH)34'!??Fi!
%5>! 4'1! A%4413! 93/82! %(! iR13:! 1%3A:! ??Fi! H%(1>! /5! 4'1!
@A%(()6)@%4)/5! /6! 1%3A:! ??F! H:! B//31! 14! %A#G! -%2A%5IB1)13!
@83<1(! E131! 91513%41>! 6/3! 4).1! 4/! KL! %5>! ?2MG! (4%H)A)4:#! $'1!
>)661315@1!H14E115!93/82(!E%(!%((1((1>!E)4'!A/9I3%5&!41(4#!71[4,!
E1!8(1>!F/[!23/2/34)/5%A!'%j%3>!./>1A!4/!31A%41!4'1!4).1!/6!KL!
/3!?2MG!(4%H)A)4:!4/!%!58.H13!/6!1[2A%5%4/3:!<%3)%HA1(!)5@A8>)59!
??F! )5)4)%4)/5! 4).1! @%419/3:,! 8.H)A)@%A! %3413:! 2K,! A%H/3!
)5>8@4)/5,!.1@/5)8.!(4%)5)59,!H)34'!E1)9'4,!%5>!4/4%A!A1594'!/6!
6)3(4I(4%91! %5>! (1@/5>I(4%91! A%H/3! )5! .)5841(#! $'1! 1[2/5154! /6!
4'1! 2%3%.1413! 1(4).%41! /6! ??F! )5)4)%4)/5! 4).1! @%419/3:!
kUWaJ2%3%.1413! 1(4).%41+l! )5>)@%41(! 4'1! 166)@%@:! /6! P)34'! ??F!
93/82! @/.2%31>! E)4'! 4'1! 3161315@1! @%419/3:! JR13:! 1%3A:! ??F!
93/82+#! ^>>)4)/5%AA:,! .1%5! KL(! E131! @%A@8A%41>! %4! *I.)5!
)5413<%A(!63/.!Y!4/!YV!.)5!%6413!H)34'#!!
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8(1>!4/!@/.2%31!4'1!1661@4!/5!(%A)<%3:!@/34)(/A!A1<1A(!H14E115!
4'1!4E/!93/82(!%5>!@%A@8A%41!1%@'!.1%5!@/34)(/A!A1<1A!Y!4).1(!
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Results !
KL(! ('/E1>! %! A/E13! 415>15@:! %./59! 4'1! H)34'! ??F!
93/82!4'%5!4'1!<13:!1%3A:!??F!93/82#!$'131!E131!()95)6)@%54!
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P_V#VS,! 31(21@4)<1A:+#! -%2A%5gB1)13! %5%A:()(! ('/E1>! %!
()95)6)@%54! >)661315@1! )5! 4'1! @8.8A%4)<1! 23/H%H)A)4:! /6! KL!
(4%H)A)4:!/6!*GVI*eV!H2.!H14E115!4'1!(8H93/82(!JP<V#V*+#!]5!
F/[!./>1A!%5%A:()(,!4'1!H)34'!??F!93/82!('/E1>!G#SG!4).1(!
4'1! 166)@%@:! /6! KL! (4%H)A)4:! @/.2%31>! E)4'! 4'1! <13:! 1%3A:!
??F!93/82!kUWaJV#ZGS+QG#SG!JZSn!F]D!*#N*IN#S*+,!P<V#VGl#!
^A(/,!4'1!@8.8A%4)<1!23/H%H)A)4:!/6!4'1!?2MG!(4%H)A)4:!/6!ZGn!
Q_! ! %5>! Zen! Q_! 8()59! -%2A%5IB1)13! %5%A:()(#! ]4! >)>! 5/4!
('/E!%5:!()95)6)@%54!>)661315@1!)5!@8.8A%4)<1!23/H%H)A)4)1(!/6!
1)4'13! ZGn! Q_! 5/3! Zen! Q_! H14E115! 4'1! (8H93/82(! JPQV#eZ!
%5>! V#YZ,! 31(21@4)<1A:+#! F/[! ./>1A!%5%A:()(! %A(/! ('/E1>! 5/!
()95)6)@%54! %((/@)%4)/5(! H14E115! )5)4)%4)/5! 4).1! /6! ??F! %5>!
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/6! Zen! Q_! %(! >1215>154! <%3)%HA1f! UWaJV#***+Q*#*G! JZSn!
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JV#SV+! 9o>A! %4! eV! .)5,! %5>! G#O*! JV#N*+! 9o>A! %4! *GV! .)5! )5!
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JV#GG+!9o>A!%4!*GV!.)5!)5!4'/(1!E'/!>)>!(/!6/3!./31!4'%5!eV!
.)5#! $'1! @/34)(/A! A1<1A! 6/3! *! .)5! E%(! 5/4! ()95)6)@%54A:!
>)6613154!H14E115!4'1!(8H93/82(!JPQV#TGN+#!?%A)<%3:!@/34)(/A!
A1<1A(! ('/E1>! >1@31%()59! 4315>(! )5! H/4'! 93/82(! %5>! 5/!
()95)6)@%54! >)661315@1! H14E115! 4E/! 93/82(! JPQV#NGZ+#! ^6413!
.8A4)<%3)%41! %>b8(4.154,! 4'1! %>b8(41>! .1%5(! J?U+! E131! S#VY!
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%./59! 4'1! )56%54(! E'/! 85>13E154! ??F! 6/3! eV! .)5! /3! A1((,!
%5>!Y#ZN!JV#GN+!9o>A!%4!eV!.)5,!%5>!G#VT!JV#G*+!9o>A!%4!*GV!
.)5! %./59! 4'/(1! E'/! >)>! (/! 6/3! ./31! 4'%5! eV! .)5#! ??F!
@/54)58)59! 6/3! ./31! 4'%5! eV! .)5! ()95)6)@%54A:! >1@31%(1>!
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H)34'! ??F! A1%>! 4/! 4'1! (4%H)A)4:! /6! KL! 1%3A)13!4'%5! <13:! 1%3A:!
??F#! ^AA! /6! .1%(831>! H/>:! 41.213%4831(! 2/(4H)34'! &124! )5!
5/3.%A! 3%591! 4'/89'! 4'1:! E131! ()95)6)@%54A:! A/E13! )5! 4'1!
H)34'!??F!93/82!4'%5!4'1!<13:!1%3A:!??F!93/82#!]5!%>>)4)/5,!
??F! @/54)58)59! 6/3! eVQ_! .)5! ()95)6)@%54A:! >1@31%(1>!
(%A)<%3:! @/34)(/A! A1<1A(! %(! %! .%3&13! 6/3! (431((! %4! G! '/83(!
2/(4H)34'!@/.2%31>!E)4'!??F!6/3!/5A:!_eV!.)5#!$'1!231(154!
(48>:! 23/2/(1>! 6834'13! 1<)>15@1(! /6! 1%3A:! ??F! 6/3! 68AAI413.!
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E)4'!@/543/A!)56%54(!E'/!E131!(12%3%41>!63/.!4'1)3!./4'13(#!
$/!/83!&5/EA1>91,!4'131!E131!/5A:!%!61E!3%5>/.)j1>!@/543/A!
(48>)1(!4'%4!@/.2%31>!H1'%<)/3%A!%5>!2':()/A/9)@%A!@'%591!/6!
)56%54(! /3! ./4'13(! H14E115! >:%>(! E)4'! >)6613154! )5)4)%4)/5!

N-3

4).1(! %5>o/3! >83%4)/5! /6! ??F#! ]5! 4'1! (48>:! H:! F'3)(415((/5! 14!
%A#*,!NN!'1%A4':!68AAI413.!)56%54(!E131!/H(13<1>!>83)59!4'1!6)3(4!
ZV! .)5! %6413! H)34'! )5! 413.(! /6! >83%4)/5! /6! @3:)59! E'15! )56%54(!
E131!@%31>!E)4'D!*+!OeITS!.)5!/6!??F!E)4'!./4'13#!G+!]5!%!@/4!
6/3!4'1!6)3(4!NS!.)5!/6!ZV!.)5!/H(13<%4)/5!213)/>!%5>!4'15!??F!
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@8.8A%4)<1!%./854!/6!@3:)59!>83)59!4'1!6)3(4!ZV!.)5!%6413!H)34'!
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41.213%4831,!KL,!31(2)3%4/3:!3%41,!%5>!HA//>!9A8@/(1!'%<1!H115!
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%54%9/5)j)59!4'1!p(431((!/6!H1)59!H/51c!A)&1!4'1!/4'13!.%..%A(#!
$'1316/31,!p`'15!('/8A>!??F!(4%34!%6413!H)34'qc!%5>!pK/E!A/59!
('/8A>! ??F! H1! 85>13E154qc! %31! 4'1! ).2/34%54! 23/HA1.(! )5!
1(4%HA)(')59!4'1!1661@4)<1!??F#!^>>)4)/5%AA:,!)4!)(!%A(/!51@1((%3:!
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Conclusions!
P)34'!??F!A1%>!4/!4'1!(4%H)A)4:!/6!KL!1%3A)13!4'%5!<13:!1%3A:!
??F#! ^AA! /6! .1%(831>! H/>:! 41.213%4831(! 2/(4H)34'! &124! )5!
5/3.%A! 3%591! 4'/89'! 4'1:! E131! ()95)6)@%54A:! A/E13! )5! 4'1! H)34'!
??F! 93/82! 4'%5! 4'1! <13:! 1%3A:! ??F! 93/82#! ]5! %>>)4)/5,! ??F!
@/54)58)59! 6/3! eVQ_! .)5! ()95)6)@%54A:! >1@31%(1>! (%A)<%3:!
@/34)(/A! A1<1A(! %(! %! .%3&13! 6/3! (431((! %4! G! '/83(! 2/(4H)34'!
@/.2%31>!E)4'!??F!6/3!/5A:!_eV!.)5#!
References
k*l!F'3)(415((/5!-,!F%H313%!$,!F'3)(415((/5!U,14!%A#!?12%3%4)/5!
>)(431((! @%AA! )5! 4'1! '8.%5! 51/5%41! )5! 4'1! %H(15@1! /6! .%4135%A!
H/>:!@/54%@4#!Acta Paediatr *ZZSfTNDNeTINOY#kGl! B//31! UL,! ^5>13(/5! =F#! P139.%5! 7#! U%3A:! (&)5I4/I(&)5!
@/54%@4! 6/3! ./4'13(! %5>! 4'1)3! '1%A4':! 51EH/35! )56%54(#!
Cochrane Datebase of Systematic Reviews GVVOf]((81!Y#%!
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Author address

UIB%)AD!4%&%'%(')#:8&)r%#.H/[#5%9/:%I8#%@#b2!

Evidence-Based Nursing Strategy for Acute Ischemic Stroke Patients Managementin the Emergency Department
Ji-Eun Baek1)
1) Department of Nursing, Yonsei University Wonju College of Medicine, Wonju, Korea

The penumbra consists of potentially salvageable brain cells,
so it is critical that oxygen-saturated blood is provided to thatarea early during a stroke. As little as 2 L/min of supplemental
nasal oxygen can raise oxygen saturation from 90% to morethan 95%, which in turn may improve tissue oxygenation[5]. If
breathing effort is inadequate the patient will require ventilatory
assistance to supply sufficient oxygen to the brain. If a patient isexperiencing a rapid deterioration secondary to increased
intracranial pressure it may be useful to hyperventilate thepatient to lower the partial pressure of carbon dioxide (pCO2).
Carbon dioxide is a potent vasodilator and lowering its
concentration may aid in constriction of the vascularcompartment and rapidly reduce intracranial pressure. However,excessive lowering of pCO2 can lead to increased ischemia. The
goal therefore is to lower pCO2 to 25 mm Hg.
Breathing rate and rhythm is controlled within the brainstemand can be affected by brain swelling. Downward displacementof the brain and brain stem can be caused by edema, increased
blood flow, or blood from a hemorrhage. This can lead toventilatory pattern changes as the body tries to decrease the sizeof the vascular bed by blowing off carbon dioxide. Abnormal
ventilatory patterns and yawning are signs of increasingpressure in the brain and on the vagus nerve(that controls
respiratory muscles) as the nerve is squeezed through theforamen magnum(herniation). A stroke occurring within thearterial blood flow of the brainstem or cerebellum can also leadto respiratory pattern changes. In addition to oxygen saturation,
patients should be monitored for respiratory rate and rhythm.

Introduction
Stroke, a sudden loss of neurologic function resulting
from an acute disruption of blood flow, is the leading causeof long-term disability and the second leading cause of deathin South Korea.
Emergency nurses are often the first health professionals
to come into contact with stroke patients on arrival at
hospital, but their understanding of the basic management of
acute stroke is often limited[1]. An important part of acutestroke management and decreasing stroke-related mortality is
preventing complications within the first 24–48 hours[2].
The purpose of this study was to establish an evidencebased nursing strategy for Emergency Department nurses toaid in understanding basic management and preventing ofcomplications of acute ischemic stroke.
MethodThis study was performed using a methodological design.
Referring to four Stroke Guidelines by the Clinical ResearchCenter For Stroke in South Korea. And the Detailed Nursing
Strategy was obtained through the procedure of critical
literature analysis.

Nursing Strategies: ABCDs of Acute Stroke Management
A IS FOR AIRWAYS
Obstruction or dysfunction of the airway is notuncommon in acute stroke. To ensure that the patient’s
airway is maintained during acute ischemic stroke, nurses
should be prepared to suction, control the airway, andprevent aspiration. Patients unable to handle secretions need
to be intubated to protect the airway. Initially, if the level ofconsciousness is decreased, but the ability to swallow is
intact, the patient may only need an oral or nasal aid tomaintain the airway.
Emergency department nurses are asked frequently togive medications or fluids to a stroke patient. Dysphagia is asign of a potentially dysfunctional airway and an obvious risk
for aspiration. In one study of 30 patients with acute stroke,dysphagia was noted in 57%. These patients had longer
hospital stays, more complications, and a higher rate ofmorbidity[3]. Assessment of swallowing ability should be
carried out according to institutional procedure guidelines.
Following a dysphagia screening protocol, or algorithm, is
recommended as standard practice in the evaluation ofpatients with acute stroke[4]. Should the patient choke, gag,or gasp for breath before or during screening, he or sheshould be kept nothing by mouth (NPO). Brain stem infarcts
increase the risk that the patient will have speech andswallowing difficulty. Patients passing the swallowing screen
can start nutrition early, but reassessment of swallowing is
recommended because symptoms may worsen or fluctuatewith time.

C IS FOR CIRCULATION
The irreversible neurologic deficits of a stroke result whenblood flow to an area of the brain is reduced to approximately
25% of the normal value[6]. This loss of perfusion leads to alack of oxygen and glucose to the cells, resulting in cell death[7].
Cells in the surrounding penumbra may still be viable[8].
Because blood flow in the penumbra is also decreased,
perfusion to this ischemic area needs to be reestablished quickly.
Action taken during this critical early phase of a stroke can
improve or maintain circulation, which allows sufficient oxygenand glucose to reach the neurons in this vulnerable area.
In acute stroke, circulation can be hindered by the increasingmass(eg, from edema) within the skull[9]. A normal response to
the lack of oxygen within the brain is a rise in blood pressure.
Although rising blood pressure can increase perfusion to thebrain for a short time, it may lead to edema, increased
intracranial pressure, and an increase in the size of brain massand potential herniation[10].
Rapidly lowering blood pressure in the ischemic stroke
patient can lead to decreased perfusion of the already stressed
brain cells. Nurses involved in stroke care need to be aware that
cerebral perfusion pressure(the difference between mean arterialpressure and intracranial pressure) should be maintained at alevel above 40 mm Hg to obtain adequate blood flow to brain
tissue. Systolic, diastolic, and mean arterial blood pressure(MAP) will be higher than usual, as MAP below 100 mm Hg
have been shown to correlate with poorer outcomes[11]. The

B IS FOR BREATHING

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exception is in patients who receive rt-PA: blood pressure
will need to be lowered to prevent complications from the
medication during reperfusion.
Classically, in patients with impairment of cerebral
circulation due to a clot, reperfusion is attempted using
fibrinolytic therapy(eg, rt-PA). Nurses should know theinclusion criteria to identify patients for such therapy, as
rapid evaluation for appropriateness and initiation ofadministration of fibrinolytic therapy is critical in preventing
cell death[12]. It is important to remember that there is only a
3-hour window from onset of symptoms in which
intravenous rt-PA can be given, after which the risk of
bleeding increases. Nurses should also facilitate obtaining
appropriate lab tests and a brain CT scan, with the highest
priority placed on rapidly securing the scan. The CT scanmust be completed and results obtained before a patient withsuspected ischemic stroke can be treated with fibrinolytic
therapy. Time is critical, and all members of the stroke careteam need to expedite the process. Communication among
pre-hospital personnel, ED nurses and doctors, and radiology
staff can produce a door-to-CT time of just a few minutes.

quicker implementation of treatment and to effectively treating
this disease as a high-priority emergency. Additionally,
continued monitoring of the ABCDs can lead to earlyrecognition of patient deterioration. Rapid intervention andpreventing poststroke complications are vital when emergency
nursing personnel evaluate stroke.
References[1]Harper JP. Emergency nurses’ knowledge of evidence-based
ischemic stroke care: a pilot study. Journal of Emergency
Nursing. 2007;33( 3):202-207.
[2]Anderson D, Neacy K, Stead L, Koshnick R, Lee J, McRaith
J, Haake B, Robinstein A, Lakshminarayan K, Wallace GJL,
Hunteman T, Metfessel B & Suber S. Health Care
Guideline: Diagnosis and Initial Treatment of Ischemic
Stroke, 5th edn. Institute for Clinical Systems Improvement.
October 2006; Minnesota.
[3]Runions S, Rodrigue N, White C. Practice on an acute stroke
unit after implementation of a decision-making algorithm for
dietary management of dysphagia. J Neurosci Nurs
2004;36:200-207.
[4]Hinchey JA, Shephard T, Furie K, Smith D, Wang D, Tonn S,
for the Stroke Practice Improvement Network Investigators.
Formal dysphagia screening protocols prevent pneumonia.
Stroke. 2005;36:1972-1976.
[5]Ali K, Sills S, Roffe C. The effect of different doses ofoxygen administration on oxygen saturation in patients withstroke. Neurocrit Care 2005;3:24-26.
[6]Dohmen C, Bosche B, Graf R, Staub F, Kracht L, Sobesky J,
et al. Prediction of malignant course in MCA infarction by
PET and microdialysis. Stroke. 2003;34:2152-2158.
[7]Aminoff MJ, Greenberg DA, Simon RR. Clinical neurology.
6th ed. New York: McGraw-Hill. 2005;285-319.
[8]Fagan SC, Hess DC. Stroke. In: DiPiro JT, Talbert RL, Yee
GC, Matzke GR, Wells BG, Posey LM, editors.
Pharmacotherapy: A pathophysiologic approach. 6th ed.
New York: McGraw-Hill. 2005;415-427.
[9]Favad PB, Awad IA. Surgery for intracerebral hemorrhage.
Neurology. 1998;51(3):69-73.
[10]Mattle HP, Kappeler L, Arnold M, Fischer U, Nedeltchev K,
Remonda L, et al. Blood pressure and vessel recanalizationin the first hours after ischemic stroke. Stroke.
2005;36:264-269.
[11]Stead LG, Gilmore RM, Decker WW, Weaver AL, Brown
RD Jr. Initial emergency department blood pressure aspredictor of survival after acute ischemic stroke. Neurology.
2005;65: 1179-1183.
[12]Adams HP Jr, Adams R, Brott T, del Zoppo GJ, Furlan A,
Goldstein LB, et al. Guidelines for the early managementof patients with ischemic stroke: A scientific statementfrom the Stroke Council of the American Stroke
Association. Stroke.2003;34:1056-1083.
[13]Nor AM, McAllister C, Louw SJ, Dyker AG, Davis
M,Jenkinson D, et al. Agreement between ambulanceparamedicand physician-recorded neurological signs with
Face Arm Speech Test (FAST) in acute stroke patients.
Stroke. 2004;35:1355-1359.
[14]Williams LS, Rotich J, Qi R, Fineberg N, Espay A, Bruno
A, et al. Effects of admission hyperglycemia on mortality
and costs in acute ischemic stroke. Neurology. 2002;59:6771.

D IS FOR DISABILITY AND DEXTROSE
Because stroke is a leading cause of long-term disability,
nurses should be able to quickly identify the patient withstroke symptoms. Assessment tools that can quickly identify
the patient at risk for stroke are the Face Arm Speech Test
(FAST) and the Los Angeles Prehospital Stroke Scale(LAPSS). Either can be administered by the ED nurse intriage or by paramedics before reaching the emergency
department. Patient information from these assessment tools
can be re-verified by the ED nurse, physician, or critical carenurse using the more comprehensive National Institutes of
Health Stroke Scale (NIHSS)[13]. The NIHSS provides a
standardized baseline and consistent set of parameters thatcan be repeated throughout the hospital stay. Some stroke
centers order a CT scan based on results of the FAST or
LAPSS and then carry out the NIHSS assessment on thepatient’s return to the ED after imaging is complete.
Many have seen how the neurologic effects of low serum
glucose(dextrose) levels can mimic the symptoms of acutestroke. A finger-stick glucose test should be done early torule out hypoglycemia. In fact, if the glucose level was done
pre-hospital and results were marginal, a repeat finger-stick
test might be in order.
In the acute stroke patient, hyperglycemia is a predictorof poor outcome. Stress of a stroke has been seen to increase
blood sugar even in the nondiabetic. Hyperglycemia isassociated with longer hospital stays(7.2days vs. 6days),increased risk of bleeding into the penumbra, and anincreased risk for death at 30days[14]. The stroke patients
who have their blood sugar tightly controlled early on withhourly blood glucose checks and intravenous insulin, seem tohave less bleeding into the penumbra, and better outcomes.
Conclusions
Public awareness of stroke symptoms as well as rapid andeffective assessment of suspected stroke is critical for
optimum patient outcomes.
Rapid and accurate assessment of patients with suspected
stroke by emergency nursing personnel is essential. The earlystages of patient stabilization and diagnosis are critical tobrain function; thus, it is imperative to assess, monitor, andcorrect the ABCDs during emergency stroke management.
These initial steps are not only crucial for maintaining brain
function, but are invaluable for salvaging penumbral cells.
Moreover, the prompt recognition of stroke will lead toAuthor address

E-Mail: anaba100@yonsei.ac.kr

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K. Nakagami1), T. Yamauchi1)1) Department of Nursing, School of Health Sciences, Nagoya University, Nagoya, Japan

Introduction:
The importance of health literacy has been highlighted inrelation to health prevention and the health promotion.
“Health literacy is a topic that has been gaining momentum
over the past few years, in the policy research agendas ofmany countries” [1]. Thus a major goal of the World HealthOraganization, Healthy People 2010, and the Joint
Commission is to improve health communication quality andprovide safe healthcare for patients with low health literacy[2-4].
Nutbeam [5] suggested that functional health literacy was
one of the subordinate concepts of health literacy, in which
there were two other conceptual configurations, interactive
health literacy and critical health literacy. According to
Nutbeam [5], Speros [6] and Mancuso [7], health literacy is
cognitive and social skills, ability of individuals to gain
access to, understand, and use health information that
promote and maintain good health. Thus, functional healthliteracy is that person’s ability to numerate, read, andcomprehend basic medical terms required to function in thehealth care environment. Furthermore, it takes various forms
such as; basic numeracy, reading and comprehension skill
that allow a person to function in the health careenvironment; the ability to apply literacy skills to material
such as prescriptions, appointment cards, medicine
instructions, and directions for self-management of diseases
and conditions; the abilities to understand and act on
information and instructions from professionals, for example
informed consent form or brochures; and patient informationseeking and shared decision-making with healthprofessionals.
In the United States and other developed countries,
evidence shows that patients with inadequate health literacy
have lower adherence to medical instructions [8], lower useof preventive services [9, 10], poor understanding of one’s
medical condition, being into a difficult situation to seek the
medical information by oneself [11], higher hospitalization[11, 12], and increased mortality [13]. In recent studies,
between 40 and 50% of U.S. adults with lack of the reading
and numeracy skills to fully understand the healthinformation are substantial [14]. Kim indicated that 35% of
Korean adults had low functional helath literacy level, below
Korean elementray school level [15]. Tokuda showed thatabout 36% of Japanese people had poor health knowledge[16]. Japanese literacy rates are very high, as most people areable to read easy texts as well as newspaper, but we have tokeep in mind that most Japanese patients can understandwhat medical staff said and showed instruction papers. Now,
there are likely to be certain evidence about the relationshipbetween the inadequate health literacy and health outcomes.
This evidence has been shown by two English healthliteracy tests, such as Rapid Estimate of Adult Literacy in
Medicine (REALM) [17] and The Test of Functional Health
Literacy in Adults (TOFHLA) [18], and one Japanese healthknowledge test, Japanese Health Knowledge Test [16].
REALM, was developed in 1995, and has been used mostfrequently. This test includes only assessing pronounciationof the medical terms correctly. This has been utilized by only

English speakers. TOFHLA was developed to measure theparticipants’ ability to successfully complete basic numeracy
and reading health literacy skills in 2001. This test includes one
numeracy and two reading passages to assess comprehension oflabeled prescription vials and hospital forms. This has been alsoutilized by only English speakers, because these questions are
based on the American health care system. Thus, it is invalid toappraise the Japanese functional health literacy. Japanese healthknowledge test was developed to estimate health knowledge
among general public, and in identifying and characterizing
Japanese with poor health knowledge, in 2010. This test is only
able to measure knowledge of 15 health related vocabularies forordinary people. In a health care setting, it is required tomeasure patient s’ abilities that focus on not only knowledge but
skills relating primarily to health care settings. Therefore, there
has been no scale or test to measure ability of Japanesefunctional health literacy yet. We will develop and examinefunctional health literacy test for Japanese adults.
Methods:
Study participants
The data for study will be collected from about three hundred
fifty out patients, whose first language is Japanese, are age 22
years or over, can answer very easy questions such as where
he/she lives at then and what day is then, are not blind and deaf.
Patients younger than 22 years old will be excluded, because
one of the aims of this study includes evaluating the potential
relationship between the functional health literacy and the final
educational attainment. Medical service personnel, such as
physicians, nurses, pharmacists, hospital workers, andcaregivers, will be excluded.
Development of the Japanese Functional Health Literacy Test
(J-FHLT)
This study is designed for a survey to examine the constructvalidity and the item adequacy. First item pool of 72 wasgenerated based on REALM, TOFHLA, J-HKT, and empiricalreferents, such as Japanese medical system, health education or
information materials from physicians or nurses, prescriptions
or materials for medicine, and information documents of X-ray
examination or endoscopic examination.
The first item pool was examined by an advisory panel ofnine nursing students in the first field test, and it was refinedand reduced items to 34 items.
The second item pool consisted of three scales: eightnumeracy items, fifteen reading items, and elevencomprehension items. Content validity for this second item pool
was tested by ten content experts panel, such as two doctors,
two medical researchers, two nurses, two pharmacists, two
educational researchers. These experts were given a rating form
with functional health literacy definition and items. They wererequired to review each item for validity, difficulty, andreadability with a 4-point scale (from 1 = no valid to 4 = very
valid). At the present stage, we calculate the index of content
validity (CVI). CVI is classified according to Lynn’s criteria[19] that are related as over 3 by the experts and the medianover 3.

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Data collection
This study also collects demographic and socioeconomic
data. Demographic data is comprised of age, sex, annual
income, final educational attainment, and occupation.
Furthermore, we measure three questions, translated into
Japanese, from the Health Literacy Screening Questions(HLSQ) [20] and J-HKT for calculating criterion-related
validity. Three questions of the HLSQ, “how often do you
have someone help you read hospital materials?”, “howconfident are you filling out medical forms by yourself?”,and “how often do you have problems learning about your
medical condition because of difficulty understanding written
information?” were each effective 5-point Likert screening
tests for inadequate health literacy in the U.S. patients.

References[1] Protheroe J, Wallace SL, Rowlands G, DeVoe JE. Healthliteracy: setting an international collaborative research agenda.
BMC Family Practice. 2009;10(51):1-11.
[2] World Health Organization. Health promotion: report by the
Secretariat. Geneva: World Health Organization; 2000.
[3] U.S. Dept. of Health and Human Services. Healthy people
2010: understanding and improving health. Washington (DC):U.S. Government Printing Office; 2000.
[4] The Joint Commission on the Accreditation of Healthcare
Organizations. [Accessed 21 Sep 2010]. Available at:www.jointcommission.org[5] Nutbeam D. Health Literacy as a public health goal: achallenge
for contemporary
healtheducationandcommunication strategies into the 21st century. Health
Promotion International. 2000;15:259-267.
[6] Speros C. Health literacy: concept analysis. J of Advanced
Nursing. 2005; 50(6): 633-640.
[7] Mancuso JC. Health Literacy: A concept/ dimensional
analysis. J of Nursing and Health Science. 2008;10:248-255.
[8] Gazmararian J, Jacobson KL, Pan Y, Schmotzer
B, Kripalani SA. Effect of a pharmacy-based health literacy
intervention and patient characteristics on medication refill
adherence in an urban health system. Pharmacother. 2010;
44(1):80-7.
[9] Sudore RL, Mehta KM, Simonsick EM, Harris TB,
NewmanAB, Satterfield S, Rosano C, Rooks RN, Rubin SM,
Ayonayon HN, Yaffe K. Limited literacy in older people anddisparities in health and healthcare access, J Am Geriatric Soc
2006;54:770–776.
[10] Baker DW, Gazmararian JA, Williams MV, Scott T, Parker
RM, Green D, Ren J, Peel J. Health literacy and use of
outpatient physician services by Medicare managed care
enrollees, J Gen Intern Med, 2004;19:215–220.
[11] Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone
MP. Literacy and health outcomes: a systematic review of theliterature. J Gen Intern Med. 2004;19:1228–1239.
[12] Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin
K, Coates WC, Nurss JR. Inadequate functional health literacy
among patients at two public hospitals, JAMA,
1995;274(21):1677-82.
[13] Baker DW, Wolf MS, Feinglass J. Thompson JA.
Gazmararian JA. Huang J. Health literacy and mortality among
elderlypersons.
ArchivesofInternal
Medicine.
2007;167(14):1503-1509.
[14] Kutner M, Greenbery E, Baer J. National Center for
Education Statistics. Washington (DC): US Dept. of Education.
2005. A first look at the literacy of America’s adults in the 21st
century.
[15] Kim SS, Lee E, The influence of functional literacy onperceived health status in Korean older adults. J Korean Acad
Nurs. 2008;38:195-203.
[16] Tokuda Y, Okubo T, Yanai H, Doba N. Development andvalidation of a 15-item Japanese Health Knowledge Test.
Journal of Epidemiology. 2010;20(4):319-328.
[17] Davis TC, Long SW, Jackson RH, Mayeaux WD. George
RB. Murphy PW. Crouch MA. Rapid estimate of adult literacy
in medicine: A shortened screening instrument. Family
Medicine. 1993;25(6):391-395.
[18] Nurss JR, Parker RM, Baker DW. TOFHLA: Test of
Functional Health Literacy in Adults. Peppercorn Books andPress, Inc. Snow Camp, NC, 2001.
[19] Lynn MR. Determination and quantification of content
validity, Nurs Res, 1986;35:382-385.
[20] Chew D L, Bradley AK, Boyko JE. Brief Questions to
Identify Patients With Inadequate Health Literacy. Family
Medicine. 2004;36(8):588-594.

Planning schedule: Fig. 1
Frist of all, we are trying to refine the second item poolbased on CVI and the median.
Second, we will conduct the second field test with about
fifteen out-patients and refining the item pool again.
Third, the second item pool based on the field test will be
generated.
Forth, the second item pool will be tested with about threehundred fifty out-patients as third field test.
Fifth, we will go over factor analysis and calculate internalconsistency reliability (Cronbach’s alpha) and criterionrelated validity (validity coefficient) from third field test data.
We also use the Rasch analysis to evaluate the adequacy of
items. Taking advantage of Rasch analysis, we calculate itemdifficulty, item-fit indices, and person separation reliability inorder to exhibit the degree to which individual items clarify
the unidimensionality of the construct “health literacy.”
Sixth, for the purpose of taking a final check, we willrecalculate internal consistency reliability (Cronbach’s alpha)and criterion-related validity (validity coefficient) by use ofdata from third field test.

Fig. 1 schedule for the study.

Author address E-Mail: pellakonk@gmail.com

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A. Hayashi1), S. Ando2)
1) Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Nursing, School of Health Sciences, Nagoya University, Nagoya, Japan

Introduction
After the medical fee for outpatient cancer chemotherapy
was accepted in 2002, the place of chemotherapy has beenshifting from hospitalization to outpatient care. Owing to the
outpatient chemotherapy, patients can spend daily life
receiving chemotherapy, and it contributes to improving their
QOL. On the other hand, good self-caring behavior isessential to improve the QOL, and to display good selfcaring behavior, patients need to possess high self-efficacy.

lower among jobless patients and patients having solitary life.
The score of all three subscales was significantly lower among
the patients who do not have hobby, the outpatients receiving
chemotherapy for 1-2 years and the patients whose PS is morethan 1. And the score of ARE and ADE were significantly lower
among the patients with no adviser or difficulty in consulting
doctors or nurses. The score of SCE was significantly lower,
only among the patients with difficulty in consulting nurses.
These findings suggest that nurses take an important role in thesymptom management for the patient. They also suggested that
we must support the outpatients in consideration of theirindividual backgrounds and provide the environment where
outpatients are easy to consult.
Relation between their needs in terms of home care and selfefficacy: The score of all three subscales was significantly lower
among the patients having troubles with adverse effectmanagement. In detail, the score of SCE and ADE weresignificantly lower among the patients who cannot cope withthe aggravation of general condition due to severe symptom andthose who cannot go out alone. And the score of ARE wassignificantly lower among the patients who cannot eat what theywant. And also, the score of all three subscales was significantly
lower among the patients who do not have an adviser and those
who cannot express their feeling well. The score of ADE wassignificantly lower among the patients who feel anxious about arelationship with the doctor. As a result, these findings suggest
the necessity to support the patients having these factors andtheir family in early stage.
Relation between physical symptom and self-efficacy: The
severity of the following physical symptoms significantly
affected the SEAC score: insomnia, inappetence, dyspnea, andfatigue. In detail, the score of ARE was significantly affected byinsomnia and fatigue. The score of SCE was significantly
affected by appetite loss and dyspnea. The score of ADE wassignificantly affected by appetite loss and insomnia. As a result,these findings suggest that the nursing system to improve thesymptom management and self-caring behavior should beestablished.
Relation between QOL/ Psychological distress and selfefficacy: The scores of the distress thermometer weresignificantly affected by ARE and ADE, and the scores of QOL
were also significantly affected by ADE and ARE. In addition, asignificant negative correlation was seen between the distressthermometer and QOL. The nursing care which enhances selfefficacy comprehensively can be the essential for the cancer
outpatients (Figure 1).

PurposeThis study aimed to identify by a survey questionnaire
the factors related to self-efficacy in cancer outpatients
receiving chemotherapy, and to discuss the appropriate
nursing care for them.
Methods
Subjects: The subjects consisted of 169 cancer
outpatients receiving chemotherapy at the national university
hospital’s chemotherapy center from August to September in2009. The study was approved by the Nagoya University’s
ethical committee and hospital’s ethical committee, andinformed consent was obtained from each patient.
Questionnaire:
The questionnaire covered patient
backgrounds, their needs in terms of home care, a Screening
Questionnaire (physical symptoms, the Severity Distress
Thermometer, overall quality of life) and the Self-Efficacy
Scale for Advanced Cancer (SEAC). SEAC consisted ofthree subscales; Affect Regulation Efficacy (ARE), Symptom
Coping Efficacy (SCE) and ADL Efficacy (ADE).
Data analysis: The relation between self-efficacy andpatient backgrounds and their needs was analyzed using thefollowing statistical analysis: Mann-Whitney’s U test,
Kruskal-Wallis test with Bonferroni correction for multiple
comparisons. And relation between self-efficacy and physicalsymptoms, QOL/ psychological distress was analyzed using
the following statistical analysis: Spearman rank correlation
coefficient, multiple linear regression analysis. PASW
version 17.0 for Windows was applied for data analysis.
Significance was set at P<0.05.
Results and discussion
The average age of the participants was 59.2 years old,and 43.2% of the participants were males, 56.8% werefemales. On Performance Status, PS0 was 34.3%, PS1 was
56.8%. On primary site, 30.2% of participants had breast
cancer, 23.1% had gallbladder or pancreatic cancer, 18.9%
had colorectal cancer.
The relation between patient backgrounds and selfefficacy: The score of SEAC was significantly lower among
patients with the following backgrounds: under 40 years old,jobless, solitary life, PS1 or more, no hobby, no adviser, anddifficulty in consulting doctors or nurses. In detail, the scoreof ARE and SCE were significantly lower among the patients
under 40 years old, and the score of ADE was significantly

Conclusions
We identified the following factors of self-efficacy incancer outpatients receiving chemotherapy: patient backgrounds,
physical symptoms, patient’s needs in terms of home care.
For improving their self-efficacy, it is significant tounderstand patient's background and their needs sufficiently andto support them individually. And we must make an effort toN-6

palliate the following symptoms especially: insomnia, fatigue,
appetite loss, dyspnea.
To generalize these findings, it is necessary to investigate
a longitudinal study in the future.
References[1]Hirai K, Suzuki Y, Tsuneto S, et al. (2002): A structuralmodel of the relationships among self-efficacy,
psychological adjustment, and physical condition in
Japanese advanced cancer patients. Psychooncology,
11(3),221-229.
[2]Morita T, Fujimoto K, Namba M, et al. (2008): Palliative
care needs of cancer outpatients receiving chemotherapy;
An audit of a clinical screening project. Support Care
Cancer,16(1),101-107.
Author address

E-Mail: akiko.H.12@gmail.com

Patient backgrounds• Age• Working status• The number of people living
together• Performance status• The presence of an adviser• Consulting Doctors / Nurses easily• Hobby
Physical symptom• Insomnia• Appetite loss
• Dyspnea• Fatigue

Self Efficacy
for Advanced Cancer
Affect Regulation Efficacy
Symptom Coping Efficacy
ADL Efficacy•••

Patient’s needs in terms of home care
• I want to know about adverse effect management.
• I want to go out alone.
• I want to eat what I want.
• I want an adviser.
• I want to express my feeling well.
• I want to make a better relation withthe doctor.
Figure 1 Related Factors of Self-Efficacy in Cancer Outpatients Receiving Chemotherapy

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Psychologicaldistress reduction,and QOL
improvement

Radiological Technology (13:30 16:10 Lecture Room 2)
Session chairs: Prof. Yoshie Kodera
Associate Prof. Masatoshi Tsuzaka

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ADVANCEMENT OF MEDICAL IMAGING AND INSTRUMENTATION IN
RADIOLOGICAL SCIENCE
Hee-Joung Kim1)
1) Department of Radiological Science and Research Institute of Health Science, Yonsei University, Korea

Background
Clinical applications as well as research activities inmedical imaging and instrumentation are rapidly growing fields
in radiological science. Recent trends of clinical research of
SPECT/CT, PET/CT, and PET/MRI as well as advanced
imaging modalities indicate that clinical applications of various
imaging modalities are very active, and have been triggeringresearch activities of medical imaging and instrumentation inradiological science. Dept. of radiological science at Yonsei
University is relatively new and has been focusing on bothresearch of new technologies in medical imaging andinstrumentation, and education and training of practical as wellas advanced technologies in radiological science.
Methods
Recently, two international congress meetings were held
and one international conference meeting will be held in 2013
in Seoul. One was the World Congress on Medical Physics andBiomedical Engineering 2006 with the theme of “Imaging thefuture medicine” and the other one was “9th Congress of theWorld Federation of Nuclear Medicine & Biology with thetheme of “Global harmonization and new horizon of nuclear
medicine” at the same place of Coex, Seoul, Korea. These twocongress meetings may cover worldwide major research
activities in medical imaging and instrumentation and played avery important role to have nationwide attention including
governmental level in Korea. Recently, it’s been decided tohave 2013 IEEE NSS/MIC conference meeting in Seoul, Korea,
and our Dept. will play a major role to host this prestigious
conference meeting for the 1st time in Asia and Oceania. There
are 4 Laboratories in our Dept. including medical physics andimaging Lab (MPIL), iTOMO Lab, Molecular Imaging Lab(MoIL), and magnetic resonance imaging Lab (MRIL). Major
interests of iTOMO Lab includes dental panorama imaging
technique, dental CT technique, dual-energy radiography
imaging technique, tomosynthesis imaging algorithm, design
digital processing filter and algorithm to improve image quality,
and image quality estimate technique of digital radiography.
MRIL has been researching on functional MRI, diffusion tensor
imaging & fiber tractography, and phase contrast MR
angiography. MoIL has been researching on developing both
small gamma camera and small PET, and image optimization.
Research interests of MPIL includes the measurements ofphysical characteristics of SPECT/PET/X-ray & CT, and theirquantitation, imaging physics and instrumentation, andsimulation of multi-modality imaging techniques. Recently, ourDept. awarded government grant of “Basic Atomic Energy
Research Institute (BAERI)” which will support for next 6
years to develop functional and anatomical multi-imaging
technology based on multi-energy photon counting. The
purpose of this project is to develop the image acquisition
technique for the optimization of multi-energy photon counting
images included in functional/anatomical information and toresearch the functional and anatomical fused imaging on thestate-of the art technologies.
Results
With these activities, in recent years, medical imaging andinstrumentation, such as digital x-ray radiography, computed
tomography, nuclear magnetic resonance, emission tomography,
animal imaging devices, multi-modality systems, and modelingand evaluation of imaging systems, have been rapidly
advancing in Korea. The Korean government has been trying tolay a foundation for medical devices and information by
providing policies and systematic funding supports on the
product and technology development. Based on thegovernment’s supports, there are strenuous and growing efforts
to improve the nation’s international competence made in
research and development of medical imaging technology andits applications by universities, industries, and national science
research institutes, although major research activities have beenleading by academic side compared to industry side. The
figure1 shows the scope of the BAERI project to be developed.
Figure 1. The scope of the development of multi-imaging
technology based on photon counting
Conclusion
Summaries of the current achievements and the future
prospects in the realm of medical imaging and instrumentationin our Dept. will be presented with overview of clinicalapplications in advanced imaging technologies. Summaries of
educational system in radiological science as well as medical
physics in our Dept. will also be presented.

RT-2

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RT-3

AN INFLUENCE OF THE BEAM QUALITY ON THE NOISE OF
THE IMAGE IN DIGITAL MAMMOGRAPHYMaki Yamada1), Yuri Kato1) Naotoshi Fujita2), Yoshie Kodera3)

1) Department of Radiological Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan2)Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
3) Department of Radiological Technology, Nagoya University School of Health Sciences, Nagoya, Japan

Introduction
The uses of digital mammography systems have become
widespread recently. However, the optimal exposure
parameters are uncertain in clinical. We need to optimize theexposure parameter in digital mammography withmaximization of the image quality and minimization ofpatient dose. The purpose of this study is to investigate an
influence of the x-ray energy on the noise of the image. We
obtained images for various tube voltage and the thickness ofcompressed breast. The noise properties of these images were
evaluated with these indices: Wiener spectrum (WS), thenoise equivalent number of quanta (NEQ), and signal-tonoise ratios derived from the perceived statistical decision
theory model with the internal noise of eye-brain system(SNRi). We measure them under the fixed average glandular
dose (ADG).

Table 1. EUREF dose acceptable level for each thickness
of PMMA and its equivalent breast thickness
PMMA
Equivalent
Dosethicknessbreastacceptable[cm]
thickness [cm] level [mGy]
2
2.1
0.6
4
4.5
1.6
5
6.0
2.4
7
9.0
5.1
Table 2. Exposure level for 4-cm-thick PMMA with Mo/Mo
25 kV
28 kV
30 kV
32 kV
AGD
[mGy]
Exposure level [mAs]
1.3
80
50
40
32
1.7
100
63
50
40

Materials and Methods
Equipment used in this study ; The mammographyequipment used in this study was Mermaid model MGU100B. The computed radiography (CR) reader used was
REGIUS V stage, Model 190. The CR plate used was
CP1M200 (with the columnar crystal phosphors). These
equipments were manufactured by Konica Minolta MG. The
x-ray images of low contrast objects were obtained for themeasurement of the SNRi. To measure the contrasts and to
calculate Wiener spectrum, we obtained images of acrylic
steps (thickness: 1-10 mm) and uniformly exposed x-ray
images. We used acrylic plates (thickness: 2, 4, 5 and 7 cm)
as breast phantoms. Mo/Mo and Mo/Rh were chosen for thetarget/filter combinations. As the source of low contrast
signal, we used a resinous disc (diameter: 4.2mm, thickness:
4.5mm). To measure the presampled modulation transfer
function (MTF) for NEQ, we obtained images of thetungstenium edge.
Measurement of the average glandular dose ; We
measured the average glandular dose (AGD) and chose theexposure level which gave the European Reference
Organization for Quality Assured Breast Screening (EUREF)
dose acceptable level for every combination of the
thicknesses of phantoms and the tube voltages (25, 28, 30, 32,
35 kV). Actually, we could not adjust the exposure level for
the AGD strictly because of the restriction of the machine.
Therefore we selected the exposure level for EUREF dose
acceptable level as near as possible (Table.1 and Table.2).
Measurement of image contrasts ; WS depends on theimage contrast, and the image contrast changes with the tube
voltage. For this reason, we evaluated WS under fixed image
contrast. In order to do this, the image contrast of each tube
voltage was measured. We obtained the images of the acrylic
plates and the acrylic steps, which were put on the chest wallside of the table for the contrast evaluation (Fig. 1). We readout the raw data of the acrylic step images and found thecontrast by the pixel value of each step.

(a) Overview(b) Overhead viewFig. 1 Layout of measurement of the contrast

RT-4

MULTI-MATERIAL DECOMPOSITION IMAGING IN THE PHOTON COUNTING
DETECTOR

Calculation of WS ; We calculated the WS by the twodimensional fast Fourier transform method. When weevaluated the WS values at 25, 30, 32 and 35 kV, we
adjusted the contrasts under these tube voltages to that under
28 kV. To tune the image contrasts, we computed the WS
and multiplied the following correction factor k.

Hyo-Min Cho1), Yu-Na Choi1), Hee-Joung Kim1)

SNRi1) Department of Radiological Science and Research Institute of Health Science, Yonsei University, Korea

=(image contrast at 28 kV/image contrast at another tube voltage)2
Calculation of NEQ ; The NEQ is described as shown
below:

25

NEQ={(Glog10e)2MTF2}/{WS!PV}In these figure, G means the gradient of the characteristic
curve for the detector.
Calculation of SNRi ; The SNRi, which takes the spatial
frequency response of the human visual system and theinternal noise of eye-brain system into consideration, is
written as
SNRi=SNRp/{1+(Ni/Np)2}1/2
In this formula, the SNRp represents the ratio of signal (Sp)to noise (Np). The value of the Sp and the Np were
calculated in consideration of the visual spatial frequency
response of the human observer 3) . The Ni means the internal
noise 4) which is inherent in an observer, for instance, thenoise in relation to the neurophysiological unstableness andto fluctuations of the observer’s memory.
Results
WS ; The WS was almost stable when the tube voltagechanged between 2-cm and 4-cm-thick phantoms. There
were few differences in the WS values for each tube voltage
with 5-cm-thick phantom, and we observed the tendency thathigh tube voltage improves the noise property of the image.
This trend was more remarkable for 7-cm-thick phantom. As
the combination of target/filter, Mo/Rh was more beneficial
than Mo/Mo for phantoms thicker than 4 cm. This trend was
also more conspicuous for thicker phantom.
NEQ ; For 2-cm-thick phantoms, the NEQ did not changewith the tube voltage and filtration except for 32 and 35 kV
with Rh filter. The NEQ values on these two exposure
conditions were lower than that on others. Also, 35 kV with
Rh filter gave the highest NEQ for phantom thicker than 4
cm. In these cases, the superiority of Rh filter to Mo filter
became clearer for thicker phantom.
SNRi ; The SNRi is shown in Figure 2. For 2-cm and 4-cmthick objects, we recognized the tendency that the SNRi
value with Mo filter was larger than that with Rh filter. The
SNRi increased when the tube voltage decreased.

Discussion

The results of WS and NEQ indicate that when the image
contrast and AGD was constant, for a phantom thinner than 5
cm, an increase of the tube voltage did not improve the noise

28

30
32
Tube voltage[kV]35

Fig.2 The results of SNRi for each thickness of phantoms
property of images very much. The results also showed thatimage property with the target/filter Mo/Rh was better than thatwith Mo/Mo for the phantom thicker than 4 cm. In general, it issaid that high tube voltage delivers fine noise property. The
result of our study contradicted this common theory on the x-ray
energy level for mammography.
The result of SNRi differers from the results of WS and NEQ.
In this study, the SNRi depends on the contrast of signal. We
should make accuracy high with the low contrast object that has
another intensity.
Conclusions
In conclusion, when the image contrast and AGD was constant,
for the phantom thinner than 5 cm, an increase of the tube
voltage did not improve the noise property of images very much.
The results also showed that image property with thetarget/filter Mo/Rh was superior to that with Mo/Mo for thephantom thicker than 4 cm. Our result signified that high tube
voltages did not improve the noise property of images with the
x-ray energy level for mammography.
The result of SNRi conflicted with the results of WS andNEQ. We need to examine SNRi with the low contrast signal
which have various intensity.
References[1]Leh-Nien D Loo, Kunio Doi, Charles E Metz. A comparisonof physical image quality indices and observer performancein the radiographic detection of nylon beads. Phys. Med. Biol.,
1984;29, No. 7;837-856[2]Masamitsu Ishida, Kunio Doi, Leh-Nien Loo, et al. Digital
Image Processing: Effect on Detectability of Simulated Low
Contrast Radiographic Patterns. Radiology 1984; 150: 569575[3]Anil K. Jain. Fundamentals of Digital Image Processing.
Prentice Hall. 1989
[4]Ken Ohara, Heang-Ping Chan, Kunio Doi, et al.Investigationof basic imaging properties in digital radiography. 8.
Detection of simulated low-contrast objects in subtraction
angiographic images. Med. Phys 1986; 13(3): 304-311
Author address

E-Mail:yamada.maki@h.mbox.nagoya-u.ac.jp

RT-4

Introduction
The photon counting detectors such as cadmium zinctelluride (CZT) and cadmium telluride (CdTe) have powerfuladvantages compared to energy integrating detectors. CZT or
CdTe can detect individual gamma-ray or x-ray photon withenergy discrimination. In recent years, energy-resolving andmaterial decomposition x-ray imaging based on photon
counting detectors has attracted attention from biomedical
imaging researchers. One group has reported two contrast
agents could be distinguished by the k-edge CT image using
photon counting detectors.
Monte Carlo simulation is an essential tool in emission andtransmission imaging that can assist in the design of new
medical imaging devices, the optimization of acquisition
protocols and the development or assessment of image
reconstruction algorithms and correction techniques. This year,
the OpenGATE collaboration has released GATE 6.0,
supporting simulations of radiotherapy and computed
tomography. They provide geometry of computed tomography
with photon counting based readout.
We evaluated a large-area CZT detector originally built as aradionuclide detector for a small animal SPECT/CT system incombination of a microfocus x-ray source with a general goalof developing a material-decomposition imaging method. In
addition, the characteristic study of two photon counting
materials, CZT and CdTe were evaluated in the GATE
environment.
Materials and Methods
The presentation will describe the basic principles of multimaterial decomposition imaging based on photon counting
detector. The experimental results from a feasibility study ofmulti-material decomposition imaging using the developed
small animal SPECT/CT system will be presented. In addition,
the simulation results for the characteristic of photon counting
detector and multi-energy imaging of multi-material phantom
will be presented.
Experimental feasibility of multi-material decomposition
imaging
The characteristics of x-ray tube from Oxford Instruments(Scotts Valley, CA, USA) are; tungsten anode, source size 80µm x 70 µm, maximum operating current 1 mA, and maximum
accelerating voltage 60 kV. The 2 mm thick aluminum filter
was used to attenuate x-rays with energies below the noise
floor of the detector.
The large area photon counting CZT detector manufactured
by Gamma Medica Ideas (Northridge, CA, USA) was used.
The detector has an active detection area of 20 x 20 cm2, withmultiple modules tiled together. The detector is configured as a
5 x 5 array of CZT modules, each with a 16 x 16 array of pixels
and a pixel width of 2.5 mm. Thus, the used CZT detector is an
80 x 80 pixel array covering an active area of 20 x 20 cm2 witha crystal thickness of 2.5 mm.
For the feasibility study of multi-material decomposition
imaging a phantom that included various materials was built.

We designed the phantom using a 15 x 15 cm2 piece ofcellophane. We had attached 7 materials, with a range ofdensities and atomic numbers, on the cellophane. The materials
are including glass (silicon dioxide), highly ordered pyrolytic
graphite (HOPG), clay, titanium, plastic, aluminum, buffalo
nickels, walking liberty half dollar coin.
The CZT detector was positioned 84.3 cm from the x-ray
tube focal spot. The phantom was taped in contact with, andcentered on, the CZT detector. The multi-material x-ray images
were obtained at 50 kVp, 0.5 mA, and images were acquiredfor 140 sec/image. Acquired images corrected for bad pixels,
gain, and offset. The attenuation of each material was obtainedby the ratio of the emergent and incident radiation intensities
I/I0 according to the x-ray energy.
CZT detector in x-ray spectroscopy with different pixel sizes
and pitches
GATE version 6.0 was used to perform an accurate
simulation of the different pixel sizes. In this simulation study,
charge sharing and pulse pileup were not considered. The Cd1xZnxTe detector (x = 0.1, density = 5.68 g/cm3) used in thisstudy. The CZT detector was 10x10 mm2 and thickness of 3
mm. The thickness was chosen since it allows >90% absorptionof the photons at 120 kVp. In an attempt to evaluate thedetection ability, we designed the CZT detector with different
pixel size on GATE. The pixels with sizes of 0.09 0.09, 0.45
0.45, and 0.900.90 mm2 were simulated.
Energy resolved photon counting x-ray imaging with CZT
detector
We designed a cylindrical PMMA phantom including three
Iodines in concentration of 140, 40, and 8 mg/cm3 and one
Gadolinium in concentration of 39.3 mg/cm3. We studied theability to separate different materials from the multi-energy
windows. We obtained images from 23-32, 33-42, 40-49 and
50-59 keV energy windows. For each energy windows thecontrast-to-noise ratio (CNR) was considered to be the image
quality.
Results
Measured attenuation of each material was in a good
agreement with the reference data of the NIST physics
laboratory. The attenuation of x-rays in the various materials isdependent on the energy of the x-rays and the atomic
composition of the material.
Three different pixel spectrums were distorted towards thelower energy region. Because the characteristic x-rays add
counts in the range of 20-40 keV. The photoelectric effect isdominant at Cd and Te of CZT material due to the high Z
numbers. The Z numbers of Cd and Te are 48 and 52. Ascharacteristic x-rays of Cd and Te process quite high energy,
they escape from crystals. Especially, these effects are evident
in the small pixel sizes.
For Iodine, the CNR was found to dramatic increase in therange of 33-42 keV. For Gadolinium, the calculated value of

RT-5

the CNR in the range of 50-59 keV was higher than thosebelow 50 keV. Because the photons with energy levels justabove the K-edge energy are more likely to be absorbed thanphotons with energy levels just below the K-edge energy.
Conclusions
We demonstrated that multi-material decomposition
imaging is experimentally feasible using the photon-counting
CZT detector and polychromatic x-ray. The photon counting
based functional and anatomical imaging system will be
designed in the GATE.

         


Takuma Matsunaga1), Tomohiro Shimozato2), Yuichi Aoyama3), Hiroshi Fukuma4), Ryuichi Yada5), Hiraku Fuse1),
Yusuke Oribe1), Masataka Komori2), Yasunori Obata2)
1) Department of Radiological Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Radiological Technology, Nagoya University School of Health Sciences, Nagoya, Japan
3) Department of Radiology, Nagoya University Hospital, Nagoya, Japan4) Central Department of Radiology, Nagoya City University Hospital, Nagoya, Japan
5) Department of Radiology, Seirei Hamamatsu General Hospital, Hamamatsu, Japan

Introduction
The flattening filter (FF) of medical linac is placed in thephoton beamline to produce a flat beam profile at the given
depth, but it decreases primary beam intensity by scatteringand absorption. Recently some researches have shown thatremoving FF from medical linac can increase dose rateconsiderably, and reduce out-of-field doses [1-4]. In thisstudy, we provide dosimetric properties of 6 MV and 10 MV
photon beams from FF free (FFF) linac using Monte Carlo(MC) simulation.
Materials and Methods
MC modeling of medical linac with and without FF: We
have developed 6 MV and 10 MV photon beam model forthe linac head of Varian Clinac series accelerator using
EGSnrc/BEAMnrc MC code [5]. The linac head components,
including target, primary collimator, vacuum window, FF,monitor ion chamber, mirror, and X and Y jaws, were
simulated on the basis of manufacturer-provided information.
To calculate dose distributions in water phantom, we applied
EGSnrc/DOSXYZnrc MC code [6].
The initial electron beam incident on the target have the
distribution of the electron energy and the radial intensity
assumed Gaussian in shape[7], and mean energy andintensity distribution of the initial electron is not clearly andvaries among the same model of linacs. To determine
electron energy, we comparing the measured and calculated
percentage depth dose (PDD) for 30 x 30 cm2 field size.
After initial electron energy selection, we determined
intensity distribution comparing the measured and calculated
off-center ratio (OCR) at the depth of 10 cm for 5 x 5, 10 x
10, 20 x 20, and 30 x 30 cm2 field sizes. To compare themeasured and calculated dose, local dose difference were
calculated by following equation:

Dosimetric properties of FFF linac: To find out thecharacteristic of FFF linac, we compared PDD and OCR forvaried field sizes, dose per incident electron, planer fluence,
energy fluence, and energy spectrum with standard linac using
EGSnrc/DOSXYZnrc and BEAMDP sub code [8].
Results and Discussion
Validation of MC modeling: To validate our MC simulation,
calculated PDD and OCR were compared with measurement
data. There were good agreement between MC andmeasurement results, and local differences were less than 3% in
all region. The examples of calculated and measured PDD and
OCR are shown in Fig. 1 and 2, respectively.

Fig. 1 PDD for 10 x 10 cm2 field size of 6 MV and 10 MV.
Monte Carlo is circle and measurement is solid.

The mean energy of the initial electron and the
distributions of the electron energy and the radial intensity
are shown in Table 1. Using determined initial electron, thephase-space (PS) file, containing data relating to particle
position, direction, charge, and energy for 5 x 5, 10 x 10, 20
x 20, and 30 x 30 cm2 field sizes at source surface distance(SSD) of 100 cm with and without FF were produced.
Table 1 Initial electron parameters. The energy andintensity spread is given at FWHM
Nominalenergy (MV)
6
10

RT-5

Derived energy
(MeV)
6.0
10.5

Energy spread
FWHM
3%
3%

Intensity spread
FWHM (cm)
0.15
0.15

Fig. 2 OCR at the depth of 5 cm, 10 cm, 20 cm, and 30 cm
for 10 x 10 cm2 field size of 6 MV. Monte Carlo is circle andmeasurement is solid.

RT-6



Dosimetric properties of FFF linac: We considered dose
per initial electron at the depth of 10 cm for dose ratecomparison. For 10 x 10 cm2 field size, the ratios of dose per
initial electron for FFF linac to standard linac were 2.38, 5.17
for 6 MV, 10 MV, respectively.
The depth dose and OCR were calculated for field sizesof 5 x 5, 10 x 10, 20 x 20, and 30 x 30 cm2. The depth dose
curves of FFF linac for 10 x 10 cm2 field for 6 MV and 10
MV, are shown in Fig. 3 and 4, respectively. The depth dose
was normalized at maximum point of measurement with FF.
In the beyond maximum dose region, the dose for standard
linac is higher than that for FFF linac due to the beamhardening effect of the FF. In the build up region, because ofsofter spectra and contamination low-energy electron, FFF
linac delivers higher dose than standard linac. Especially, for
10 MV, significant increasing dose in the build up region isobserved due to the excessive contamination electron. It
seems that more penetrating electron through the target reachthe phantom for 10 MV than for 6 MV, because the target of
6 MV is tungsten and copper, but that of 10 MV is copper
only.

fluence was reduced with distance from central axis as a resultthat removing FF reduced scattering radiation from linac head.

Fig. 4 Comparison of depth dose for with and without FF
for 10 x 10 cm2 field size of 10 MV. without FF, MC iscircle and with FF, measurement is solid.
The OCR at the depth of 10 cm of 10MV FFF linac for
10 x 10 cm2 is shown in Fig. 5. OCR was normalized at thecentral axis dose. By removing of FF, the dose was reducedwith distance from the central axis. In addition, removed FF
reduced the out-of-field dose. For example, in Fig. 5, at a
distance of 7 cm from the central axis, the ratio of doses for
FFF linac to standard linac was 0.8. This is because photon   



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2J@>'DG>H=>I6 ,=J?>%DN6B6 !:E6GIB:CID;+69>DAD<>86A,8>:C8:H(6<DN6.C>K:GH>IN!G69J6I:,8=DDAD;':9>8>C:(6<DN6$6E6C
!:E6GIB:CID;+69>DAD<>86A-:8=CDAD<N(6<DN6.C>K:GH>IN,8=DDAD;":6AI=,8>:C8:H(6<DN6$6E6C
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Fig. 5 Comparison of OCR at the depth of 10 cm for withand without FF for 10 x 10 cm2 field size of 10 MV. without
FF, MC is circle and with FF, measurement is solid.
Conclusions
The MC model of Varian Clinac series accelerator with andwithout FF were developed and compared. Our results showsthat removing FF can increase dose rate and decrease out-offield dose. These could be an advantage of FFF linac, but forclinical usage, FFF linac should equip the filter to remove theexcessive contamination electron.

Fig. 3 Comparison of depth dose for with and without FF
for 10 x 10 cm2 field size of 6 MV. without FF, MC iscircle and with FF, measurement is solid.



References[1]Oleg N Vassiliev, Uwe Titt, Falk Pönisch, Stephen F Kry,
Radhe Mohan, Michael T Gillin. Dosimetric properties ofphoton beams from a flattening filter free clinical accelerator.
Phys. Med. Biol. 2006;51:1907-1917.
[2]Oleg N Vassiliev, Uwe Titt, Stephen F Kry, Falk Pönisch,Michael T Gillin, Radhe Mohan. Monte Carlo study ofphoton fields from a flattening filter-free clinical accelerator.
Med. Phys. 2006;33:820-827.
[3]Asghar Mesbahi. Dosimetric characteristics of unflattened 6
MV photon beams of a clinical linear accelerator. Appl.
Radiat. Isot. 2007;65:1029-1036.
[4]Gabriele Kragl, Sacha af Wetterstedt, Barbara Knäusl,Mårten Lind, Patrick McCavana, Tommy Knöös, Brendan
McClean, Dietmar Georg. Dosimetric characteristics of 6 and
10 MV unflattened photon beams. Radiother Oncol.
2009;93:141-146.
[5]D.W.O. Rogers, B. Walters, I. Kawrakow. BEAMnrc Users
Manual. NRCC Report PIRS-509 (A) revK. 2009.
[6]B. Walters, I. Kawrakow, D.W.O. Rogers. DOSXYZnrc
Users Manual. NRCC Report PIRS-794 revB, 2009.
[7]Daryoush Sheikh-Bagheri, D. W. O. Rogers. Sensitivity of
megavoltage photon beam Monte Carlo simulations toelectron beam and other parameters. Med. Phys.
2002;29:379-390.
[8]C.-M. Ma, D.W.O. Rogers. BEAMDP Users Manual. NRCC
Report PIRS-0509 (C) revA. 2009.
Author address

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RT-8

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RT-8

Sleep disorder and sleep-disordered breathing in the elderly

Medical Technology (13:30 16:00 THP Seminar Room)
Wakusawa
Session chairs: Prof. Shinya
Sinya Wakusawa
Prof. Tsutomu Kawabe

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C.Nakazaki1), A.Noda2), N.Fujita3), S.Yamada1), 4), Y.Koike2), S.Wakusawa1), 4)
1) Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of
Medicine, Nagoya, Japan
2) College of Life and Health Sciences, Chubu University3) Department of Clinical Laboratory at Nagoya University Hospital4) Department of Medical Technology, Nagoya University School of Health Sciences, Nagoya, Japan

Introduction
The elderly spend more time in bed, experience more
awakenings during the night,1) and have increased complaintsof sleep disorder such as the difficulty initiating sleep,
difficulty remaining asleep and early morning awakenings.2)
Elderly individuals complain primarily about sleep disorder,
which are often secondary to other disorders. 1)
Aging substantially increases the risk of obstructive sleep
apnea syndrome (OSAS),3) and OSAS is associated withhypertension, cerebrovascular disorder, cardiovasculardisease and all-cause mortality.4) However, effects of aging
on pathophysiology of apnea/hypopnea in clinical settings
have not been clearly investigatedWe assessed the sleep disorder in middle-aged andelderly people, and examined the relation between sleep
disordered-breathing (SDB) and cardiovascular function in
the elderly.
Materials and Methods
Subjects: 32 middle-aged subjects (51.3±4.1 years, male:
16 subjects, female: 16 subjects) and 20 elderly (71.7±5.8
years, male: 5 subjects, female: 15 subjects) were targeted.
The study protocol was approved by the appropriate
institutional review committee at the Nagoya University, andinformed written consent from the subjects was obtained at
the beginning of the assessment.
Functional Outcome Measures: Subjective sleep
symptoms, disturbances, and patterns were assessed with thePittsburgh Sleep Quality Index (PSQI). The total global score
ranges from 0 to 21, and greater scores indicate higher levelsof sleep symptoms.5)2P=E@>ONRDOC/20(]R@M@?@ADI@?<N
insomnia. Daytime sleepiness was quantified using the
Epworth Sleepiness Scale (ESS). Possible scores ranges from0 to 24, and higher scores reflect greater sleepiness. A cut-off
Q<GP@]DI?D><O@?@S>@NNDQ@?<TODH@NJHIJG@I>@$#2 6).
Actigraphy: The actigraph (Ambulatory Monitoring, Inc,
USA) was worn around the wrist of a non-dominant hand.
The actigraph data were assessed using the algorithm
supplied by the ActionW-2 clinical sleep analysis software
package for Windows (Ambulatory Monitoring, Inc, USA).
Sleep and activity were scored according to the Cole-Kripke
formula.7) Total sleep time (TST) was measured using
actigraphy.8)
Measurements for Sleep Apnea: To assess the sleep
apnea, overnight examination was performed on eachsubjects using the portable home monitoring (apnomonitor:
CHEST) and we calculated apnea-hypopnea index/h (AHI/h),
oxygen desaturation index/h (ODI/h) and lowest arterial
oxyhemoglobin saturation (Lowest SpO2). We determined
OC@NP=E@>ONJA '(]C<NNG@@K<KI@<NTI?MJH@2 2 

MT-1

Markers of Atherosclerosis: We evaluated atherosclerosis
from Pulse Wave Velocity (PWV) and carotid ultrasonography.
PWV was measured using a volume-plethysmographic (from
PWV/ABI; Nihon Colin Co.,Ltd.,, Komaki, Japan), which
simultaneously records brachial-ankle PWV (baPWV), bloodpressure, an electrocardiogram, and heart sounds.9) The intimamedia thickness (IMT) of the carotid arteries was estimated by
B-mode ultrasound (HEWLETT PACKARD SONOS 2000#
PHILIPS) with a 7.5MHz. 10) 11), 12)
Echocardiograph: Standard echocardiography including
measurement of transmitral flow velocity indices (HEWLETT
PACKARD SONOS 2000 # PHILIPS) was performed in all
subjects. Left atrium dimension (LAD), left ventricular enddiastolic dimension (LVDd) and left ventricular end-systolicdimension (LVDs) were measured by two-dimensional M-mode,and the left ventricular ejection fraction (LVEF) was calculated.
The peak early velocity (E) and atrium contraction velocity (A),their ratio (E/A) and the deceleration time of peak E velocity(DcT) were measured from mitral inflow velocities.
Data analysis: All statistical analyses were performed using
a statistical software package (Statview for Windows version
4.54 SAS Institute Inc; Cary, NC). Data were presented bymean ± standard deviation (SD), and analysis of variance follow(ANOVA) by Scheffe’s test was used to compare means ofcontinuous values between subgroups. A probability (p) value <0.05 were considered statistically significant.
Results
ESS was significantly higher in the middle-aged groupthan in the elderly group (8.1±5.1 vs 3.9±2.9, p=0.01). (Figure1)
Bed time was significantly earlier in the elderly group thanin the middle-aged group. (21:25±0.19 vs 22:59±0.17, p=0.019)
There was no significantly difference between two groups inwake-up time. (Figure 2)
3C@ KM@Q<G@I>@ JA /20( ]  DINJHID< R<N  DI OC@elderly group, and it was 28% in the middle-aged group. In theelderly, Time in bed was significantly extended in the insomnia
group than in the non-insomnia group. (8.6±1.6h vs 7.5±1.0h,
p=0.038) (Table 1)
There were no significantly differences between SAS andnon-SAS groups in atherosclerotic and echocardiographic
parameters. (Table 2)

Discussion
Epidemiological studies have implicated OSAS as a risk
factor for the development of cardiovascular andcerebrovascular disease. However, in this study, cardiovascularfunction did not significantly differ between SAS and non-SASgroups in the elderly. Moreover, AHI did not significant changewith a presence of hypertension or hyperlipidemia.
ESS score was significantly higher in the middle-aged
group than in the elderly group, and bed time was significantly
later. Daytime sleepiness was found in the middle-aged groupand TST during the night was short. In the elderly, daytime
sleepiness was not detected, but insomnia was permitted
especially who spend long time in bed. Sleep disorder may
relate to decrease of daytime activity and sleep quality.
In conclusion, comparison of sleep disorder/SDB andcardiovascular function between middle-aged and elderly
population may provide insight into the pathophysiology ofsleep disorder/SDB associated with aging.

p=0.010

14
12

ESS

10
8
6
4
2
0

middle-agedelderly

Figure 1. ESS between middle-aged and elderly group
ESS: Epworth Sleepiness Scale

middle-aged

p=0.019elderly
000

600

1200 1800 2400

600

Bed time

middle-agednselderly
000

600

300

900

Wake-up time

Figure 2. Bed time and wake-up time between middle- aged
and elderly group
Table 1. Time in bed in the elderly group

insomnia

non-insomnia

P value

7.22.4

4.31.2<0.001

8.61.6

7.51.0

<0.05

n=9

PSQI
Time in bed (hr)n=11Data are presented as mean ± SD.
PSQI: Pittsburgh Sleep Quality Index
Table2 . Atherosclerotic and echocardiographic
parameters in the elderly group
SAS
n=11

R-IMT Max (mm)
L-IMT Max (mm)R-baPWV (cm/s)
L-baPWV (cm/s)
LVEF (%)
E/A
DcT (sec)

0.9  0.4
0.9  0.5
1608.0  382.0
1628.0  300.0
66.4  6.1
0.8  0.2
207.0  36.5

non-SASn=9

1.1  0.5
1.0  0.3
1568.0  285.0
1597.0  256.0
70.0  12.1
0.9  0.3
210.0  59.4

P value
ns
ns
ns
ns
ns
ns
ns

Data are presented as mean ± SD.
IMT: intima-media thickness; baPWV: brachial-ankle pulse
wave velocity; LVEF: left ventricular ejection fraction; E/A:
peak early systolic velocity (E)/atrial contraction velocity(A); DcT: deceleration time of peak E velocity

References[1] Sonia Ancoli-Israel, J. Steven Poceta, et al. Identificationand treatment of sleep problems in the elderly. Sleep Med
Rev 1997; 1: 3-17
[2] Ohayon MM, et al. Epidemiology of insomnia: what weknow and what we still need to learn. Sleep Med Rev 2002;
6(2):97–111.
[3] Matthias E, Amy S. Jordan, Nancy L. Chamberlin, et al. The
influence of aging on pharyngeal collapsibility during sleep.
Chest 2007; 131: 1702-1709[4] Heather E, David J, et al. Neuropsychological function in
obstructive sleep apnoea. Sleep Med Rev 1999; 1: 59-78[5] Buysse DJ, Reynolds CF, 3rd, Monk TH, et al. The
Pittsburgh Sleep Quality Index: a new instrument forpsychiatric practice and research. Psychiatry Res 1989; 28:
193-213[6] Johns MW, et al. A new method for measuring daytime
sleepiness: the Epworth sleepiness scale. Sleep 1991; 14(6);540-545[7] Cole RJ, Kripke DF, Gruen W, Mullaney DJ, Gillin JC:
Automatic sleep/wake identification from wrist activity.
Sleep 1992; 15: 461-469[8] Van Den Berg JF, Van Rooij FJ, Vos H, et al. Disagreement
between subjective and actigraphic measures of sleep
duration in a population-based study of elderly persons. J
Sleep Res. Sep 2008;17(3):295-302[9] Yufu K, Takahashi N, Hara M et al. Measurement of thebrachial-ankle pulse wave velocity and flow-mediateddilatation in young, healthy smokers. Hypertens Res 2007;30(7); 607-612[10] Kitamura A, Iso H, Imano H, et al. Prevalence andcorrelates of carotid atherosclerosis among elderly Japanesemen. Atherosclerosis 2004; 172:353-359[11] Renzhe Cui, Kitamura A, Yamagishi K, et al. Ankle-arm
blood pressure index as a correlate of preclinical carotid
atherosclerosis in elderly Japanese men. Atherosclerosis
2006; 184: 420-424[12] Handa N, Matsumoto M, Maeda H, et al. Ultrasonicevaluation of early carotid atherosclerosis. Stroke 1990; 21;1567-1572
Author address
E-Mail: nakazaki.chie@h.mbox.nagoya-u.ac.jp

MT-1

Mycobacterium tuberculosis-induced expression of Granulocyte-Macrophage
Colony Stimulating Factor is mediated by ERK1/2 MAPK or PI3-K/Akt signaling
pathwayJang-Eun Cho1), Sang-Jung Park1), Yong-Mi Kim2), Sang-Nae Cho2) , Hye-Young Lee1) and Yoon-Suk Kim1)
1) Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju
2) Department of Microbiology, College of Medicine, Yonsei University, Seoul

Introduction
Mycobacterium tuberculosis, the causative agent oftuberculosis, has already infected nearly a third of the world’s
population causing approximately 2 million deaths yearly.
Infection with MTB affects the recruitment and activation of
circulating effector leukocytes by influencing induction andsecretion of cytokines from infected macrophages. Infected
macrophages release a variety of inflammatory cytokines as
defense mechanisms against MTB. The cytokine GM-CSF
plays an important role in the differentiation of monocytes,
alveolar macrophages and dendritic cells. GM-CSF acts locallyas a proinflammatory cytokine. In the lungs, GM-CSF is very
important for macrophage maturation and differentiation andhost defense. It was previously reported that GM-CSF can
induce up-regulation of MHC class II and costimulatory
molecules such as CD80 and CD86 on antigen presenting cells(APCs) as well as increasing their phagocytic activity andstimulatory capacity. When this cytokine is lacking, as in genedisrupted mice, the architecture of the lung is altered andalveolar macrophages become foamy in appearance. In addition,these cells have defects in phagocytosis, bacterial killing, as
well as loss of Toll-like receptor expression and signaling. In
the context of tuberculosis, GM-CSF may also contribute to thecytokine/chemokine milieu responsible for granuloma
formation in the lung. Over-expression of GM-CSF in the lungs
impairs protective immunity against MTB and therefore careful
regulation of pulmonary GM-CSF levels may be critical insustaining protection against chronic tuberculosis disease. GMCSF act as a pivotal factor for the development of alveolar
macrophages in lung. Increasing GM-CSF levels into thechronic stage of the infection results in elevated cellproliferation and phagocytic activity. GM-CSF regulates both
pulmonary surfactant homeostasis and the differentiation andproliferation of functionally competent alveolar macrophages.
But the intracellular signaling pathways involved in theregulation of GM-CSF expression in alveolar macrophages areunclear. In this study, we aimed to elucidate the involvement of
GM-CSF in the host immune response against MTB infection.
We observed mycobacterium-stimulated induction of GM-CSF
and evaluated the associated with signal transduction pathway.
Materials and Methods
Preparation of Mycobacteria
Mycobacterium tuberculosis H37Rv (ATCC 27294), M.
bovis BCG (ATCC 35748) and clinical isolated Beijing family
of MTB strain (K-strain) obtained at Yonsei Medical school in
Seoul and used in this study was grown for about four weeks at
37°C as a surface pellicle on Sauton medium enriched with
0.4% sodium glutamate and 3.0% glycerol. The surface
pellicles were collected and disrupted by gentle vortexing with
6mm glass beads. After clumps had settled, the upper
suspension was collected and aliquots were stored at -80°C.
Before infection,

MT-2

aliquots were thawed and quantitated for viable colony-forming
units (CFU) on Middlebrook 7H10 agar (Difco, USA)..
Cell culture and infection of mycobacteria
THP-1 cell line was maintained in RPMI 1640 medium
with 2 mM glutamine, 10% heat inactivated fetal bovine serum,
100 U/ml penicillin and 100 µg/ml streptomycin (Gibco-BRL,USA) at 37 under 5% CO2 condition. THP-1 cells wereseeded in six-well plates and treated with 50 nM phorbol-12myristate-13-acetate (PMA; Sigma) for 48 h to induce
differentiation into macrophage-like cells, then washed threetimes with antibiotics free RPMI 1640 medium. Before
infection, differentiated THP-1 cells were reconstituted in
antibiotics free RPMI 1640 medium with 5% FBS. Cells wereincubated with MTB at 10 MOI for 0, 1, 1.5, 3, 6, 9, 12, 18, 24,
48 or 72 h. PMA-differentiated THP-1 cells were pretreatedwith inhibitors for 45 min before stimulation with MTB H37Rv
for 4 h at 10 MOI.
RNA extraction and Semi-quantitative RT-PCR
Total RNA was extracted from cultured cells using Trizol
Reagent (Invitrogen, USA) according to the manufacturer’s
instruction. cDNA was synthesized by reverse transcription
with 2 µg total RNA, 0.25 µg of random hexamer (Invitrogen)and 200 unit of Murine Molony Leukemia Virus Reverse
Transcriptase (MMLV-RT; Invitrogen) for 10min at 25°C,
50min at 37°C and 15min at 70°C. Diluted reverse-transcribed
cDNA was used subsequent 25 µl PCR amplification. PCR
amplification using 0.2 units of G-Taq polymerase (Cosmo
Genetech, Korea) was performed in a thermocycler (Applied
Biosystems, USA) for 35 cycles using GM-CSF primer.
GAPDH was ampilifed as an internal control. The intensity ofeach band amplified by RT-PCR was analyzed using Gel Doc
EQ Quantity One (Bio-rad, Italy) and normalized to GAPDHmRNA in corresponding samples.
Enzyme-linked immunosorbent assay (ELISA)
Cell culture supernatants from MTB-infected THP-1 cells
were collected 24 h after infection. Cell culture supernatants
were analyzed using Human GM-CSF ELISA MAX™
Standard (BioLegend, USA), as recommended by the
manufacturer.
Statistics
All values are given as mean ± standard deviation (SD).
When a significant difference was detected, further analysis
was performed using a Student’s t-test. A p value of less than
0.05 was considered significant.
Results
MTB infected THP-1 cells induced a dose-dependent mannerand a time-dependent increase in GM-CSF mRNAExpression of GM-CSF was up-regulated by infection of
MTB in a dose-dependent manner, reaching a peak at 20 MOI
of MTB. We also examined the effects of mycobacterial
infection on the timing of GM-CSF expression. GM-CSF
expression was up-regulated in response to MTB in a timedependent manner. The mRNA level of GM-CSF peaked at 6 hafter mycobacterial infection, and then declined gradually for
72 h.
Induction of GM-CSF by MTB is mediated by p38 MAPK,
ERK1/2 MAPK, PI3-K or PLC signaling pathway.
To elucidate the mechanism by which mycobacterial
infection affects expression of GM-CSF, we determined thesignaling pathway associated with MTB-stimulated inductionof GM-CSF. Treatment with Ro-31-8425 (an inhibitor ofcalsscial PKC) or SP600125 (an inhibitor of JNK) did not
influence of GM-CSF induction by MTB. SB202190 (aninhibitors of p38 MAPK), PD98059 (inhibitor of ERK1/2),
Ly294002 (inhibitor of PI3-K) and U73122 (inhibitor of PLC)
had negative effects on MTB-stimulated GM-CSF expression.
Mycobacterial infection induces GM-CSF secretion and theinduction of GM-CSF by MTB is mediated by ERK1/2 MAPKor PI3-K/PDK1/Akt signaling pathway.
Differentiated THP-1 cells were pre-treated with indicatedconcentrations of PD98059 (ERK1/2 inhibitor), Ly294002(PI3-K inhibitor), OSU03012 (PDK1 inhibitor) or Akt (Aktinhibitor IV) for 45 min, followed by MTB infection (10 MOI).
Supernatants were harvested 24 h after infection and secretionof GM-CSF was measured by ELISA. All signal inhibitors
were decreased GM-CSF secretion at high dose of specificsignal inhibitors. PD98059 and Ly294002 decreased about
85 % of GM-CSF secretion, OSU03012 and Akt decreased
about half of GM-CSF secretion.
Discussion
The Members of the CSF cytokine family play importantroles in macrophage recruitment and activation to regions ofinflammation. In mycobacterial infection, alveolar macrophagedisplays increasing levels of GM-CSF. However, mechanism of
GM-CSF induction does not poorly understood. We
investigated whether increasing levels of GM-CSF in
mycobacteria infected THP-1 cell mediated mycobacterial
secreted proteins. The increase in expression and secretion of
GM-CSF was caused by MTB was reduced in cells treated with
inhibitors of ERK1/2 MAPK. In addition the induction of GMCSF caused by MTB was partially reduced in cells treated with
inhibitors of p38 MAPK. In addition, the increase in secretionof GM-CSF caused by MTB was reduced in cells treated with
inhibitors of PI3-K, PDK1 and Akt. These results suggest that
GM-CSF plays important role in the immune response against
mycobacterium infection. Therefore this signal transduction
system might be a target for screeing therapeutic candidates formycobacterial disease
References[1]Szeliga J, Daniel DS, Yang CH, Sever-Chroneos Z,
Jagannath C, Chroneos ZC. Granulocyte-macrophagecolony stimulating factor-mediated innate responses intuberculosis. Tuberculosis. 2008; 88; 7–20.
[2]North RJ, Jung YJ. Immunity to tuberculosis. Annu Rev
Immunol. 2004;22;599–623.
[3]Fleetwood AJ, Cook AD, Hamilton JA. Functions of
granulocyte–macrophage colony-stimulating factor. Crit Rev
Immunol. 2005;25;405–28.
[4]Bonfield TL, Raychaudhuri B, Malur A, Abraham S,

MT-2

Trapnell BC, Kavuru MS, et al. PU.1 regulation of humanalveolar macrophage differentiation requires granulocyte–
macrophage colonystimulating factor. Am J Physiol Lung
Cell Mol Physiol. 2003;285;L1132–6.
[5]Algood, H.M., Chan, J., and Flynn, J.L., Chemokine andtuberculosis. Cytokine Growth Factor Rev. 2003;14;467–477.
[6]Bozinovski S, Jones JE, Vlahos R, Hamilton JA, Anderson
GP. Granulocyte/macrophage-colony-stimulating factor(GM-CSF)
regulateslunginnateimmunitytolipopolysaccharide through Akt/Erk activation of NF-kappa
B and AP-1 in vivo. J Biol Chem. 2002;277(45):42808-14.
Author address

E-Mail: hyelee@yonsei.ac.kr        !        
       
A. Suzuki1), Y. Miyawaki1), J. Fujita1), A. Maki1), Y. Fujimori1), A. Takagi1, 2), T. Murate1, 2),
H. Saito3) and T. Kojima1, 2)
1) Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya,Japan2) Department of Medical Technology, Nagoya University School of Health Sciences, Nagoya, Japan
3) Nagoya Central Hospital, Nagoya, Japan

Introduction
Anticoagulant Protein S (PS) is a vitamin K-dependent
plasma protein that functions as a nonenzymatic cofactor for
activated protein C in the anticoagulation pathway [1].
Decreased levels of plasma PS are known as a risk factor forthe development of deep venous thrombosis, and there aremany factors to cause the PS deficiency [2-4].
Hereditary PS deficiency is determined by detection ofgenetic mutation in PS" gene (PROS1) [5]. PS deficiency
can also occur throughout life under the acquired conditions
such as oral anticoagulant (i.e. warfalin) use and liver disease[6]. Furthermore, acquired PS deficiency has been reported
in individuals with high levels of estrogen during pregnancy
and in those taking oral contraceptives [7-9].
Estrogens are reported as the regulator of the specific gene
expression via estrogen receptors [10]. The estrogen receptor(ER) is one of the steroid/nuclear receptor, and the ligandbound ER functions as a transcriptional factor [11]. The
classical ER action involves ligand-induced formation of an
ER homodimer, which interacts with estrogen responsive
elements (EREs) in target gene promoters [11]. The ligandoccupied ER is also known to associate with othertranscription factors, not mediating EREs to modulate liganddependent gene expression [12-15].
In this study, we investigated the molecular basis of the PS
decrease caused by E2, and thus the genomic ER signaling
pathway modulating ligand-dependent PROS1 gene
repression, in HepG2-ER" cells stably expressing humanER".
Materials and Methods
Establishment of HepG2-ER! cell line: HepG2 cells thatstably express human ER" (HepG2-ER") was established byG418 selection and used for further study.
Quantitative RT-PCR and ELISA: Quantitative reverse
transcription (RT)-PCR was performed to determine PS
mRNA and GAPDH mRNA using Power SYBR Green
Master mix. Enzyme-linked immunosorbent assay (ELISA)
was carried out to determine human PS antigen.
Luciferase Reporter Assay: To determine the PROS1
promoter activity, luciferase reporter assay was performed in
respective cell lines. Luciferase activity was normalized tothe activity of co-transfected !-galactosidase.
Electrophoretic Mobility Shift Assay (EMSA), DNA Pulldown Assay and Chromatin Immunoprecipitation (ChIP)
assay: EMSA and DNA pulldown assay were carried out todetermine the transcription factors binding to the PROS1
promoterregionsusing
artificial
double-stranded
oligonucleotides. ChIP assay was performed with specificantibodies against various transcription factors boundintracellular DNA of the cells.

MT-3

Results
PS expression was repressed by 17"-estradiol in humannormal hepatocytes and HepG2-ER! cells: To determine theeffect of 17!-estradiol (E2) to the PROS1 expression, we
analyzed PS mRNA in human normal hepatocytes (hNHeps)and HepG2 or its-derived cell lines. In ER"-positive hNHeps
treated with 100nM E2, PS mRNA was decreased comparedwith vehicle-treated cells. In HepG2-ER" cells, PS mRNA andantigen were also repressed by E2 treatment, but not in ER"negative other cell lines.
Down-regulation of PROS1 promoter activity by E2: To
investigate of the effects on PROS1 promoter activity, wecloned the promoter region of PROS1 and constructedluciferase-reporter vectors. In the full-length promoter construct(PS-4229/pGL3) and its-truncated constructs (PS-1826/pGL3 to
PS-175/pGL3), luciferase activities were down-regulated by E2,
but PS-137/pGL3 was not. There are two adjacent GC-richmotifs between -175 and -137, and PS-175Mut/pGL3
containing mutations of these GC-rich motifs did not show E2dependent repression.
ER! mediated E2-dependent PROS1 down-regulation: We
also examined the necessity of ER" expression for the PROS1
repression by E2 in HepG2-derived cells. In HepG2-mocktransfected cells, the PROS1 promoter activity was not downregulated by E2 treatment, but was in HepG2-ER" cells. A pureER antagonist, ICI 182,780, blocked this E2-induced PROS1
repression.
Transcription factor Sp1, Sp3 and ER! bound to the PROS1
promoter region, and Sp1 was necessary for E2-dependent
repression: Next, we performed the DNA pulldown assay andthe electrophoretic mobility shift assay (EMSA) to identify thetranscriptional factors interacted with the PROS1 promoter. In
DNA pulldown analyses, we found that Sp1, Sp3 and ER"
bound to the oligonucleotide containing the GC-rich motifs of
PROS1 promoter. We also observed the bindings of Sp1 andSp3 to the same oligonucleotide in EMSA, but could notdetected ER" binding. To verify the functions of Sp proteins in
the E2-induced PROS1 repression, we carried out knockdown
experiments for Sp1 and Sp3 by RNA interference using
specific siRNAs against them. The knockdown of Sp proteins
resulted in reduced promoter activities, but E2-dependent
repression did not occur by knockdown of Sp1, whereas
remaining E2-responsiveness by knockdown of Sp3.
Sp1/ER! interacted receptor interacting protein 140 (RIP140),
and recruited co-repressor-HDAC complex: We performed thechromatin immunoprecipitation (ChIP) assay and ChIP reimmunoprecipitation (IP) assay to investigate the chromatinstates of E2-treated HepG2-ER" cells. In ChIP assays, weobserved the bindings of Sp1, Sp3 and ER" to the PROS1
promoter region containing GC-rich motifs as well as DNA
pulldown assay. Sp1 and Sp3 were bound to the GC-rich motifs

in an E2-independent manner, but Sp1 binding was enhancedby E2 treatment. The binding of ER" was completely in an
E2-dependent manner. In further analyses of transcription
factors interacting with the PROS1 promoter, we found thatco-repressor nuclear receptor co-repressor (NCoR) andsilencing mediator of retinoid and thyroid hormone receptors(SMRT) were E2-dependently recruited to the GC-richmotifs. These co-repressors were not known to be recruitedby liganded ER", however, we tried ChIP assays for receptor
interacting protein 140 (RIP140) [16] and ligand-dependent
co-repressor (LCoR) [17], which are known to interact
liganded ER", and we identified only RIP140 bound to the
PROS1 promoter containing GC-rich motifs. Because
RIP140 is also known to interact histone deacetylases(HDACs) [18], we investigated the recruitment of them. We
observed class I HDAC; HDAC3 was robustly recruited by
E2-treatment, whereas class II HDACs did not affected.
To confirm the interaction of these transcription factors
upon the PROS1 promoter region containing GC-rich motifs,
we performed ChIP re-IP assays. The results suggested thatSp1 interacted ER", and Sp1/ER" recruited NCoR/SMRTHDAC3 complex via RIP140. A HDAC inhibitor trichostatin
A (TSA) blocked E2-dependent repression, so PROS1 gene
repression was mediated HDACs, which induced a hypoacetylated chromatin state and less permissive transcription.
Discussion
The decreased level of plasma PS during pregnancy is awell-known risk factor for deep venous thrombosis, but its
precise mechanism has not been unknown. In this study, weclarified that PS decrease was induced by 17!-estradiol
through transcriptional repression.
Meanwhile, the action of estrogen has been investigatedwell, which is ligand-dependent modulation of estrogen
receptor and regulation of transcription in target gene.
Although the positive regulation of target gene expression by
estrogen receptor has been reported in various studies,
negative regulation of target gene expression has been lessunderstood. Especially, liganded ER had been thought toonly regulate the transcription positively. We identified
liganded ER has a potential of negative regulation, mediating
RIP140 and co-repressor-HDAC complex. RIP140 is known
to interact HDACs, whereas HDACs exist sometimes ascomplex such as NCoR/SMRT-HDAC, so there might beanother formation accompanied with ER-RIP140 upon thetarget gene promoter.
In the down-regulation of protein S gene expression, theinteraction of Sp1 and ER" might be important. The Sp1formed complex with ER" upon the GC-rich motifs of the
PROS1 promoter, and consequently they reinforced thestability of Sp1/ER"-DNA complex. The interacted ER"
recruited RIP140, and RIP140 recruited the NCoR/SMRTHDAC3 complex. The NCoR/SMRT-HDAC3 complex
might induce the hypoacetylated histones, in which DNA
could coil tightly and limited accessibility of the basaltranscription factors and thus repressing the PROS1
expression.
Conclusions
In this study, we have demonstrated that 17!-estradiol
down-regulates protein S gene expression via ER". Liganded
ER" interacts basal transcriptional factor Sp1 and recruits
RIP140, which associates directly with HDAC3 complex
containing NCoR and SMRT. Thus E2-dependent PROS1
repression results in decreased levels of plasma PS, and thisMT-3

leads to the risk of deep venous thrombosis during pregnancy ororal contraceptive use.
References[1] Dahlbäck, B. (1991) Thromb Haemost 66, 49-61[2] Schwarz, H. et al, (1984) Blood 64, 1297-1300[3] Engesser, L. et al. (1987) Ann Intern Med. 106, 677-682[4] Makris, M. et al. (2000) Blood 95, 1935-1941[5] Gandrille, S. et al. (2000) Thromb Haemost. 84, 918[6] D'Angelo, A. (1988) J Clin Invest. 81, 1445-1454[7] Comp, P. et al. (1986) Blood 68, 881-885[8] Malm, J. et al. (1988) B J Haematol 68, 437-443[9] Tans, G., et al. (2000) Thromb Haemost 84, 15-21[10] Hall, J. et al. (2001) J. Biol. Chem. 276, 36869-36872[11] Gruber, C. et al. (2002) N Engl J Med 346, 340-352[12] Delfino, F. et al. (1999) Mol Cell Endocrinol 157, 1-9[13] Kushner, P. J. et al. (2000) J Ster Biochem Mol Biol 74,
311-317[14] Levin, C. (2005) Eur J Nuclear Med Mol Imaging 32,
S325-S345[15] Safe, S. et al. (2004) Nuclear Receptor-MediatedTransactivation Through Interaction with Sp Proteins. in
Progress in Nucleic Acid Research and Molecular
Biology, Academic Press. pp 1-36
[16] de Wolf, C. J. et al. (2006) J Biol Chem 281, 1763517643[17] Safe, S., and Kim, K. (2008) J Mol Endocrinol 41, 263275[18] Owen, G. et al. (1998) J Biol Chem. 273, 10696-10701
Author address

E-Mail: suzuki.atsuo@d.mbox.nagoya-u.ac.jp

COMPARISON OF REBA HPV-ID WITH DNA CHIP BASED ASSAY FOR HPV
GENOTYPING
Sung-Hyun Kim1)*, Dong-Sup Lee2)*, Sang-Jung Park1), Tae-Ue Kim1),
Gwang-Hwa Park2), and Hye-Young Lee1)
1) Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University2) Department of Pathology, College of Medicine, Yonsei University Wonju Christian Hospital,
Wonju-si, Gangwon-do, Republic of Korea

Introduction
Human papillomaviruses(HPV)have been known to cause
human cervical cancer which is the second most common
cancer among women worldwide and the most common cancer
among wo men in developing countries [1, 6, 9].
Even though, the HPV prevalence among subgroups ofpeople classified by disease severity varies, overall prevalenceof HPV in people with cervical cancer has been reported toreach up to 95 to 100% [9]. So far, more than 100 genotypes of
HPV have been known. Among those, certain groups of HPV
have been implicated to have high association with cervicalcancer, whereas other types have low association [2]. In detail,the most associated geno-types with malignant cervical cancer
are 16, 18, 45, 31, 33, 52, 58, and 35. Of these, HPV16 and 18
are mostly related to the malignant cervical cancer [1].
For this reason, HPV genotyping rather than mere detectionof HPV has been recommended and thus, the test volume for
HPV genotyping has been rapidly increasing. Nowadays,
reliable and accurate detection method that able to identify the
specific HPV genotypes is required, thus several PCR-based
assays have been developed to detect specific genotypes of
HPV [8]. Currently, many genotyping tests kits in clinicalsettings have been commercially available and evaluated to bevaluable for clinical diagnosis [3, 8].
This study was set to evaluate a new HPV genotyping kit,
REBA HPV-IDfrom M&D (Wonju, Korea) for its usefulness
for genotyping HPV using clinical specimens.

recommendation. Briefly, for REBA HPV-ID assay, PCR
products added to the genotype specific probe labeled
membrane strips, washed non-specific binds, and then stainedwith staining solution of PCR product-probe linked region of
strips. For MyHPV DNA Chip assay, PCR product loaded tothe probe labeled glass chip and then read the result signal
using by scanner.

Materials and Methods
HPV samples and liquid based cytological smears
The clinical specimens were obtained since November of2008 to July of 2009 using by standard procedure from 356
women in Gangwon province, Korea from Yonsei university
Wonju Christian Hospital.

Genotyping of HPV in abnormal cytology, REBA HPV-ID
versus MyHPV DNA chip
The overall positivity of REBA HPV-ID was 80.86%(186) using clinical specimens with abnormal cytologicalinterpretation: the positivity rate of HPV with abnormal
cytology was 91.67% (11) in SCC, 96.66% (29) in HSIL, 92%(46) in LSIL, 100% (2) in ASC-H, and 64.17% (43) in ASCUS.
When the results from REBA HPV-ID were compared with
MyHPV DNA Chip, the overall positivity rate of MyHPVDNA chip was 69.75%, and the positivity rate of HPV withabnormal cytology was 91.67% (11) in SCC, 96.88% (29) in
HSIL, 84 % (42) in LSIL, 100% (2) in ASC-H, and 43.28%(29) in ASCUS with MyHPV DNA chip. The positive rate of
HPV in ASCUS was significantly lower with MyHPV DNA
chip than with REBA HPV-ID. These data shows that REBA
HPV-ID has about 30% higher sensitivity than MyHPV DNA
chip.
The five most frequently detected HPV sub-types using
REBA HPV-ID were HPV16, 53, 58, 56, and 33 withabnormal cytological diagnosis, while using Mygene DNA chip,

Cytological diagnosis
The Liquid-based cytological smears obtained using
recommended procedures and clinical diagnoses wereinterpreted by the pathologists and were classified by 2001
Bethesda System terminology.
HPV genotyping
HPV genotyping using REBA HPV-ID (M&D, Wonju,
Korea) and MyHPV DNA Chip (Mygene, Seoul, Korea) werecarried out according to the manufacturer's recommendation.
Both genotyping methods, REBA HPV-ID and MyHPV DNA
Chip require the target region (firstly, amplify MY11 and MY9then, amplify GP5 and GP6) amplification before performing
the examination. After amplification of target region by PCR,
post PCR steps performed according with manufacturer’s

MT-4

Sequencing
Total eight samples were analyzed by sequencing forconformational test. These eight samples have got positive
result which appear single HPV genotype infection with REBA
HPV-ID, however the result was negative with MyHPV DNA
Chip. For sequencing analysis, one-tube nested PCR was
performed to amplify the target region (GP5 and GP6) and then,sequencing analysis was performed at Xenotech (Dae-joen,
Korea).
Results
Clinical diagnosis of HPV
According to the cytological interpretations, 180 specimens(50.56%) were normal, 162 specimens (45.5%) were abnormal,
and 14 specimens (3.93%) have not been diagnosed because
which were prescribed to perform HPV genotyping directly
without cytological diagnoses. Abnormal cytological diagnoses
were classified 6 grades. Respectively, 67 (18.82%) ASCUS, 2(0.56%) ASC-H, 50 (14.04%) LSIL, 30 (8.42%) HSIL, 12(3.37%) SCC, and 1 (0.28%) C B2C.

HPV subtypes 16, 58, 56, 53, and 18 were most frequently
detected.
Genotyping of HPV in normal cytology, REBA HPV-ID versus
MyHPV DNA chipOn the other hand, the rate of HPV positive was 64.44%(116) in REBA HPV-ID and, 34.44% (62) in MyHPV DNA
chip based assay with normal cytology. The data shows REBA
HPV-ID has about 2 fold higher positivity than DNA chipwith normal cytological diagnosis. In this study, The five mostremarkable HPV sub-types detected were HPV16, 53, 58, 18,
and 56 with normal cytological diagnosis using REBA HPVID and HPV16, 52, 18, 53, and 58 using MyHPV DNA chip.
These data suggest that REBA HPV-ID has higher specificity
than MyHPV DNA chip.
Sequencing analysis with specimens that have different results
To confirm the accuracy and reliability of two methods,
sequencing analysis was performed. Before the sequencing
analysis, sorting of suitable specimens was required. Total
seven specimens, which have negative results with MyHPVDNA Chip, have a strong signal of PCR and have single
genotype infection result (one-band) with REBA HPV-ID,
were selected. GP5, GP6 region was amplified and sequenced.
Five out of seven samples sequenced clearly to interpret data
and these results were corrected with REBA HPV-ID
because these samples had negative results with MyHPV DNA
Chip. The rest two samples could not be interpreted bysequencing analysis. They would be mixed infection which
infected with more than two genotypes of HPV or non-HPV
infection (negative). Therefore, these data suggest that REBA
HPV-ID has higher sensitivity (72.42%) and accuracy than
MyHPV DNA Chip (28.57%).
Discussion
In this study, we evaluated the performance of the REBA
HPV-ID system which based on reverse blot hybridization
assay compare with the results of DNA chip assay andcytological interpretation with clinical specimens.
Recently available HPV genotyping kit REBA HPV-ID
has several advantages over a DNA chip based HPV
genotyping method. First of all, REBA does not require
expensive equipments such as scanner. Second, it is moresuitable for the laboratory with large volume of tests by saving
labor and reducing turn-around time. The total time required
for the REBA HPV-ID was from PCR to genotyping analysis
was about 4 hours. In brief, it can be more economical and time
consuming.
According to our finding, the positivity of the REBA HPVID was higher (80.86%) than other DNA chip based method(69.75%) in abnormal cytological samples and also positivityof REBA HPV-ID (64.44%)was higher than MyHPV DNA
chip (34.44%) in normal cytological samples. Thus, it seems
that REBA HPV-ID would provide more sensitive andspecific detection rate for samples with abnormal and normal
cytology.
To confirm the reliability of REBA HPV-ID, Sequencing
analysis was performed. Sequencing results show that REBA
HPV-ID was more reliable and higher sensitivity.

MT-4

Conclusions
Sequencing analysis has a limitation that is not a golden
standard method as a confirmative test because if some patients
who infected with more than 2 HPV genotypes, the results
could not be interpreted clearly. Therefore, other kinds ofconfirmative tests are required for accurate HPV genotype
detection and need to further evaluation.
References[1] Bosch F X, Lorincz A, Munoz N, Meijer C J and Shah K,
The causal relation between humanpapillomavirus andcervical cancer. J. Clin. Pathol. 2002; 55 244–265.
[2] De Villiers EM, Fauquet C, Broker TR, Bernard HU, Zur
Hausen H, Classification of papilloma-viruses. Virology
2004; 324:17-27.
[3] Fatima Galan-Sanchez, M A Rodriguez-Iglesias,
Comparison of human papillomavirus genotyping using
commercial assays based on PCR and reverse hybridization
methods. APMIS 2009; 117: 708–15.
[4] F X Bosch, A Lorincz, N Muñoz, C J L M Meijer, K V
Shah, The causal relation between human papillomavirus
and cervical cancer. J. Clin. Pathol. 2004; 55:244–265.
[5] Roden R, Wu T C, How will HPV vaccines affect cervicalcancer? Nat. Rev. Cancer. 2006; 6:753–763.
[6] Schiffman MH, Bauer HM, Hoover RN, Glass AG, Cadell
DM, Rush BB(1993) Epidemiologic evidence showing thathuman papillomavirus infection causes most cervicalintraepithelial neoplasia. J. Natl. Cancer. Inst. 1993; 85:958–
64.
[7] S R Hong, I S Kim, D W Kim, M J Kim, A R Kim, Y O
Kim, H S Kim, Prevalence and genotype distribution of
cervical human papillomavirus DNA in Korean women : amulticenter study. Kor. J. Pathol. 2009; 43:342-50.
[8] Thomas Iftner, Liesje Germ, Ryan Swoyer, Development
and clinical evaluation of a highly sensitive PCR-reverse
hybridization line probe assay for detection andidentification of anogenital human papillomavirus. J. Clin.
Microbiol.1999;37:2508–2517.
[9] Walboomers, J. M. M., M. V. Jacobs, M. M. Manos, F. X.
Bosch, A. Kummer, K. V. Shah, and P. J. F. Snijders.
Human papillomavirus is a necessary cause of invasive
cervical cancer worldwide. J. Pathol. 1999; 189:12–19.

Corresponding Author address

E-Mail: Hyelee@yonsei.ac.kr

Morphometric and FISH Analyses of Adenocarcinoma andMesothelial Cells Using Liquid-Based Cytology
A.Morimoto1), T.Nagasaka1), 2), K.Hashimoto1), 2), T.Yokoi3)1) Department of Pathophysiological Laboratory Sciences, Nagoya University Graduate School of Medicine,
Nagoya, Japan
2) Department of Medical Technology, Nagoya University School of Health Sciences, Nagoya, Japan
3) Department of Diagnostic Pathology, Aichi Medical University Hospital, Nagakute, Aichi, Japan
Introduction
Cytological diagnosis of malignant effusions is often
difficult mainly because of the presence of reactive
mesothelial cells. The evaluation of cellular morphology
with conventional Papanicolaou or Giemsa stains tend to be
more or less subjective as shown by the interobserver andeven the intraobserver variabilities. Immunocytochemistry
has been applied to aid the differentiation of adenocarcinoma
and reactive mesothelial cells, but is not very useful largely
because of the limitation of the specimen. LBC is superior toconventional cytology in that it provides smear slides with auniform cell density and a distribution that enables a precise
cytological examination. Moreover, one can preserve cells in
the LBC solution for a long period of time and always utilize
it for a variety of purposes, such as immunocytochemistry
and molecular analysis. To establish a more objective
diagnostic system, we performed morphometric and FISH
analyses on adenocarcinoma and mesothelial cells, using aliquid-based cytology method, and evaluated its usefulness.
Materials and Methods
Fourty five tumors of alimentary tract, 20 gastricadenocarcinomas and 25 colonic adenocarcinomas, werestudied. Cells were harvested from the surface of tumor andserosa of resected fresh specimen, suspended in the solution
for fixation and preservation (Liqui-PREPTM Preservative
Solution), and processed for Papanicolaou staining and FISH.
Digital images were taken from Papanicolaou-stained slides
for the following measurements. The nuclear area andperimeter of 100 cells per each case were measured using thesoftware ImageJ (NIH), and the mean nuclear area (NA), themean nuclear perimeter (NP), the mean length of nuclear
longer axis (LLA) and their standard deviations (SNA, SNP,
SLLA) were calculated. The shape factor (SHF) was
obtained by the following formula: (4××area)/perimeter2.
SHF is dimensionless and its value is equal to 1.0 in circlesand <1.0 in spheroid nuclei (Figure 1). Standard deviationsof the shape factor (SSHF) were also calculated. FISH
analysis was performed to detect chromosome 8 polysomy
and c-myc amplification.
Results
The nuclear area (NA) was smaller in gastricadenocarcinoma cells than in colonic adenocarcinoma cells
and mesothelial cells, although the differences were notstatistically significant. Results of the standard deviation of
nuclear area (SNA) demonstrated that adenocarcinoma cells
had more variable-sized nuclei than mesothelial cells(**P<0.01) (Figure 2).
Results of the nuclear perimeter (NP) showed a similartendency to NA. As for the standard deviation of nuclear
perimeter (SNP), colonic adenocarcinoma cells showed thehighest value, followed by gastric adenocarcinoma cells, andmesothelial cells showed the lowest value (**P<0.01)(Figure 2).

MT-5

As for the length of nuclear longer axis (LLA), colonicadenocarcinoma cells had longer nuclei (*P<0.05, **P<0.01)
than gastric adenocarcinoma cells or mesothelial cells without asignificant difference between the latter two. Results of thestandard deviation of length of nuclear longer axis (SLLA)
showed a similar tendency to SNP (**P<0.01) (Figure 2).
As for the shape factor (SHF), mesothelial cells had themost rounded nuclei, followed by gastric adenocarcinoma cells,
and nuclei of colonic adenocarcinoma cells were the least
rounded (**P<0.01). Results of the standard deviation of shapefactor (SSHF) showed a similar tendency to SNP and SLLA(**P<0.01) (Figure 2).
Adenocarcinoma cells of both stomach and colon in allcases showed significant percentages of chromosome 8polysomy and c-myc amplification, whereas mesothelial cells inall cases showed normal cell pattern.
Discussion
Morphometricanalysis
revealed
thatgastric
adenocarcinoma cells were less atypical and more uniform thancolonic adenocarcinoma cells and had even smaller nuclei thanmesothelial cells. One should always take these facts into
consideration on cytological examination, since gastric andcolonic adenocarcinoma cells are definitely the most frequently
encountered atypical cells in intraoperative peritoneal washingcytology, although cellular atypia should be more integratedly
assessed using other indices. By FISH analysis using LBC
specimens, quantitation of positive signals was more easily
performed than with histology sections, resulting in detection ofchromosome 8 polysomy and c-myc amplification in significant
percentages of both gastric and colonic adenocarcinoma cells,
whereas all the mesothelial cells showed the normal pattern.
Conclusions
Morphometric and FISH analyses, together withconventional stains and immunocytochemistry, using LBC
method can be used as ancillary techniques in differentiation of
adenocarcinoma and mesothelial cells.
Acknowledgment
The author is grateful to Dr. Akihiro Ito, Toki General
Hospital, for providing clinical materials and Prof. Tsutomu
Kawabe, Nagoya University School of Health Sciences, forreviewing the manuscript and giving useful advice.
References[1]Bernstein SJ, Sanchez-Ramos L, Ndubisi B. Liquid-based
cervical cytologic smear study and conventional
Papanicolaou smears: a metaanalysis of prospective studies
comparing cytologic diagnosis and sample adequacy. Am J
Obstet Gynecol 2001;185:308-17.
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Tamada Y, Banno K, Suzuki A, Suzuki N, Tsuda H,
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applicable to intraoperative cancer cytodiagnosis. Cancer
Lett 2000;158:165-9.

MOLECULAR MECHANISM OF CERAMIDE KINASE GENE REPRESSIONON ATRA-INDUCED NEURONAL DIFFERENTIATION
Masashi Murakami1), 2), Hiromi Ito2), Kazumi Hagiwara2), 3), Noriko Sasaki2),
Misa Kobayashi2), Asuka Hoshikawa2), Akira Takagi2), Tetsuhito Kojima2),
Keiko Tamiya-Koizumi4), Yoshiko Banno5), Yoshinori Nozawa6), Takashi Murate2), 7)
1) Research Fellow of the Japan Society for the Promotion of Science, 2) Department of Pathophysiological Laboratory
Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan, 3) National Hospital Organization, Nagoya
Medical Center, Nagoya, Japan, 4) Division of Molecular Pathology, Aichi Cancer Center, Nagoya, Japan, 5)
Department of Cell Signaling, Gifu University Graduate School of Medicine, Gifu, Japan, 6) Gifu International Instituteof Biotechnology, Kakamigahara, Japan, 7) Department of Medical Technology, Nagoya University School of Health
Sciences, Nagoya, Japan
Introduction
Ceramide kinase (CERK) is the enzyme that
phosphorylated ceramide to ceramide 1-phosphate (C1P).
Previous studies suggested that ceramide kinase (CERK)
and its product, ceramide 1-phosphate (C1P) have been
implicated in various cellular function including cellular
proliferation, survival, mast cell degranulation, andphagocytosis.
However, the regulatory mechanism of CERK gene
expression remains to be determined.
In the current study, we examined the regulatory
mechanism of CERK gene expression during all-transretinoic acid (ATRA)-induced neuronal differentiation of ahuman neuroblastoma cell line, SH-SY5Y cells.

Figure 1. A: The shape factor (SHF) is dimensionless and its
value is equal to 1.0 in circles and <1.0 in spheroid nuclei.
B: The shape factor (SHF) of this picture shows 0.743, thenuclear area (NA) is 84.065m2, the nuclear perimeter (NP)is 37.700m, and the length of nuclear longer axis (LLA) is
14.183m.

Figure 2. Results of morphometric analysis of mesothelial cells
and adenocarcinoma cells on LBC slides. MC: mesothelial cells,
GAC: gastric adenocarcinoma cells, CAC: colonicadenocarcinoma cells.
Author address

E-Mail: morimoto.ayumi@b.mbox.nagoya-u.ac.jp

MT-5

Materials and Methods
Cell line: A human neuroblastoma cell line, SH-SY5Y,
was cultured in Dulbecco’s Eagle’s medium supplemented
with 10% fetal bovine serum.
Establishment of CERK stable transfectants: Human
CERK cDNA was the kind gift of Dr. Kohama T. (DaiichiSankyo Co., Ltd., Tokyo, Japan). hCERK cDNA wasinserted into pcDNA3.1(+) expression vector (Invitrogen,
California, USA). To establish the stable transfectants of
CERK, DNA transfection was performed by the calcium
precipitation method. A subclone (sc 17) showing the highest
CERK protein expression was used for further experiments.
Cell proliferation and cell death: Cell proliferation wasdetermined in triplicate with WST-1 assay kit (Roche
Applied Science, Mannheim, Germany). Cell death was
determined with LDH-cytotoxic test (Wako Pure Chemical
Industry, Osaka, Japan).
CERK enzyme activity: CERK activity was determined as
described previously [1] with some modification.
 Western blotting: Western blotting was performed using
ECL plus western blotting system (Amersham Pharmacia
Biotech, Buckinghamshire, UK).
Quantitative RT-PCR: Quantitative RT-PCR was
performed as described previously [2]. The primers were as
follows: CERK sense 5’-AGTCCACCACAACAGCAC-3’,
antisense
5’-GAGGAAGGTCTTTAAACCTG-3’,
Sphingosine
kinase1(SPHK1)sense
5’TCCTGGCACTGCTGCACTC-3’,
antisense
5’TAACCATCAATTCCCCATCCAC-3’, and GAPDH sense5’-CAGGAGCGAGATCCCTCCAA-3’,
antisense
5’CCCCCTGCAAATGAGCCC-3’.
Cloning of the 5’-promoter region of human CERK:
Human CERK 5’-promoter region was prepared using a
PCR-based method. Using suitable restriction enzymes, thispromoter region was inserted into pGL3 Basic vector(Promega, Madison, USA). The deletion mutants were

MT-6

prepared using Exonuclease III digestion, PCR-based cloning,
and restriction enzymes digestion method. To introduce themutation to the RARE like motif, overlap extension PCR
method was performed.
Luciferase assay: SH-SY5Y cells were plated at a density of
5x105cells/ml in 35mm dishes. After 2 days of incubation,
0.5µg of promoter construct and 2µg of -galactosidase
expression vector were co-transfected into cells using lipofectin
reagent (Invitrogen) according to the manufacturer’s protocol.
Luciferase activity and -galactosidase activity were measured
according to the method described previously [3].
Electrophoresis mobility shift assay (EMSA): EMSA was
performed as described previously [4]. One µg of nuclear
extract and 600 fmol of biotin-labeled probe were incubated atroom temperature for 40 min. Cold probe was used for thecompetition experiment (x20 excess). For the supershift
experiments, anti-RARantibody, anti-RXR antibody, andanti-COUP-TFI antibody (Santa Cruz) were used.
DNA pull-down assay: Nuclear extract, biotin-labeled
double strand probe and Poly dI-dC were incubated in DNAP
buffer for 30min on ice. Following the incubation, Dynabeads
M-280 streptavidin (Invitrogen Dynal AS, Oslo, Norway) wereadded and mixed with rotator at 4oC for 30 min. Prior to thisstep, the beads were washed in DNAP buffer for 10 min withrotator at three times. After washing, dissolved in SDS sample
buffer and heated at 95oC for 5 min. Western blotting was
performed using anti-RAR, anti-RXR, and anti-COUP-TFI
antibody.
Chromatin immunoprecipitation assay (ChIP assay): ChIP
assay was performed as described previously [4]. For
immunoprecipitation, normal IgG, anti-RAR, anti-RXR,
anti-COUP-TFI, anti-N-CoR, anti-SMRT, and anti-HDAC3
antibody (Santa Cruz) were added to the lysate. The CERK
promoter region was amplified by PCR using the following
primerset.
Sense:
5’-GTCCCCTCCGCGGTCCCC-3’,
antisense: 5’-GCTTCACCCACAGCACGGATT-3’.
Transient transfection followed by co-immunoprecipitation:
The plasmids of RAR RXR, and COUP-TFI were the giftof Dr. W. H. Miller (McGill University, Quebec, Canada), Dr.
R.M. Evans (The Salk Institute for Biological Studies, CA,USA), and Dr. G. Salbert (Universite de Rennes I, Rennes,
France), respectively. After transfection with respective plasmid
DNA using lipofectin reagent (Invitrogen), SH-SY5Y cells weretreated with either ATRA or methoprene acid, a specific agonistof RXR, for 24 h. Co-Immunoprecipitation assay was
performed by described previously [5] with some modification.
Results
ATRA reduced CERK enzyme activity, CERK protein, andmRNA expression whereas another sphingolipid metabolic

enzyme, SPHK1 that had similar function to CERK, did notshow significant changes with ATRA.
To examine transcriptional regulation of ATRA-induced
CERK gene repression, promoter analysis was performed.
ATRA reduced CERK promoter activity, and thisreduction was mainly because of the region between -40 and-28 bp from the first exon. In this region, the tandem retinoic
acid responsive element (RARE) like motifs were identified
with one base space. Introduction of mutation into these
RARE like motifs, erased ATRA-induced inhibition of
CERK promoter activity.
To determine which transcription factor was bound inthese RARE like motifs, EMSA, DNA-pull down assay, andChIP assay were performed.
These experiments revealed that ATRA induced bindingof retinoic acid receptor  (RAR), retionid X receptor (RXR),
Chickenovalbumin
upstreampromotertranscription factor I (COUP-TFI) to these RARE like motifs.
Moreover, ChIP assay showed that HDAC3, N-CoR, and
SMRT were recruited to these RARE like motifs.
Transient expression of RAR, RXR, and COUP-TFI
and siRNA transfection of these genes concluded that
COUP-TFI inhibited CERK mRNA.
Another ATRA-induced differentiation model, humanacute myeloblastic leukemia cell line, HL60 cells, showedsome increase of CERK mRNA with ATRA. Interestingly,
ATRA induced binding of RARand RXRto these RARE
like motifs, but COUP-TFI didn’t.
These results suggested that the relative ratio of
RAR/RXR and COUP-TFI/RXR or COUP-TFI/RAR might
determine the level of CERK transcription in different celllines.
To examine a function of CERK on cell proliferation,
cell death, and neuronal differentiation of SH-SY5Y cells,
we established stable transfectants of CERK. CERK overexpression counteracted ATRA-induced inhibition of cellproliferation and cell death under the serum starvation. On
the contrary, siRNA of CERK enhanced the effect of ATRA
on cell growth and cell death.
Furthermore, to examine the effect of neuronaldifferentiation, ATRA-induced neurite extension and growth
associated protein-43 (GAP-43) protein expression, which
was main component of growth cone, was examined. CERK
over-expression
inhibited
ATRA-induced
neuronaldifferentiation. On the contrary, siRNA of CERK enhanced
neuronal differentiation.
These results revealed that CERK promoted cellproliferation and cell survival, and had an inhibitory effectagainst ATRA-induced neuronal differentiation.
Discussion
Recent analysis revealed that sphingolipid and their
metabolic enzymes were involved in cellular signalling, cell
survival, and cell death. CERK and its product, C1P havealso been suggested to play an important role of cell survival
and inflammation [6, 7]. Intriguingly, CERK is mainly
distributed in brain, especially, highly expressed in
cerebellum [8].
Our results of stable transfectants of CERK and siRNAof CERK not only confirmed previous results but also
revealed CERK as the unique modulator of neuronal cellfunction in SH-SY5Y cells. It is very interesting that further
analysis of elucidating the function of CERK in central
nervous system.
We recently reported that SPHK1 gene expression wasincreased during glial-cell line derived neurotrophic factor(GDNF) induced neuronal differentiation of humanMT-6

neuroblastoma cell line, TGW cells [9]. But in ATRA-induced
neuronal differentiation of SH-SY5Y cells, SPHK1 expression
didn’t show any change. This result suggested that CERK andSPHK1 play non-overlapping roles in neuronal differentiation.
Vitamin A and its major metabolite, ATRA, are essential for
network formation during early brain development [10]. COUPTFI involvement in modulating ATRA-induced differentiation
has been reported in multiple cell types [11, 12]. Our results
suggested that COUP-TFI modulated ATRA-induced CERK
expression, and the possible role of CERK in the early
physiological process of normal neuronal differentiation.
Conclusion
CERK is antagonistic to ATRA-induced neuronaldifferentiation and that a tandem RARE like motifs located in
the 5’-promoter region was responsible for ATRA
responsiveness, and found that COUP-TFI induced with ATRA
treatment was responsible for CERK gene repression.
References[1]Bajjalieh SM, Martin TF, Floor E. Synaptic vesicle ceramide
kinase. A calcium-stimulated lipid kinase that co-purifies withbrain synaptic vesicles. J. Biol. Chem. 1989;264:14354-14360.
[2]Sobue S, Iwasaki T, Sugisaki C, et al. Quantitative RT-PCR
analysis of sphingolipid metabolic enzymes in acute leukemia
and myelodysplastic syndromes. Leukemia 2006;20:2042-2046.
[3]Nakade Y, Banno Y, T-Koizumi K, et al. Regulation of
sphingosine kinase 1 expression by protein kinase C in a humanleukemia cell line, MEG-O1. Biochim. Biophys. Acta
2003;1635:104-116.
[4]Sobue S, Hagiwara K, Banno Y, et al. Transcription factor
specificity protein 1 (Sp1) is the main regulator of nerve growth
factor-induced sphingosine kinase 1 gene expression of the rat
pheochromocytoma cell line, PC12. J. Neurochem.
2005;95:940-949.
[5]Lee HK, Park UH, Kim EJ, Um SJ. MED25 is distinct from
TRAP220/MED1 in cooperating with CBP for retinoid receptor
activation. EMBO J. 2007;26:3545-3557.
[6]Gomez-Munoz A, Kong JY, Parhar K, et al. Ceramide-1phosphate promotes cell survival through activation of thephosphatidylinositol 3-kinase/protein kinase B pathway. FEBS
Lett. 2005;579:3744-3750.
[7]Mitsutake S, Kim TJ, Inagaki Y, et al. Ceramide kinase is amediator of calcium-dependent degranulation in mast cells. J.
Biol. Chem. 2004;279:17570-17577.
[8]Mitsutake S, Yokose U, Kato M, et al. The generation andbehavioral analysis of ceramide kinase-null mice, indicating afunction in cerebellar Purkinje cells. Biochem. Biophys. Res.
Commun. 2007;363:519-524.
[9]Murakami M, Ichihara M, Sobue S, et al. RET signalinginduced SPHK1 gene expression plays a role in both GDNFinduced differentiation and MEN2-type oncogenesis. J.
Neurochem. 2007;102:1585-1594.
[10]Ross SA, McCaffery PJ, Drager UC, De Luca LM.
Retinoids in embryonal development. Physiol. Rev.
2000;80:1021-1054.
[11]Beland M, Lohnes D. Chicken ovalbumin upstream
promoter-transcription factor members repress retinoic acidinduced Cdx1 expression. J. Biol. Chem. 2005;280:1385813862.
[12]Zhuang Y, Gudas LJ. Overexpression of COUP-TFI in
murine embryonic stem cells reduces retinoic acid-associatedgrowth arrest and increases extraembryonic endoderm gene
expression. Differentiation 2008;76:760-771.
Author address

E-Mail: murakami.masashi@c.mbox.nagoya-u.ac.jpPhysical Therapy (13:30 16:00 Lecture Room 3)
Chaired by the academic adviser of each presenter

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S. Ota1), M.Kawamura1)
1) Department of Physical Therapy, School of Health Sciences, Nagoya University, Nagoya, Japan

Introduction
Passive patellar mobility was believed to be one of theimportant forms of assessment for patient withpatellofemoral pain (PFP) and the decreased range of motion(ROM) at the knee joint. Moreover, it shows the laxity of theknee joint which could also contribute to sports knee injuries.
However, there is no methods to assess the quantitative
measurment of patellar mobility in clinical situation. Given
the need for objective measurements of patellofemoral (PF)joint impairments, we have developed a clinical device(patellofemoral joint arthrometer [PFA]) to quantify mediolateral patellar displacement.
The purposes of this research were 1) to assess the validyof prototype PFA, 2) to apply PFA to the person with PF andto compare with the healthy subjects, 3) to investigate therelationship of patellar mobility and knee ROM after total
knee arthroplasty (TKA).
Materials and Methods
Study 11)
Subjects: A total of 26 individuals (24 females and 2
males) participated, and 14 were asymptomatic with PFP.
The average ± SD age, height and body mass of theparticipants was 27 ± 4 years, 164 ± 5 cm, and 59 ± 8 kg,
respectively. Twelve of the participants had a current historyof patellofemoral pain at the time of testing, while 14 wereasymptomatic.
Methods: A custom designed prototype PFA was used toassess the amount of lateral patellar displacement. PFA wassecured to the femoral condyle, and the femur was refer tothis measurement. The adjustable arm allowed the medial
border of the patella to be localized in the frontal plane withrespect to the fixed ruler. Subjects were measure thedisplacement of lateral patella between quadriceps relaxed
and isometirc contracted by PFA. Following assessment oflateral patellar displacement using the PFA, participants
underwent MRI of the patellofemoral joint. The sameprocedures of using PFA was performed on using MRI.
Bisect offset index and patellar tilet angle was measured thetrue lateral patellar displacment. The comparion of thesepatellar mobilities using both methods was performed as thevalidity study.
Study 22)
Subjects: The study comprised 22 females with PFP (PFP
group) and 22 females who had no knee pain (control group)
who were matched to the subjects with PFP based on age,height, and body mass index.
Mehtods: Patellar mobility was measured objectively
using PFA. Measurements of lateral and medial patellar
displacement, patellar mobility balance (lateral minus medialpatellar displacement), lateral patellar mobility index (LPMI:
lateral patellar displacement/ patellar width), and medialpatellar mobility index (MPMI: medial patellar displacement/
patellar width) were used.

Figure 1. Patellofemoral arthorometer!

Figure 2. Initial positon of the patellar mobility (set 0 mm ofthe digital caliper)
The PFA was clamped to the femoral condyles aligned
parallel to the table. The digital caliper was positioned at anangle of 90 degrees to the line between the center of the patella
and the ASIS using the plane adjuster. Before each subject wasmeasured, the amount of force (approximately 80N) to be used
to move the patella for testing was practiced using a hand-helddynamometer, MicroFET2 (Hoggan Health Industries Inc.,
West Jordan, UT) to enable the examiner “to feel” what it was
like to apply an 80N force. For testing, relaxation of themusculature was confirmed by palpation of the quadriceps andpassively moving the patella in the lateral and medial
directions.17 To measure lateral patellar mobility, the lateralborder of the patella was palpated and located with a laser using
the adjustable laser module arm, and the digital caliper was
zeroed, setting this point as the initial position. Lateraldisplacement of the patella was then achieved by manuallypushing the patella laterally (applying approximately 80N offorce), at which point the lateral border of the patella was again

PT-1



located by sliding the laser module arm on the caliper andreading the measurement. Medial passive patellar mobility
was assessed in the same manner except for the force
application being applying toward the medial direction. Allof these procedures for passive patellar mobility were
performed by the same tester for all subjects.
Study 33)
Subjects: Fifty-one patients [osteoarthritis (OA) group:
34 knees; rheumatoid arthritis (RA) group: 22 knees] were
examined after TKA.
Methods: Patellar mobility was measured preoperatively
and 1, 2, and 6 months postoperatively using a patellofemoral
arthrometer (PFA) fixed to the femoral condyles to measure
medial and lateral patella displacement at 30 degrees of knee
joint. Knee joint ROM was also measured in each of these 4
sessions.
All participates in these studies were approved by each
Ethics Committee of the University of Southern California
and the school of Health Sciences, Nagoya University.
Data analysis: Patellar mobility was measured threetimes, and the averages of the displacements were used inthese studies.
For the validity study was used intra-class correlation(ICC2,k), and t test was performed to compare thedisplacements between PFP group and control group in study
2. For the analysis of the relationship between patellar
mobility and ROM in the study 3 were used the Pearson
correlation. The differences between each session was using
ANOVA and Tukey’s procedure. Significance was set at
P<0.05.
Results
Study 1: The ICC assessing the level agreement between
the MRI and PFA measures of lateral patellar displacement
was good (0.86). Excellent intratester (ICCs of 0.96 and0.97) and intertester reliability (ICC 0.92) was demonstrated.
Study 2: Lateral and medial patellar mobility values were
not significantly different between the individuals in the PFP
and control groups. When normal patellar mobility wasarbitrarily defined as the average ± 2SD based on the datafrom the control group, normal lateral patellar displacement
was within a range of 7.2 to 17.6 mm and normal medialpatellar displacement was within a range of 6.8 to 14.0 mm.
Study 3: In the OA group, lateral patellar mobility was
positively correlated with knee flexion angle, while there wasno correlation between medial patellar mobility and knee
flexion angle. Knee joint extension was not correlated witheither lateral or medial patellar mobility. In the RA group,
both lateral and medial patellar mobility were positively
correlated with knee joint flexion/extension 1 and 2 months
after TKA.
Although, knee ROM were significantly improved from 1
month to 6 months after TKA, medial and lateral patellar
mobility were not improved.
Discussion
From the study 1, the validity of the prototype PFA
compared to MRI method was acceptable range in theclinical application. This prototype was made ofpolyethylene for using in side of MR imaging.
Study 2 was introduced to PFA to apply the clinicalevaluation. PFA was adjusted the patellar mobility using
equipped the adjustable lever, lever joints and laser. Based on

an arbitrarily defined normal range of values calculated using
the mean ± 2SD of the patellar displacements measured for theindividuals in the control group, we note that the distribution of
the data points are very similar between the 2 groups, with only
few subjects with PFP falling outside what we considered anormal range of scores. From the results of this study, abnormal
patellar mobility might not be a factor in female adults withmild symptoms of PFP.

Figure 3. Changes of knee flexion angle and patellar
mobility in OA group
In the study 3, although patellar mobility was shown to berelated to knee ROM after TKA, there were differences in therelationship between OA and RA groups. In both groups, lateral
patellar mobility was positively related to knee flexion angle 1
and 2 months after TKA. In the OA group, knee extension was
not associated with patellar mobility, while lateral and medialpatellar mobility were related to knee ROM (flexion andextension) after TKA in the RA group. Although these features
should be taken into consideration in planning of physicaltherapy treatment regimens to improve patellar mobility after
TKA, the relations identified in the present study represent only
cross-sectional findings. However, our findings demonstrated
that medial and lateral patellar mobility had no sufficientlongitudinal relationship with knee ROM after TKA.
Conclusions
We have developed PFA to asess the patellar mobility
quantitatively, and we apllied it to patients with PFP and after
TKA. The patellar mobility might not be a factor in thisresearch sujects with PFP (mild symptom). The knee ROM after
TKA could not be related to medial and lateral patellar
displacement. This study woulbe a framework for a future
clinical trial on patellar mobility in patient with knee disorder.
References[1]Ota S, Ward SR, Chen YJ, Tsai YJ, Powers CM. Concurrent
criterion-related validity and reliability of a clinical device
used to assess lateral patellar displacement. J Orthop Sports
Phys Ther. 2006;36(9):645-652.
[2]Ota S, Nakashima T, Morisaka A, Ida K, Kawamura M.
Comparison of Patellar Mobility in Female Adults With andWithout Patellofemoral Pain. J Orthop Sports Phys Ther.
2008;38(7):396-402.

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0=:C   8:AAH 9>;;:G:CI>6I:9 >CID H@:A:I6A BJH8A: 8:AAH
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DI=:G  -=:N ;>C6AAN 8DCHIGJ8I:9 H6G8DB:G:H :M=>7>I>C< 76C9H
L>I=BNDH>C6C968I>C;>A6B:CIHG:<JA6GAN6GG6N:9  ;:L    8:AAH :MEG:HH:9 ' 869=:G>C >BBJCDG:68I>K>IN7JII=:N9>9CDI;DGBBNDIJ7:HJC9:GI=:H6B:8DC9>I>DC 





A dipogenesis C D105(endoglin)Osteogenesis M agnetic C ell SortingChondrogenesis
MSCs
 M A CS
M usculogenesisA dipose 9>ED<:C:H>H,8:AAH
cells[3]Ota S, Nakashima T, Morisaka A, Omachi T, Ida K,
Kawamura M. Is latero-medial patellar mobility related to
the range of motion of the knee joint after total knee
arthroplasty? Manual Therapy. 2010 (in press)
Author address

E-Mail: s-ota@met.nagoya-u.ac.jp

F ig. 1

Schematic view of the induction and isolation of MSCs from ES cells



PT-1

 

PT-2



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>CID H@:A:I6A BJH8A:H D; >C?JG:9 I>7>6A>H 6CI:G>DG BJH8A:H  AA
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Discussion
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8:AAH >C8AJ9>C< ,H  ABDHI 6AA G:EDGIH 9:H8G>7>C<
B:H:C8=NB6AHI:B8:AAH=6K:9:BDCHIG6I:9I=::MEG:HH>DCD;  DC I=: 8:AA HJG;68: ;JGI=:G <:C: :MEG:HH>DC EGD;>A:H
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:MEG:HH     -=>H >C9>86I:H I=6I DCAN HI:B 8:AAH DG
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8=DC9GD8NI:H DHI:D<:C>8 8:AAH 6C9 H@:A:I6A BJH8A:H >C K>IGD
6C9 >C K>KD  -=:>G 9>;;:G:CI>6I>DC EDI:CI>6A >C9>86I:H I=6I  8:AAH L:G: B:H:C8=NB6A HI:B 8:AAH ',H  )JG',H L:G: :6H>AN 9>;;:G:CI>6I:9 >CID H@:A:I6A BJH8A:H
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9:E:C9H DC I=: B:9>JB 8DCI6>C>C< >CHJA>C 6C9 - ;DG

References
4 5#O69E6C6=+-GN<<*6I:A%G>:9IJ;DJG$!>B7A:
$'JCC:AA >DAD<>8EGDE:GI>:HD;B:H:C8=NB6AHI:B
8:AAH9:G>K:9;GDB7DC:B6GGDL6C969>EDH:I>HHJ:  &&$)# '    
45,8=P;;A:GR8=A:G DC8>H:G:K>:L69>EDH:I>HHJ:
9:G>K:9HIGDB6A8:AAH 76H>86C98A>C>86A>BEA>86I>DCH;DGCDK:A
8:AA 76H:9I=:G6E>:H - ' &&,    
45%6L6<J8=>$ !:C:G6I>DCD;)HI:D7A6HI6C9=DC9GD8NI:H;GDBB7GNDC>8,I:B:AAH #C-JG@H:C%:9 B7GNDC>8,I:B:AA*GDID8DAH>;;:G:CI>6I>DC'D9:AH ,:8DC99>I>DC -DIDL6(L$:GH:N"JB6C6*G:HH#C8     
456C>,B>I=!:HHDA>C,&:GDN*,I688>C>
&/>AA6<:D>H*6G>BDCI>A=6J9! >;;:G:CI>6I>DCD;
:B7GNDC>8HI:B8:AAH>CID69>ED8NI:H>CK>IGD  &&$ *I    45-G>K:9>*":B6II>* :G>K6I>DC6C9>BBJCDAD<>86A
8=6G68I:G>O6I>DCD;B:H:C8=NB6AHIGDB6A8:AAH;GDB=JB6C
:B7GNDC>8HI:B8:AAH 0* '-)&   
45JCC:AA A66I'!6<A>6G9>*6I:A+>EDAA 
9>EDH: 9:G>K:9HI:B8:AAH>HDA6I>DC:ME6CH>DC6C9
9>;;:G:CI>6I>DC  -#),    
450>AHDC'+DIL:>C* DCIGDAD;'ND;JC8I>DC9JG>C<>C>I>6I>DCD;BJH8A:9>;;:G:CI>6I>DC7N6C6JID8G>C:H><C6A>C<
E6I=L6N68I>K6I:97N>CHJA>C A>@:<GDLI=;68IDG ##  $)&# '    A uthor address!"#$%&'()%)$*$+$,)$)$-.,/.01,)$*02$"3,$4,56((

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-+!6DA:5B&=%'5?5;=!)<(!J:)'<!7>'D<>D,!6);5=)!K'C=!E<'FD:%'C=!G:)(A)CD!7>&55?!5H!.D('>'<D,!6);5=),!I)B)<!
8+!LDB):C0D<C!5H!9&=%'>)?!4&D:)B=,!7>&55?!5H!/D)?C&!7>'D<>D%,!6);5=)!E<'FD:%'C=!6);5=),!I)B)<!

!
!
Introduction
M5:>D(! '0B)':D(! H5:D?'0N! A%D! OMPE+! '%! 1<52<! )%! )<!
DHHD>C'FD! 0DC&5(! C5! B:505CD! HA<>C'5<)?! :D>5FD:=! 5H! C&D!
)HHD>CD(! H5:D?'0N! )HCD:! &D0'B?D;'>! %C:51D! OD#;#,! >5<%C:)'<CQ'<(A>D(! 05FD0D<C! C&D:)B=+! R*,-S#! /52DFD:,! C&D! (DC)'?D(!
0D>&)<'%0! 5H! MPE! DHHD>C! 5<! C&D! N:)'<! 2)%! %C'??! A<>?D):#! $<!
C&'%! %CA(=,! 2D! '<FD%C';)CD(! 2&DC&D:! MPE! '<(A>D%! HA<>C'5<)?!
:D>5FD:=!)HCD:!%0)??!'<C:)>D:DN:)?!&D05::&);D!O$K/+!)<(!&52!
C&D!(50'<)<C!A%D!'<(A>D%!'0B:5FD0D<C!5H!05C5:!HA<>C'5<%#!!
!
Materials and Methods!
Experimental setup:! "(A?C! 0)?D! T'%C):! :)C%! O-UVQ8VV;+!
2D:D!&5A%D(!)C!)!*-!&!?';&CW():1!>=>?D!2'C&!H55(!)<(!2)CD:!)(!
?'N'CA0#! X)C%! 2D:D! :)<(50?=! )%%';<D(! C5! H5A:! ;:5AB%Y! $K/!
O<Z[+,!$K/QMPE!O<Z\+,!7&)0!O<ZU+!)<(!7&)0QMPE!OH5:>D(Q
B:DHHD:D(!?'0N!A%DY!<Z]+#!!"??!D^BD:'0D<C)?!B:5>D(A:D%!2D:D!
BD:H5:0D(! '<! )>>5:()<>D! 2'C&! C&D! )<'0)?! >):D! ;A'(D?'<D%! 5H!
C&D! 6);5=)! E<'FD:%'C=#! M';A:D! *! %&52%! )! C'0D?'<D! 5H! C&D!
BD:H5:0D(!D^BD:'0D<C%#!
Intracerebral hemorrhage: $<!C&D!B:D%D<C!%CA(=,!2D!A%D(!
'<CD:<)?! >)B%A?D! &D05::&);D! 05(D?! R8S#! E<(D:! (DDB!
)<D%C&D%'),! *#_! ?! K5??);D<)%D! O*U! E<'C%W0?,! 4=BD! $`a!
7';0)Q"?(:'>&,!7C#! P5A'%,! .@,!E7"+! 2D:D! '<bD>CD(!'<C5!C&D!
'<CD:<)?!>)B%A?D!>5<C:)?)CD:)?!C5!C&D!B:DHD::D(!H5:DB)2#!M';A:D!
-!%&52%!)!C=B'>)?!&'%C5?5;'>)?!)BBD):)<>D!5H!&D05::&);D#!
Forced-impaired limb use: MPEQC:D)CD(! )<'0)?%! 2D:D!
H'CCD(! 2'C&! )! *Q%?DDFD! B?)%CD:! >)%C! -_&:%! )HCD:! $K/! %A:;D:=#!
4&D! ABBD:! C5:%5! )<(! C&D! A<'0B)':D(WA<B:DHD::D(! H5:D?'0N!
2D:D! 2:)BBD(! '<! %5HC! HD?C! )<(! 9?)%CD:! 5H! 9):'%! %C:'B%#! X)C%!
2D:D! H5:>D(! C5! >50B?DCD?=! :D?=! 5<! D'C&D:! C&D':!
'0B)':D(WB:DHD::D(!H5:D?'0N!H5:!*!2DD1#!!
Behavioral assessment: "HCD:!:D%C:)'<C,!:)C%!2D:D!)%%D%%D(!
F):'5A%! H5:D?'0N! 05C5:! HA<>C'5<%,! %A>&! )%! %1'??D(! :D)>&'<;!
O)%%D%%D(!N=!%'<;?D!BD??DC!:D)>&'<;!CD%C+,!>55:('<)CD(!H5:D?'0N!
%CDBB'<;! ON=! ?)((D:! CD%C+,! %B5<C)<D5A%! A%D! 5H! C&D! '0B)':D(!
H5:DB)2! ON=! >=?'<(D:! CD%C+,! )<(! C)>C'?DQDF51D(! H5:D?'0N!
B?)>'<;! O>5<C)>C! B?)>'<;! :D%B5<%D+#! M';A:D! 8! %&52%! C&D!
)BBD):)<>D%! 5H! C&D%D! CD%C%#! "%%D%%0D<C! 2)%! >)::'D(! 5AC! )C!
B5%C5BD:)C'FD!()=!*VQ*-!)<(!-]Q-[#!JDH5:D!$K/,!%'<;?D!BD??DC!
:D)>&'<;!CD%C!)<(!?)((D:!CD%C!2D:D!B:DQC:)'<D(!)<(!(DCD:0'<D(!
N)%D?'<D!BD:H5:0)<>D#!!
Lesion volume: "HCD:!C&D!>50B?DC'5<!5H!ND&)F'5:)?!CD%C'<;,!
)??! )<'0)?%! 2D:D! (DDB?=! )<D%C&DC'cD(! )<(! BD:HA%D(!
C:)<%>):(')??=! 2'C&! V#\d! %)?'<D! H5??52D(! N=! _d! B&5%B&)CDQ
NAHHD:D(! B):)H5:0)?(D&=(D! OB/! e#_+#! 4&D! N:)'<%! 2D:D!
:D05FD(! )<(! B5%CH'^D(,! )<(! C&D<! _V! 0! C&'>1! >5:5<)?!
%D>C'5<%!2D:D!5NC)'<D(!A%'<;!)!>:=5%C)C#!4&D%D!%D>C'5<%!2D:D!
B:5>D%%D(! 2'C&! &D0)C5^=?'<DfD5%'<! %C)'<'<;! )<(! F5?A0D! 5H!
?D%'5<!2)%!(DCD:0'<D(#!
Retrograde labeling of corticospinal tract: "<!)(('C'5<)?!
;:5AB! 5H! :)C%! O$K/a! <Z],! $K/QMPEa! <Z],! 7&)0a! <Z\+! 2)%!
A%D(! H5:! gA)<C'H'>)C'5<! 5H! C&D! :D0)'<'<;! >5:C'>5%B'<)?! C:)>C#!
"HCD:! %)0D! MPE! C:D)C0D<C,! )<'0)?%! 2D:D! )<D%C&DC'cD(! )<(!
C&D':! %B'<)?! >5:(%! 2D:D! D^B5%D(! )C! C&D! K]fK[! ?DFD?! A%'<;!
?)0'<D>C50=#! _d! H?A5:5;5?(! OMGa! J'5C'A0,! /)=2):(,! K"+!
2)%! '<bD>CD(! '<C5! C&D! %B'<)?! >5:(! 2'C&! )! ;?)%%! 0'>:5B'BDCCD#!

h)>&! )<'0)?! &)(! H5A:! '<bD>C'5<%! 5H! -UV! <?! 5H! MG! %B)>D(!)C! V#U!
00,! )?5<;! C&D! %B'<)?! >5:(! OV#eU! 00! ?)CD:)?! H:50! C&D! 0'(?'<D!
)<(! *#-! 00! ND?52! C&D! %B'<)?! >5:(! %A:H)>D+#! 7DFD<! ()=%! )HCD:!
'<bD>C'5<,! )<'0)?%! 2D:D! BD:HA%D(! )<(! B:5>D%%D(! H5:!
>:=5%D>C'5<'<;#!7D:'D%! 5H! 8V! 0! N:)'<!>:5%%! %D>C'5<%! O2'C&! *[V!
0!;)B%+!2D:D!A%D(!H5:!gA)<C'H'>)C'5<!5H!?)ND?D(!>D??%#!
Real-time PCR: 7DB):)CD!>5&5:C%!5H!)<'0)?%!D^B5%D(!C5!C&D!
%)0D! MPE! C:D)C0D<C! 2D:D! A%D(! H5:! gA)<C'C)C'FD! C:)<%>:'BC'5<!
B5?=0D:)%D!:D)>C'5<!O9KX+!)<)?=%'%!O$K/a!<Z],!$K/QMPEa!<Z],!
7&)0a! <Z],! 7&)0QMPEa! <Z]+#! 7D<%5:'05C5:! >5:CD^! H5:D?'0N!
:D;'5<!&):FD%CD(!)C!C&D!D<(!5H!C&D!MPE!BD:'5(!2)%!)<)?=cD(!N=!
:D)?QC'0D!9KX!5H!N:)'<Q(D:'FD(!<DA:5C:5B&'>!H)>C5:!OJL6M+!)<(!
;:52C&Q)%%5>')CD(!B:5CD'<!_8!OG"9_8+#!!
! Statistical analyses: @<DQ2)=! "6@`"! H5??52D(! N=! )!
4A1D=! B5%C! &5>! CD%C! 2)%! A%D(! H5:! %C)C'%C'>)?! )<)?=%D%! 5H!
ND&)F'5:)?! CD%C%,! MGQB5%'C'FD! >D??! <A0ND:,! )<(! :D)?QC'0D! 9KX!
)%%)=#!7CA(D<Ci%!CQCD%C!2)%!A%D(!H5:!?D%'5<!F5?A0D#!"??!%C)C'%C'>)?!
)<)?=%D%! 2D:D! >5<(A>CD(! A%'<;! C&D! %C)C'%C'>)?! %5HC2):D! 7977!
O:D?D)%D!*-#V+#!L)C)!):D!B:D%D<CD(!)%!0D)<%!j7h.#!
!
Results !
Behavioral assessment:!"HCD:!MPE!C:D)C0D<C,!'0B:5FD0D<C!
5H! C&D! %1'??D(! :D)>&'<;! C)%1! '<! %'<;?D! BD??DC! :D)>&'<;! CD%C! 2)%!
H5A<(! '<! C&D! $K/QMPE! '<! >50B):'%5<! 2'C&! $K/! :)C%#!
"(('C'5<)??=,! C&D! :D)>&'<;! %C=?D! 5H! $K/QMPE! ;:5AB! 2)%! 05:D!
<5:0)??=! C&)<! $K/! ;:5AB#! JDCCD:! BD:H5:0)<>D! 5H! %1'??D(!
%CDBB'<;! '<! ?)((D:! CD%C! 2)%! )?%5! %&52<! '<! C&D! $K/QMPE! ;:5AB!
C&)<! $K/! ;:5AB#! /52DFD:,! <5! %';<'H'>)<C! ('HHD:D<>D%! 2D:D!
H5A<(! '<! >=?'<(D:! CD%C! )<(! >5<C)>C! B?)>'<;! :D%B5<%D! )05<;!
D^BD:'0D<C)?!;:5AB%#!!
Lesion volume and remaining corticospinal tract:!$<bD>C'5<!
5H!?52Q(5%D!>5??);D<)%D!>)A%D(!%0)??!&D05::&);D!?5>)?'cD(!C&D!
'<CD:<)?!>)B%A?D!O%DD!H';A:D!-+#!/52DFD:,!?D%'5<!F5?A0D!2)%!<5C!
('HHD:D<>D! NDC2DD<! $K/! )<(! $K/QMPE! ;:5AB#! $<! B):)??D?,! C&D!
<A0ND:! 5H! MGQB5%'C'FD! <DA:5<%! '<! %D<%5:'05C5:! >5:CD^!
(D>:D)%D(! %';<'H'>)<C?=! )HCD:! $K/,! NAC! MGQB5%'C'FD! <DA:5<!
<A0ND:!2)%!%'0'?):!NDC2DD<!$K/!)<(!$K/QMPE!;:5AB#!!
Real-time PCR:!JL6M!)<(!G"9_8!):D!1<52<!)%!;:52C&Q
B:505C'<;!H)>C5:!)<(!'<F5?FD(!B?)%C'>!>&)<;D!5H!>D<C:)?!<D:F5A%!
%=%CD0#!"HCD:!MPE!C:D)C0D<C,!0X6"!D^B:D%%'5<!5H!JL6M!)<(!
G"9_8! 2)%! %';<'H'>)<C?=! D<&)<>D(! '<! $K/QMPE! )<'0)?%!
>50B):D(! 2'C&! $K/! )<(! 7&)0! )<'0)?%#! 4&D%D! >&)<;D%! 2D:D!
H5A<(!'<!C&D!%D<%5:'05C5:!>5:CD^!>5<C:)?)CD:)?!%'(D!C5!C&D!H5:>D(Q
A%D!%'(D!H5:D?'0N!O'B%'?)CD:)?!%'(D!C5!>5??);D<)%D!'<bD>C'5<+,!NAC!
<5C!'<!'B%'?)CD:)?!%'(D!O>5<C:)?)CD:)?!C5!'<bD>C'5<+#!!
!
Discussion$<! C&'%! %CA(=,! 2D! (D05<%C:)CD(! D):?=! MPE! B:505CD!
HA<>C'5<)?! :D>5FD:=! 5H! C&D! %1'??D(! 05FD0D<C! 5H! H5:D?'0N!
O:D)>&'<;,!?)((D:!%CDBB'<;+#!MA:C&D:05:D,!AB:D;A?)C'5<!5H!JL6M!
)<(!G"9_8!2)%!%&52<!'<!C&D!%D<%5:'05C5:!>5:CD^!>5<C:)?)CD:)?!
C5! C&D! H5:>D(QA%D! H5:D?'0N#! 4&D%D! ()C)! %A;;D%CD(! C&)C! A%DQ
(DBD<(D<C! B?)%C'>! )?CD:)C'5<%! '<! C&D! H5:D?'0N! %D<%5:'05C5:! ):D)!
25A?(!ND!'<(A>D(!N=!MPE!)HCD:!$K/,!>)A%'<;!%1'??D(!HA<>C'5<)?!
:D>5FD:=! 2'C&! :D?)C'5<! C5! D<&)<>D(! D^B:D%%'5<%! 5H! JL6M! )<(!
G"9Q_8#!

PT-3

!

hQ.)'?Y!'%&'()#)1'0)%)m>#0N5^#<);5=)QA#)>#bB!!

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Figure 1. Timeline of the experiments
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Figure 2. Typical photograph of internal capsulehemorrhage/D0)C5^=?'<!)<(!D5%'<!%C)'<'<;!8V!()=%!)HCD:!$K/!%&52%!
%0)??!&D05::&);D!?5>)?'cD(!C&D!'<CD:<)?!>)B%A?D!O)::52+#!

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Yuji Kono1), Sumio Yamada2), Kenta Kamisaka3), Amane Araki4), Yusuke Fujioka4),
Keizo Yasui4), Yasuhiro Hasegawa4), Yasuo Koike2)
1) Program in Physical and Occupational Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Physical Therapy, School of Health Sciences, Nagoya University, Nagoya, Japan
3) Rehabilitation Center, The Tazuke Kofukai Kitano Hospital, Osaka, Japan
4) Department of Neurology, Nagoya Daini Red Cross Hospital, Nagoya, Japan

Introduction
The high rate of stroke recurrence during several years
after first ever stroke has suggested in Hisayama study inJapan. Furthermore, the 70% of ischemic stroke patients havemild motor paresis. However, stroke recurrence has notstudied depends on the severity of the paresis, so precise datain the recurrence rate and predictive variables for strokerecurrence in mild stroke remained unknown. Threfore, This
study aimed to estimate 3 year cumulative recurrence rates
and identified independent predictors of vascular events after
TIA and mild ischemic stroke (IS).
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Figure 3. Behavioral tests!
O"QJ+!7'<;?D!BD??DC!:D)>&'<;!CD%CY!"!%&52%!C&D!)BB):)CA%!5H!
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<)::52!%?'C!N=!C&D':!'0B)':D(!H5:D?'0N!2)%!)<)?=cD(!OJ+#!
OKQL+!P)((D:!CD%CY!K:5%%'<;!C&D!*Q0!?5<;!?)((D:!2)%!F'(D5C)BD(!
)<(!)%%D%%D(!C&D!:)CD!5H!>5::D>C!%CDB!)<(!H)??#!K!(D05<%C:)CD(!
>5::D>C!%CDB!O0'(B5:C'5<!5H!?'0N!B?)>D(!5<!:A<;+!)<(!L!%&52D(!
H)??#!
Oh+!K=?'<(D:!CD%CY!X)C%!2D:D!B?)>D(!'<!)!B?D^';?)%!>=?'<(D:!U0'<,!
)<(!C&D!BD:>D<C);D!5H!C&D!'0B)':D(!?'0N!A%D!2&D<!C5A>&'<;!C&D!
>=?'<(D:!2)??!2)%!)<)?=cD(#!
OMQG+!K5<C)>C!B?)>'<;!:D%B5<%DY!X)C%!2D:D!&D?(!2'C&!C&D!
H5:D?'0N!%A%BD<(D(,!)<(!)(F)<>D(!A<C'?!C&D!(5:%A0!5H!C&D!
H5:DB)2!C5A>&D(!C&D!D(;D!5H!)!C)N?D!OM+#!65:0)??=,!:)C%!%&52!)!
B?)>'<;!:D%B5<%D!N=!D^CD<('<;!C&D!H5:DB)2!(';'C%!)<(!BACC'<;!
C&D0!5<!C&D!C)N?D!OG+#!
!

Materials and Methods
Subjects: From December 2005 to September 2006,
patients with acute TIA or IS who met criteria of modified
Rankin Scale 0~2, no communication disability andemergent admission to a sophisticated acute hospital in
Nagoya city district were consecutively enrolled in this study.
Patients with age over 80 years old, cardiogenic stroke,
severe dementia, psychiatry disorder and extracorporenal
dialysis were excluded. During hospitalization, we assessed
sex, family history, age, height, weight, stroke subtype, bloodpressure, lipid profile, fasting glucose, HbA1c, smoking,alcohol consumption, exercise habits, waist circumference,
and ankle-brachial pressure index (ABI). And we also
assessed physical activity and salt-intake at 3 month after
discharge. We divided into 4 groups followed by physicalactivity and salt intake. Primary outcome was recurrence ofstroke or other vascular events such as myocardial infarction,
angina pectoris, and peripheral artery disease during 3 years.
Statistical analysis: Continuous variables are expressed asmeanstandard deviation (SD). Univariate associations
between pathophysiological / lifestyle factors and recurrence
were assessed using Kaplan–Meier survival analysis, andsignificance was determined using the log rank test with
continuous variables analyzed as median value. Hazard ratios(HRs) for recurrence were determined by univariate Cox
proportional hazards regression analyses and variables with a
P value of <0.1 at univariate analysis were entered into a
multivariate Cox model to determine HRs. All statisticalanalyses were performed with the SPSS 16.0 software
package (SPSS Japan, Tokyo, Japan), and a P value of <0.05
was considered significant.
Results
�Study population
A total of 102 patients (78 men and 24 women) weresuccessfully followed for 3 years. The mean follow-up period
was 1134�80 day. The mean age at study entry was 65.0�
10.5 years.

PT-3

�Outcome at 3 years
Figure 1 shows the Kaplan–Meier estimates of cumulative
recurrence rates of stroke for all subjects. Twenty-five out of
102 patients (24.5%) had stroke recurrence, 4 (3.9%) had acoronary event, 2 (2%) died due to cancer, and 1 (1%) had no
fixed residence. Eight patients of the 25 who had recurrent
strokes had a severe stroke (mRS ≥ 3).
�Pathophysiological factors
In univariate analyses in patients with LVD, abnormal ABI
and MetS were significantly associated with higher recurrence
rates. In multivariate Cox regression analyses, LVD (HR:2.81,
CI:1.13-6.96, P=0.025), abnormal ABI (HR:3.30, CI:1.33-8.20,
P=0.009) and MetS (HR:2.67, CI:1.23-5.80, P=0.013) wereselected as significant independent predictors for strokerecurrence or cardiovascular events.
�Lifestyle factors
In univariate analyses, higher salt intake was associated withhigher recurrence (HR: 2.43, CI:1.04-5.68, P=0.040) and lower
physical activity tended to be associated with higher
recurrence(HR: 1.10, CI: 0.36 - 3.33, P=0.076). When divided
into four groups, the poor lifestyle management group was
associated with higher stroke recurrence (HR:1.62, CI:1.10-2.39,
P=0.013). In multivariate Cox regression analyses, the poor
lifestyle management group remained associated withrecurrence. Kaplan–Meier survival curves for lifestyle
management are presented in Figure 2.

Cumulative recurrence rate$<! )(('C'5<,! N:)'<! ?D%'5<! F5?A0D! )<(! ()0);D! 5H!
>5:C'>5%B'<)?! C:)>C! 2D:D! 05%C?=! A<>&)<;D(! N=! D):?=! MPE#!
750D! B:DF'5A%! :D%D):>&! &)%! :DB5:CD(! '00D(')CD! MPE! )HCD:!
>5:C'>)?! '<%A?C! D<?):;D(! ?D%'5<! F5?A0D! )<(! D^);;D:)CD(!
HA<>C'5<)?! :D>5FD:=! R_,US#! $<! C&'%! %CA(=! 2D! A%D(! %AN>5:C'>)?!
?D%'5<!05(D?,!C&D:DH5:D!C&D%D!('%>:DB)<>=!0';&C!ND!:D?)CD(!C5!
B)C&5?5;'>)?!>5<('C'5<%!O>5:C'>)?!F%#!%AN>5:C'>)?!?D%'5<+#!
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Conclusions
M5:>D(QA%D! 5H! '0B)':D(! H5:D?'0N! )HCD:! >)B%A?):!
&D05::&);D! '<(A>D(! NDCCD:! :D>5FD:=! 5H! %1'??D(! :D)>&'<;! )<(!
%CDBB'<;! 5H! C&D! '0B)':D(! ?'0N#! 4&'%! HA<>C'5<)?! :D>5FD:=!
0';&C! ND! :D?)CD(! A%DQ(DBD<(D<C! )?CD:)C'5<%! 5H! C&D! ;:52C&Q
B:505C'<;!H)>C5:%!D^B:D%%'5<!'<!C&D!%D<%5:'05C5:!>5:CD^#!
!
References
R*ST5?H! 7P,! T'<%CD'<! KI,! .'??D:! I9,! 4)AN! h,! E%2)CCD! G,!
.5::'%!L,!G'A?')<'!K,!P';&C!3h,!6'>&5?%QP):%D<!L#!hHHD>C!
5H! >5<%C:)'<CQ'<(A>D(! 05FD0D<C! C&D:)B=! 5<! ABBD:!
D^C:D0'C=! HA<>C'5<! 8! C5! \! 05<C&%! )HCD:! %C:51DY! C&D!
hkK$4h! :)<(50'cD(! >?'<'>)?! C:')?#! JAMA. -VV]a! -\]Y!
-V\UQ*V_#!
R-S.)'D:!$K,!J)A0)<<!3,!4&)??0)':!.,!TD'<0)<<!@,!7>&5??!
I,! 7>&2)N! .h#! K5<%C:)'<CQ'<(A>D(! 05FD0D<C! C&D:)B=! '<!
C&D! )(A?C! :)C! )HCD:! A<'?)CD:)?! >5:C'>5%B'<)?! C:)>C! '<bA:=#! J
Neurosci.!-VV[a-[Y\8[]Q_V8#!
R8S.)%A()!4,!/'()!/,!3)<()!l,!"'&):)!6,!@&C)!3,!l)0)()!
3,! 6'%&'<5! /#! @:)?! )(0'<'%C:)C'5<! 5H! 0DC)?! >&D?)C5:!
)0D?'5:)CD%! 05C5:! (=%HA<>C'5<! )HCD:! )! %0)??! &D05::&);D!
<D):! C&D! '<CD:<)?! >)B%A?D! '<! :)C#! J Neurosci Res.!
-VVea[UY-*8Q--#!
R_S35c?52%1'! L",! I)0D%! LK,! 7>&)??D:C! 4#! E%DQ(DBD<(D<C!
D^);;D:)C'5<! 5H! <DA:5<)?! '<bA:=! )HCD:! A<'?)CD:)?!
%D<%5:'05C5:!>5:CD^!?D%'5<%#!J Neurosci. *\\]a*]Y_ee]Q[]#!
RUSL:50D:'>1! "T,! P)<;! Kh,! J':1D<0D'D:! XP,! T);<D:! I.,!
.'??D:!I9,!`'(DD<!4@,!952D:%!TI,!T5?H!7P,!h(2):(%!LM#!
`D:=! h):?=! K5<%C:)'<CQ$<(A>D(! .5FD0D<C! (A:'<;! 7C:51D!
XD&)N'?'C)C'5<! O`hK4@X7+Y! "! %'<;?DQ>D<CD:! XK4#!
Neurology. -VV\ae8Y*\UQ-V*#!
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Author address

60%

Recurrence rate
1 year : 18.9%
2 year : 23.8%
3 year : 29.0%

40%
20%
0%

0

200

400 600 800
Day from onset

1000 1200

Figure 1.
Kaplan–Meier estimates of cumulative recurrence rates ofstroke. Deaths without stroke recurrence were censored.

PT-4

LS Groups

Step �5800steps, Salt �10.7g

Step�5800steps, Salt �10.7g

Step�5800steps, Salt �10.7g

Cumulative recurrence rate

60%

Step�5800steps, Salt �10.7g

40%

P=0.037

20%

0%

0

200

400
600
800
Day from onset

1000

1200

Figure 2.
Kaplan–Meier estimates of cumulative recurrence rates
of stroke according to lifestyle management.
Discussion
The results of the present study showed thatapproximately 30% of mild ischemic stroke patients
experienced vascular events during the 3 years after onset.
To our knowledge, this report is the first study todemonstrate the high recurrence rate in Japanese patientswith mild strokes. Moreover, the findings of this study
provide several predictive risk factors which include not only
pathophysiological factors but lifestyle factors for vascular
events.
In the present study, the 3-year risk of recurrence after
mild stroke was approximately 30%, exceeding the 10% to
20% rates reported in previous community-based studies
which included mild to severe stroke. There might be several
reasons for this discrepancy. First, a high proportion of LVD
in the present study might have influenced the recurrence rate.
For the background behind this higher recurrence rate,increasing prevalence of recurrent risk factors may raise therate of recurrence. These risk factors have gradually
increased during the past decade in Japanese population.
Secondly, race may be a possible reason for high strokerecurrence. High stroke recurrence results in increase of
severity of the effects of stroke. Indeed, approximately 30%
of cases of stroke recurrence in the present study resulted insevere disability.
Pathophysiological factors for recurrent predictors
The results of the present study indicated that abnormal
ABI, MetS and LVD were independent predictive factors for
3-year vascular events. This suggests that advances ofarthrosclerosis or complexity of traditional risk factors are
essential for moderate-term vascular events in mild stroke.
Low ABI, a subclinical marker for lower extremity
arterial disease. Previous study showed that ABI is inversely
related to traditional risk factors for vascular disease andrepresents a marker for atherosclerotic changes in othervascular beds. Thus the etiology of abnormal ABI isatherothrombosis. Prevalence of abnormal ABI with otheratherothorombosis like stroke in this study has reported toresult in poor prognosis. The findings of this study are in linewith these previous reports, suggesting abnormal ABI can bea powerful prognostic factor for stroke recurrence in mild stroke.
MetS shows that obesity with visceral fat accumulation
closely associates with atherosclerotic vascular events.
Moreover visceral fat obesity is closely related to adipose tissue.
Several studies have demonstrated that adipose tissue actively
produces a variety of locally and systemically functioning
bioactive molecules, including tumour necrosis factor-α,
plasminogen-activator inhibitor type-1 and adipocytokine, that
also interact in cardiovascular diseases. Especially, adiponectine
and leptine effect on increase blood pressure, sympathetic
nervous system activity, and expressed within atherosclerotic
plaques.[1]Lifestyle factors for recurrent predictors
High salt intake and lower physical activity were also
indicated as independent predictive factors for stroke recurrence.
This result highlights that lifestyle modification can help toprevent vascular events. Results from Japanese populationbased prospective cohort studies have showed significant
associations between salt intake and stroke incidence[2]. As
reported in a previous study, stroke mortality has a strong
relationship to dietary salt intake independent of blood pressure.
The mechanism responsible for the association between salt
intake and strokes is still unknown, but may be related to arterythickness, stiffness and platelet reactivity.
Physical activity also tended to be associated with strokerecurrence. In a meta-analysis, lower physical activity had a
33% higher risk of stroke incidence compared with more active
individuals[3]. Although the association between physicalactivity and strokes has not been well established, it has beenclearly demonstrated that insulin resistance and HDLcholesterol, which contribute to prevent the progression ofatherosclerosis, are related to higher physical activity.
Improvement of endothelial dysfunction by exercise is also
other possible mechanism for the prevention of strokerecurrence.
Conclusions
The findings of the present study suggest that the recurrence
rate in mild strokes has increased in conjunction with increased
prevalence of cardiovascular risk factors. The results alsosuggest that risk reduction through a combination of medicationand lifestyle intervention will improve this higher recurrence
rate.
Reference[1] Okamoto Y, Kihara S, Funahashi T, Matsuzawa Y, Libby P:
Adiponectin: a key adipocytokine in metabolic syndrome.
Clin Sci (Lond). 2006;110:267-278[2] Takachi R, Inoue M, Shimazu T, et al: Consumption of
sodium and salted foods in relation to cancer andcardiovascular disease: the Japan Public Health Center-based
Prospective Study. Am J Clin Nutr. 2010;91:456-464[3] Lee CD, Folsom AR, Blair SN: Physical activity and stroke
risk: a meta-analysis. Stroke. 2003;34:2475-2481
Author: Yuji Kono

E-Mail: el-condor-pasa@tiara.ocn.ne.jp
Corresponding Author: Sumio Yamada

E-Mail: yamadas@met.nagoya-u.ac.jp

LOCOMOTOR IMAGERY TRAINING IMPROVES GAIT PERFORMANCE IN PEOPLE
WITH CHRONIC HEMIPARETIC STROKE
Su-Jin Hwang1), Hye-Seon Jeon1), Chung-hwi Yi1), Oh-Yun Kwon1), Sang-Hyun Cho1), Sung-Hyun You1)
1) Department of Physical therapy, College of Health Sciences, Yonsei University, Kangwon-do, Korea

Introduction
Motor imagery practice is an active practice in which thepatient imagines or visualizes the performance of a function, amovement, or a task without overt physical therapy.11
Beneficial effects of motor imagery practice have been
supported through studies of brain-imaging. The same areas of
the central nervous system are activated during real
performances and during motor imagery practice of theequivalent tasks.12,13 Neuroplasticity of motor activity arisingfrom physical therapy is also reproduced on the neural substratein the brain involving motor imagery practice of the sameactivity.12,14 Recently, motor imagery of gait training forindividuals with stroke has been introduced by someresearchers.5-7 Most studies on motor imagery practice arefocused on treating loss of upper extremity function11 and on
improving performance in activities of daily living.15 There are
not full studies of intervening in lower extremity and gait
dysfunction5-7,11
Dickstein et al. (2004) reported remarkable improvement inspatiotemporal parameters after gait-focused motor imagery
practice. Locomotor imagery training (LIT) for persons withhemiparetic stroke is a motor imagery training technique that
improves gait performance without requiring actual movementsby paretic or less paretic limbs. LIT may be beneficial forpatients who unable to participate in physical gait training
secondary to fatigue, severe paralysis, or improper balance.
The purpose of this study was to evaluate whether motor
imagery for gait training improves spatiotemporal parameters
on gait, related kinematic gait variables and clinical measures
for gait in individuals with hemiparetic stroke.
Materials and Methods
Participants: Thirteen hemiparetic hemiparetic subjects
were experimental group. Then we recruited same number ofage, lesion, sex, post-stroke duration matched control groupsubjects. However, two subjects in the control group were dropout before completing post-test. The study was approved by thehuman research ethics committee of all participating
institutions, and all subjects signed an informed consent form
after they received information about the study’s purpose,procedure, possible benefits and risks, privacy and use of data.
The inclusion criteria were (1) six months or more sincestroke onset, (2) ability to walk independently over-ground forat least 10 m with or without use of an ankle foot orthosis or
assistive device, (3) absence of any cognitive impairment(scores above 24 on the Mini Mental State Examination),16 (4)ability to understand verbal instructions, (5) no cerebellar
lesion, (6) no significant body or visuospatial hemineglect, and(7) a good ability for imagery functioning (a score of 32 or
higher on the revision of movement imagery questionnaire).17
Table 1 explains the general characteristics of the LIT andcontrol groups
Interventions: The subjects in the LIT group participated infour weeks of LIT five-times weekly, with each session lasting
25 to 30 minutes. Subjects in the control group watcheddocumentary television programs for the same period of time.
The first week of the four-week training focused onfamiliarizing patients with normal gait sequences andidentifying their own problems in gait by studying thedifferences between the first knowledge of performance of thesubject’s gait and that of the normal gait. Normal gait
sequences were described on the eight phases of gait cycle
including initial contact, loading response, midstance, terminal
stance, preswing, initial swing, midswing, and terminal swing.
The therapist explained the kinematic changes in each phasehip, knee, ankle, and foot. During the last three weeks, the LITgroup performed motor imagery practice according to a fivestage protocol: progressive relaxation, external imagery(analysis of task sequences), problem identification, internal
imagery, and mental rehearsal. This protocol was developed
based on the “active relaxation, imagery, and mental rehearsal(AIM)” strategy, which is commonly used in studies of motor
imagery practice for sports.18 A detail description of the fivestage protocol is shown in Appendix 1.
Outcome Measures and Analysis: 3-dimensional motion
analysis system and workstation software, Activities-specificbalance confidence scale, Berg balance scale, Dynamic gait
index.
Statistics: Pre-treatment demographic data of the subjects
were compared between the LIT and control groups using
DI?@K@I?@IOO O@NON<I?>CD NLP<M@h2) tests. Independent t-tests
were used to determine whether the changes from the pretest to
the posttest of the spatiotemporal, kinematic, clinicalparameters significantly differed between the two groups. An
alpha level of P<.05 was used as statistical significance. All
statistical analyses were performed using the SPSS statisticalpackage 12.01.
Results
Spatiotemporal parameters
The increase of walking velocity from the pretest to posttest
was significantly greater in the LIT group than in the control
group (P=0.034) (Figure 2). However, the changes between thepretest and posttest for cadence were not significantly different
between the two groups (P=0.722). The changes of affected
and less affected limbs stride length between the pretest andposttest were significantly greater in the locomotor imagery
training group (Figure 3). Spatiotemporal parameters except forwalking velocity and stride length of both limbs were notsignificantly different between the groups.
Kinematic data
In the affected hip joint, the peak-to-peak extension-toflexion angular displacement increased from 31.95±9.68°
during the pretest to 38.08±5.51° after the locomotor imagery
training. However, the peak-to-peak joint angular displacementof hip extension-to-flexion in the control group decreased
1.46±4.30°. In the affected knee joint, the peak-to-peakextension-to-flexion angular displacement increased from30.25±14.27° during the pretest to 41.20±12.37° after the
locomotor imagery training. However, the peak-to-peak joint
angular displacement of knee extension-to-flexion in thecontrol group decreased by 3.73±6.26°. This change wassignificantly greater in the locomotor imagery training groupcompared with the control group (P=0.001). However, the test
SPSS Inc, 233 S Wacker Dr, Chicago, IL, USA 60606



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changes of other joint motions were not significantly different
between the two groups (P>0.05).
In less affected hip joint, the peak-to-peak angulardisplacement of rotation decreased by 8.77±10.57°, from
22.18±11.63° during the pretest to 13.41±5.15° at the posttest,in the locomotor imagery training group. However, the peak-topeak joint angular displacement of hip rotation in the control
group decreased by 0.21±9.17°. This change was significantly
greater in the locomotor imagery training group compared withthe control group (P=0.048). However, the test changes ofother joint motions were not significantly different between thetwo groups (P>0.05).
Clinical measures
The changes in the scores of ACTIVITIES-SPECIFICBALANCE CONFIDENCE scale BBT, and DGI weresignificantly greater in the locomotor imagery training groupcompared with the control group (Table 2) (P=0.000). The total
mEFAP time scores was more decrease in the locomotor
imagery training group than in the control group. The change oftime scores was significantly greater decreased in locomotor
imagery training group compared with control group (P=0.035).
The performance time in performing all mEFAP (floor, carpet,up & go, obstacles, and stairs) decreased upon termination of
the experiment in both the groups. The change of time scores inlocomotor imagery training group were significantly greater inall subtests except for up & go compared with those of thecontrol group.
Conclusion
The LIP is a cost effective and relatively safe motor
rehabilitation intervention for individuals with stroke.9
Locomotor imagery training maximizes practice opportunities
for individuals with stroke with hemiakinesia, low-level
functional ability, and little or no movement in the paralyzed
limb. locomotor imagery training is possible form of early gait
training despite focusing cognitive stage in motor learning
without overt motor output.
Key Words
Gait, Locomotor imagery training, Motion analysis, Stroke
References[1]Eng JJ, and Tang P. Gait training strategies to optimize
walking ability in people with stroke: a synthesis of theevidence. Expert Rev Neurother 2007; 7(10): 1417-36.
[2]Lord SE, McPherson K, McNaughton HK, Rochester L,
Weatherall M. Community ambulation after stroke: how
important and obtainable is it and what measures appear
predictive? Arch Phys Med Rehabil 2004; 85(2): 234-9.
[3]Stevens JA, Stoykov ME. Using motor imagery in the
rehabilitation of hemiparesis. Arch Phys Med Rehabil
2003; 84: 1090-2.
[4]O’SullivanSB, Schmitz TJ. Physical rehabilitation, fifth
edition. F.A. Davis, 2007.
[5]Dickstein R, Dunsky A, Marcovitz E. Motor imagery for
gait rehabilitation in post-stroke hemiparesis. Phys Ther
2004; 84(12): 1167-77.
[6]Dunsky A, Dickstein R, Ariav C, Deutsch J, Marchvitz E.
Motor imagery practice in gait rehabilitation of chronic
post-stroke hemiparesis: four case studies. Int J Rehabil
Res 2006; 29: 351-6.
[7]Dunsky A, Dickstein R, Marcovitz E, Levy S, Deutsch J.
Home-based motor imagery training for gait rehabilitationof people with chronic poststroke hemiparesis. Arch Phys
Med Rehabil 2008; 89: 1580-8.

PT-5[8]Batson G. Motor imagery for stroke rehabilitation: current
research as a guide to clinical practice. Altern Complement
Med 2004; 10: 84-9.
[9]Dickstein R, Deutsch J. Motor imagery in physicaltherapist practice. Phys Ther 2007; 87(7): 942-53.
[10]Mahoney MJ, Avener M. Psychology of the elite athlete:
an exploratory study. Cognit Ther Res 1977; 1: 135-41.
[11]Jackson PL, Lafleur MF, Malouin F, Richards C, Doyon J.
Functional cerebral reorganization following motor
sequence learning through mental practice with motor
imagery. Neuroimage 2003; 20: 1171-80.
[12]Lafleur MF, Jackson PL, Malouin F, Richards CL, Evans
AC, Doyon J. Motor learning produces parallel dynamic
functional changes during the execution and imaginationof sequential foot movements. Neuroimag 2002; 16: 14257.
[13]de Vries S, Mulder T. Motor imagery and stroke
rehabilitation: a critical discussion. J Rehabil Med 2007;
39: 5-13.
[14]Lacourse MG, Turner JA, Randolph-Orr E, Schandler SL,
Cohen MJ. Cerebral and cerebellar sensorimotor plasticity
following motor imagery-based mental practice of asequential movement. J Rehabil Res Dev 2004; 41: 505-24.
[15]Yoo E, Park E, Chung B. Mental practice effect on linetracing accuracy in persons with hemiparetic stroke: apreliminary study. Arch Phys Med Rehabil 2001; 82:1213-8.
[16]Folstein MF, Folstein SE, McHugh PR. Mini-mental
state: a practical method for grading the cognitive state ofpatients for the clinician. J Psychiat Res 1975; 12: 189198.
[17]Sharma N, Pomeroy VM, Baron J. Motor imagery: abackdoor to the motor system after stroke? Stroke 2006;
37: 1941-52.
[18]Sheikh AA, Korm ER. Imagery in sports and physicalperformance: imagery and human development series,
New York, Baywood Publishing Company Inc, 1994.
[19]Botner EM, Miller WC, Eng JJ. Measurement propertiesof the activities-specific balance confidence scale amongindividuals with stroke. Disabil Rehabil 2005; 27(4): 15663.
[20]Kornetti DL, Fritz SL, Chiu YP, Light KE, Velozo CA.
Rating scale analysis of the Berg balance test. Arch Phys
Med Rehabil 2004; 85: 1128-35.
[21]Marchetti GF, Whitney SL. Construction and validationof the 4-item dynamic gait index. Phys Ther 2006;
86(12): 1651-60.
[22]Baer HR, Wolf SL. Modified Emory functional
ambulation profile: an outcome measure for the
rehabilitation of poststroke gait dysfunction. Stroke 2001;
32(4): 973-9.
[23]Carr JH, Shepherd RB. Stroke rehabilitation: guidelines
for exercise and training to optimize motor skill, Seatle,WA, Butterworth-Heinemann Medical Books, 2003.
[24]Chen G, Patten C, Kothari DH, Zajac FE. Gait differences
between individuals with post-stroke hemiparesis andnon-disabled controls at matched speeds. Gait Posture2005; 22: 51-6.
[25]Olney SJ, Richards C. Hemiparetic gait following stroke.
Part I: characteristics. Gait Posture 1996; 4: 136-48.
[26]Perry J. Gait analysis: normal and pathological function,
first edition. Thorofare, SLACK Incorporated, 1992.
[27]Kirtley C. Clinical gait analysis: theory and practice, firstedition. Philadelphia, Churchill Livingstone, 2006.
[28]Rose J, Gamble JG. Human walking, third edition.
Philadelphia, Lippincott Williams & Wilkins, 2006.

[29]Shumway-Cook A, Wollacott MH. Motor control:translating research into clinical practice, third edition.
Philadelphia, Lippincott Williams & Wilkins, 2007.
[30]Schmidt RA, Lee TD. Motor control and learning: abehavioral emphasis, fourth edition. Champaign, IL,
Human Kinetics, 2005.
[31]Johnson SH. Imaging the impossible: intact motor
representations in hemiplegics. Neuroreport 2000; 11:729-32.
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1998; 3: 47-52.
[33]Georgopolous AP, Lurito JT, Petrides M, Schwartz AB,
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Author address

E-Mail: hyeseonj@yonsei.ac.kr

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The effects of an isometric knee extension with hip adduction (KEWHA) exercise on
selective VMO muscle strengthening
Bo-ram Choi1), Hye-seon Jeon2)
1) Department of Rehabilitation Therapy, The Graduate School, Yonsei University, Wonju, Republic of Korea
2) Department of Physical Therapy, College of Health Science, Yonsei University, Wonju, Republic of Korea

Introduction
In general, patellofemoral rehabilitation involves
maximizing quadriceps strength while minimizing thepatellofemoral joint reaction forces and stress (Tang et al.,2001). There are many types of quadriceps strengthening
exercises. Traditionally, quad sets (Cerny, 1995) and kneeextension exercises have been used (Hanten and Schulthies,1990). However, these are designed to strengthen the wholequadriceps femoris. The VL muscle is naturally stronger thanthe VMO muscle; therefore, sustained exercise of bothfacilitates further strengthening of the VL muscle. In addition,
during these exercises, lateral and medial forces are notadequately balanced, and increased lateral displacement of thepatella into the trochlear groove occurs (Grabiner et al., 1994).
This continued imbalance between the VMO and VL muscles
accentuates PFPS (Hanten and Schulthies, 1990).
In this study, we investigated the 4-week training effects ofknee extension with hip adduction on onset timing of EMG
activity for the VL muscle and VMO muscle in asymptomaticparticipants. We also compared different methods for thedetermination of EMG onset times.
Methods
Design: The training effect was evaluated using a onegroup pretest–posttest study design. We measured EMG onset
times during pre- and post-stair ascending tasks. We
determined whether VMO muscle onsets were earlier thanthose of the VL muscle and whether the times of EMG onsetchanged after training.
Participants: Thirty-three participants with no known lower
extremity surgical, musculoskeletal, or neurological history
participated in the pretest session of this study. Participants
showed faster VL muscle than VMO muscle EMG onset times
when they ascended stairs, were selected as participants for the
4-week training using the knee extension with hip adduction(KEWHA) exercise.
Equipment: Muscle EMG activities were recorded using a
Noraxon Telemyo 2400T (Noraxon Inc., Scottsdale, AZ, USA)with two bipolar Ag–AgCl surface electrodes (Blue sensor,
Olystyke, Denmark) during a stair-ascending task. Custommade stairs were used in this study and consisted of two steps,
20 cm in height, leading to a 60-cm-long platform. The firststair had a run of 28 cm, and the second stair had a run of 90cm.
The stair ascending task: During the pre-test, the stairascending task was used to identify subjects with earlier VL
muscle onsets, as described previously (Cowan et al., 2001;
Crossley et al., 2004; Hinman et al., 2002). Participants placed
the non-dominant foot on the floor, 20 cm away from thedominant foot which was on top of the first step, with the hipand knee joints at approximately 45°; their arms were relaxedby their sides. Both feet were parallel and shoulder-width apart,with no hip rotation and no pelvic rotation. Weight-bearing was
mainly on the non-dominant foot, with minimal weight-bearing
on the dominant foot where it was in contact with the stair(controlled by an EMG biofeedback program, threshold 1.0–
 ^5  3C@ K<MOD>DK<ION R@M@ DINOMP>O@? OJ <N>@I? RDOC OC@DM

PT-6

non-dominant foot, to keep their trunk in an upright position,and to maintain a steady gaze to the front. Ascending speed
was at a rate of 96 steps per min, as paced by a metronome,
because it is not known if onset time is affected by different
walking speeds. Ascending began randomly when the examinersounded a bell. Prior to the examination, participants practiced
ascending the stairs to ensure they were able to step in time tothe metronome. The EMG onsets for the VMO and VL musclesin the stair-ascending task during the pre-test were used to
select participants with a 10-ms later onset for the VMO
muscle than for the VL muscle (Cowan et al., 2002).
Intervention: Subjects were selected on the basis of thepretest participated in the 4-week KEWHA exercise.
Participants sat on the Noland–Kickoff table (N-K table) andperformed isometric knee extension exercises with 15° hip
adduction, as described by Monteiro-Pedro et al. (1999). The
subjects performed the exercise 3 days a week with a trainerand 2 days a week at home for a total of 4 weeks. Each session
consisted of five trials of 10 repetitions (resting for 5 s between
repetitions). One trial involved alternating legs to prevent
asymmetry between the strength of the right and left quadriceps
muscles. Subjects were seated with their arms folded acrosstheir chests and used a back-rest set at a hip angle of 130°. A
belt was attached to both the pelvis (from the anterior superior
iliac spine [ASIS] line to the chair) and the trunk (under theinferior angle of the scapula to the chair) to prevent motion of
the pelvis and the trunk. The chair height was adjusted so thatboth feet were off the floor.
Results
Effect of the knee extension with hip adduction (KEWHA)
exercise on VMO and VL muscles onset time differences
The means ± SDs of the EMG onset time differences in the
pre- and post-tests are shown in Figure 1. There was no
significant difference among the EMG onset time differences
for the VMO muscle compared with the VL muscle between
the pre- (7.72 ± 95.88) and post-tests (-4.22 ± 40.98) (p = 0.63)
when data at two SDs of the mean baseline activity wereanalyzed. Very large variations in individual onset times wereobserved. When data at three SDs of the mean baseline activity
were analyzed, less variation in individual onset times wasfound, and there was a significant difference in the onset timedifferences for the VMO muscle compared to the VL muscle
between the pre- (23.78 ±13.61) and post-tests (-15.44 ±34.70)(p = 0.00).
EMG onset time difference(ms)

!"#$%

2SD
3SD

30
20
10
0
-10
-20
-30
Pre

Post

Pre

Post

Figure 1. Mean EMG onset time differences (OTD)
between VMO and VL during ascending stair task. The dot
indicates the mean EMG OTD and the each line indicates thestandard deviation (SD). Two and three standard deviations of
the mean baseline activity; (2SD, 3SD), VL onset time fasterthan VMO onset time; (VMO < VL), VMO onset time fasterthan VL onset time; (VMO > VL).
Discussion
The results of this study indicate that participants with adelayed onset time for the VMO muscle showed a decreased
difference between VMO and VL muscles onset time after
performing the KEWHA exercise for 4 weeks. These results
are in accordance with those of Cowan et al. (2002), who
conducted studies during a McConnell-based rehabilitation
program. However, their study focused on the effects of theposition of hip adduction on VMO muscle onset time during
the knee-extension exercise, not on a complex exercise
program. In addition, our investigations showed that when thethreshold for activity was set at two SDs of the mean baseline
activity, the results were more variable than those using athreshold of three SDs.
Knee extension with hip-adduction (KEWHA) exercise
Hip adduction exercises can be used to selectively
strengthen the VMO muscle (Coqueiro et al., 2005). Previous
studies combined hip adduction and open- or closed-chain
exercises performed by asymptomatic subjects. The VMO
muscle exhibited a significantly greater amount of activity thanthe VL muscle during open chain hip-adduction exercises(Hanten and Schulthies, 1990). No change in the activity of the
VMO muscle was found during a combination of isometric hip
adduction and open-chain knee extension, although VL muscle
activity was significantly less than that of the VMO muscle.
These data indicate that extensor mechanisms can reinforce
decreased VL muscle activity (Rice et al., 1995). Earl et al.
(2001) produced more overall activity in the quadriceps by
combining isometric hip adduction with a closed-chain minisquat. However, this exercise did not specifically support theactivity of the VMO muscle, as VMO and VL muscles activity
increased by the same amount. Reports on the activation of the
VMO and VL muscles s during open- or closed-chain exercises
cannot be applied to our study, as they are not directly related
to it. We did not consider open- or closed-chain exercises, as
we modified the methods of traditional quadriceps
strengthening exercises that use extension of the knee joint
from 90° flexion to full extension on the N-K table.
Furthermore, the purpose of our study was to investigate thedifferences in onset times that arise from changes in motor
control as well as the differences in quadriceps activation after
exercise. Herrington and Pearson (2006) found no significant
differences in onset times between open- and closed-chain knee
extension exercises. This suggests that the interactions between
the VMO and VL muscles s remain fairly constant irrespectiveof the type of exercise.
Conclusion
The knee extension exercise is an established 'self-exercise'used for knee pathology treatment and strengthening exercises.
However, if therapists do not adequately instruct the subject onproper positioning, the patella will receive a negative impact
due to an imbalance in the activation of the VMO muscle andVL muscles. This study describes the 4-week training effects of
the KEWHA exercise, which was used in an attempt todecrease the onset-time difference between the VMO muscle
and VL muscles. This is one factor that influences the lateral
tracking of the patella. As a result of the 4-week training period,
the onset time difference between the VMO and VL muscles
was decreased. In our study, the KEWHA exercise removed

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one of the PFPS risk factors that reduced the onset timedifference between the VMO muscle and VL muscle.
Furthermore, we suggest that the use of a correct KEWHA
exercise may reduce the risk of lateral tracking of the patella.
Reference[1]Cerny K. Vastus medialis oblique/vastus lateralis muscle
activity ratios for selected exercises in persons with andwithout patellofemoral pain syndrome. Physical Therapy
1995;75(8):672-83.
[2]Coqueiro KRR, Bevilaqua-Grossi D, Bérzin F, Soares AB,
Candolo C, Monteiro-Pedro V. Analysis on the activation of
the VMO and VLL muscles during semisquat exercises withand without hip adduction in individuals withpatellofemoral pain syndrome. Journal of Electromyography
and Kinesiology 2005;15(6):596-603.
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McConnell J. Delayed onset of electromyographic activityof vastus medialis obliquus relative to vastus lateralis insubjects with patellofemoral pain syndrome. Archives ofPhysical Medicine and Rehabilitation 2001;82(2):183-9.
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and Exercise 1994;26(1):10-21.
[8]Hanten WP, Schulthies SS. Exercise effect onelectromyographic activity of the vastus medialis obliqueand vastus lateralis muscles. Physical Therapy
1990;70(9):561-5.
[9]Herrington L, Pearson S. Does exercise type affect relative
activation levels of vastus medialis oblique and vastus
laterialis? Journal of Sport Rehabilitation 2006;15(4):271-9.
[10]Hinman RS, Bennell KL, Metcalf BR, Crossley KM.
Temporal activity of vastus medialis obliquus and vastus
lateralis in symptomatic knee osteoarthritis. American
Journal of Physical Medicine and Rehabilitation
2002;81(9):684-90.
[11]Monteiro-Pedro V, Vitti M, Bérzin F, Bevilaqua-Grosso D.
The effect of free isotonic and maximal isometriccontraction exercises of the hip adduction on vastus
medialis oblique muscle: An electromyographic study.
Electromyography and Clinical Neurophysiology
1999;39(7):435-40.
[12]Rice MA, Gregory Bennett J, Ruhling RO. Comparison of
two exercises on VMO and VL EMG activity and force
production. Isokinetics and Exercise Science
1995;5(2):61-7.
[13]Tang SFT, Chen CK, Hsu R, Chou SW, Hong WH, Lew
HL. Vastus medialis obliquus and vastus lateralis activity
in open and closed kinetic chain exercises in patients withpatellofemoral pain syndrome: An electromyographic
study. Archives of Physical Medicine and Rehabilitation
2001;82(10):1441-5.
Author address
E-Mail:boram@yonsei.ac.kr        

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Session chairs: Prof. Yuji Sawada
Prof. Eun Young Yoo
Prof. Kunifumi Suzuki

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References

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OT-1

OCCUPATIONAL THERAPY AS A CAREER: KOREAN UNDERGRADUATE OTSTUDENT’S PREFERENCES AND CONCERNS REGARDING THEIR FUTURE AS
OCCUPATIONAL THERAPISTS
Joo-Hyun Lee1)
1) Department of Occupational Therapy, College of Health Sciences, Yonsei University, Kangwon-do, Korea

Introduction
With the growing number of newly graduating occupational
therapy students, there has been recent concern regarding thefuture job market for occupational therapists and emphasis on
the need to reorganize the areas of OT service in Korea. The
present study analyzed Korean undergraduate occupational
therapy (OT) students' preferences and concerns regarding their
future as occupational therapists using a survey method. The
primary purpose of this study was to examine (1) OT students'
reasons for choosing occupational therapy as their major, (2)their thoughts and beliefs concerning their future as
occupational therapists, and finally (3) to contribute to thedevelopment of the field of OT in Korea by providing
information regarding students' preferred fields of employment
and their professional interest areas.
Materials and Methods
The participants in the study were 1,666 Korean
undergraduate OT students from 19 universities and colleges
across Korea. A packet of questionnaires was given to students.
The questionnaire was made up of three different areas: (1)students’ demographic characteristics in addition to reasons forselecting OT as their major, (2) concerns and anxiety regarding
their future, and finally (3) their current preferred field of
employment and professional interest areas. Demographic
variables included variables such as year in college, student
group type, gender, age, and religion. Students were asked tochoose among 7 reasons that led them to choose OT as theirmajor. 16 items on a 4-point Likert scale were created toaddress students’ concerns regarding their future as
occupational therapists. Lower score indicated greater future
career concerns. Students also responded to a question
regarding their preferred field of employment. Data wasanalyzed using SPSS 12.0.
Results(1) Demographic Characteristics
A total of 723 universities and 606 colleges that had
departments of occupational therapy were represented in thepresent study. The sample consisted of 352 (26.5%) male and977 (73.5%) female students. The sample consisted of483(36.3%) freshmen, 457 (34.4%) sophomore, 335 (25.2%)
juniors, and 54 (4.1%) seniors. The student group typeconsisted of 1139 (85.7%) currently enrolled students, 133(10%) students returning to school after taking time off, 28(21%) transfer students, and 27 (2%) readmission students.
(2) Reasons for Selecting OT as their Major
The results indicated that 675 (50.8%) OT students chose
OT as their major following recommendations made by others(parent, teacher, sibling). 654 (49.2%) OT students replied thatthey chose the major on their own. The principle reason forrecommendation and selection was to work in a professional
field or to secure employment. 476 (70.4%).

(3) Thoughts Concerning their Future
The results indicated that 693 (52.1%) OT students havehigh career confidence, 504 (37.9%) OT students have average
career confidence and 117 (8.8%) OT students have low careerconfidence when they first entered the department. However,362 (27.3%) OT students reported high career confidence, 603(45.4%) OT students average career confidence and 352(26.4%) OT students low career confidence presently. Such
results indicate that career confidence is lower in the present
than in entering school. Female students reported greater future
career concerns than male students. Freshmen reported greater
future career concerns than sophomores, juniors, seniors. 831(62.5%) OT students hoped to transfer to another academic
department.
(4) Preferred Field of Employment and Professional Areas ofInterest
The results indicated that most 1157 (36.4%) OT students
were most interested in the areas of mental health, physicaldisability, and autism-spectrum disorders, respectively. The
most desired place of work following graduation was in a
medical center / teaching hospital (n=908; 68.3%). Thispreference held true in students' response to the question,"Where would you like to be working in 10 years?". OT
students indicated that would prefer working with the children(n=792; 40.6%), followed by the adult population (n=632;
32.3%) and elderly (n=425; 21.7%).
(5) Additional Analysis: Relationship between OT Students'
Demographic Characteristics and Preferences and Concerns
Regarding their FutureFirst of all, there was a meaningful effect of gender on
future career concerns. Female students reported greater future
career concerns than male students (t = 3.46, p < .05). Second,
there was a meaningful positive correlation between year incollege and career concerns. More specifically, the higher theyear in college, students reported greater future career concerns(r = -.126, p < .01).
Conclusions
In conclusion, the results of the present study indicate that
Korean OT undergraduate students’ degree of future careerconcerns is affected by factors such as gender and year incollege. This suggests the need for departments in OT to tailor
their education and student mentoring depending on students'
gender and year in college. Also, this study indicates that thepreferred interest or work field of Korean OT undergraduate
students was mostly limited to medical institutions. Therefore,
further guidance is required to expose OT students to morediverse areas of interest and work field.

OT-2



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EFFECTS OF SCHEDULED EXERCISE PROGRAM COMBINED WITH FORCED USE
ON UPPER EXTREMITY FUNCTIONING IN INDIVIDUALS WITH HEMIPLEGIA
Hae-Yean Park 1)
1) Department of Occupational Therapy, College of Health Sciences, Yonsei University, Kangwon-do, Korea

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References
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Introduction
Although individuals with hemiplegia need continuous
therapy to improve upper extremity functioning, they spend
most of their time alone and not exercising spontaneously
outside the outpatient clinic setting (Bernhardt, Chan, Nicola,& Collier, 2007). The goal of the present study was hence tosuggest the potential effectiveness of an exercise program thatcan encourage client's voluntary participation while minimizing
therapist involvement. More specifically, the purpose of thisstudy was to investigate the effects of scheduled exercise
program combined with forced use in improving upper
extremity functioning in individuals with hemiplegia.
Materials and Methods
Participants: Two males and one female diagnosed withchronic stroke participated in the present study. The inclusion
criteria were as follows: (1) a minimum of 6 months post
single unilateral stroke and currently neurologically stable, (2)no significant cognitive deficits as indicated by a score > 25 on
the Korean Mini Mental Status Examination(MMSE-K)(Kwon& Park, 1989), (3) ability to actively extend at least 10 ° at theaffected metacarpophalangeal and interphalangeal joints and
20 ° at the more affected wrist and (4) no balance problems that
may compromise safety.
Design: A-B-A'-C reversal design was used in the study.
Setting: Home-based.
Intervention: The treatment process consisted of two
conditions: forced use only (B intervention period) andindividual customized scheduled exercise program in addition
to forced use (C intervention period). During the B and C
intervention periods, participants had their healthy arm
immobilized by wearing mittens for 6 hours such that they
were not able to manipulate objects using the non-affected hand.
During the C intervention period, exercise programs wereconducted 14 times along with forced use according to the
fixed schedule. A total 10 activities (5 tasks targeting arm
functioning and 5 tasks of activities of daily living: ADL) wereadopted which differed across the three participants based on
their level of functioning in the affected upper extremity. The
present researcher selected tasks for improving arm functioning
based on individual’s performance with the goal of improving
functioning of the shoulder, elbow, hand, and finger. ADL
tasks were determined based on information gathered fromparticipant and caregiver interviews, with the goal of selecting
tasks that were deemed essential in minimizing other’s help.
Outcome measures: The Box and Block Test
(BBT)(Cromwell, 1976) and the Wolf Motor Function Test
(WMFT)(Wolf, Lecraw, Barton, & Jann, 1989) were used toassess motor function of the upper extremity. Participant’s rateof performance of assigned activities was determined by the
number of assigned acrivities accomplished on a day divided
by the total of 30 activities multiplied by 100. To determine therate of implementation of scheduled exercise activities, thenumber of scheduled exercise tasks implemented on a day
divided by the total of 10 assigned tasks multiplied by 100. The
Motor Activity Log(MAL)(Page, Sisto, & Levine, 2002) wasused to assess ADL. In order to examine the psychosocial
status of the participants, the Self-Esteem Scale (Rosenberg,1965) and the Psychosocial Well-Being Index Short Form (SFPWI)(Chang, Cha, Won, & Koh, 2001) were measured pre- andpost-intervention.
Data analysis: The scores for each participant on theabove-mentioned outcome measures were visually analyzed
using graphs.
Figure 1 Trial Design

Results
The results of the present study can be summarized asfollows:

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1.

Performance rates to measure motor functioning ofParticipant 1, 2, and 3 were 99.0%, 22.1%, and 74.6%,
respectively, on the BBT. Compared to the baseline
period, the number of wood blocks which were moved
during the period of intervention improved. The degreeof performance on the WMFT showed improvement in
the post-intervention period C compared to the baseline
A period and the amount of time needed to complete thetasks also decreased.

2.

Performance rates on tasks of ADL for Participant 1, 2,
and 3 were 57%, 113%, and 48.8%, respectively,
markedly improving from the baseline period. Resultsfrom the MAL indicate improvement in the use andquality of movement in the post-baseline C period
compared to the baseline A period.

3.

During the intervention C period, the implementation
rates of ADL schedule for Participant 1, 2, and 3 were85%, 70%, and 90%, respectively.

4.

On measures of psychosocial status, improvement in
self-esteem was found for Participant 1 and 3, while
their sense of psychosocial stress declined. For
Participant 2, the self-esteem score declined and thepsychosocial stress remained unchanged.

Conclusion
The results of the present study indicate that scheduled
exercise program combined with forced use had positive effects
on improving upper extremity functioning and activities ofdaily living in persons with post-stroke hemiparesis in thehome setting. Such scheduled intervention program also
showed partial effects on improving psychosocial status.
Furthermore, the present study also suggests that chronic stroke
patients can take part in exercise programs on their own within
the home setting and improve upper extremity functioning
without therapist intervention.
Key Words
Activities of Daily Living, Arms Function, Forced Use,
Schedule, Stroke
References[1]Bernhardt, J., Chan, J., Nicola, I., & Collier, J. M. (2007).
Little therapy, little physical activity: Rehabilitation within
the first 14 days of organized stroke unit care. Journal of
Rehabilitation Medicine, 39(1), 43-48.
[2]Chang, S. J., Cha, B. S., Won, J. U., & Koh, S. B. (2001). A
study on the distribution and risk factors for psychosocial
distress, and the development of worksite stress reduction
program. Seoul: Ministry of Health and Welfare.
[3]Cromwell, F. S. (1976). Occupational therapist manual forbasic skills assessment: Primary pre-vocational evaluation.
Altndena, C. A.: Fair Oaks Printing.
[4]Kwon, Y. C., & Park, J. H. (1989). Korean version of MiniMental State Examination (MMSE-K). Journal of Korean
Neuropsychiatric Association, 28(1), 125-135.
[5]Page, S. J., Sisto, S. A., & Levine, P. (2002). Modified
constraint-induced therapy in chronic stroke. American
Journal of Physical Medicine and Rehabilitation, 81(11),870-875.
[6]Rosenberg, L. A. (1965). Rapid changes in overt behavior
reflected in the Draw-a-Person. Journal of Projective
Techniques, 29(3), 348-351.
[7]Wolf, S. L., Lecraw, D. E., Barton, L. A., & Jann, B. B.
(1989). Forced use of hemiplegic upper extremities toreverse the effect of learned nonuse among chronic strokeand head-injured patients. Experimental Neurology, 104(2),125-132.
Author address

E-Mail: libra33@hanmail.net

2010 Nagoya-Yonsei University
Research Exchange Meetings on Health Sciences

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