2015 Yonsei-Nagoya University
Research Exchange Meetings in Health Sciences & Nursing
2015. 11. 5. – 11. 7.

Yonsei University Wonju Campus
Wonju, Republic of Korea

2015 Yonsei-Nagoya University
Research Exchange Meetings in Health Sciences & Nursing
2015. 11. 5. – 11. 7.

Yonsei University Wonju Campus
Wonju, Republic of Korea

Table of Contents

1.

Preface…………………………………………………………………………………………... 42.

Itinerary…………………………………………………………………………………………. 5

3.

Map……………………………………………………………………………………………….. 6

4.

Organizing committee………………………………………………………………….. 8

5.

Abstract
A. Nursing……………………………………………………….………………………………. 9
B. Physical Therapy…………………………………………………………………………

26

C. Occupational Therapy……………………………………………………................. 45
D. Biomedical Laboratory Science……………………………………..................

66

E. Radiological Technology…………………………………………………………….. 83

6.

List of Participants………………………………………………………………………… 110

Preface
As the Dean of College of Health Sciences, it is my utmost pleasure to host 2015 YonseiNagoya University Research Exchange Meeting in Health Sciences (November 5-7th, 2015) at theYonsei University Wonju Campus. On behalf of the Yonsei University Wonju Campus, I would liketo extend my heartfelt welcome to the delegates from Nagoya University who travelled long
distances to take part in this research exchange meeting. I am very excited to welcome you to
our community here at Yonsei

I believe that this meeting will be a unique forum to exchange ideas, to discuss not only the
results of their research work but also matters of mutual interest and concerns, and to shareexperiences among professors and students between the two universities.

This is the 6th meeting jointly held by the two institutions, since the 1st meeting was held in
Nagoya University in 2010. The history of this meeting is still young and beginning stage of our
joint efforts. We’ve just taken a first step toward building a greater cooperation. I am very excited
to see what we will be able to produce and accomplish through this joint meeting.

I also hope that your visit to our campus will provide you with a great opportunity to get toknow Korea and the Korean people as well as experience Korean culture in a fragrant fallatmosphere. I once again welcome all of you who are visiting Yonsei University Wonju Campus
and I believe that your visit to our campus ensure for our bilateral cooperation and partnership
between the two institutions to closely work together in the years to come.

Thank you.

Jong Bae Kim, DVM, PhD
Dean
College of Health Sciences, Yonsei University

Professor
Department of Biomedical Laboratory Science, Yonsei University-4-

Itinerary
Date

Time

Schedule- 11:35Flight from Nagoya to Incheon

11:50 - 13:00

Lunch in Korean restaurant2015. 11. 5.

13:00 - 15:00

Move to Namisum in Chuncheon

15:00 - 16:00

Namisum tour

(Thursday)

16:00 – 17:40

Move to Inter-Burgo hotel

17:40 - 18:00

Check in, Inter-Burgo hotel

Professors

18:00 - 21:00

Welcome ceremony and banquet

Inter-Burgo hotel

21:00 -

Move to dormitory and check instudents

8:00 - 9:30

Breakfast

9:30 - 10:00

Move to conference site

10:00- 11:00

Opening ceremony

Baekwoon Hall 120

11:00 - 12:00

Departmental presentations

Arranged by each department

12:00 - 14:00

Lunch

14:00 - 17:00

Departmental presentations

Arranged by each department

17:00 - 19:00

DinnerArranged by each department

19:00 -

Move to Inter-Burgo hotel

Professors

8:00 - 9:00

Breakfast and check-out

09:00-09:30

Move to Inter-Burgo hotel

09:30-09:45

Inter-Burgo hotel checkout

2015. 11. 7.

9:40 - 09:50

Move to hanji theme park

(Saturday)

10:00 - 11:00

Hanji theme park tour

11:00 – 11:30

Move to pig culture center

11:30 - 13:30

Lunch and tour

13:30 - 16:00

Move to Incheon international airport

2015. 11. 6.
(Friday)

Departure for Nagoya-5-

Others11 professors and 17 students
KE752
Near Incheon airport

Professors: Inter-Burgo hotel
Students: school cafeteria
Yonsei University, Wonju
CampusCommittee meeting(Baekwoon 4th floor, iBMW)Students: Dormitory
2 students
Professors: Inter-Burgo hotel
10 professor

Pig culture center
10 professors, 2 students
KE751

-6-

-7-

Organizing committee
Dean, College of김종배(Jong Bae Kim)

Department of Biomedical Laboratory Science김희중(Hee Joung Kim)

Professor

Department of Radiological Technology최지혜(Ji Hea Choi)

Assistant Professor

Department of Nursing민철희(Chul Hee Min)

Assistant Professor

Department of Radiological Technology

전보영(Bo Young Jeon)

Associate Professor

Department of Biomedical Laboratory Science전혜선(Hey-Seon Jeon)

Professor

Department of Physical Therapy박지혁(Ji Hyuk Park)

Assistant Professor

Department of Occupational Therapy

Health Science

Sponsors
College of Health Sciences Yonsei University
Institute of Health Science Yonsei University
Yonsei University Wonju Campus-8-Abstracts

NURSING-9-

2015 Yonsei-Nagoya University Joint Symposium on
Department of Nursing

Date: 2015.11.06.(Fri)Moderator: Prof. Jihea CHOI

Session I
11:20~11:40

Welcome & Introduction of YUWCM Dept. of Nursing

Prof. SoMi PARK

11:40~12:00

Introduction of Nagoya University Dept. of Nursing

Prof. Midori ASANO

12:00~14:00

Lunch BreakSession II
14:00~14:15

Recognition of the family and child in allergy nursing
practice for shared decision-making in Japan

Prof. Midori ASANO

14:15~14:30

Effects of simulation-based training for basic life support
using video-assisted debriefing on non-technical skills
and technical skills of nursing students

Jin Hwa KOH

14:30~14:45

Relation between patients’information sharing and job
satisfaction among home visiting nurses

Akiyo TSUJI

14:45~15:00

Nursing clinical judgement for schizophrenic inpatients toprevent the early readmission : The case of one nurse

Shigeyoshi MAKI

15:00~15:15

Coffee BreakSession III
15:15~15:30

Husbands’experiences on their partners’postpartum
depression in Japan: A qualitative study

Prof. Hiroe YAMAMOTO

15:30~15:45

The factors to affect the during of exclusive breast
feeding of the infant mothers

Yong Ju JUNG

15:45~16:00

Current status and issues of research on the burden offamily care-givers of elderly with dementia

Tsubasa AOYAMA

16:00~16:15

Effects of self-directed feedback practice using
smartphone videos on basic nursing skills, confidence inperformance and learning satisfaction

Seul Gi LEE

16:15~16:45

Discussion

Prof. Hee Young SONG

16:45~17:00

Closing Mark

Prof. SoMi PARK

-10-

Recognition of the Family and Child in Allergy Nursing Practice for
Shared Decision-Making in Japan
Midori Asano1), Tomoko Yamada2), Makoto Ishii1)2), Chikae Yamaguchi 1)3)
2)

1) Department of Nursing, Graduate school of Medicine, Nagoya University, Nagoya, Japan
Department of Nursing, College of Life and Health Sciences, Chubu University, Kasugai, Japan
3) School of Nursing, Nagoya City University, Nagoya, Japan

Purpose and Background

Methods

In this presentation, I would like to talk aboutshared decision-making (SDM) between the childand family dyad, in which the child has an allergy,
and health care providers, especially nurses in
outpatient settings in Japan.
The background of the situation of allergic
diseases in children in Japan as follows, the mostprevalent is allergic rhinitis, which occurs in 9.2%of school-aged children. Asthma and atopic
dermatitis is over 5%. On the other hand, foodallergy and anaphylaxis are under 3%, although
recently both diseases are increasing year on year.
Another side of prevalence, there are thedifference in prevalence of the allergic diseases
between children and parents generations. Eachdisease is three to five times greater in the child’s
generation than in the parents’ generation.
Shared decision making (SDM) has been
defined as: ‘an approach where clinicians andpatients share the best available evidence when
faced with the task of making decisions, andwhere patients are supported to consider options,to achieve informed preferences”(Glyn Elwyn et. al.,2012). Furthermore, Sufficient explanation andguaranteed choice by health care providers
enhance the patient’s and family’s adherence tomedical treatment (Charles et.,al,1997). Therefore,
nursing practice based on SDM is essential for thepatient and family’s consent to medical treatment.
The purpose of this study was to clarify therecognition and expectations of the nurses’ role in
the practice of mutual partnership between thehealth care providers and child-family dyad, inwhich the child has an allergic disease, such asasthma, atopic dermatitis, and food allergy, in theoutpatient setting.

Semi-structured interviews were conducted with six
families who have a child with an allergic disease,such as asthma, atopic dermatitis, or a food allergy.
Categories were extracted using qualitativedescriptive analysis. Most parents were around 30 to
40 years old. The average age of children was 9.7
years old.
The interview questions were as follows:
Q1: How do nurses usually interact with the childand family in the clinic?
Q2: With what kind of interaction with the nurses doyou feel comfortable?
Q3: What do you think is the role of a pediatricallergy nurse？
This study was part of the project “Exploring
the characteristic of pediatric allergy nursing
practice based on shared decision-making.” This
study was performed with the approval of Nagoya
University ethics committee (2013-0194).
This project was funded by Grants-in-Aid for
Scientific Research B in Japan (No. 25293453).

Results
Table.1 shows the results of the first question. Seven
categories were extracted from the interview data.
Unfortunately, children with allergic diseases andtheir families mentioned that it was quite rarethat nurses were concerned with them directlyin the outpatient setting.

Nurses were mainly concerned with the childand family when the child needed medical treatment
or a medical examination, such as an injection,-11-

inhalation, blood test, or oral food challenge(OFC) in the allergy outpatient setting. On theother hand, children and mothers felt happy thatthey had effective education about care skills likea skin care of child more easily and successful
and also they felt comfortable talking about theirfamily daily life with nurses, because they
thought that nurses concerned about their childand daily life of family who have child withchronic condition.
The result of third question, specialty of thepediatric allergic nursing (expectation of nurses
by the family), as follows; Explanation of medical
treatment, examination and practice, because they
hesitated to ask the doctor about small matters,
Explanation of a medical examination from along-term perspective, communication thatindicates an interest in the patient, such as their
daily life, school life, friends, and family; andRespect for the child's point of view andcommunicating with them. On the other hand,some children and family did not expect anything.

Discussion
Shared decision-making between service
users and health care providers is increasingly
being suggested as a key component of good
health care. As the first step, nurses have to talkwith the child and family more in various
situations in the outpatient setting/clinic in Japan.
Edbrooke-Childs et al. (2015) mentioned thatthe child-reported experience of SDM was only
associated with higher levels of child-reported
improvement when their parents also reported
higher levels of SDM. Therefore, it is very
important that child and parents both usually talkabout the issue of family daily life with nurses.
In our former study, the pharmacists
perceived that nurses play a wide range of roles
that are difficult to visualize and verbalize. They
hoped to enhance communication between
families and health care providers, and had
expectations toward nurses to appeal to theirexpertise by sharing information they obtained
regarding patients (Asano et al., 2014).
In our country the training system of thepediatric allergy educator (PAE) was establishedin 2009. This system was constructed trying tofacilitate the adherence of child and family inwhich the child has allergic diseases. The PAE isa qualification that covers all allergic diseases inchildhood that is certified by the Japan PediatricSociety of Intractable Asthma and Allergic
Diseases (JSPIAAD). The PAE’s ultimate

responsibility is to educate and encourage patientsand their families, and to facilitate the developmentof appropriate patient self-care competence. Initially,
PAE training was intended for nurses, but thecandidates of the PAE have been expanded toinclude pharmacists and dieticians since 2013.
Although we could not find clear evidences of thenursing practice which contribute to create shareddecision making between the child and family dyad
with allergic disease and health care providers in
out-patient settings in this study, we belief nurses
are required to provide information regarding thechild and family’s real daily life to otherprofessionals.

Conclusions
First, children with an allergic disease and theirfamilies mentioned that it was quite rare that nurses
talked to them about their daily life directly andcasually in the outpatient setting. They recognizedthat nurses were concerned about them, when thechild needed medical treatment or a medical
examination, such as an injection, inhalation, blood
test, or OFC in the allergy outpatient clinic. Mothers
felt comfortable and want to talk with nurses, notonly the condition of their child, but also small
worries about family daily life.Unfortunately, we
could not find clear evidence of nursing practice
and/or an approach that contributes to create SDM
by the child with an allergy and their family in thisresearch. Then, in the near future, we have to makespecialized nursing practice for SDM in pediatricallergy settings clearly.
References[1] Charles C, Gafni A, Whelan T. Shared Decision-Making in
the medical encounter: What does it mean? (Or it takes atleast two to tango) Soc Sci Med.1997; 44:681-692.
[2] Glyn Elwyn et. al., Shared Decision Making: A Model for
Clinical Practice J Gen Intern Med. 2012 Oct; 27(10): 1361–
1367.
[3] Arlene M.Butz, Jennifer M.Walker, et.al., Shared Decision
Making In School Age Children with Asthma Pediatr Nurs.
2007; 33(2): 111– 116.
[4] Edbrooke-Childs J, Jacob J et.al., The relationship between
child- and parent-reported shared decision making and child-,
parent-, and clinician-reported treatment outcome in routinely
collected child mental health services data. Clin Child
Psychol Psychiatry. 2015 Jun 22. pii: 135910451559122[5] Midori A, Chikae Y et.al., Pharmacists’ Perception andExpectations about Nurses ’ Role to Enhance Shard
Decision Making in Children with Allergic Disease. The First
Asia Pacific Paediatric Nursing Conference 2014

Author address

E-Mail: midoria@met.nagoya-u.ac.jp-12-Effects of Simulation-based Training for Basic Life Support using Video-assisted
Debriefing on Non-technical Skills and Technical Skills of Nursing Students
Jin Hwa Koh1)
1)
2)

Hea Kung Hur2) SoMi Park2) Gi Yon Kim2)

Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju.
Professor, Department of Nursing Wonju College of Medicine, Yonsei University

Introduction
Cardiac arrest resulted unexpected death due tosudden circulatory arrest[1]. Situation that you need toperform CPR in clinical was demanded the non-technicalskills and technical skills and team should be appropriate
harmony in CPR because they perform different activities asa team who several structures rather than one person at thesame time[2]. Simulations are useful to improve the nontechnical skills and technical skills. Especially, it helps todetermine the difference between the team members to using
video-assisted debriefing in performing simulations[3].
Therefore, the purpose of this study was to investigate theeffects of simulation-based training for basic life support
using video-assisted debriefing on non-technical skills andtechnical skills in order to apply CPR accurately andeffectively in a situation of cardiac arrest.
Methods
Study design: The control group pre-test, post-test
non-synchronized experimental study was conducted fromMarch 6 to June 22, 2015.
Participants: A total of 36 students in the
Department of Nursing of Y. University located in W. City,
and a total of 12 teams, six teams in an experimental groupand six teams in a control group, with one team of three
persons who were randomly assigned according to their CPR
knowledge score.
Measurements: The tool for non-technical skills of
the emergency medical team developed by Cooper et al.
(2010) was used as a tool measuring non-technical skills,
which was composed of a total of 11 questions, while thechecklist of basic life support performance developed byJung, Ji-su (2013) was used as a tool measuring technicalskills, which was composed of 26 questions.
Data analysis: Data were analyzed using
Cronbach’s α, Intraclass Correlation Coefficient (ICC), χ2test, Fisher's exact probability test, t-test, Mann-Whitney U
test and Willcoxon signed rank test with IBM SPSS 20.0.

non technical skills are an important factor that can lead CPR
successfully, so video-assisted debriefing can be used as anefficient teaching-learning strategy in the simulation-based
training for basic life support for nursing students or nurses.
References[1] Holmberg, M., Holmberg, S., & Herlitz, J. (2000). Effect ofby stander cardiopulmonary resuscitation in out of hospital
cardiac arrest patients in Sweden. Resuscitation, 47, 59-70.
[2] Field, J. M., Hazinski, M. F., Sayre, M. R., Chameides, M.,
Schexnayder, M. R., & Hemphill, R., et al. (2010). Part 1:
Executive Summary of 2010 AHA Guidelines for CPR and
ECC. Circulation, 122(3), S640-S656.
[3] Rudolph, J. W., Simon, R., Reamer, D. B., & Eppich, W. J.
(2008). Debriefing as formative assessment: Closing
performance gaps in medical education. Academy ofEmergency Medicine, 15(11), 1010-1016.
Author address
E-Mail: blanc411@naver.com

Results
Of the 36 participants, 85.7% were women and themean age was 22.86 years old.
1) Non technical skills
In simulation-based training for basic life support, theexperimental group had significantly higher score in nontechnical skills than the control group (Z=-2.65, p<.01)
2) Technical skills
In simulation-based training for basic life support, theexperimental group had significantly higher score intechnical skills than the control group (Z=-2.04, p<.01).
Conclusions
The hypotheses were supported in simulation-based
basic life support training, and debriefing using video was
effective for improving both non technical skills andtechnical skills. In other words, in a situation of cardiac arrest,-13-

Relation between patients’ information sharing andjob satisfaction among home visiting nurses
A.Tsuji1), H.Sakakibara1)
1) Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan

Introduction
Home visiting nurses are expected to increase thequantity and provide high quality care because of progress inaging society. However, home visiting nurses’ turnover rate
is higher than hospital nurses’ turnover rate (home visiting
nurses’ turnover rate=15.0%, hospital nurses’ turnover
rate=12.6%) [1]. Job tenure and job satisfaction were thestrongest predictors of nurse retention [2]. Eight independent
subscales were validated: Relationship with Patients,
Relationship with Peers, Professional Pride, Relationshipwith Physician, Relationship with Organization, Autonomy
and Control, Stress & Workload, and Salary & Benefits [3].
Relation between retention and job satisfaction of visiting
nurses was conducted to prove the credibility and validity of
the job satisfaction measurement indices in Japan [4]. In the
study, the four components of job satisfaction in home
visiting nurses were defined as “specialty of home-visit
nursing care”, “management”, “difficulty in nurturing
relationship between users, their family and doctors”, and“preference for home-visit nursing care”. In addition, thestudy indicates that the importance of environmental
planning for satisfying visiting nurses’ household andoccupational responsibilities together, as well as keeping
their personal health.
First purpose of this study was to reveal how to sharepatients’ information among home visiting nurses and somefactors which influence on sharing the information. Second
purpose was to clarify the relation between sharing theinformation and job satisfaction of home visiting nurses. It is
expected to enhance quality of home visiting nurses andreduce turnover rate of home visiting nurses.
Methods
Sample: A cross-sectional study with nonymous selfadministered questionnaire was carried out in 2015 in one
district of Japan; Aichi. Home healthcare agencies wereselected based on the database announced by the national
association for home-visit nursing care. Of 101 directors ofagencies which I contacted by telephone, 67 agencies
assented to participate in this study. Then 495 questionnaires
were mailed to the 67 agencies for this study.
This research was approved by the Ethics Committee ofthe school of Health Sciences, Nagoya University.
Materials: Demographic variables included sex, age,
spouse and child. Organizational variables included agency
size, the existence of clerks, being on call at night and charge
system. Job-related variables included kinds of license, yearsof nursing experience, years of home visiting nursing
experience, experience of working at a hospital, years ofworking at current agency, employment status, pay system,
the number of visiting per week, role of a care manager, roleof a director, the number of days working on weekend permonth, the number of days being on call at night per month,joining workshop in the last three month and eating lunchwith colleagues in the last three month. Health condition andSleep quality was asked. Communication related variables
include a friendly adviser in an agency, talking to a director
friendly and communicating tools. Patients’ information

share related variables included 4 items (“Do you feel anxiety
because you cannot grasp patient’s information when you visit
patient’s home?” “Are you confused about talking with patientor the family members because you cannot grasp patient’s
information when you visit patient’s home?” “Are you confused
about talking with other medical staff because you cannot grasp
patient’s information when you visit patient’s home?” “Can you
visit patient’s home with grasping patient’s information
sufficiently?”). These items are rated on a 4 point scale.
Patient’s information sharing opportunities related variables
included each using or participating frequency. These items are
rated on a 4 point scale. Job satisfaction measurement indicesfollowed the questions used in the research paper of Nakano(2008), “The relation between retention and job satisfaction ofvisiting nurses”. Job satisfaction measurement indices included
4 items. These items are rated on a 4 point scale.
Data analysis: All the data were analyzed by using IBM
SPSS Statistics (version 22.0 for Windows). Descriptive
analyses were performed on all variables, using Chi-square test
and the like. Particularly “uneasy feelings due to insufficient
sharing of patients’ information“ were analyzed.
Results
SampleThe number of respondents was 280 of 495 home visiting
nurses. Among them, 277 respondents completed thequestionnaires (valid response rate: 56%). The number of male
was 7(2.5%) and the number of female was 268(96.8%). The
largest number of generation was from 40 to 44 years old(22.0%). 54.2% of the respondents were full-time employees.
53.1% of the respondents were monthly-pay system, 13.7% ofthem were hourly-pay system and 32.5% of them were fixed by
the number of home visiting. 40.8% of respondents were lessthan 4 years that they have been working as home visiting
nurses.
Relationship between characteristics and information Sharing
Table1 shows characteristics associated with uneasiness due
to insufficient sharing of patients’ information. Nurses who had
longer experiences as nurses or as home visiting nurses had lessuneasiness due to insufficient sharing of patient information.
The uneasiness was also less found in those who had roles ofcare managers or duties of being on call at night, joined
workshops, had a friendly adviser in an agency and talked to a
director friendly. People who worked as directors, were in good
health condition and used some communication tools tended tohave less uneasiness.
Table2 shows sharing measures associated with uneasinessdue to insufficient sharing of patient information. The
uneasiness was less encountered in people who wellcommunicated by telephone and attended some conferences.
People who well talked with colleagues tended to have lessuneasiness.
Relationship between job satisfaction and information Sharing
Table3 shows an association between job satisfaction andthe uneasiness due to insufficient sharing of patient information.
People without uneasy feeling about insufficient sharing ofpatient information were likely to be satisfied with their job.

-14-

Discussion
The results have suggested that longer experiences as
nurses or home visiting nurses help share patient information.
Nurses who had roles of care managers or duties of being on
call at night could often share the information because they
probably needed to understand the information fully. The
present study also indicated that better information sharing
could be linked with good communicating with colleagues
such as having a friendly adviser in an agency, talking to a
director friendly, calling, attending a conference and talking
with colleagues. These results imply that promoting better
information sharing, nurses can visit patients’ home withoutanxiety, which may lead to improving their job satisfaction.
Conclusions
The results suggest that it is important to build
relationship with colleagues or to promote friendly
communication, which can contribute to better information
sharing. Sharing patient information might be effective inenhancing quality of home visiting nurses and possibly
reducing turnover rate of home visiting nurses.
References[1]Japanese Nursing Association. Perspective on home-based
medical care and home visiting nursing. Japan. 2011[2] Carol Hall Ellenbecker, Frank W. Porell, Linda Samia,
James J. Byleckie, Michael Milburn. Predictors of Home
Healthcare Nurse Retention. Journal of Nursing Scholarship.
2008;40:2. 151-160.
[3] Carol Hall Ellenbecker, James J. Byleckie, Linda W.
Samia. Further Psychometric Testing of the Home
Healthcare Nurse Job Satisfaction Scale. Research in Nursing& Health. 2008;31. 152-164.
[4] Yasuko Nakano. The relation between retention and job
satisfaction of visiting nurses. Home Care Nursing, College
of Nursing Art and Science, University of Hyogo. UH CNAS,
RINCPC Bulletin. 2008;Vol.15

Author address
E-Mail: tsuji.akiyo@f.mbox.nagoya-u.ac.jp

Table 2, Methods of sharing according to anxiety
anxcietyyesnursing recordsnoyestalking with colleaguesnoyes
e-mailnoyescallingnosummary of nursing yesreportnoyeselectronic chartnoyes
hand overnoyesconference
no

yes
n
%
66 100.0%0
0.0%
64 95.5%3
4.5%
36 53.7%
31 46.3%
31 46.3%
36 53.7%
60 89.6%
7 10.4%24 36.4%
42 63.6%
43 65.2%
23 34.8%
50 74.6%
17 25.4%

no
n
196
13
208
2
135
75
129
81
189
21
70
140
147
61
183
26

%
93.8%
6.2%
99.0%
1.0%
64.3%
35.7%
61.4%
38.6%
90.0%
10.0%
33.3%
66.7%
70.7%
29.3%
87.6%
12.4%

P
0.038
0.059
0.122
0.029
0.916
0.650
0.397
0.011

Table 1, Characteristics according to anxiety
anxiety
age

≦29
30-39
40-49
50≦
years of nursing≦9
experience
10-19
20≦
years of home visiting ≦9nursing experience 10-1920≦experience of working yes
at a hospitalno＜5
agency size
5-9(the number of nurses)
10≦
yes
the existence of clerksnoyesbeing on call at nightnoyescharge systemnofull-time
employment status
part-time
pay systemmonthly-pay
hourly-pay
fixed by the
number of home
visiting

yes
no
yes
role of a directorno≦19
the number of visiting
20-29(/week)30≦
the number of days 0
working on weekend 1-2(/month)3≦
the number of days 0
being on call at night 1-4(/month)5≦
best
health condition
good
bad
good
sleeping qualitybadyesjoining workshop
noeating lunch withyescolleagues
nohaving a friendly
yesadviser in an agency notalking to a director yes
friendlynoyescommunicating tools
norole of a care manager

yes
n
3
16
29
19
12
31
22
54
10
2
65
1
7
24
36
58
9
63
4
53
14
34
33
35
12

%
4.5%
23.9%
43.3%
28.4%
18.5%
47.7%
33.8%
81.8%
15.2%
3.0%
98.5%
1.5%
10.4%
35.8%
53.7%
86.6%
13.4%
94.0%
6.0%
79.1%
20.9%
50.7%
49.3%
52.2%
17.9%

no
n
7
43
81
78
25
80
102
130
66
13
207
3
25
76
109
175
33
201
9
181
28
116
94
112
26

%
3.3%
20.6%
38.8%
37.3%
12.1%
38.6%
49.3%
62.2%
31.6%
6.2%
98.6%
1.4%
11.9%
36.2%
51.9%
84.1%
15.9%
95.7%
4.3%
86.6%
13.4%
55.2%
44.8%
53.8%
12.5%

20

29.9%

70

33.7%

1
66
5
61
42
24
1
23
28
16
37
15
15
8
41
18
56
11
42
25
43
24
56
11
45
17
32
35

1.5%
98.5%
7.6%
92.4%
62.7%
35.8%
1.5%
34.3%
41.8%
23.9%
55.2%
22.4%
22.4%
11.9%
61.2%
26.9%
83.6%
16.4%
62.7%
37.3%
64.2%
35.8%
83.6%
16.4%
72.6%
27.4%
47.8%
52.2%

26
184
35
175
133
62
15
64
108
38
76
69
65
48
118
44
185
25
162
46
145
63
196
13
161
20
128
82

12.4%
87.6%
16.7%
83.3%
63.3%
29.5%
7.1%
30.5%
51.4%
18.1%
36.2%
32.9%
31.0%
22.9%
56.2%
21.0%
88.1%
11.9%
77.9%
22.1%
69.7%
30.3%
93.8%
6.2%
89.0%
11.0%
61.0%
39.0%

P
0.602

trendP
0.219

0.080

0.029

0.013

0.006

0.959
0.938

0.630
0.570
0.137
0.521
0.516

0.863

0.009
0.067
0.177

0.553

0.355

0.845

0.022

0.017

0.135

0.066

0.339
0.013
0.397
0.010
0.002
0.057

Table 3, Job satisfaction according to anxiety
yesnoanxciety
n
%
n
%
yes
46
68.7%
183
87.6%
satisfaction
no
21
31.3%
26
12.4%
yes
58
86.6%
203
97.6%
like this work
no
9
13.4%
5
2.4%
yes
43
64.2%
175
85.0%
suited for this work
no
24
35.8%
31
15.0%
yes
53
79.1%
196
93.8%
worthwhile
no
14
20.9%
13
6.2%

-15-

0.734

P
＜0.01
＜0.01
＜0.01
＜0.01

186,1*&/,1,&$/-8'*0(17)256&+,=23+5(1,&,13$7,(1767235(9(17
7+(($5/<5($'0,66,217+(&$6(2)21(1856(S. Maki1), S. Ando1)
1) Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japan

Introduction
Mental health system have been shifted from the facility
centered to the community centered. Japanese government
promotes community centered care in mental health.
However, even after some patients are discharged once fromthe psychiatric hospital, they are readmitted repeatedly. They
have not been able to settle in the community. The risk thepatients would no longer live in the community has been
pointed out [1]. In the previous studies, they focused on theclinical judgment made by the community mental healthnurses. They were carried out in Sweden [2], Australia [3],UK [4], and USA [5.] However there are few studies aboutclinical judgment made by the hospital mental health nurses.
The purpose of this study is to investigate the nursing
clinical judgment which the hospital mental health nurses
make for schizophrenic inpatients to prevent the earlyreadmission.
Subject
The participant was the nurse who;xworked in Japanese public psychiatric hospital.
x
worked more than five years.
x
was recommended to be proficient or expert by thehospital nursing manager.
x
had much knowledge, many skills and experiences.
Methods
This is a qualitative study with the semi-structured
interview. The semi-structured interview, lasting 60 minutes,
was carried out in relaxed and private environment. Theinterview was recorded.
In the interview, the participant was asked to remember
the schizophrenic patient who;x
was readmitted within three months.
x
was nursed in the hospital by the participant.
x
was discharged from the hospital.
x
continued community life more than three months.
The participant was questioned: “How did you grasp of
the patient?” and “How did you make a judgment on nursing
intervention?”
The patient information and the nurse’s demographic
data were written on paper.
Data analysis
A qualitative approach using Saiki’s grounded theory
was chosen. A two-stage coding process was applied, startingwith a substantive coding (open and descriptive codes)
followed with the theoretical coding (increasingly higherlevel conceptual categories that encompassed the descriptive
codes and the relationships between them).
Ethical considerations
 The informed consent was obtained from the nurse,
and this study was approved by the Ethics Committee of
Nagoya University Graduate school of Medicine.

Results
Nurse
Male, 50s, ordinary employee. His psychiatric experience
was 30 years. He had the experiences of psychiatric nursing in
the community.
Patient
Male, 40s. He lived with his mother and younger brother.
His stress coping methods were to drink juice and to eat ice
cream. 10 years ago, he was readmitted. After discharge, hecontinued living in community for 5 years He attended to the
day hospital and received home-visiting nursing after discharge.
The clinical judgment process
The process of the nursing clinical judgment was composedof three phases: predicting the patient’s lifestyle after discharge,
letting the patient have good habits he can keep in thecommunity, requesting for cooperation of the family and thehome-visiting nurses.
Predicting the patient’s lifestyle after discharge
When the patient was readmitted, the nurse grasped of thecharacteristics of the patient and grasped of the lifestyle before
the readmission. The nurse thought the reason why the patient
was readmitted. And the nurse compared the patient’s lifestyle
between before and after the readmission. The nurse predicted
the patient’s lifestyle after discharge and judged what the nurse
could do in the hospital.
Letting the patient have good habits which he can keep in thecommunity
The nurse let the patient have good habits which the patient
could keep in the community (e.g. the nurse urged the patient tocheck the table of lifestyle every day.). Then the nurse focusedon the compulsive aspects of the patient. In other word, thenurse did the intervention for changing the patient’s weakness
to the strength.
A short time later, the nurse did intervention for letting thepatient keep the habits (e.g. the nurse praised the patient when
the patient check the table every day).
The nurse encouraged the patient to change behavior
gradually because he had the opinion that rapid changes in thepatient’s lifestyle would worsen the patient’s condition.
Requesting for cooperation of the family and the home-visiting
nursesThe nurse grasped of the things the family had done
unconsciously (e.g. the family gave stresses unconsciously tothe patient by scolding). Then the nurse explained thecharacteristics of the illness and let the patient and the family
perceive the unconscious. The nurse requested that the family
let the patient keep the lifestyle also after discharge. By this, thepatient had been able to keep the same lifestyle. So the patient
had lived in the community with the family without the problem.
Similarly, the nurse requested for cooperation of the homevisiting nurses who would provide the services after discharge.

-16-

The nurse requested that the home-visiting nurses continued
the intervention made in the hospital.
Discussion
After grasping of the lifestyle of the patient, the nurse
predicted the patient’s lifestyle after discharge. The nurse let
the patient have good habits which the patient could keep inthe community. This intervention was to encourage thepatient to change behavior gradually. By nurse’s requestingfor cooperation of the family and the home-visiting nurses,
the patient could keep the same lifestyle also after discharge.
Relapse of schizophrenia and worsening of thesymptoms are pointed out to be caused subsequent to thestressful life events [6]. Keeping the same lifestyle would
reduce the patient’s stresses caused by the changes oflifestyle after discharge. It is important for nurses to predictthe patient’s lifestyle after discharge early. By doing so, thenurse could let the patient have good habits which the patient
could keep in the community.
Conclusions
The nursing clinical judgment for schizophrenic
inpatients to prevent the early readmission was;x
to predict the patient’s lifestyle after discharge.
x
to let the patient have good habits which he could
keep in the community.
x
to encourage the patient to keep the lifestyle also
after discharge.
References[1]Tai M., Noda T., Takako O. et al.(2010): The Nursing
Care for Acquirement of Symptom Management andEstablishment of Community Support System for
Patients with Schizophrenia Who Were Re-hospitalized,
The Japan Academy of Psychiatric and Mental HealthNursing, 19(1),63-73 [Japanese][2] Magnusson A., Högberg T., Lützen K. et al. (2004):
Swedish mental health nurses’ responsibility insupervised community care of persons with long-term
mental illness, Nursing and Health Sciences, 6, 19-27[3] McCann T.V. & Clark E. (2003): A grounded theory
study of the role that nurses play in increasing clients’
willingness to access community mental health services,
International Journal- of Mental Health Nursing, 12,279-287[4]Murphy N. (2004): An investigation into how community
mental health nurses assess the risk of violence from theirclients, Journal of Psychiatric and Mental Health Nursing,
11,407-413[5]Dearing K. S. (2004): Getting It, Together: How the Nurse
Patient Relationship Influences Treatment Compliancefor Patients With Schizophrenia: Archives of PsychiatricNursing, 18(5), 155-163[6] Walker E., Mittal V., & Tessner K. (2008)㸸Stress andthe Hypothalamic Pituitary Adrenal Axis in theDevelopmental Course of Schizophrenia, The Annual
Review of Clinical Psychology, 4,189-216
Author address
E-Mail: maki.shigeyoshi@a.mbox.nagoya-u.ac.jp-17-

Husbands’ experiences on their partners' postpartum depression in Japan: A qualitative study
H.Yamamoto１）
1) Department of Nursing, Graduate School of Medicine, Nagoya University, Nagoya, Japansignificantly affected their life. All participants wereconscious of disease about postpartum depression.
Nevertheless, they were not aware of physicalsymptoms of their partners’ postpartum depression(e.g. insomnia, appetite disturbances). Theirawareness of partners’ postpartum depression wasconsisted of three categories. Initially, they were
aware of “ difficulty of their partners’ emotional
control”and“feeling of strangeness”. Then, they
were aware of “ their partners’ verbal
expression”.Their perception was consisted of four
categories that were categorized as “ little minor
trouble for my wife”，“helpless feeling”，“out ofideas”and“hopeless”．

Introduction
Pregnancy and childbirth involve many biological,
psychological and social changes that require
adjustment and adaptation for both parents.
Postpartum depression is a serious mental healthproblem affecting about 13% of women in the first
three months after delivery [1].Risk factors forpostpartum depression include antenatal depression,
recent life stressors, previous traumatic birth,obstetric and infant complications and a perceived or
actual lack of practical and emotional support.
Postpartum depression has a negative influence onchild health and development. While the concern onmaternal postpartum depression has been increasingover the past two decades, much less is known about
the impact of postpartum depression among husbands.
As many as 24% to 50% of men whose partners have
postpartum depression may also experience
depression [2].
The purpose of this study was to identify husbands’
experiences on their partners' postpartum depression
in Japan for supporting family with new born babies.

Discussion
This study is the first approach to identify husbands’
experiences on their partners’ postpartum depression
in Japan. This study revealed the husbands were hard
to be aware of physical symptoms of their partners.
Thus they might delay to find their partners’
depression. The content of their perceptions showedthat they faced a serious aspect. This finding was inline with previous study [3].The previous study
reported that men whose partners suffered frompostpartum depression were experienced fear,
confusion, much concern for their partners, and felt
unable to help them in overcoming postpartum
depression.
Furthermore, this study also revealed that thehusbands tend to struggle the difficult situation that
leads family to crisis. Beestin L et al. reported that thehusbands whose partners had experienced postpartum
depression emphasized the inescapable, unexpected
and isolating experiences [4]. Thus, medical
professionals may pay more attention to husbands
whose partners had experienced postpartum
depression for providing appropriate care.
One of the limitations of the study was the relativelya small sample size. Further study may consider toincrease samples for conforming this result.

Methods
This study was conducted from November 2012 toFebruary 2013.Semi-structures interviews wereconducted among three men whose partners had
experienced postpartum depression and resided inTokyo and Aichi prefecture. The interviews exploredhow husbands were aware of and perceived theirpartner’s depression. The interviews were audiorecorded and transcribed verbatim. Data wereanalyzed using qualitative descriptive approach.
The informed consent was obtained from allparticipants. This study was approved by the Ethics
Committee of the Nagoya University Graduate
School of Medicine, Nagoya University, Nagoya,Japan.

Findings
The age of participants were between 35 and 61years
old .Their children’s age were between 1 and 12 years
old. The participants felt that their partner’s
experience of postpartum depression had-18-

postpartum depression associated with maternal
postpartum depression? Population-based study in
Brazil, Acta Psycheatr Scand 113:230-232.
[3]Meighan M, Davis MW, Thomas SP.T, Droppleman
PG. (1999) Living with postpartum depression: The
father’s experience, The American Journal of
Maternal/Child Nursing 24(4):202-208.
[4]Beestin L,Hugh-Jones S,Gough B.(2014)The impact
of maternal postnatal depression on men and their waysof fathering:an interpretative phenomenologicalanalysis,Psychology & Health.29(6):717-735.

Clinical Implications
This study revealed experiences of husbands on theirpartners’ postpartum depression in Japan.
The result of present study could be committed tosupporting the well-being of family with new bornbabies.
References[1] O’Hara MW, Swain A (1996) Rates and risk of
Postpartum Depression: A meta-analysis, International
Review of Psychiatry 8: 37-54.
[2] Pinheiro RT, Magalhaes PVS, Horta BL, Pinheiro
KAT, da Silva RA, Pinto RH.（2006） Is paternmal

Author address

E-Mail: yamamoto@met.nagoya-u.ac.jp-19-

The Factors to Affect the Duringof Exclusive Breast Feeding of the Infant Mothers
Jung, Yong Ju1) Choi, Jihea2) Park, SoMi3)

Kim, Ki Kyong3)

1)

2)

Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea
Assistant Professor, Department of Nursing, Wonju College of Medicine, Yonsei University
3)
Professor, Department of Nursing, Wonju College of Medicine, Yonsei University

PASW Win 20.0 statistics program for t-test,
ANOVA, Scheffe post-hoc test, Kruskal Wallis test,
Pearson's Correlation Coefficient, and multiple
regression analysis. The main outcomes of this study
are as follows:

Introduction
This is the descriptive study to understand thefactors to affect the duration of exclusive breast
feeding in the mothers who have 6 to 12 month-old
infants until 6 months after their deliveries. This
study was conducted in the subjects of 136 mothers
who had 6 to 12 month-old infants in Y university
hospital, two pediatric clinics, and a public healthcenter. The data collection period was from March
31 to April 30, 2015. We investigated the factors toaffect the duration of exclusive breast feeding in themothers including the characteristics of breast
feeding such as past experience of breast feeding,training experience of breast feeding, first breast
feeding duration, and successful breast feeding
experience during hospitalization period; knowledge
and attitude on the breast feeding and supports fromtheir husbands and parents.

Results
1) The scores of each domain were 15.79 (±3.73)
points on average out of 25 for the knowledge of
mothers on the breast feeding 75.88 (±11.55) out of
100 for the attitude of breast feeding 36.35 (±6.70)
out of 45 for husband supports 34.93 (±6.38)out of
45 for parents support and 4.14 (±2.09) months forthe duration of exclusive breast feeding.
2) The duration differences of exclusive breast
feeding were significant by age (x2=9.18, p=.027),
occupation existence 6 months after the delivery(t=3.72, p<.001), past deliver experiences (t=-2.31,
p=.022), delivery methods (t=2.11, p=.037), pastbreast feeding experiences (t=12.58 p=.011), training
experience on the breast feeding (t=-2.21, p=.028),
and successful breast feeding experience during the
hospitalization period (t=-2.85, p=.005).

Methods
To measure the knowledge on the breast feeding,we utilized the measurement tool in ‘breast feedingknowledge’ by Lee (1997) which dealt with the
topics of the advantages of mothers’ milk to infants,
the advantages of breast feeding to the mothers, andthe solutions to overcome when they encountered themethod and technical problems of breast feeding.
Regarding the attitude of breast feeding, we applied
the measurement tool in ‘ the attitude of breast
feeding’ by Jeong (1997) to check the cognitive,
emotional and behavioral domains. For the supports
from husbands and parents, we used the amended
tools of ‘husband supports,’ and ‘parents supports’from the original measurement tool by Sung (2003)
which focused on the psychological, physical, andevaluative supports in the subjects of puerperium
mothers, so as to check the supports from theirhusbands and parents on the exclusive breast feedingin the subjects of infant mothers. The statisticalanalysis of the collected data was conducted using

3)
Positive correlation was found statisticallybetween the exclusive breast feeding duration of theinfant mothers and the followings; knowledge on thebreast feeding (r=.348, p<.001), attitude on breast
feeding (r=.461, p<.001), husband supports (r=.211,
p=.014), and parents supports (r=.194, p=.023).
4) The factors to affect the duration of exclusive
breast feeding in the infant mothers were knowledge
on the breast feeding (β=.19) and attitude of breast
feeding (β=.35). It demonstrated that the higher theknowledge scores on the breast feeding and the morepositive attitude to the breast feeding, the more toaffect the duration of breast feeding. These factors
could explain 28.6% of the duration of exclusive
breast feeding in the infant mothers (F=7.33, p<.001).

-20-

of Breast-Feeding.

Author address

Discussion

hera9918@hanmail.net2

From these study results, we learned that theknowledge and attitude on the breast feeding
significantly affected to the duration of
exclusive breast feeding in the infant mothers.
Therefore, the developmental needs of nursing
intervention programs were found to enhancetheir knowledge and attitude for the exclusive
breast feeding.

Conclusions
Based on this, this study played a role toprovide with the basic data for further studies on
the duration of exclusive breast feeding to findvarious variables as well as to suggest theinstitutional and educational supports frompublic health institutions, and moreover needs ofnational policy and publicity to educate thepeople on the advantages and importance of the
exclusive breast feeding with the initiatives of
the national and public health institutions.

References[1] Chezem,J.(2003). Breastfeeding knowledge,

breastfeeding confidence, and infant feedingplans: Effects on actual feeding practice.
Journal of Obstetric, Gynecologic, andNeonatal Nursing, 32(1), 40-47.
[2]Y.M. Kim(2005). Effects of breastfeeding
empowerment program on exclusive breastfeeding.
[3] H.L. Kim(2013). Breastfeeding Trends, Affecting
Factors and Poilicy Options for Breastfeeding
Promotion in Korea. Health and welfare policy
forum, 201, 49-60.
[4] S.O. Lee, S.S. Na & K.Y. Park(2012). Exclusive
Breastfeeding Rates of Breastfeeding-Willing
Mothers and Its Influencing Factors by the 1st, 3rd,and 6th Month of Postpartum. Journal of richis,
16(1), 44-55.
[5]M.J.
Park(2007).
Trendsinexclusive
breastfeeding by maternal socioeconomic status inSouth Korea : findings from the 1997, 2000, 2003
national fertility and family and family healthsurvey.
[6] I.A Son(2007). A Study on the Factors Affecting
Knowledge about, Attitudes towards and Practice-21-

CURRENT STATUS AND ISSUES OF RESEARCH ON THE BURDEN OF FAMILIYCAREGIVERS OF ELDERLY WITH DEMENTIA
T.Aoyama1), Y.Ikematsu1), M.Matsunami2)
1) Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Research Filed of Nursing, Gifu University Graduate School of Medicine, Gifu, Japan

Introduction
Currently, due to the aging society of Japan, the number of
elderly people with dementia is steadily increasing. Since
Japanese health policy encourages the elderly to stay at home,
the role of the family will become more and more importantin caring the home dwelling elderly with dementia. However,caring for people who keep declining their daily life activities
and their decision-making capability may be stressful. In
order to clarify direction of research studies to develop
strategies to alleviate such stress, a literature review was
conducted to determine the present status and problems ofexisting research studies on the burden of family caregivers
who take care of the elderly with dementia.

and
their
percept
ionsMaterials and Methods
The purpose of this was to organize the knowledge about
the care burden of family caregivers caring for the elderlywith dementia at home.
Subjects: The sample articles published from 2003 to 2014
were identified through the Ichushi-Web (Japan Medical
Abstracts Society) and the CiNii databases using thefollowing key words: "dementia elderly", "family", "burden"and "home".
Data analysis: Among the 40 searched articles (31 articles
from Ichushu-Web and 9 articles from CiNii), a total of thirty
research articles were used for analysis excluding duplicatedsearch. The extracted articles were classified and organizedby their study topics, published date, research methods, andstudy results.
Results

Caregiv
ers’burdenandfamilyfunction

Negative effect on HRQOL
Identified six domains of physical,
mental, psychological, social burden
Sense of limitation, negative
emotion, and economic burden
increase care needs
Lower education is related toeconomical, time, mental restrain;
married caregivers feel social
restrain; having alternate caregivers
is related to unstable physicalcondition
Family exchanges between
caregivers suppress the care burden
Dementia severity, BPSD, thenumber of the caregivers, the main
caregiver of health, nursing time
were related to the feeling ofburden.
"Social activity restriction feeling"and "economic crunch feeling"possibly of increase "deny feelings"

Table. Results of research studies on caregivers’ burden
Categor
AuthorResultsies(year)
Enhanced by day-to-day care
Takahashi.J
Familyet al. (2013)caregiv Execrated by loneliness and anxiety
ers’
Sugihara.Y
Reluctance for long-term careburdenet al. (2012)

Medical-22-

Horie.M(2014)

Saeki.A(2006)*
Saeki.A et
al. (2008)*

Yu.H et al.
(2007)
Fujiwara.K
et al. (2011)

Highest burden in “extreme” family
Influenced by caregiver’s
personality and familial
environment

Fujiwara.K
et al.
(2011)

No relationship with family system

Associated with BPSD at home
Behaviouralandpsychol
ogicalsymptoms ofdementia(BPSD)
andcaregiv
ers’burdenMatsumoto.
K (2008）

Lowest burden in “balanced” family

No relationship with family system
There were 20 quantitative studies, 4 qualitative studies, 2
mixed method studies, 1 literature review study, 1 case study,and 2 abstracts. None of the articles was published in 2003
and 2004, 12 were published from 2005 to 2009, 18 were
published from 2010 to 2014.
Study topics were classified into the following 6
categories: "Family caregivers’ burden and theirperceptions"(9), " Caregivers’ burden and family function"(3), " Behavioural and psychological symptoms of dementia(BPSD) and caregivers’ burden"(7), “Medical institution
related burden"(3), " Care service related burden"(3),"Evaluationof assessment tools and interventions toalleviate the burden "(7). Six articles focused on more than
one topic

Fujiwara.K
et al.
(2010）
Kudou.S etal. (2009)

Significant correlation withagitation, depression, irritability
Wandering care did not alleviate
Related to fear for unpredictability,
not understood by the elderly,
irritability for not understandable,elderly’s agitation and delusion
Caregivers tend to attribute BPSD topoor caregiving
Frequent wandering increased andpositive self-evaluation decreased
the burden
Caregivers of elderly with higher
BPSD maintained a sense of
purpose in life
Utilization of resources was
effective for family’s decisionmaking

Saeki.A et
al. (2008)*
Saeki.A(2006)*
Hashidate.Y
et al. (2012)
Kajiwara.K
et al. (2012)
Takizawa.Y
et al. (2011)
Sugiura.K etal. (2007)
Utsuki.T etal. (2008)
Utsuki.T etal. (2007)
Komatsu.S
et al. (2011)
Tanaka.Y et
al. (2013)

institutionrelatedburdenMoving to the hospital, waiting
time, and attendant caused theburdenFamily caregivers’ burden was
statistically involved in medical
needsContinued use of day care reduced
the burden through respite effectand lowering social constraints
Care
serviceHigh needs for “short stay” while
relateddissatisfied with user fees andburdenfrequency (or length of time)
Use of “short stay” did not reducethe care burdenIntervention to improve knowledge
about dementia was ineffective inthe long-term care burden
Tactile Care reduced “physicalpain” in HRQOL but did not
alleviate direct care burden nor
Evaluatpsychological stression ofCognitive Behavioral Therapy andassessSocial Skills Training werement
provided for the caregivers but not
tools
evaluated
andOriginal assessment toolinterve
discriminated severity of dementia
ntionsbut not related to care burden
toCare burden was not reduced byalleviatfamily support intervention
e theCoping and social support wereburdenrelated to the burden implying
intervention for coping skills to beeffective
Stress coping behavior was related
to the burden indicating needs ofcoping behavior intervention*Duplicated listing

Nakai.Y et
al. (2012)
Matsumoto.
K et al.
(2007)
Fujiwara.K
et al. (2012)
Nakai.Y et
al. (2012)
Arakawa.A(2010)
Yoshizawa.
M et al.
(2012)
Suzuki.M etal. (2012)

Yuuki.C(2010)

agitation, depression, irritability, delusions, and loitering as“problems”. Therefore, they feel distressed when the elderly
exhibit BPSD, and their psychological stress is aggravated by
the BPSD.
Findings of studies of “Care service related burden" indicate
using the short-stay service do not always have a beneficial
effect on the care burden, and other factors are thought to be
involved. Those factors may be intricately intertwined.
Using medical service is also found to be the source of
caregivers’ burden according to the studies of “Medical
institution related burden." Such burden was triggered by theexperience of being unable to smoothly use medical institution.
It is revealed that outpatient visits and hospitalizations canworsen the family caregivers’ burden. Specifically, bringing theelderly to the hospital, waiting time, and attendance of
hospitalization were such factors. There was a qualitative studyof single case. However, it did not elucidate caregivers’ burden
because its scope was limited to discharge planning.
Due to the studies in the category of “Evaluation andmitigation of the care burden ", effectiveness of interventions
was inconclusive. Only tactile care was partially effective toalleviate care burden but was not conclusive. None of theassessment tool successfully quantified family caregivers’
burden.
Conclusions

Kamijou.K
et al. (2008)
Kamijou.K
et al. (2010)
Watanabe.
M et al.
(2009)
Watanabe.
M (2009)

Discussion
Published research articles on the family caregivers’
burden who take care of elderly with dementia have been
increasing since 2005. It was studied not only in nursing but
also in other fields such as rehabilitation sciences and social
welfare studies. This trend may be attributed to the elevating
societal awareness on the burden of the family caregivers
who take care of home-dwelling elderly with dementia. Moreresearch studies are expected to be conducted in the future
because of a national plan which is called “Orange plan”
proposed by the Ministry of Health, Labour and Welfare inJune 2012.
Results of the studies of "Family caregivers’ burden andtheir perceptions” imply that family caregivers are confusedwith the changes of the dementia symptoms and having
difficulty in admitting the changes while keep working fortheir care. These emotions may enhance the physical, mental
and psychological exhaustion. Anxiety and loneliness of the
caregivers are also implied.
Studies of “Caregivers’ burden and family function"
revealed that the majority of the families were "extremetype" or "intermediate type" in their family function while a
few families were "balanced type". Families of “upsetting”
and “extremely cohesive” types showed high tendency ofaggregation implying their adaptability is diminished.
According to the studies of “BPSD and caregivers’
burden", family caregivers perceive those behaviors such as

1. Thirty articles on family caregivers’ burden who take careof the home-dwelling elderly with dementia were identified byliterature search and were classified into six categories.
2. The burden of the family caregivers who take care of theelderly with dementia are influenced by BPSD, family function,
length of care period, the degree of caregivers’ acceptance ofcare, the relationship between a caregiver and the elderly, theirenvironment, and caregivers’ self-evaluation.
3. Improvement of systems in medical institutions and carefacilities is warranted to avoid additional burden of the familycare givers of elderly with dementia.
4. Strategies including nursing intervention to mitigate theburden of the family taking care of elderly with dementia need
to be developed.
References
1．Niimura.T (2002)：History of the elderly with dementia
Form of swaying aging, HOSEI UNIVERSITY PRESS of
Publication Administration, Tokyo [Japanese]
2．The Japanese Society for Dementia Care (2004)：Basis ofdementia care - Dementia care standard text (3rd revised
edition), The Japanese Society for Dementia Care Editing, Ltd.
World Planning, Tokyo [Japanese]
3．The Japanese Society for Dementia Care (2004)：Actual ofdementia care : General remarks - Dementia care standard text
(3rd revised edition), The Japanese Society for Dementia Care
Editing, Ltd. World Planning, Tokyo [Japanese]
Author address

E-Mail: aoyama.tsubasa@d.met.nagoya-u.ac.jp-23-Effects of Self-Directed Feedback Practice Using Smartphone Videos on Basic
Nursing Skills, Confidence in Performance and Learning Satisfaction
Lee, Seul Gi 1)

Shin, Yun Hee 2) Lim, Young Mi2)

Choi, Jihea3)

1)

Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea
2)
Professor, Department of Nursing Wonju College of Medicine, Yonsei University3) Assistant Professor, Department of Nursing, Wonju College of Medicine, Yonsei University‘wearing protective equipment when entering and exiting
the quarantine room and the management of wastematerials’, and ‘L-tube feeding’.
Data analysis: Collected data were analyzed, using
χ2-test and independent t-test with IBM PASW for
Windows Version 21.0 Program.

Introduction
Nursing is a professional and practical study tomeet the health needs of human in the advanced
medical care and aging society[1], practicaleducation is occupied very large proportion.
Nursing practical education can be divided into
clinical practice it takes place in a hospital orcommunity and school practice using laboratory of
the university. Recently, many universities are inneed of an efficient clinical practice teaching modelof development that the clinical practice site inconjunction with the university campus to promote
the training of students performing experience[2].
Self-directed practice is autonomous practicemethod to acquire practice skills students themselves.
And it needs checking effects of nursing practicaleducation utilizing the advantages of smartphone
video to enable the active learning in consideration of
student’s characteristics in response to society thatchanges rapidly.
So this study was done to verify the effects of aself-directed feedback practice using smartphone
videos on nursing students' basic nursing skills,
confidence in performance and learning satisfaction
and to contribute to increasing efficiency of selfdirected practice and improving systematic nursing
practice.

Results
The results of this study are summarized asfollows.
1) Basic nursing skills were higher for all three
items in the experimental group compared to thecontrol group, and the differences were
statistically significant (t=-2.10, p=.039; t=-4.74,
p<.001; t=-2.70, p=.009). (Table 1)
2) Confidence in performance was higher for eachof the three items in the experimental groupcompared to the control group, but thedifferences were not statistically significant (t=1.77, p=.081; t=-1.35, p=.181; t=-1.88, p=.066),
and after the practice of the three items, there
were statistically significant differences in theoverall score for confidence in performance (t=3.07. p=.003). (Table 2)3) Learning satisfaction was higher in theexperimental group than in the control group,
but there were no statistically significant
differences (t=-1.67, p=.100). (Table 3)

Methods
Study design: This study was an experimental
study with a randomized control group post-test
design.
Participants: The randomly assigned participants
were from the Department of Nursing at Y.
University located in Gangwon-do and final
participants for analysis were 29 students in theexperimental group and 29 students in the control
group.
Measurements: The main point of the intervention
in this study was the exchange feedback on
deficiencies through smartphone recording videos of
the nursing practice process taken with peers during
self-directed practice. And the items for basic nursing
skills in this study were the 3 items of ‘vital signs’,

Table 1. Comparisons of Basic Nursing Skills between theExperimental and Control Group-24-

Exp. G(n=29)

Con. G(n=29)

Basic
nursingskillsMean±SD

Mean±SD

Item 179.88±8.80

Item 2Item 3tp

73.87±12.56

-2.10

.039

89.45±7.4578.13±10.45

-4.74

〈.001

94.28±4.41

89.90±7.53

-2.70

.009

Table 2. Comparisons of Confidence in Performance
between the Experimental and Control Group
Exp. G(n=29)

Con. G(n=29)

Mean±SD

Mean±SD

Item 175.79±11.51

Item 2

Basic nursing
skillstp

69.87±13.75

-1.77

.081

78.96±11.14

73.94±16.51

-1.35

.181

Item 385.39±12.81

78.65±14.43

-1.88

.065

OverallConfidence

76.74±10.99

64.98±17.42

-3.07

.003

Table 3. Comparisons of Learning Satisfaction between theExperimental and Control GroupBasic
nursingskillsLearning
Satisfaction

Exp. G(n=29)

Con. G(n=29)

Mean±SD

Mean±SD

4.27±0.39

4.04±0.62

t

p

-1.67

.100

Conclusions
This study verified that self-directed feedback
practice using smartphone videos could improvebasic nursing skills. It has significance that it could
help nursing students gain confidence in their nursing
skills in the future through the improvement of basic
nursing skills and perform quality patient care byproviding patients with safer care. In addition, it isexpected that, in the future, actively applying theself-directed feedback practice using smartphone
videos, which can be used regardless of time andplace, in the education of nursing practice will
improve the nursing students’ basic nursing skills.

References[1] Kitajima Y, Nakamura M, Maeda J, Kanai-

Pak M, Aida K, Huang Z, et al. Robotic as atool in fundamental nursing education. Digital
Human Modeling. 2014;8529:392-402.
[2] Choi SH, et al. Comparison of Blended Practicum
Combined E-learning between Cooperative andIndividual Learning on Learning Outcomes.
Journal of Korean Academic Society of Nursing
Education. 2014;20(2):341-349.

Author address
E-mail: nej250725@daum.net-25-

Abstracts

Physical Therapy-26-

2015 Yonsei-Nagoya University Joint Symposium on
Physical Therapy

11:00~12:00

Session I

11:00~11:30

Comparison of Psoas Major Muscle Thickness measured sonography

Chair: Prof. Heon-Seok Shin

during Active Straight Leg Raising
In-Chul Jeon (Yonsei Univ.)
11:30~12:00

Selective

muscleactivation

withvisualelectromyographic

biofeedback during scapular posterior tilt exercise in subjects withround-shoulder postureJae-Ik Son (Yonsei Univ.)

12:00~13:30

Lunch

13:30~14:10

Session II

13:30~13:50

Development of animal model of post-stroke spasticity and study of

Chair: Prof. Sachiko Lee

its mechanisms
Sachiko Lee (Nagoya Univ.)
13:50~14:10

The kinematic analysis of passive stretching by physical therapists
for equinovarus after stroke
Naomi Yamada (Nagoya Univ.)

14:10~14:30

20 Minute Coffee Break-27-

14:30~15:10

Session III

14:30~14:50

The Validity of a dynamic neuromuscular stabilization-Heel sliding

Chair: Prof. Chung Hwi Yitest for core stability
Young-Joo Cha (Yonsei Univ.)
14:50~15:10

Event related desynchronization(ERD) of Mu rhythm duringconcentric and eccentric contraction
Joo-Hee Park (Yonsei Univ.)

15:10~15:30

20 Minute Coffee Break

15:20~16:00

Session Ⅳ

15:20~15:40

Intensensory facilitation and interference during stepping task

Chair: Prof. Sumio Yamada

Tatsunori Watanabe (Nagoya Univ.)
15:40~16:00

Relationship between self-reported walking time and objectively
measured moderate to vigorous physical activity in middle-aged:
Cross-sectional, correlational research
Masaki Kato (Nagoya Univ.)※ 15 minutes presentation and 5 minutes Q&A-28-

Comparison of Psoas Major Muscle Thickness measured by sonography during Active
Straight Leg Raising in Subjects with and without Uncontrolled Lumbopelvic Rotation
Jeon IC1), Kwon OY2), Weon JH3), Choung SD2), Hwang UJ2)

1) Department of Physical Therapy, Graduate School, Yonsei University, Wonju, South Korea
2) Department of Physical Therapy, Kinetic Ergocise Based on Movement Analysis Laboratory, College of Health Science,
Yonsei University, Wonju, South Korea
3) Department of Physical Therapy, College of Tourism & Health Science, Joongbu University, Geumsan, South Korea
Introduction
Recent studies have shown that the psoas major (PM)contributes to stabilization of the lumbar spine (LS)(Santaguida and McGill, 1995). Hu et al. (2011) stated thatduring active straight leg-raising (ASLR), various muscles areactive, including the iliacus, rectus femoris, and ipsilateral PM(iPM); the contralateral PM (cPM) is also active. In addition,
most authors agree that PM activity increases with greater hip
flexion, while Yoshio et al. (2002) even concluded that the PM
mainly works as a stabilizer of the lumbar spine and thefemoral head over the first 15°of hip flexion, and does not
become an effective hip flexor prior to 45°of flexion. ASLR
evaluates the ability to transfer a load between the spine andlegs via the pelvis. Therefore, the optimal movement pattern forthe lumbopelvic region must be controlled by the stabilizing
muscles and remain neutral (Sahrmann, 2002). Comerford andMottram (2012) defined ipsilateral lumbopelvic rotation in thetransverse plane during ASLR as uncontrolled lumbopelvic
rotation (ULPR). ULPR may contribute to the asymmetric
symptoms, leading to pain in the lumbopelvic region(Comerford and Mottram, 2012). Repetitive unwanted rotationin the lumbopelvic region during ASLR might result in lower
back pain (Sahrmann, 2002). Although recent studies agree that
iPM activity increases with the angle of hip flexion (Andersson
et al., 1995), whether the cPM acts as a lumbar stabilizer
remains controversial (Santaguida and McGill, 1995; Yoshio etal., 2002; Hu et al., 2011). Therefore, this study compared therelative cPM thickness ratios (thickness during ASLR /thickness at rest) in subjects with and without ULPR, during
ASLR. We hypothesized that the thickness of the cPM would
be significantly greater during ASLR (10º) in subjects without
ULPR.
Methods
Subjects: Thirty-seven healthy males were recruited for thisstudy (18 without ULPR, 19 with ULPR). To screen for ULPR,
a pressure biofeedback unit (PBU) was located on either side ofthe lumbopelvic region. The pressure of each PBU was
adjusted to 40 mmHg. ULPR was regarded as present when the
difference in the pressure between the sides of the lumbopelvic
region exceeded 5 mmHg during a 90° single-heel slide in thesupine position (Comerford and Mottram, 2012).
Kinematic data collection procedure An electromagnetic
tracking device (LIBERTY™; Polhemus) was used to measurepelvic rotation at 120 Hz (accuracy of 0.08 cm for position and
0.15° for orientation). The electromagnetic motion sensor was
attached to the pubic symphysis on tight- fitting clothing wornby the subjects. The orientation of the electromagnetic tracker
system (global reference frame) was defined in alignment withthe orientation of ASLR, with +Z vertically upward, +X
parallel to the line of both anterior superior iliac crests (ASIS),
and +Y directed along the anterior–posterior axis. The
difference between the angles of the initial and final positionsin the transverse plane during ASLR was determined tomeasure the pelvic rotation. During ASLR, the contralateral

ASIS ascends 0.5 inch, which identifies subjects with andwithout ULPR (Sahrmann, 2002). Therefore, subjects withULPR exhibited pelvic rotation of ≥ 6 º which can be converted
to 0.5 inch. The mean angle of three trials was used for analysis.
US imaging A high-resolution US machine (Sonoace X8;
Samsung Medison, Seoul, Korea) with a 7.5-MHz linear
transducer and a 50-Hz wall filter setting was used to measure
the thickness of the cPM (de Oliveira et al., 2013). The
transducer was placed transversely on the cPM medial to the
ASIS and observed below the level of the inguinal ligament(Sajko and Stuber, 2009). Using a marker pen, the location of
the transducer was marked with a straight line on the skin tomaintain the contact area between the two surfaces (thetransducer and the skin). We used the inbuilt program tocapture and save images for calculation of cPM thicknesses.
Procedures The subjects’ arms were crossed over theirchests, and their legs were straight and positioned 20 cm apart.
The target bar was placed 10 cm above the table. Each subject
raised the dominant leg and touched the target bar with thestraight leg. The subjects were asked to maintain contact
between the leg and target bar for 5 s. An examiner with 5 yearsof experience measured the thickness of the cPM in eachsubject group. All measurements were performed on the sameday. The order of measurements with loading on the dominantankle joint and between the groups was random. The examiners
were blinded to the results of the measurement and the subjects’
information.
Statistical analysis The one-sample Kolmogorov–Smirnov
test was employed to ensure a normal distribution of themeasurement data. Two-way mixed-model analysis of variance(ANOVA) was used to identify statistically significant
differences in the cPM thickness during ASLR / cPM thickness
during rest ratio between the two groups (with vs. without
ULPR). The level of statistical significance was set at α = 0.05.
If a significant interaction was observed between the loading
status (with vs. without loading) or groups (with vs. without
ULPR), the simple effect was compared using Bonferroni
correction (α = 0.05 / 4 = 0.0125). The angle of lumbar rotation
was compared using the paired t-test for both no loading andloading within each subject group. The Statistical Package for
the Social Sciences for Windows, ver. 18.0 (SPSS, Chicago, IL,
USA) was used for statistical analysis.
Results
No statistically significant differences were found in initialcPM thickness between groups with and without ULPR (0.64 ±0.06 mm in subjects without ULPR vs. 0.64 ± 0.05 mm insubjects with ULPR; t = 0.41, p = 0.69). There was significant
interaction effect between the loading status and the group (F =225.87, p < 0.01). Therefore, the simple effect was comparedusing Bonferroni correction. The relative muscle thickness(thickness during ASLR /thickness at rest) in subjects without
ULPR was significantly greater that in subjects with ULPR (p< 0.01). The angle of lumbar rotation was significantly-29-different in subjects without ULPR (2.84 ± 1.06 for ASLR, 3.10
± 0.89 for ASLR with 1-kg loading; p = 0.09) and with ULPR
(7.27 ± 1.12 for ASLR, 8.49 ± 1.82 for ASLR with 1-kg
loading; p < 0.05).

contraction of the PM provides compressive forces thatstabilize the LS by increasing stiffness in the spinal joints. The
contraction of the cPM can act as a lateral stabilizer of the LS
in the frontal plane. We found that the cPM was thicker insubjects without than with ULPR in the present study.
Therefore, contraction of the cPM might contribute tostabilization of the LS during ASLR in subjects without ULPR.
Second, it is possible that the cPM muscle thickens due to cocontraction with the external and internal obliques andtransversus abdominis as well as the diaphragm and pelvic
floor muscles for lumbar stability during ASLR in subjects
without ULPR (Hodges, 1999). Further investigation of theinteraction between the cPM and other stabilizing muscles,
such as the abdominal muscles, pelvic floor muscles, anddiaphragm, is needed. This study had several limitations. First,
contraction of other muscles—such as the diaphragm, pelvic
floor muscles, and abdominal muscles—was not taken into
account. Second, the findings in this study cannot be
generalized to females because all subjects in the study were
healthy males. Finally, further investigation of the mechanism
underlying the lack of increase in the thickness of the cPM in
subjects with ULPR is needed.
Conclusion
The thickness of the cPM as determined by US imaging was
significantly greater during ASLR (10º) in subjects without
than with ULPR. This finding indicates that the cPM can be
activated to stabilize the LS during ASLR. Activating the cPM
before lifting a leg might increase lumbopelvic stability during
ASLR exercises when managing individuals with ULPR.
References[1] Andersson E, Oddsson L, Grundström H, Thorstensson A.
The role of the psoas and iliacus muscles for stability andmovement of the lumbar spine. Scand J Med Sci Sports.
1995;5(1):10-16.
[2] Comerford M, Mottram S. Kinetic Control: The
Management of Uncontrolled Movement. Edinburgh: Churchill
Livingstone; 2012.
[3] de Oliveira CA, de Sá RA, Velarde LG, da Silva FC, doVale
FA, Netto HC. Changes in ophthalmic artery Doppler indices inhypertensive disorders during pregnancy. J Ultrasound Med.
2013;32(4):609-616.
[4] Nachemson A. Electromyographic studies on the vertebral
portion of the psoas muscle; with special reference to its
stabilizing function of the lumbar spine. Acta Ortho Scand.
1966;37(2):177-190.
[5] Sahrmann SA. Diagnosis and Treatment of Movement
Impairment Syndromes. St Louis: Mosby; 2002.
[6] Sajko S, Stuber K. Psoas Major: a case report and review of
its anatomy, biomechanics, and clinical implications. J Can
Chiropr Assoc. 2009;53(4):311-318.
[7] Santaguida PL, McGill SM. The psoas major muscle: athree-dimensional geometric study. J Biomech. 1995
Mar;28(3):339-345.
[8] Hodges PW. Is there a role for transversus abdominis in
lumbo-pelvic stability? Man Ther. 1999;4(2):74-86.
[9] Hu H, Meijer OG, van Dieën JH, Hodges PW, Bruijn SM,
Strijers RL, Nanayakkara PW, van Royen BJ, Wu WH, Xia C.
Is the psoas a hip flexor in the active straight leg raise? Eur
Spine J. 2011;20(5):759-765.
[10] Yoshio M, Murakami G, Sato T, et al. The function of thepsoas major muscle: passive kinetics and morphological studies
using donated cadavers. J Orthop Sci. 2002;7(2):199-207.

Discussion
The thickness of the cPM was measured during ASLR insubjects with and without ULPR. The thickness of the cPM
was significantly greater in subjects without ULPR, but was not
significantly changed in subjects with ULPR even with 1-kg
loading. This implies that the cPM acts to stabilize the LS
during ASLR. The cPM was thicker, and became increasingly
thicker upon 1-kg loading, during ASLR in subjects without
ULPR. This result supports our study hypothesis. A possible
explanation for this finding is that the cPM may be activatedfor lumbar stabilization rather than hip flexion to control
ipsilateral lumbar rotation during ASLR. Hu et al. (2011) foundthat during ASLR, the muscle activity of the iPM using needle
EMG was consistent as a hip flexor, that the cPM was recruited
to stabilize the LS in the frontal plane, and that the muscle
activity of the cPM also increased as weight was applied
during ASLR. That study also found that the cPM contributed
to lumbar stability during ASLR in healthy subjects (Hu et al.,2011). Some possible reasons that contraction of the cPM acts
to stabilize the LS are as follows. First, during the initial rangesof ASLR, the greatest moment arm from the leg passes throughthe pelvis. This moment might evoke ipsilateral pelvic rotation,and the LS also rotates with the pelvis in the same direction.
From this viewpoint, contraction of the cPM might be activated
to control this ULPR. Nachemson (1966) suggested that

Author address
E-Mail: kwonoy@yonsei.ac.kr; jeon6984@naver.com-30-

Selective Muscle Activation with Visual Electromyographic Biofeedback during
Scapular Posterior Tilt Exercise in Subjects with Round-Shoulder PostureJae-ik Son, BPT, PT1), One-bin Lim, MSc, PT1), Hae-rim Han, BPT, PT1)
Heon-seock Cynn, PhD, PT2),3), Chung-hwi Yi, PhD, PT 2),3)
1) Dept. of Physical Therapy, The Graduate School, Yonsei University2) Dept. of Physical Therapy, College of Health Science, Yonsei University3) Dept. of Ergonomic Therapy, The Graduate School of Health and Environment, Yonsei University
Introduction
Round-shoulder posture (RSP) is typified by a protracted,
anterior tipped, and downwardly rotated scapular position [1].
One of the commons factor that contributes to RSP is weaknessof the lower trapezius (LT) and serratus anterior (SA) muscles[1-3], the main muscles of scapular posterior tilting. A decreasein scapular posterior tilting causes subacromial impingement[1]. Therefore, strengthening the LT and SA is often included
in exercise programs for subjects with RSP. Scapular posterior
tilting exercise (SPTE) in the prone position was highly
efficient in activation of the LT and SA [3,4], but subjects with
RSP typically tend to use the upper trapezius (UT) and highactivation of the UT is regarded to cause the decrease of
scapular posterior tilting [2]. So, the selective activation of LT
and SA while reducing the UT activity is needed for effective
exercise. One of the methods for selective activation is visualelectromyographic (EMG) biofeedback. The visual EMG
biofeedback is recommended approach for learning functional
motor control in rehabilitation settings [5,6]. Thus, the purposeof this study was to investigate whether using visual EMG
biofeedback can reduce the UT activity while increasing LT
and SA activities during SPTE, and to determine changes in thescapular upward rotation angle after visual EMG biofeedback.
Materials and methods
Subjects: Twenty-four subjects (15 males and 9 females)with RSP participated in this study. The RSP was identified bymeasuring the distance between the posterior border ofacromion and the table in the supine position. The subjects with
distance ≥2.5 cm were included in this study [1]. The subjects
with current shoulder pain or problems and history ofneurological, musculoskeletal, or cardiopulmonary disease that
could interrupt shoulder motion were excluded [4].
Instrumentation: Surface EMG (Noraxon TeleMyo DTS,
Noraxon Inc., AZ, USA) was used to collect muscle activity.
LT electrodes were attached obliquely upward and laterally
along the line between the intersection of spine of the scapulaand the 7th thoracic spinal process [4,7]. SA electrodes wereattached anterior to the latissimus dorsi and posterior to thepectoralis major [4,7]. UT electrodes were attached midway
between the spinous process of the 7th cervical vertebra and theposterior tip of the acromion process [7]. Raw signals were
filtered using a band-lass filter (10-450 Hz), while 60 Hz and
120 Hz notch filter were used to diminish electrical noise.
EMG data were processed by the root mean square.
Experimental procedure: EMG activities in two conditions(SPTE with and without visual EMG biofeedback) and scapularupward rotation angles in three different conditions (baseline,
after performing SPTE with and without visual EMG
biofeedback) were collected. The experimental procedure ofthis study was as follow: (1) Before the exercise, theinvestigator measured the subject’s scapular upward rotation
angle; (2) Subject performed SPTE; (3) After the SPTE, theinvestigator immediately measured subjects’ scapular upward
rotation angle; (4) Subject performed a 10-min session tofamiliarize themselves with visual EMG biofeedback for 10; (5)After the familiarizing session, subjects performed SPTE withvisual EMG biofeedback; (6) After the SPTE with visual EMG
biofeedback, the investigator immediately measured subjects’scapular upward rotation angle.
Scapular posterior tilting exercise: In the quadruped position,
the researcher instructed the subjects to rock backward andplace the non-dominant hand under the forehead. The
researcher passively abducted subjects’ arm until 145° and thesubjects lifted their arms while maintaining arm extension until
the target bar, which was set at the subjects’ earlobe level [1,4].
Scapular upward rotation angle measurement: The scapularupward rotation angle was measured in shoulder abduction at
135° by two inclinometers. One inclinometer was used tomeasure shoulder abduction angle and the other one was used
to directly measure the scapular upward rotation angle withmanually aligned along the scapular spine [1].
Visual EMG biofeedback session: EMG biofeedback
measurement option of MyoResearch Master Edition 1.07 XP
software (Noraxon Inc., AZ, USA) was used. Biofeedback
information was displayed on the computer screen and theresearcher instructed the subject to reduce UT activity while
increasing the LT and SA activities [7,8].
EMG data collection: The EMG data of LT, SA, and UT
were collected for 6-s for each trial during the isometric phaseand data of 2-5 seconds were analyzed. The subjects performed
each exercise (SPTE with and without visual EMG biofeedback)for three trials with a 2-min resting time between trials toprevent muscle fatigue. A 5-s maximal voluntary isometriccontraction (MVIC) was calculated to determine a basis for
EMG signal normalization; normalized muscle activities were
presented as %MVIC [4].
Statistical analysis: SPSS ver. 21.0 (SPSS Inc., Chicago, IL,
USA) was used to analyze statistical significance, and thesignificance level was set at α<0.05. The paired t-test was used
to analyze the EMG activities (LT, SA, and UT) and the EMG
activity ratio (LT/UT and SA/UT). The one-way repeatedmeasures analysis of variance was used to analyze scapularupward rotation angles among the three conditions (baseline,
after performing SPTE without and with visual EMG
biofeedback). The Bonferroni correction was used forclarifying differences among three conditions (0.05/3=0.017).
Results
EMG activities and EMG activity ratios: The EMG activities
of LT and SA were significantly increased during SPTE withvisual EMG biofeedback (LT: p=0.006, SA: p<0.001). Also the
EMG activity of UT was significantly decreased during SPTE
with visual EMG biofeedback (p=0.002) (Figure 1). The
LT/UT and SA/UT EMG activity ratios were significantly
increased during SPTE with visual EMG biofeedback (LT/UT:
p=0.001, SA/UT: p<0.001) (Figure 2).
Scapular upward rotation angle: The scapular upward
rotation angle was significantly different among the three
conditions (p<0.05). The scapular upward rotation angles inboth, with and without visual EMG biofeedback, conditions
were significantly increased when compared to the baseline-31-

(both p<0.001). No significant difference in scapular upward
rotation angles was noted between with and without visual
EMG biofeedback during SPTE (p>0.017) (Figure 3).

Figure 1. The muscle activities of LT, SA and UT
during scapular posterior tilting exercise with andwithout visual EMG biofeedback (LT: lower
trapezius, SA: serratus anterior, UT: upper trapezius,
VEB: visual EMG biofeedback, *p<0.05).

Figure 2. The muscle activity ratios of LT/UT and
SA/UT during scapular posterior tilting exercise
without and with visual EMG biofeedback. (LT: lower
trapezius, SA: serratus anterior, UT: upper trapezius,
VEB: visual EMG biofeedback, *p<0.05).

Figure 3. The scapular upward rotation angles in thethree different conditions (SPTE: after performing
scapular posterior tilting exercise without visual
EMG biofeedback, SPTE with VEB: after
performing scapular posterior tilting exercise withvisual EMG biofeedback, *p<0.017).
Discussion
The results of this study indicate that using visual EMG
biofeedback during SPTE can successfully reduce the UT
activity while increasing LT and SA activities. The use ofvisual EMG biofeedback during SPTE may be beneficial
because it is user-friendly and easy to learn. In particular, visual
EMG biofeedback can help persons with RSP because it canselectively facilitate weak muscles while selectively inhibiting
the overactive muscle [5,6,7,8]. In addition, EMG activity
ratios of LT/UT and SA/UT were improved. Increased activityof the LT and the SA would contribute to prevent subacromial
impingement [4], and reduced activity of the UT would lead todecreased compensation in subjects with RSP.

Scapular upward rotation angles in both with and withoutvisual EMG biofeedback conditions were significantly
increased compared with the baseline. However, contrary to our
expectation, there was no significant difference in the scapularupward rotation angle between with and without visual EMG
biofeedback during SPTE. This finding could have been due tothe immediate effect of visual EMG biofeedback (because thisstudy was a cross-sectional study). A longitudinal study istherefore needed to determine the long-term effect of visual
EMG biofeedback on muscle activity and kinematic data inpathological patient groups.
Conclusion
Visual EMG biofeedback is user-friendly and easy to learn.
The SPTE using visual EMG biofeedback could be an effective
method to reduce the UT activity and increase LT and SA
activities, as well as EMG activity ratios of LT/UT and SA/UT.
Therefore, visual EMG biofeedback should be advocated toreduce overactivation of the UT while selectively enhancing the
LT and the SA activity during SPTE.
References[1] Lee JH, Cynn HS, Yoon TL, et al. The effect of scapular
posterior tilt exercise, pectoralis minor stretching, andshoulder brace on scapular alignment and muscles activity
in subjects with round-shoulder posture. J Electromyogr
Kinesiol. 2015;25(1):107-114.
[2] Ludewig PM, Braman JP. Shoulder impingement:
Biomechanical considerations in rehabilitation. Man Ther.
2011;16(1):33-39.
[3] Ekstrom RA, Donatelli RA, Soderberg GL. Surface
electromyographic analysis of exercises for the trapezius
and serratus anterior muscles. J Orthop Sports Phys Ther.
2003;33(5):247-258.
[4] Ha SM, Kwon OY, Cynn HS, et al. Comparison ofelectromyographic activity of the lower trapezius andserratus anterior muscle in different arm-lifting scapular
posterior tilt exercises. Phys Ther Sport. 2012;13(4):227232.
[5] Holtermann A, Roeleveld K, Mork PJ, et al. Selective
activation of neuromuscular compartments within thehuman trapezius muscle. J Electromyogr Kinesiol.
2009;19(5):896-902.
[6] Holtermann A, Mork PJ, Andersen LL, et al. The use of
EMG biofeedback for learning of selective activation of
intra-muscular parts within the serratus anterior muscle: A
novel approach for rehabilitation of scapular muscle
imbalance. J Electromyogr Kinesiol. 2010;20(2):359-365.
[7] Huang HY, Lin JJ, Guo YL, et al. EMG biofeedback
effectiveness to alter muscle activity pattern and scapularkinematics in subjects with and without shoulder
impingement. J Electromyogr Kinesiol. 2013;23(1):267-274.
[8] Lim OB, Kim JA, Song SJ, et al. Effect of selective muscle
training using visual EMG biofeedback on infraspinatus andposterior deltoid. J Hum Kinet. 2014;44:83-90.
Author address
E-Mail: jaeiggy@naver.com-32-

Development of animal model of post-stroke spasticity and study of its mechanisms
Sachiko Lee

Department of Physical and Occupational Therapy, Graduate School of Health Sciences, Nagoya University
including the ulnar nerve and stimulated with a stimulator (1 3 mA in 0.1 mA increments, SEN - 7103, Nihon Kohden
Corporation, Aichi, Japan). For recording, a pair of stainlessneedle electrodes fixed with manipulator was transcutaneously
placed into the abductor digiti minimi muscles and obtained
recordings with an amplifier and an A/D converter.

Introduction
Spasticity is common in patients with brain and spinal cord
injuries. Approximately 20% to 40% of patients with stroke
exhibit spasticity, whereby neurologic damage disrupts
voluntary movement control. Consequently, these patients’quality of life is significantly lower compared to that ofpatients without post-stroke spasticity.[1]It is clear that stroke can cause inhibitory and excitatory
impulse imbalance, leading to upper motoneuron symptoms,
and it is known that lesion location and extent can result indiffering symptoms and degrees of spasticity severity;
however, the pathophysiologic basis of spasticity remains
poorly understood. It is accepted that spasticity involves overreactivity of alpha motoneurons and alterations in primary Ia
reciprocal inhibition and Renshaw recurrent inhibition, further
understanding of the underlying mechanisms is hindered by
the lack of animal models. In one study, Fulton and colleagues
used primates to demonstrate that lesions in both primary andpremotor areas can induce spasticity;[2] however, a rodent
model is needed to analyze the precise mechanisms underlying
spasticity after cortical injuries, such as those in stroke.
Here, we investigated whether spasticity is induced after
photothrombotic injury to the rostral and caudal forelimb
motor areas of mice, which are considered the premotor andforelimb primary motor cortices in rodents, respectively.[3]Given that enhanced excitability of affected motoneurons has
frequently been reported in studies of spasticity after strokeand spinal cord injury, we further examined whether a similar
phenomenon occurred in our mouse model of post-stroke
spasticity.

Immunohistochemical analysis
The tissues were embedded in optimal cutting temperaturecompound and stored at ‒80°C. Coronal sections of the spine(20‒30-µm thick) were prepared with a cryostat. We preincubated the tissue in blocking buffer (5% normal bovine
serum and 0.25% Triton X-100 in PBS) for 1 h at 25°C,
followed by incubation with a first antibody in blocking buffer
for 24 h at room temperature. After washing in PBS, the tissue
was incubated for 1 h in a solution containing second antibody.
The sections were counterstained with DAPI (4',6-diamidino2-phenylindole).
Statistical analyses
Group measurements are expressed as mean ± standard errorof the mean (SEM). H-reflex RDDs were determined as ameasurement of spasticity and analyzed with one-way analysis
of variance (ANOVA) and Tukey‒Kramer Tests. For
immunohistochemical
analysis,weused
ANOVA,
Tukey‒Kramer tests, and Spearman’s correlation coefficientby rank test. p values less than 0.05 were consideredsignificant.
Results
Reduction of H-reflex RDD after stroke
To test whether an affected muscle exhibited spastic
symptoms after stroke, we measured H-reflex RDDs in theaffected and unaffected abductor digiti minimi muscles 3 days
and 1, 2, 3, 4, 6, and 8 weeks after stroke. The H-reflex
magnitudes were attenuated by repeated activations at
frequencies higher than 0.1 Hz. In particular, we observed a
reduction of more than 80% of the H-reflex magnitude at 5 Hz
in sham-operated mice (Figure 1A, upper panel). In contrast,
the H-reflex magnitude in 4-week stroke mice was not strongly
attenuated by repeated activation (Figure 1A, lower panel).
Moreover, we found that RDDs for the affected muscles weresignificantly weakened in stroke mice (n = 6) compared to
sham-operated mice (n = 7) 3 days after stroke, and this was
still observed on week 8 after stroke (p < 0.01, Figure 1B);
however, the RDDs were not significantly weakened at week 3.
In addition, the RDDs of stroke mice were significantly
smaller at week 6 than at weeks 4 and 8 (p < 0.01). Four weeks
after stroke, the RDDs induced at all frequencies higher than
0.1 Hz were significantly smaller in stroke mice than in sham-Materials and methods
Photothrombotic cortical lesion
Focal cortical ischemia was induced by cortical microvessel
photothrombosis, as described previously. Rose Bengal (30mg/kg body weight) was injected into the tail vein 5 min
before illumination, and the skull was exposed via a midline
incision of the skin. Focal illumination of the rostral andcaudal forelimb motor areas was carried out with a cold lightsource [4] through the intact skull; the brain was illuminatedfor 15 min. Control mice either received the same injection ofRose Bengal without illumination (n = 10) or were
photostimulated after an intravenous injection of 0.9% NaClsolution (n = 4).
Electrophysiological recordings
We modified a previously described method to use the ratedependent depression (RDD) of the H-reflex as a measurementof spastic symptoms[5-6] We transcutaneously inserted a pairof stainless needle electrodes fixed with micromanipulator(SM-15, NARISHIGE, Tokyo, Japan) into nerve bundles,-33-

operated mice (Figure 1C). This indicates that the affectedmuscles exhibited spastic post-stroke symptoms in our model.

Discussion
Spasticity is a common complication after stroke; however,the underlying pathophysiology remains unclear, and research
into this area is hampered by the lack of appropriate animalmodels. The present study reveals that lesions in the rostraland caudal forelimb motor areas of the mouse brain induce
spasticity, as indicated by weakened H-reflex RDDs, increased
motoneuron excitability of affected muscles, and recovered
RDDs in stroke mice following baclofen treatment. Ourfindings raise the possibility that this protocol may yield aviable animal model of post-stroke spasticity.
References
1.

2.

3.

4.

5.

6.
Motoneuron hyperactivation after stroke
It has been reported that one of the mechanisms underlying
spasticity in stroke patients is increased neuronal excitabilityof the propriospinal neurons and motoneurons. We measured
c-Fos immunoreactivity in motoneurons labeled for choline
acetyltransferase (ChAT) using spinal sections from thecervical to the thoracic level (C4‒T1) obtained 1, 2, 4, and 8
weeks after stroke. At 1 week after stroke, c-Fos induction in
the affected and unaffected neurons was significantly
increased in stroke mice compared to sham-operated mice at
most spinal levels (n = 3 for groups; **p < 0.01, in C4‒T1,
compared between sham-operated and stroke mice on theaffected side; #p < 0.05, in C4, ##p < 0.01, in C6‒T1, compared
between sham-operated and stroke mice on the unaffected
side)

Urban PP, Wolf T, Uebele M, Marx JJ, Vogt T, et al.
(2010) Occurence and clinical predictors of
spasticity after ischemic stroke. Stroke 41: 20162020.
Fulton JF and Kennard MA (1934) A Study of
Flaccid and Spastic Paralyses Produced by Lesionsof the Cerebral Cortex in Primates. Res Publ Assoc
Res N 13: 158-210.
Rouiller EM, Moret V and Liang F (1993)
Comparison of the connectional properties of thetwo forelimb areas of the rat sensorimotor cortex:
support for the presence of a premotor or
supplementary motor cortical area. Somatosens Mot
Res 10: 269-289.
Tennant KA, Adkins DL, Donlan NA, Asay AL,
Thomas N, et al. (2011) The organization of theforelimb representation of the C57BL/6 mouse
motor cortex as defined by intracortical
microstimulation and cytoarchitecture. Cereb Cortex
21: 865-876.
Boulenguez P, Liabeuf S, Bos R, Bras H, JeanXavier C, et al. (2010) Down-regulation of thepotassium-chloride cotransporter KCC2 contributes
to spasticity after spinal cord injury. Nat Med 16:
302-307.
Navarro X, Verdu E and Buti M (1994) Comparisonof regenerative and reinnervating capabilities ofdifferent functional types of nerve fibers. Exp Neurol
129: 217-224.

Lee S et al. Weakened rate-dependent depression of
Hoffmann's reflex and increased motoneuron
hyperactivity after motor cortical infarction in mice. Cell
Death Disease. 16, e1007, 2014•
Lee S et al. Down-Regulation of KCC2 Expression andPhosphorylation in Motoneurons, and Increases the
Number of in Primary Afferent Projections toMotoneurons in Mice with Post-Stroke Spasticity. PLOS
ONE. 9(12), e114328, 2014
This work was supported by a grant from the JSPS KAKENHI(Grant Number 23700598) and a grant from the Hayashi
Memorial Foundation for Female Natural Scientists.
Sachiko Lee: lee@met.nagoya-u.ac.jp•-34-

The kinematic analysis of passive stretching by physical therapists
for equinovarus after stroke.
Naomi Yamada1), Shogo Okamoto2), Yoji Yamada2) and Yasushi Uchiyama1)
1) Department of Physical and Occupational Therapy, Graduate School of Health Sciences, Nagoya University2) Department of Mechanical Science and Engineering, Graduate School of Engineering, Nagoya University
Introduction
Stretching is one of major intervention for spasticity. But in asystematic review, the evidence of the effects of stretching inspasticity was inconclusive because of a wide diversity in studies
included this review which investigate the effects of stretching on
spasticity [1]. And this review suggested there were no criteria ofintervention to measure the effects of stretching, especiallymanual stretching by therapists.
So we are establishing an analyzing system for identifying
kinematic properties of passive stretching by physical therapist(PT) for ankle joint. In this study we investigated whether an
established system could be used in clinical application as ameasure of therapists’ manual stretching techniques.
Materials and Methods
An analyzing system of stretching techniques
1) Measurement method
We made the instrument to measure forces applied to both theforefoot and heel, as shown in Fig 1, because, in clinical, PTs
generally push the plantar surface using their forearms while
gripping the heel of the patient in order to stretch the ankle plantar
flexors. This instrument could be fastened to the patient’s footusing fabric bands, and the gaps between the foot and brace werefilled with rubber plates and sponges to tightly fix them while
avoiding pain. This tightening allowed the therapists to apply
sufficient forces to the instrument as they clinically do for thebarefoot of patient.
A three-dimensional motion capture system (VENUS3D,
Nobby Tech. Ltd., Japan) was used for measuring the motion
during stretching, which also allowed for synchronization of theforce sensors and cameras. The system recorded the positions ofreflective markers attached to the patient's thigh and brace at therate of 120 Hz. Seven reflective markers were used for the motion
capture system (Fig. 1). Two markers were placed on the anteriorborder of the patient's tibia shin bone. One marker was also
attached on the bone's medial surface. The instrument had four
markers attached. Two of them were located on the frontal part,and the other two markers were on the medial part of the
instrument. Using these markers, two coordinate systems were
defined: lower leg (∑𝑙 ) and foot (∑𝑓 ), as shown in Fig. 2.
2) Kinematic properties of stretching
In order to investigate stretching techniques, the following three
types of kinematic data were used: foot posture, foot force, andtorques.
The foot posture was defined as the roll-pitch-yaw angles
between the lower leg and foot coordinate systems. For this end,
we computed the rotation matrix 𝒍𝑹𝒇 between the twocoordinate systems and decomposed it into roll, pitch, and yaw
angles ( 𝑙 𝜃𝑥 , 𝑙 𝜃𝑦 , 𝑙 𝜃𝑧 ). The six-axial torque sensor on the heel𝑓𝑓𝑓
output three force components ( 𝑓𝑥 , 𝑓𝑦 , 𝑓𝑧 ) and moments𝑓𝑓𝑓( 𝑚𝑥 , 𝑚𝑦 , 𝑚𝑧 ). These properties are almost equivalent tomotions and forces along axes of ankle (Table.1).
Note that it was not possible to acquire the outputs fromanother force sensor on the forefoot owing to a problem ofelectronic circuits; therefore, data from the forefoot sensor was
not used in the analysis.

Experiment in clinical
1) Subjects
We applied the previous system to PT stretching forequinovarus in clinical. A male PT with twenty years ofexperience in rehabilitation and three stroke survivors wereinvited to participate in this experiment (Table. 2). This study wasapproved by the local ethics committee (Graduate School of
Medicine, Nagoya University, approval no. 14-501).
2) Experimental task
The patients wore the measuring instrument on their paralyzed
foot and lay relaxed on a bed. PT stretched the patient's footthrough the instrument The PT was instructed to perform thestretching as they did in a clinical setting. One trial of stretchinglasted ten seconds, and in a single set of the experiment, three
trials were repeated with a rest period of five seconds between
trials. In total, three sets were conducted for each therapist, witha one-minute break after each set.

Fig. 1 Foot brace with two force sensors.

Fig. 2 Coordinate systems (∑𝑙 , ∑𝑓 and ∑𝑠 ).
Table. 1 Meanings of each kinematic properties

Table. 2 Characteristics of patients(BRS: Brunnstrom Recovery Stage)-35-

Fig. 3 Average of kinematic properties each stretching trial for patient A, B and C.

Fig. 4 1st and 2nd Components of kinematic properties.
On the other hand, from the spectrum analysis, two principal
components ( √𝜆1 𝒂𝟏 ， √𝜆2 𝒂𝟐 ) were acquired, with thecontribution ratios of each component being 64.8% and 15.9%.
Fig. 4 shows the primary and secondary components for the footposture, force, and torque. We could find 1st component
corresponds to the average profile of the techniques in otherwards similarity of the techniques because this component
showed summarized all trials, and 2nd component expressed
where there were individual differences by the change ofproperties value. For example, value of 𝜃𝑧 was increasing in 2ndcomponents and this indicated that there were individual
differences in dorsi or plantar flexion of stretching. Thus,
according to these results, we could identified the mainly PT
stretching techniques for all patients and the differences
properties in stretching for each patient.

Data analysis of stretching
We used a spectrum analysis for identifying PT stretching
techniques. Nakanishi et al. suggested a spectrum analysis could
be used for motion analysis including time series data [2]. But
their method included only posture angles to analysis, so we
expanded their methods to use not only angles but also forces andmoments.
For the spectrum analysis, a single foot stretching was split into
two phases: transitional and keeping. The transitional phase spansfrom the beginning of the stretching to the point at which the footwas dorsiflexion. The keeping phase is the period during which
the muscles were continuously stretched with relatively large
manual forces. A border between these two phases was definedusing the velocity of the dorsi/plantar flexion angle of the foot. In
this study, the main focus was on the transitional phase in theanalysis because it was possible to see the movement to correct
the equinovarus in this phase.
After the segmentation, each time-sequence data were
downsampled to the length of 100 and normalized, and we
defined the extended vector asv = ( 𝒍𝜽𝑻𝒙 𝒍𝜽𝑻𝒚 𝒍𝜽𝑻𝒛 𝒇𝒇𝑻𝒙 𝒇𝒇𝑻𝒚 𝒇𝒇𝑻𝒛 𝒇𝒎𝑻𝒙 𝒇𝒎𝑻𝒚 𝒇𝒎𝑻𝒛 ) T
which had a length of 900. This extended vector was used foreach stretching. Secondly, data matrix of all stretching trials were
performed and we decomposed DDT into the matrix of eigen
vectors and values using spectrum expansion.

Discussion & Conclusions
In this experiment, the primary component with 64.8 %contribution ratio was statistically extracted as similarity despite
the diverse severity of included patients. This suggests it ispossible to separate a commonality of the stretching techniquesfrom a specificity of each patient by this analyzing system.
Using the kinematic analysis of manual stretching for ankle
which we are developing, we identified the mainly stretching
techniques and differences among patients. So this system could
be useful for standardization of each PT stretching techniques forseveral patients and contribution of education in PT.

1

𝑫 = 𝑨𝜦2 = (√𝜆1 𝒂1 √𝜆2 𝒂2 ⋯ √𝜆𝑚 𝒂𝑚 ) ， (𝜆1 > 𝜆2 > ⋯ > 𝜆𝑚 )Then we looked at the eigen vectors with large eigen values tospecify the principal components.

References[1]Bovend’Eerdt TJ, Newman M, et al.: The effects of stretchingin spasticity: a systematic review. Arch Phys Med Rehabil. 2008;
89(7): 1395-1406.
[2]Nakanishi H, Kanata S, et al. Extraction of coordinative
structures of motions by segmentation using singular spectrum
transformation. Journal of Advanced Computational Intelligenceand Intelligent Informatics, 2011, 15(8): 1019-1029.

Results
The averages of foot position, force, and moment of all trials
which applied to each patients are shown in Fig.3. According thisfigure, we could find some properties, such as 𝜃𝑦 , 𝑓𝑧 , 𝑚𝑦 , had
the tendency in their change during stretching whereas otherproperties, such as 𝜃𝑧 , 𝑓𝑥 , 𝑚𝑥 , had different change among trialsof each patient. So we couldn’t define the characteristic of PT
stretching techniques from kinematic properties averages.

Author’s address: yanagihara.naomi@b.mbox.nagoya-u.ac.jp-36-

The Validity and Reliability of A Dynamic Neuromuscular Stabilization-Heel Sliding
Test for Core Stability
Young J. Cha 1), Jae J. Lee 1) Sung H. You 2)
1) Department of Physical Therapy, The Graduate School, Yonsei University, Wonju, Korea
2) Department of Physical Therapy, College of Health Science, Yonsei University, Wonju, Korea
Introduction
Conventionally, core stability has been measured by various
methods, including straight leg lowering test (SLLT) prone
formal test [1-7], and the global muscular endurance test
[8].Basically, SLLT is a mostly widely used, reliable and valid
test to measure core abdominal muscle strength in supine.
To accommodate the shortcomings associated with severe
core instability and pain during conventional core stabilization
tests, we have recently developed a dynamic neuromuscularstabilization based heel sliding (DNS-HS) test. The DNS-HS
test is conceptually derived from the DNS technique which
involves subconscious coactivation of the diaphragmtransverse abdominis-multifidus in coordination with othersuperficial core muscles to provide uprighting and stability of
the lumbopelvic system in a supine position [9].
The present study was to establish the validity and reliabilityof the DNS-HS core stability test by comparing theconventional SLLT core stability.
Materials and methods
Instrumentation: The ultrasound (SonoAce, 6000, Medison
Co., Ltd, korea) in M-mode with a 3.5 MHz curved transducer(HC2-5) was used to measure diaphragm movement. The
pressure biofeedback unit (PBU, Chattanooga Group, Hixon,
TN, USA), which contains a 3-chamber pressure bag connected
to a pressure gauge and inflation device, was used to detect core
instability [10]. The motion analysis system (Simi Aktisys
GmbH, Unterschleissheim, Germany) was used to determine
hip joint angle during the core stability tests. The corestabilization tests included the SLLT and DNS-HS.
Experimental procedure: A total 20 subjects were recruited.
All subjects underwent a physical health screening and SLLT
for checking core instability [11, 12]. A procedural checklist
along with the standardized verbal instructions was followed toensure a consistent experimental procedures. All measurement
systems were calibrated for each participant before dataacquisition.
Validity: Criterion validity was determined by comparing hip
joint angle data that were sequentially assessed by the SLLTand DNS-HS methods. The hip joint angle during the SLL test
was first determined. For the SLLT, the participant was initially
positioned in supine with both hips and knees at 90° flexion.
Participants were asked to contract abdominal muscle
concentrically into the lumbar spine and consciously tomaintain this stabilization position and then was gradually
lowering both legs toward the floor without any lumbopelvic
movement. For DNS-HS, the participant was initially
positioned in a hook-lying position with 70° of hip flexion.
Participants were asked to breathe in and subconsciously or
automatically descend the diaphragm so as to activate the TrA,
multifidus, and pelvic floor chain muscles. The investigator
palpated anteriorly the xiphoid process; laterally 10~12 ribs;
and posteriorly angulus costae to ensure the symmetricalactivation against the therapist’s fingers while expanding thelower ribs (10~12th ribs) in a lateral direction. The corrective
movement involves caudal movement and widening of theintercostal spaces, and relatively stable rib motion (no cranial
motion) in a transverse plane [13] .
Once this core stabilization was obtained, participants wereasked to breathe naturally and then slide the both heels along
the floor without any lumbopelvic movement.
Test-retest reliability: The test-retest reliability wasestablished for determining the intra-rater consistency of DNSHS measurement. The reliability test was performed on 2
separate occasions, approximately 24 hours apart. All thetesting conditions were maintained as consistent as possible,
including the same investigators, experimental procedures (i.e.,
consistent instruction, calibration, testing sequence, the same
established hook-lying positions), time of day and interval, andtesting environment (lighting, temperature).
Statistical design and analysis: SPSS ver. 21.0 software(SPSS, Inc., Chicago, IL, USA) was used for all statisticalanalyses. Intra-rater reliability and validity were determinedusing intraclass correlation coefficients, [ICC (1,2)]. The
significance level was set at 0.05 for all statistical analyses.
Results
The validity of the DNS-HS test was determined bycomparing conventional SLLT that were recorded by Simi
Reality Motion Systems. ICC between DNS-HS and SLLT wasgood on 20 different subjects (ICC = 0.700, p<0.05) (Table 1).
Table 2 shows results of the test-retest reliability of
performers’ repeated measure by using Simi Reality Motion
Systems. ICC was calculate one examiner test respective 2
measure approximately 24 hours apart subjects (ICC = 0.953,
p<0.05).
Discussion
The present study established the validity and test-retest
reliability of a novel core stability test because there is a dearthof clinical evidence regarding established validity and testretest reliability of core stability measurements. Core instability
is one of the most perplexing and clinically challenging
neuromusculoskeletal conditions, which involve multiple
components including core stabilization, strength, power,
endurance, flexibility, motor control, and function.
Furthermore, it lacks a universal definition about corestabilization, and currently, there has been no gold standard
assessment of core stability with established evidence forvalidity and reliability.
The present study compared the DNS-HS core stability testwith the SLLT because it is a universally accepted clinicalassessment of abdominal muscle strength and is presumed tocharacterize abdominal core stability [1-6, 14].
The test-retest data in the present study revealed ICC = 0.953,
representing an excellent consistency or repeatability in the
DNS-HS core stability measurements. This finding was-37-

consistent with pervious intra-session measurements of SLLT
[1].
Zannotti et al examined the kinematics of the double-leglowering (DLL) test (or also known as ‘SLLT’) of abdominal
muscle strength in healthy young adults using ICC for intrasession measurements of pelvic tilting occurring at 5 hip joint
angles (15°, 30°, 45°, 60°, 75°) during DLL under controlled or
uncontrolled pelvic stability conditions [1]. The intra-session
ICC measures recorded early in the DLL maneuver were lessthan acceptable although ICCs for the latter hip angles were
found to be more acceptable and higher than for the initial
angles, ranging from 0.63-0.95 [1]. In fact, for the angle of first(1°) pelvic tilting, the ICCs were observed to be 0.55 for thecontrolled pelvic stability condition and 0.24 for theuncontrolled pelvic stability condition [1]. Furthermore, theDLL maneuver can provide a considerable challenge to theabdominal muscles and none of the tested young healthy
subjects were unable to successfully stabilize the pelvic tilting,which jeopardizes internal validity of the scoring systemassociated with the DLL.
However, the DLL test was incapable of discriminating
essential core stability function from abdominal muscle
strength because the DLL test identifies only global differencesin abdominal strength capability. The majority of the subjects
were able to complete the grade 1 level test only and it was notable to provide appropriate resistance necessary for accurate
evaluation of trunk muscle strength in individuals with a historyof low back pain. For these reasons, the DLL test has beenchallenged and questioned as a valid or reliable measure of core
instability which is also applicable for most clinical populations
with low back pain [1, 2, 5-7].

Table 1. Validity obtained by comparing the SLLT and DNS-HS measurement data
SLLTa
79.45±6.49d

DNS-HSb
49.37±9.29

ICCc (1,2)
0.700p-value
0.006*

Test
Re-testICC a (1,2)
b
Hip angle (°)
49.37±9.29
51.60±8.43
0.953
aIntraclass correlation cofficientbMean ± SD; Reliability ICC was computed based on 95% CI with 0.882-0.981 range.

p-value<0.001*

Hip angle (°)
aStraight leg lowering testbDynamic neuromuscular stabilization based heel sliding
cIntraclass correlation coefficientdMean ± SD; Validity ICC was computed based on 95% CI with 0.241-0.881 range.
Table 2. Test-retest reliability of the DNS-HS measurement

Conclusion
Clinically, the core stability test using the DNS-HS test is a
new approach, and the potential efficacy of the DNS-HS for
patients who have a core instability with low back pain. The
DNS-HS measure may be useful for examination, prevention,and training of patient who have a back pain, older adult with
impaired core instability. Objective quantification of corestability may help early detection in evaluation and monitor
even minute progress after rehabilitation.
References[1]
Zannotti CM. Kinematics of the double-leg-lowering
test for abdominal muscle strength. Journal of
Orthopaedic & Sports Physical Therapy. 2002;
32(9):432-436.
[2]
Cutter NC and Kevorkian CG. Handbook of manualmuscle testing. 1999[3]
Kendall FP, McCreary EK, Provance PG. Muscle
testing snd function. 1993
[4]
Gilleard WL and Brown J. An electromyographic
validation of an abdominal muscle test. Archives ofphysical medicine and rehabilitation. 1994;75(9):1002-1007.
[5]
Smidt GL and Blanpied PR. Analysis of strength
tests and resistive exercises commonly used for lowback disorders. Spine. 1987;12(10):1025-1034.
[6]
Smidt GL. Comparison of Clinical and Objective
Methods of Assessing Trunk Muscle Strength-An
Experimental Approach. Spine. 1987;12(10):10201024.
[7]
Smith EB. The effects of lumbosacral support belts
and abdominal muscle strength on functional lifting
ability in healthy women. Spine. 1996;21(3):356-366.

[8]

[9]

[10]

[11]

[12]

[13]
[14]

McGill SM, Childs A, Liebenson C. Endurance times
for low back stabilization exercises: clinical targets
for testing and training from a normal database.
Archives of physical medicine and rehabilitation.
1999;80(8):941-944.
Frank C, Kobesova A, Kolar P. Dynamic
neuromuscular stabilization & sports rehabilitation.
International journal of sports physical therapy.
2013;8(1):62.
von GK. Reliability of a test measuring transversus
abdominis muscle recruitment with a pressure
biofeedback unit. Physiotherapy. 2009; 5(1):8-14.
Ferreira PH, Ferreira ML, Hodges PW, Changes inrecruitment of the abdominal muscles in people withlow back pain: ultrasound measurement of muscle
activity. Spine. 2004;29(22):2560-2566.
Faries MD and Greenwood M. Core Training:
Stabilizing the Confusion. Strength & Conditioning
Journal. 2007;29(2):10-25.
Liebenson C. Rehabilitation of the spine: apractitioner's manual. 2007.
Moreland J, Finch E, Stratford P, Balsor B, Gill C.
Interrater reliability of six tests of trunk muscle
function and endurance. Journal of Orthopaedic &Sports Physical Therapy. 1997;26(4):200-208.

Author address
E-Mail: neurorehab@yonsei.ac.kr; chazoo2009@naver.com-38-

Event Related Desynchoronization (ERD) of MU Rhythm During Concentric andEccentric Contraction
Joo H. Park 1), Kyung H. Kim 2), Heon S. Shin 3), Kwang S. Cha 2), Hye S. Jeon 3)
1) Department of Physical Therapy, The Graduate School, Yonsei University, Wonju, Korea
2) Department of Biomedical Engineering, College of Health Science, Yonsei University, Wonju, Korea
3) Department of Physical Therapy, College of Health Science, Yonsei University, Wonju, Korea
Introduction
Concentric contractions are achieved by the shortening ofmuscle fibers when a person performs movements against
gravity and external force. Eccentric contractions are achievedby the lengthening of muscle fibers when a person performs
movements in line with gravity or that lower the load. Previous
studies using electroencephalography (EEG) and functional
magnetic resonance imaging (f-MRI) reveal differences
between the brain activities associated with these two types ofcontractions in patients. This study designs an experiment toexamine the changes in cortical activation patterns as subjects
undergo familiarization with tasks by repeating concentric andeccentric elbow flexor contractions. We speculate that
previously observed differences in brain activities are
possibilities induced by the level of required attention andfamiliarity with motor tasks, rather than due to fundamental
differences in the biomechanical characteristics of the tasks.
Accordingly, the purposes of our study are, first, to compare theEEG pat-terns and reaction time (RT) of electromyographic(EMG) between concentric and eccentric biceps brachii (BB)contractions under the RT paradigm, and subsequently, toevaluate how the EEG patterns and RT of EMG change after
the same amount of practice.
Materials and methods
Subjects: For this study, we recruited 16 volunteers (male =12, female = 4; mean age ± standard deviation = 22.43 ±2.149). . Inclusion criteria were age (between 20 and 29 years),and dominant use of the right hand. That is, to prevent thepossible interference of age and dominance of the brain on EEG
cortical signals (Klimesch 1999), only right-handed young
adults were included in this experiment. Furthermore, anyone
suffering from pain or with any history of psychiatric,
neurological, and/or musculoskeletal dis-orders was excluded
from this experiment.
Experimental procedure: The entire experiment consisted ofthree phases. Each phase included 30 trials of concentric
contractions and 30 trials of eccentric contractions, together
with three maximum isometric contractions. The order ofmuscle contractions was randomized within each phase usingdrawing lots (eccentric → concentric or concentric →eccentric). Phase II was exclusively for practice, and phase II
data was not analyzed. Only data from phases I and III wereused for comparing concentric and eccentric contractions
among participants. After finishing the muscle contractions,
three maximum isometric contractions were performed at theend of each phase to determine whether fatigue was developedby the repetitive muscle contractions. Ten-minute rests were
given between phases.
Data analysis: All the EMG and isokinetic data were
processed and analyzed using MyoResearch 1.08 software.
EMG onset determined that EMG amplitude increased over two
standard deviations in comparison to the baseline level for aminimum of 50 ms (Hodges and Bui 1996). The medianfrequency of the left BB was analyzed by the fast Fouri-ertransform method. Reaction time (RT) was defined as theduration of time between the Go signal (yellow circle) and theonset of BB EMG.
The MATLAB R2008a (MathWorks Inc. Natick,
Massachusetts, USA) was used to analyze recorded EEG data.
To process the spectral analysis of EEG, each single-trial eventrelated potential was applied using a continuous wavelet
transform (CWT) of a complex Morlet wavelet (Tallon-Baudry
et al. 1996). In mu rhythms, suppression occurs when theneurons in the somatosensory area receive inhibitory inputs
from other areas of the brain, particularly during preparation formotor acts. This phenomenon is called Event related
desynchronization (ERD). The variables of ERD onset and
ERD amplitude of mu rhythms were used for data analysis.
%
100 (figure 1).

Figure 1. Detection of the baseline, onset time, and amplitude
of ERD.
Statistical analysis: PASW Statistics version 18 (SPSS, Inc.,
Chicago, IL, USA) was used for statistical analyses of the data
herein. The median frequency and peak torque values of the
before phase (I) and after phase (III) were compared using
paired t-tests to determine whether fatigue was developed
among the participants by repeated submaximal muscle
contractions. The RT was analyzed using two-way repeatedanalysis of variance (ANOVA; phases x contraction types).
Three-way repeated ANOVA (contraction types x phases x
hemisphere) was used to analyze ERD onset and ERD
amplitude (contraction type: concentric contractions and eccentric contractions, phase: phase I and phase III, and hemisphere:
C3 and C4). The Greenhouse-Geisser epsilon correction ofdegree of freedom was applied due to repetition of the measure.
When interaction effects were observed, the Bonfer-ronicomparison was used as a post hoc test. Statistical significancewas set at 0.05.
Results
Fatigue Effects: To evaluate whether or not any fatigue ofthe BB developed among the participants, we compared thevalues of EMG median frequency and peak torque before andafter completion of the experimental procedures. Neither the
EMG median frequency nor peak torque values after-39-

completion of phase III were significantly changed from theinitial values (p > 0.05).
RT of EMG: Interaction effects were observed (p < 0.05).
The results of the post hoc test re-vealed that, in phase I, the RT
was significantly longer in eccentric contractions than inconcentric conditions (p < 0.05). In contrast, there was no
significant dif-ference in RT between the two contraction types
in phase III (p > 0.05). In the concentric condition, the RT in
phase I was not significantly longer than the RT in theconcentric condition of phase III (p > 0.05). However, the RTof the ec-centric contraction condition decreased significantly
from phase I to phase III (p < 0.05) (Figure 2).

Topography of Averaged ERD Activity of Mu Rhythms: In
phase I, substantial ERD was observed bilaterally during bothtypes of muscle contractions. In phase III, however, bilateral
ERD activity was observed only during eccentric contractions.
ERD mu rhythms tended to be localized in the C4 region(contralateral) during concentric contractions (figure 4).

Figure 4. Topography of averaged mu rhythm ERD in 1000 ~2000 ms prior to the EMG onset
Figure 2. Two-way interaction plot for the RT (Contraction
typeｘ Phase).
ERD Onset Time of Mu Rhythms: There were interaction
effects between contraction types, phases, and hemi-spheres (p< 0.05) (Figure 3). In the post hoc test, the ERD onset times
were significantly faster for eccentric contractions than the
ERD onset times of concentric contractions in both phases I and
III (p < 0.05). While the ERD onset was faster in phase III thanphase I for both types of contractions, the difference was foundto be statistically significant only in the concentric contraction
condition (p < 0.05). ERD onset times in both C3 and C4 weresignificantly faster for ec-centric contractions in comparison toconcentric contractions (p < 0.05). ERD onset in theperformance of both concentric and eccentric contractions
occurred significantly earlier in C4 than C3 (p < 0.05).

Discussion
Reaction time represents the amount of information to beprocessed by the central nervous system (CNS) before initiationof a given motor action. In the same way, early ERD onset ofmu rhythms in the sensory motor cortex is related to lesspreparation required for a given motor task. Therefore, theseresults seem to suggest that eccentric contractions require thebrain to work harder in preparation for the task. Furthermore,in the case of both types of muscle contraction herein, themental demand decreased as familiarity with the motor action
increased with practice, which supports the observed changes
in both ERD onset and amplitude in repetitive contractions.
However, in contrast to our expectation, eccentric contractions
still required more brain activity for preparation and cognitive
load, even after repetitive training to familiarize the subjects
with the task. Therefore, we conclude that the differences inbrain activity during eccentric and concentric muscle activity
do not disappear with motor learning or practice.
References[1] Enoka RM. Eccentric contractions require uniqueactivation strategies by the nervous system. J Appl
Physiol. 1996;81(6):2339-2346.
[2] Fang Y, Siemionow V, Sahgal V, Xiong F, and Yue GH.
Greater movement-related cortical potential during
human eccentric versus concentric muscle contractions. J
Neurophysiol. 2001;86(4):1764-1772.
[3] Olsson C-J, Hedlund M, Sojka P, Lundström R, andLindström B. Increased pre-frontal activity and reduced
motor cortex activity during imagined eccentric compared
to concentric muscle actions. Front Hum Neurosci.
2012;6.
[4] Pfurtscheller G, and Aranibar A. Evaluation of eventrelated desynchronization (ERD) preceding andfollowingvoluntary
self-paced
movement.
Electroencephalogr Clin Neurophysiol. 1979;46(2):138146.
Author address
E-Mail: hyeseonj@yonsei.ac.kr; pjh1325@naver.com

Figure 3. ERD onset time plot
A: Interaction between Contraction type and Phase
B: Interaction between Contraction type and Hemisphere
C: Interaction between Phase and Hemisphere-40-Intersensory facilitation and interference during stepping task
Tatsunori Watanabe1), Kazuto Ishida1), Soichiro Koyama2), Shigeo Tanabe3), Ippei Nojima1)
1)
2)
3)

Department of Physical and Occupational Therapy, Graduate School of Health Sciences, Nagoya University
Department of Rehabilitation, Kawamura Hospital
Faculty of Rehabilitation, School of Health Sciences, Fujita Health Universityand > was assigned to the right leg) onto a woodplate placed right front of the force plate, andbrought the other leg alongside. Participants were
instructed to execute the movement as quickly andaccurately as possible, and after the stepping, they
were required to move back to the same starting
position and prepare for the next trial.
Stimuli
Each participant performed two blocks of the CRT
task and four block of the Simon task which
consisted of congruent and incongruent conditions(Fig. 1). For all blocks, acoustic accessory stimuli
were presented randomly in 50 % of the trials.

Introduction
Taking a quick correct step response while
inhibiting an incorrect one to environmental stimuli
is a fundamental human function. When there is
uncertainty about the appropriate postural response,
however, errors in the direction of initial weighttransfer (i.e., anticipatory postural adjustment(APA) errors) could occur [1]. Increased stepping
reaction errors [2], and delayed step initiation andcompletion of a voluntary step [3] are associatedwith falls in the elderly. The presence of an APA
error can result in those situations. Most previous
studies, however, examined the stepping behavior
using only one sensory modality, even though inreality humans receive information simultaneously
from multiple sensory modalities. Moreover, thecontrol of balance and posture in fall prevention is acomplicated central sensorimotor function that
integrates information from visual, vestibular, andaudiosomatosensory systems. Therefore, to advanceour understanding of the control of gait initiationand falls associated with it, it is necessary toinvestigate such executive functions as stimulus
identification, response selection, and posturalpreparations during stepping movement, in thecontext of intersensory integration. The purpose of
the current study was to investigate the effects of an
acoustic stimulus simultaneously presented with avisual imperative stimulus on stepping performance.

Figure.1 Visual imperative stimuli
Data collection and analysis
The data of ground reaction forces during step
executions were collected using a force plate at asampling rate of 1000 Hz, and the following
temporal parameters were identified offline using
programs written in Matlab (MathWorks, Natick,
MA, USA); reaction time (RT), APA duration, andfoot-lift time (Fig. 2A). APA errors were identified
by the first mediolateral deviation of COP toward
the stance leg, indicating the presence of two or
more postural adjustments before the final
mediolateral shift toward the stance leg in one step
execution (Fig. 2B).

Materials and Methods
Subjects
Eleven participants (5 males, 6 females, mean age ±SD = 22 ± 2.24) without a history of hearing,neurological, or orthopedic disorders that could
influence the balance function were recruited from
Nagoya University School of Health Sciences. All
participants had normal or corrected-to-normal
vision. The study was approved by the Ethics
Committee of Nagoya University, and written
informed consent was obtained before their
participation.
Apparatus and procedures
Participants were required to maintain a stationary
standing posture on a force plate with their bare feetand stepped forward in response to a visualimperative stimulus that appeared on a computer
screen set just below the eye level at a 1.0 m
distance from the participant. Acoustic accessory
stimuli (1000 Hz, 80 dB) were also delivered
randomly and simultaneously with the visual stimuli
from two speakers, one placed on each sides of themonitor.
The visual stimulus was an arrow (< or >) appearing
either right or left side of the fixation point on thecomputer screen, and the participant stepped
forward with the leg that corresponded to thedirection of an arrow (< was assigned to the left leg

APA duration

A
COPx (mm)Foot-lift

50
RT

0

C

- 50

COPx (mm)B

APA duration
Foot-lift

50
0

C

RT

- 50

0

0.5
Time (seconds)

1.0

Figure. 2 Examples of force plate data forforward step execution with the right leg

-41-

A

Results
APA error rates of trials with sound weresignificantly higher than trials without sound in theincongruent condition (p = 0.001) but not in otherconditions. RTs of trials with sound weresignificantly shorter than trials without sound in allconditions (p < 0.001). APA durations of the trials
with sound were significantly longer than the trials
without sound in the incongruent condition (p <0.001). Foot-lift times of the trials with sound weresignificantly shorter than the trials without sound in
CRT (p = 0.028) and congruent (p = 0.016)
conditions, but not in the incongruent condition.

APA duration (ms)Bsound offsound on

330

300

CRT*

CON*

INC*

CRT

CON

INC*

CRT**

CON**

INC

460
430
400
370
340

C

sound offsound onAPA error rate (%)

360

270

Foot-lift time (ms)80

Reaction Time (ms)

Statistical analysis
First, two-way repeated-measures analysis ofvariance (ANOVA) was conducted to determine theeffects of acoustic accessory stimuli and task
conditions on APA errors. Next, we used a linear
mixed model to determine the effect of accessory
stimuli and task conditions on RT, APA duration,and foot-lift time with sound (off and on) and thecondition (CRT, congruent, and incongruent) as
fixed factors and participant as a random factor.
Bonferroni post-hoc analyses were performed to test
interaction effects and to determine the locus of thedifference.

60

40

20

780

720

660

600

Condition

0
CRT

CON

INC*

Figure.4 Changes in temporal parameters of step
execution for the sound off and on trials.

Condition

Figure. 3 Mean anticipatory postural adjustment(APA) error rates for sound off and on trials
obtained from all the participants in threedifferent conditions.

Conclusion
This study revealed that acoustic accessory stimuli
simultaneously presented with visual imperative
stimuli modulate the initial motor programming of
stepping. Consequently, they caused an increase in
the anticipatory postural adjustment error rates
under spatial incompatibility, and the facilitation
effects of them on reaction times did not remain
until foot lift in the incongruent condition.

Discussion
The APA error rate of the trials with accessory
stimuli was higher than the trials without accessory
stimuli only in the incongruent condition (i.e., when
there is a spatial incompatibility) (Fig. 3). In
contrast, the RTs were shortened in all theconditions (Fig. 4A). Facilitation of RTs indicatesthat accessory stimuli speed stimulus-encoding
process (identification of visual stimuli) or lower thedecision threshold regardless of the stimulus type
(direction or location). An increase in the APA error
rate solely in the incongruent condition suggests thataccessory stimuli additionally facilitate automatic
response activation toward the stimulus location
under spatial incompatibility. The lengthened APA
durations in the incongruent condition (Fig. 4B)
were most likely caused by the increased APA errorrate, since more than one APA would occur in the
APA error trials. The foot-lift time of theincongruent condition was delayed by thelengthened APA duration and thus APA errors (Fig.
4C).

References[1] Cohen RG, Nutt JG, and Horak FB. Errors inpostural preparation lead to increased choice
reaction times for step initiation in older adults.
J gerontol A Biol Sci Med Sci 66: 705-713,
2011.
[2] Schoene D, Smith ST, Davies TA, Delbaere K,
and Lord SR. A Stroop Stepping Test (SST)
using low-cost computer game technology
discriminates between older fallers and nonfallers. Age Ageing 43: 285-289, 2014
[3] Pijnappels M, Delbaere K, Sturnieks DL, andLord SR. The association between choice
stepping reaction time and falls in older
adults-a path analysis model. Age Ageing 39:
99-104, 2010.

-42-

Relationship between self-reported walking time and objectively measured Moderate
to vigorous physical activity in middle-aged: Cross-sectional, correlational research
Masaki Kato1), Takuji Adachi1), Kuniyasu Kamiya1), Daichi Takagi1), Yuko Simizu2), Yuta Hagiwara2), Hironobu Ashikawa1), Kiho
Hagiwara3), Shogo itamoto3), , Kana Inuzuka1), Sumio Yamada2)
1.
Department of Physical and Occupational Therapy, Graduate School of Health Science, Nagoya University
2. Program in Physical Therapy, School of Health Sciences, Nagoya University
3.
Department of Rehabilitation Sciences, Nagoya University Graduate School of Medicine
Introduction/Objectives
The prevalence of cardiovascular disease (CVD) is increasingin 60 years or older1). Therefore, it is important to focus on theyounger population less than 60 years to improve lifestyles andprevent incidence of CVD. The main cause of CVD isatherosclerosis which is related with excess diet/drinking, smoking,physical inactivity and psychological stress. Especially, increasing
physical activity is considered as a key method to control lipid
profile, blood pressure and insulin resistance which are related toincidence of CVD2-4). In Japanese population, physical activity had
been yearly decreasing5). Low intensity physical activity, such as
light walking, is not associated with reduced risk of CVD, while
moderate to vigorous physical activity (MVPA), such as brisk
walking, swimming and up- and down- stairs, is reported topossibly lower the risk6). Accelerometer is an objective method tomeasure physical activity. It takes a long time to measure, and thecost is high. Instead of accelerometer, questionnaires have been
widely used to measure physical activity. However, there is not
fully valid and reliable questionnaire to measure MVPA. Therefore,
the aim of this study was to investigate the relationship between
self-reported walking time and objectively measured MVPA duringcommuting in Japanese office workers over thirty years old todevelop a physical activity questionnaire for MVPA.

the lateral side of a waist belt for the whole day, except for sleeping,bathing or swimming. Participants were asked to conduct their lives
normally while wearing the accelerometer. The maximum pulse(i.e., the gravity value of an acceleration) detected by theaccelerometer during the manufacturer determined 4-second
sampling interval is taken as the acceleration value. Each interval iscategorized into one of 11 activity-intensity levels (0, 0.5 and 1-9).
MVPA is defined as ≧ 4 which had been validated in adults (1-3=
light intensity, 4-6= moderate intensity, 7-9= vigorous intensity)7).
Statistical analysis
First, participants were divided into three groups which are
30-39 years, 40-49 years and 50-59 years group. Then, we
performed spearman correlation coefficient to investigate therelationship between self-reported walking time and objectively
measured MVPA during commuting in each age groups. All data
were analyzed using SPSS version 23.0. A P value < 0.05 wasregarded as statistically significant.
RESULTS
Table 1 shows the participants characteristics, self-reported
physical activity (measured by PAQ), and objectively-measured
duration of the MVPA. Of the 301 participants 79.4% were men,and 20.6% were women (aged 47.4±7.8 years [mean±SD]).
Self-reported and objectively measured Physical activity
Median of self-reported walking time was five minutes (Inter
quartile range : IQR 5-10 minutes), the prevalence of answering“none” to the question “How often do you take a brisk walking
during commuting?” was 31.8% (a little 30.8%, often 23.1%, very
often 14.4%). Self-reported walking time and objectively measured
MVPA during commuting was significantly correlated each age
groups. But the relationship was poorer in 50-59 years group(r=.493, P<0.01, y=0.53x+3.59) than 30-39 years (r=.610, P<0.01,
y=0.7x+3.16) and 40-49 years groups (r=.641, P<0.01,
y=0.8x+1.49). Furthermore, 50-59 years group was divided into
two groups; which were defined as brisk walker (n=55) andnon-brisk walker (n=78). The non-brisk walker group consists who
answered “none” or “a little” to the question of the frequency oftaking a brisk walking during commuting to work, while the brisk
walker group consists who answered “often” or “very often” to it.
In these groups the correlation coefficients of the relationshipbetween self-reported walking time and objectively measured
MVPA remained lower (r=.392, P<0.01) in non-brisk walker, while
it became moderate (r=.612, P<0.01) in brisk walker. Secondary
analysis, each age groups were divided into two groups by gender.
In each age groups, the association of walking time and MVPA
were higher in men than women (30-39years men/women
r=.627/r=.434, 40-49years men/women r=.679/r=.479, 50-59years
men/women r=.587/r=.067).

Materials and Methods
Participants
We enrolled workers sampled from a company. Eligible
participants were 30 to 59 years who were free from disease andpain which restrict exercise participation. A total of 330 individuals(264men) completed the physical activity questionnaire. 29
subjects were excluded from the analyses due to missing values ofphysical activity questionnaire or accelerometer data. Finally, datafrom 301 participants (239men) were included in this study. This
study was approved by the ethics review board of the Nagoya
University Graduate School of Medicine (approval no. 14-508).
Written informed consent was obtained from each of theparticipants prior to enrollment in this study.
Data collection
Self-reported physical activity was measured by the PAQ. PAQ
consists of commuting, working and leisure time activities(fitness/sports and recreational activity) in a week. Commuting
section consists of 1) means of commuting, 2) commuting time, 3)
walking time and 4) the frequency of brisk walking (none, a little,
often, very often). Participants completed the physical activity
questionnaire (PAQ). In this study, self-reported walking time andthe frequency of brisk walking were used for analysis.
MVPA was measured by using an accelerometer (Kenz
Lifecorder EX/GS, Suzuken Co., Ltd., Nagoya, Japan) attached to-43-

*Walking time [min]*Commuting MVPA [min]Brisk walking

5 [5-10]5 [5-10]

5 [4-10]5 [5-10]

7.2 [4.5-10.3]

7.2 [5-12.4]

6.9 [4-10]

7 [4.7-10]

n,[%]
None

95 (31.8)

24 (37.5)

32 (31.4)

39 (29.3)

A little

92 (30.8)

15 (23.4)

38 (37.3)

39 (29.3)

often

69 (23.1)

13 (20.3)

22 (21.6)

34 (25.6)

29.4 [20.5-40.2]

29.3 [20.5-42.7]

24.4 [20.1-34.9]

33.1 [22.2-44.5]: Participant
Very oftenTable
43 (14.4)
12 (18.8) characteristics
10 (9.8)
21 (15.8)*Daily MVPA [min/day]group declined physical function and a few of them further
declined who walked more than 20 minutes during commuting
plotted below the regression line in non-brisk walker. The
frequency of taking a brisk walking might be useful information to
detect them (brisk walker r=0.612, non-brisk walker r=0.392). In
addition, because men walk faster than women8), we performed
analysis stratified by gender. Duration of MVPA could be predictedaccurately from walking time in men but could not in women. Most
women in each age groups walked less than 20 minutes in thisstudy participants. Therefore, small variation might be one cause ofsmall correlation coefficients in women. Based on the above, notonly physical function, but also gender might effect on theprediction of MVPA during commuting.
Limitations
This study has several limitations. First, study sample wasrelatively small. We performed analysis stratified by gender, but thedata in women from small samples. Therefore, the results of thisstudy might not reflect the general office workers. Second,
test-retest reliability of PAQ have not investigated. Finally, durationof MVPA during commuting might not precisely-measured.
Because accelerometer could not measure cycling and up- anddown- stairs. However, this study suggested several key points ofview to develop a physical activity questionnaire for predicting
duration of daily MVPA in Japanese office workers.
Conclusion
The findings of this study suggested the need to consider
characteristics of the subjects when using a physical activity
questionnaire.

*Median [IQR: Inter quartile range]

Objectively measured
MVPA (min)30-39 years group40-49 years groupr = 0.610

r = 0.641

P < 0.01

P < 0.01

n = 64n = 104

50-59years group(brisk walker)

Objectively measured
MVPA (min)50-59 years groupr = 0.392

r = 0.612

P < 0.01

P < 0.01

n = 78n = 55

Self-reported walking time (min)Self-reported walking time (min)Figure : Relationship between walking time and MVPA duringcommuting in each age groups (30-39, 40-49, 50-59 years)

Discussion
The main findings of this study as follows. First, self-reported
walking time during commuting might be able to predict
objectively measured duration of MVPA. Second, stratification ofsubjects by age, gender and the frequency of taking a brisk walking
would be key method to predict duration of MVPA. In 30 to 49
years Japanese workers, walking time and MVPA duringcommuting were closely-correlated. However, in 50-59 years group,
some of them could not be predicted duration of MVPA fromwalking time.
Kinugasa et al8) reported physical function is declining with age,for example, maximum walking speed in 30-39 years wereequivalent to 85% of that of 20-29 years, while 50-59 years areequivalent to 70%. In other words, in 50-59 years, usual walking
speed was slower than walking speed which was approximately
equal to moderate to vigorous intensity. Slopes of the linear
regressions lines showing the relationship between walking timeand duration of MVPA during commuting were difference in eachage groups. Thus, it might suggest that participants in 50-59 years-44-

Reference
1. Ministry of Health, Labour and Welfare of Japan. Summary ofPatient Survey,2011. Avalable at:
http://www.mhlw.go.jp/english/database/db-hss/ps.html.
(Accessd August 12, 2015)
2. Atterhög JH, Jonsson B, Samuelsson R. Exercise testing: A
prospective study of complication rates. Am Heart J.
1979;98(5):572-9.
3. Kesaniemi YK, Danforth E Jr, Jensen MD et al. Dose-response
issues concerning physical activity and health: anevidence-based symposium. Med Sci Sports Exerc. 2001;
33(6):S351-8.
4. Manson JE, Greenland P, LaCroix AZ et al. Walking comparedwith vigorous exercise for the prevention of cardiovascular
events in women. N Engl J Med. 2002; 347(10):716-25.
5. Ministry of Health, Labour and Welfare of Japan. The national
health and nutrition survey 2011. 2012,Available at:
http://www.mhlw.go.jp/stf/houdou/2r9852000002q1st-att/2r9852
000002q1wo.
6. Tanasescu M, Leitzmann MF, Rimm EB et al. Exercise type andintensity in relation to coronary heart disease in men. JAMA.
2002 30;288(16):1994-2000.
7. Kumahara H, Schutz Y, Ayabe M et al. The use of uniaxial
accelerometry for the assessment of physical-activity-related
energy expenditure: a validation study against whole-bodyindirect calorimetry. Br J Nutr. 2004; 91(2):235-43.
8. Kinugasa T, Nagasaki H, Ito hazime et al. Effect of aging on
motor ability in men aged 18 to 83 years. J Sports Med Phys
Fitness. 1994; 43(5):343-3

Abstracts

Occupational Therapy-45-

2015 Yonsei-Nagoya University Joint Symposium on
Occupational Therapy

11:00~12:00

Session I

11:00~11:30

Improvement of Attention and Short-term Memory of Dementia
Using iPad: A Single Case Study

Chair: Prof. Ji-Hyuk Park

Seung Woo Hwangbo (Yonsei Univ.)
11:30~12:00

Change in connectivity among cortices of auditory evoked responseby music learning
Haruko Kahsiwagi (Nagoya Univ.)

12:00~14:00

Lunch

14:00~15:00

Session II

14:00~14:20

Prospective Memory of the People with Schizophrenia: Relationship

Chair: Prof. Makoto Chshima

between Experimental Tasks and Daily Living Tasks
Kil Choon Cho (Nagoya Univ.)
14:20~14:40

Effect of Horticultural Therapy for Elderly with Schizophrenia :Discriminating between Active and Passive Aspects of Horticultural
Therapy
Takuya Kenmochi (Nagoya Univ.)

14:40~15:00

Heart rate variability in anorexia nervosa
Tatsuya Omori (Nagoya Univ.)

15:00~15:20

20 Minute Coffee Break-46-

15:20~16:00

Session III

15:20~15:40

The relationship between participation and health related quality of

Chair: Prof. Hae Yean Parklife(HRQoL) in persons with spinal cord injury
Ye Jin Lee (a) (Yonsei Univ.)
15:40~16:00

Effectiveness of Occupational Therapy for Improving Participation:
A Systematic Review
Yeon Ju Kim (Yonsei Univ.)

16:00~16:20

20 Minute Coffee Break

16:20~17:00

Session Ⅳ

16:20~16:40

Activities Outside the Home of the Parents of Children with

Chair: Prof. Sumio Yamada

Movement Disorders
Asuka Suzuki (Yonsei Univ.)
16:40~17:00

Home environment modification for safe activities of daily living of
dementia: A single case study
Ye Jin Lee (b) (Yonsei Univ.)※ 15 minutes presentation and 5 minutes Q&A-47-

Improvement of Attention and Short-term Memory ofMild Dementia Using iPad Applications: A Single Case Study
Hwangbo, Seung Woo1), B.H.Sc., O.T.,
Kim, Jong-bae2), Ph.D., Park, Hae Yean2), Ph.D., O.T.
1) Department of Occupational Therapy, The Graduate School, Yonsei University2) Department of Occupational Therapy, College of Health Science, Yonsei University

Introduction
Due to rapid ageing, it is reported that prevalence ofelderly with dementia is increasing every year in Korea[1].
Since dementia is a progressive disease which requires longterm treatment and care, it is important to prevent or delay
functional decline and maintain current functional status if
once diagnosed[2]. Therefore, delaying the progress ofdementia is crucial especially to people with mild dementia
whom are in the early stage of dementia[3].
Elderly people recently started to use smartphones,
portable computers like iPad, and tablet PC[4, 5]. These
devices have lately been utilized for blind, deaf, andcognitive impairment for therapeutic purposes and shown theeffectiveness[6, 7].
Several studies indicate that cognitive training andcomputerized cognitive rehabilitation improved memory andattention of the mild dementia[8, 9]. Considering theseresults, cognitive training is necessary for preventing andinhibiting progress of dementia. Therefore, the purpose ofthis study was to identify whether using iPad applications
could improve short-term memory and attention of people
with mild dementia.
Methods
Subjects: A female elderly diagnosed dementia
participated in this study. The participant was recruited from
H elderly welfare center in Wonju, Korea. The participant
was 84 years old, living alone, and had no education. The
inclusion criteria were: a diagnosis of dementia from a
specialist, MMSE-K score below 24, CDR score over 0.5,
and the agreement of participation. The participant scored 23
in MMSE-K and 0.5 in CDR. This research was approved by
the Yonsei University Wonju Institutional Review Board.
Study design: The study design was single-subject ABA
design.
Procedure: The study consists of 5 sessions of baseline,
10 sessions of treatment, and 5 sessions of baseline, 20
sessions total(Figure 1). In the baseline phases, nointervention was provided. During treatment phase, theintervention was provided for 30 minutes based on theprevious study[10]. The intervention was using“Memorado“ and “Circles“ applications to improve shortterm memory and attention. An iPad Air 16GB with 9.7 inch
(2048x1536) touch screen and a touch pen was used forintervention. Before proceeding the study, the participant wasprovided sufficient explanation about the applications and thetrial was given only once. Not any clues were offered but
however, if the participant showed any possibility of giving
up, soem clues were than provided flexibly. Before and after
the intervantion phase, MMSE-K, Korean Trail Making Test
for Elderly persons part A & B(K-TMT-E A, B), Digit Span
Test Forward & Backward(DST-F, B) were used for
identifying the improvement of short-term memory andattention. In the treatment phase, the application “Fitbrains“ was used for evaluating short-term memory andattention every session.

Subject recruitment
Pre-test
MMSE-K, K-TMT-A, B, DST-F, B
Baseline A
Use “Fit brains”to evaluate memory and attention (5 sessions)
Treatment B
Use “Memorado”and “Circles”to train memory and attention(10 sessions)Baseline A’
Use “Fit brains”to evaluate memory and attention (5 sessions)Post-test: MMSE-K, K-TMT-A, B, DST-F, B
Figure 1. Study process

Instruments: The application “Memorado - Moving
balls“ was used for improving attention. The application“Circles“ was used for improving short-term memory. The
application “Fit brains – Matching game“ and “Fit brains –Remember items“ were each used to evaluate and compare
particpant’s short-term memory and attention. MMSE-K, KTMT A, B, DST F, B were used before and after intervention to
identify the rate of change in scores of memory and attention.
Data analysis: The correct scores obtained from “Fitbrains“ application during 20 sessions were presented by visualgraphs. The results of pretest and posttest were compared andindicated in tables.
Results
The attention score increased during treatment phasecompared to baseline phases(Table 1). Moreover, the memory
score increased sharply during treatment phase compared tobaseline phases(Table 2). The baseline A‘ indicates theremaining effects of intervention when comparing the scoreswith baseline A.
The results of K-TMT-E A, B, DST F, B, MMSE-K showedno significant differences. In K-TMT-E A, the partipant took
more time in post-test than pre-test to complete the evaluation(Table 3). However, more corrects and less errors were found in
post-test compared to pre-test. Since completing the assessment
earlier indicates the better result, it is difficult to insist whether
there were any improvements between pre-test and post-test.
The participant failed completing the K-TMT-E B in both pretest and post-test but more corrects and no errors were recordedin post-test(Table 4). Both DST F, B and MMSE-K showedsame scores or just slight different scores meaning no
significant differences(Table 5, 6).

-48-

Table 3. K-TMT – E Part A Results
Trial
Time
Pre-test
1min 42sec
Post-test
2min 54sec

Corrects
1113

Errors5
3

Table 4. K-TMT – E Part B Results
Trial
Time
Pre-test
5min over
Post-test
14min 40sec

Corrects
411Errors2 (failure)0 (give-up)

Table 5. Digit Span Test Results
Pre-test (score)
Forward4
Backward
2
Total (score)6

Post-test (score)
52
7

References[1] Cho, H., & Ko, Z. (2012). Current State of Senile Dementia
and Improvement of the Long Term Care Insurance forElderly People. Journal of the Korea Academia-Industrial
Cooperation Society, 13(12), 5816-5825.
[2] Cho, M., Kim, D., Chung, J., Park, J., You, H., & Yang, Y.
(2015). Effects of a cognitive-enhancement group training
program on daily living activities, cognition, and depression
in the demented elderly. Journal of Physical Therapy
Science, 27(3), 681-684.
[3] Huntley, J. D., Gould, R. L., Liu, K., Smith, M., & Howard,
R. J. (2015). Do cognitive interventions improve general
cognition in dementia? A meta-analysis and meta-regression.
BMJ open, 5(4), e005247.
[4] Lee, I., S. (2014). Improvement of Attention and Memoryof Stroke Patient Using Smart Phone Applications: Single
Case Study. Therapeutic Science for Neurorehabilitation,
3(1), 57-65.
[5] Leng, F. Y., Yeo, D., George, S., & Barr, C. (2013).
Comparison of iPad applications with traditional activities
using person-centered care approach: Impact on well-being
for persons with dementia. Dementia, 0(0), 1-9.
doi:10.1177/1471301213494514.
[6] Abu-Ghanem, S., Handzel, O., Ness, L., Ben-Artzi-Blima,
M., Fait-Ghelbendorf, K., & Himmelfarb, M. (2015).
Smartphone-based audiometric test for screening hearing
loss in the elderly. European Archives of Oto-RhinoLaryngology, 1-7. doi:10.1007/s00405-015-3533-9.
[7] Crossland, M. D., S Silva, R., & Macedo, A. F. (2014).
Smartphone, tablet computer and e‐reader use by people
with vision impairment. Ophthalmic and Physiological
Optics, 34(5), 552-557.
[8] Kanaan, S. F., McDowd, J. M., Colgrove, Y., Burns, J. M.,
Gajewski, B., & Pohl, P. S. (2014). Feasibility and efficacy
of intensive cognitive training in early-stage Alzheimer’s
disease. American journal of Alzheimer's disease and otherdementias, 29(2), 150-158.
[9] Herrera, C., Chambon, C., Michel, B. F., Paban, V., &Alescio-Lautier, B. (2012). Positive effects of computerbased cognitive training in adults with mild cognitive
impairment. Neuropsychologia, 50(8), 1871-1881.
[10] Jang, J. S., Lee, J. S., Kim, S. K., & Jeon, B. J. (2012). Thechange in spaced retrieval training (SRT) Combined witherrorless learning on cognitive function and depression indementia sufferers. Journal of Korean Society ofOccupational Therapy, 20(20), 43-55.
Author address

E-Mail: hwangbo@yonsei.ac.kr

Table 6. MMSE-K Results
Pre-test (score)
Post-test (score)

MMSE-K
19 + 4 = 23
19 + 4 = 23

Conclusions
The iPad applications were positively effective on
improving short-term memory and attention of the elderlywith mild dementia. Therefore, more interesting andmotivating contents of conitive training applications should
be developed and also utilized.

-49-

Change in connectivity among cortices of auditory evoked response by music learning

Haruko Kashiwagi1)
1) Department of Occupational Therapy, School of Health Sciences, Nagoya University, Nagoya, Japan

Introduction
Brain activities relating sensory input and output weremodulated by learning. Change in the brain activity bylearning has been known as adaptation and priming. Many
previous studies reported the brain activity regarding
adaptation and priming [1], recent studies have emphasizedthat change in temporal relationship among cortices wasimportant. The temporal relationship means the similarity ofbrain activity between two different regions of brain. In otherwords, the similarity was termed as connectivity between thebrain regions. However, it has not been clear that the change
in the connectivity among cortices by learning processes.
Therefore, the objective of the present study was toclarify change in connectivity among cortices in auditory
evoked response. I used music for auditory stimulation andthe difference in the connectivity among auditory related
cortices was investigated before and after learning the music.
For the present analysis, I used the latest system ofmagnetoencephalography, MEG, which enabled to collectand analyse the brain activity with high temporal and spatial
resolutions.

Data analysis: Coherence analysis was applied to assessconnectivity among auditory related cortices, primary auditory
cortex, left posterior section of superior temporal gyrus(Wernicke’s verbal area for the left side), and dorsolateralprefrontal area (DLP) in each hemisphere. In the right side,
Coherence analysis can be used to see synchronicity between
two cortices. The analysis showed similarity between
waveforms in different locations, and high coherence value
indicated the neural signals spread from one to the other cortex.
I chose the three brain areas, because I thought that learning of apiece of music included prediction of the rhythm and a kind oftranslation of the music into verbal information. The
Wernicke’s area and DLP area was responsible to verbal andtiming processing, respectively.
In the present study, study gamma-bands were assessed toanalysis, gammma-1: 30-60 Hz and gamma-2: 60-100 Hz. The
gamma activity was related with various cognitive processes,
such as memory, learning and attention [2]. The coherence
values were statistically compared between before and after thelearning. A p-value less than 5% was considered to besignificant.

Materials and Methods

Results

Subjects: Seven healthy subjects participants in this study(2 males and 5 females, age range: 21-22 years). All subjects
had no history of auditory and cognitive disturbance in their
daily life. Each subject gave informed consent prior tomeasurement. This study was approved by the EthicalCommittee of Nagoya University, School of Health Science.

The coherence value in gamma-1 band after the learning
was lower than that before learning in between the right primary
auditory cortex and the posterior section of superior temporalgyrus, and between the right primary auditory cortex and the
DLP area (p<0.05, Fig. 1). In the right hemisphere, thecoherence value also decreased significantly between thoseareas (Fig. 2). Distribution of brain areas with high coherence
values were more before learning than after learning (Figs. 3
and 4).

Experimental Procedures: Subjects lay supine on theexperimental table in a magnetically shielded room and wore
earphones. Two series of music were delivered though theearphones, a well-known piece of music, Do-Re-Mi, and a
newly developed music, as described below. During thelistening of the music, the MEG signals were recorded. Afterthe initial measurement, subjects were asked to memorize the
new melody for within a couple of weeks, and the second
measurement was applied. Prior to the second measurement,
subjects were asked to hum the melody to be checked
whether they had memorized the piece of music.

Fig. 1: Coherence value in right primary auditory cortex
and posterior section of superior temporal gyrus.

Auditory stimulation: New melodies, which the subjects
had never heard, were produced using tones in the Do-Re-Mi.
The tones were re-ordered in random order, using software(Allegro, Mi7, Japan). Thus, the content of sound in thepieces of the music was identical between the Do-Re-Mi andthe new melody. Duration of the Do-Re-Mi and the newpieces of music were approximately 1 minute.
MEG recording: I used the whole-cortex 160-channel
MEG system to measure auditory evoked response, auditory
evoked magnetic field (AEF). The MEG signals werecollected after the onset of each sound in the pieces of musicdelivered for 300 ms. Sampling frequency was 5,000 Hz, andbandpass filter was 0.2-2,000 Hz.

-50-

Fig. 2: Coherence value in right primary auditory
cortex and DLP area.

Fig. 3: The brain distribution of areas with highcoherence value of the primary auditory cortex
before learning.

Discussion
The present results indicated that decrement insynchronicity, de-synchronization in other words, wasrecognized before and after the learning of the piece of music.
In the previous studies, presentation of an unfamiliar stimuli
resulted in an increase of gamma band responses [3][4], and thatbrain activity at gamma band synchronized during memory[5][6]. In this study, the stimuli of before learning were
unfamiliar. Thus, it was considered that brain activity before
learning showed more synchronization among cortices than thatafter learning. In addition, since the subjects hear the unfamiliarmusic repeatedly in the initial MEG recording, memory
processes might be partially occurred during the record.
In the second MEG recording after learning, the music had
become familiar and the memory consolidation could beestablished. Therefore, relatively less synchronization wasobserved than before learning.
In this study, the coherence value decreased significantly inthe right hemisphere and there was no significant difference inleft hemisphere. The results suggested that right hemisphereinvolved in melody process. Also it was found that listening inthis melody resulted of the translation of the music into verbal
information.
Conclusion
In the present study, the connectivity among auditory
related cortices changed before and after learning a piece ofmusic. The coherence values decreased compared between
before and after learning the music, which indicated regional
de-synchronizationofneuralactivity
relating
tomemory/learning.
References

Fig. 4: The brain distribution of areas with highcoherence value of the primary auditory cortex
after learning. Note gray area was decreased,compared with the areas in Fig. 3.

[1] Schacter DL, Buckner RL. Priming and the brain. Neuron.
1998;20(2):185-195.
[2] Kaiser J, Lutzenberger W. Induced gamma-band activity andhuman brain function. Neuroscientist. 2003;9(6):475-484.
[3] Gruber T, Müller MM. Oscillatory brain activity dissociates
between associative stimulus content in a repetition priming
task in the human EEG. Cereb Cortex. 2005;15(1):109-116.
[4] Marshall L, Mölle M, Bartsch P. Event-related gamma band
activity during passive and active oddball tasks. Neuroreport.
1996;7(9):1517-1520.
[5] Jensen O, Kaiser J, Lachaux JP. Human gamma-frequency
oscillations associated with attention and memory. Trends
Neurosci. 2007;30(7):317-324.
[6] Headley DB, Paré D. gamma oscillations and emotional
memory.
Front
Behav
Neurosci.
2013;7:170.
doi:10.3389/fnbeh.2013.00170.
Author address

E-Mail: kashiwagi.haruko@f.mbox.nagoya-u.ac.jp-51-

Prospective Memory of the People with Schizophrenia:
Schizophrenia:
Relationship between Experimental Tasks and Daily Living Tasks
Kil Choon Cho1),2)
1) Department of Physical and Occupational Therapy, Graduate School of Medicine, Nagoya University, Japan
2) Department of Occupational Therapy, HOKUSEI Hospital, Mie, Japan

Introduction
Prospective memory (PM) is the ability to keep in mind
and carry out future intentions. PM is divided into two, in
terms of characteristics of the cues when people recall:
Event-based PM and Time-based PM. Also, PM has twoelements, one is just recalling “I have something to do”(existence recalling) and another is recalling the contents ofthe things have to do (contents recalling)[1], [2]. Several
previous studies reported the PM performance of the people
with Schizophrenia (Sz) from the experimental tasks [3].
However, we found no study examining PM in terms of dailyliving tasks. Therefore, the purpose of this study was to
examine the relationship between the performance ofexperimental tasks and daily living tasks of PM. In addition,
the relationship between PM task performance and theseverity of schizophrenia was also investigated in terms ofexperimental tasks and daily living tasks respectively.

2. Daily living tasks
Daily living tasks were randomly conducted when they cameto day care facility, and tasks were offered by the day-carefacility staff, not them to realize that the tasks were a part ofexperiments. The tasks were offered after daily morning
meeting. Implementation of the tasks were four hours andover after offering. Those tasks were conducted one by one ata time, and once a day.
Event-based tasks were offered to implement a controlledchore; such as asking staff “Have you finished replacing
fluorescent?” after finished the meeting, which held before
going back to their home. This task was conducted third times.
Time-based task was also offered to implement a controlledchore, but the period was designated. Sample chore was asfollows: asking staff “Have you finished doing the laundry?” at
14 o’clock. This task was conducted once for each ofparticipants.

Materials and Methods
Subjects
23 Sz ( 20 males and 3 females) age from 30 to 73 (meanage: 56.2±12.2) who used day-care service in one hospitalwere recruited in this study. The inclusion criteria were: adiagnosis of schizophrenia, normal cognitive function (scoreof HDS-R was higher than 20), and to agree to participate
with this researches both themselves and their attending
psychiatrists.

3. Severity of schizophrenia
The severity of schizophrenia was evaluated by Positive And
Negative Syndrome Scale (PANSS). PANSS was consisted bythree components, positive scale (delusions, conceptual
disorganization, etc.), negative scale (blunted affect, emotional
withdrawal, etc.), and general psychopathology scale (somaticconcern, anxiety, etc.). This evaluation was conducted byparticipants’ attending psychiatrists.

Evaluation
1. Experimental tasks (Fig.1)
Experimental tasks were conducted one participant-on-one
examiner in quiet surrounding by reference to Einstein and
McDaniel, and Umeda. Participants did a 100-piece jigsaw
puzzle, in total, 22 minutes. After 10 minutes passed, they
took three minutes break. To motivate them, examiner told
them to take a photograph of the puzzle, during the break andafter finished.
Event-based task was offered before starting the puzzle.
Examiner gave a card and asked them to return the card when
they take a break. If the participants could not return thecard, examiner provided two steps of cue, asking as follows:
step 1, “Don’t you forget something?” and step 2 “I gave you
something” to evaluate existence recalling and contents
recalling.
Time-based task was offered after the break. Examiner
asked them to raise their hand every five minutes. Analog
clock was set on the front wall of the participants.
Description
Performing
Offering
EventConcentrate Event-based
task
based task
on puzzle(10min)

0

5

15

Break
(3min)

Offering
Timebased
task

18

20

Concentrate
on puzzle(12min)25
30①②
Raise hand each 5 min

Figure1 Protocol of Experimental Task(min)

Data analysis
The results of experimental and daily living task performance
were divided into two groups: Higher-scored and Lower-scoredgroup respectively.
For the analysis of the relationshipbetween experimental tasks and daily living tasks, the Chisquare test was used, and relationship between PANSS and eachtasks, the Mann-Whitney U test was used. Significance was set
at P<0.05.
Results
1. Relationship between experimental tasks and daily livingtasks
21 participants’ data were analyzed. Two participants’ data
were excluded because they could not continue to using daycare service by hospitalization. Participants were divided into
following two groups respectively.
i. Experimental tasks
Event-based task: Nine participants could perform the task:
they could return the card (existence recalling intact group), and12 participants required clues to recall the task (existence
recalling impaired group).
Time-based task: 14 participants could perform the task atleast once: they could (Experimental Time-based task intact
group), and seven participants could not do that (Experimental
Time-based task impaired group).
ii. Daily living tasks
Event-based task: Nine participants could perform all thetasks: they could recall staff’s offer (Daily living Event-based-52-task intact group), and 12 participants failed once or more
(Daily living Event-based task impaired group).
Time-based task: 14 participants could perform the task:
They could recall staff’s offer at around the designated time,from before 15 minutes to after 30 minutes (Daily living
Time-based task intact group). Seven participants could not
do that (Daily living Time-based task impaired group).
There were no significant differences of the number ofparticipants between intact group and impaired group in bothExperimental Tasks and Daily living tasks respectively.
2. Relationship between PM task performance and PANSS
i. Experimental tasks
Event-based task: There were significant differences
between intact group and impaired group of the following
general psychopathology scale score of PANSS: Anxiety,
Unusual thought content, Lack of judgment and insight, andDisturbance of volition.
Time-based task: There were significant differences
between intact group and impaired group of the following
negative scale score of PANSS: Blunted affect, Emotional
withdrawal, Lack of spontaneity and flow of conversation,and Stereotyped thinking.
ii. Daily living tasks
There were no significant differences between intact groupand impaired group of the score of PANSS.
Discussion
1. Relationship between experimental tasks and daily livingtasks
The result shows that there is no relationship between
experimental tasks and daily living tasks, both Event-basedtask and Time-based task. Generally, human’s memory
function declines with aging. The mean age of participants is56.2, hence the performance of experimental tasks is perhaps
affected by their aging. However, since daily living tasks
include the elements of interpersonal relationship and social
adaptation, metacognitive strategy possibly enhance thememory function and reduce the effect of aging. For
example, people who have a consciousness of being apt toforget become attentive at work. Therefore, further study isrequired to clarify the participants’ strategy, with increasing
the number of participants.

These results show that disturbance of volition and several
negative symptoms affect prospective memory, especiallyexistence recalling.
It is said that people with schizophrenia tend to failperforming prospective memory tasks when they have low
motivation, and it is dual or multiple task. Umeda reported
that prospective memory performance is enhanced when the
person is highly motivated. The motivation in daily living isaffected by the necessity and certainty of doing the task for the
person. In addition, experimental situation sometimes enhanceor decease participants’ motivation improperly[2]. We madeeffort that participants not to realize that the tasks were a part ofexperiments. However, in consideration of negative symptoms
of patients with schizophrenia, they have lower motivation to
implementing things for other people than for themselves.
Furthermore, there are a lot of situations to perform dual ormore tasks simultaneously in daily life. Hiruta reported thatpeople with schizophrenia tend to have some trouble creating
priorities and performing multiple tasks together. Therefore, itenhances their operation efficiency to give instructions
concretely and one by one step to them[4].
References[1] S. Umeda, “Prospective memory deficits,” Neurol.
Med., vol. 76, no. 4, pp. 345–349, 2012.
[2] S. Umeda and T. Oyaizu, “Prospective memory and its
theoretical considerations.,” Japanese J. Psychol., vol. 69,
no. 4, pp. 317–333, 1998.
[3] Fu-Chun Zhou et al. :Characteristics and Clinical ofprospective memory performance in first-episodeschizophrenia. Schizophrenia Research 135 34-39,2012.
[4] G. Hiruta, Behavior Characteristics of the Patients with
Schizophrenia: Support and ICF. Kongo Shuppan, 2007.
Author address
E-Mail: cho.kilchoon@d.mbox.nagoya-u.ac.jp

2. Relationship between PM task performance and PANSS
i. Experimental tasks
In Event-based task, there were significant differences
between intact group and impaired group of the following
general psychopathology scale score of PANSS: Anxiety,
Unusual thought content, Lack of judgment and insight, andDisturbance of volition.
“Disturbance of volition” isdefined the disturbance in the willful initiation, sustenanceand control of one’s thoughts, behavior, movements andspeech. Umeda states that existence recalling has a deep
connection with willful initiation and control one’s thoughts,
behavior, movements and speech[1]. This result shows thatsevere disturbance of volition caused the impairment ofprospective memory.
In Time-based task, there were significant differences
between intact group and impaired group of the following
negative scale score of PANSS: Blunted affect, Emotional
withdrawal, Lack of spontaneity and flow of conversation,and Stereotyped thinking. Time-based task requires several
strategies such as time monitoring and changing the task to
Event-based task by themselves because surrounding
environment does not become a clue of existence recalling.

-53-

Effect of Horticultural Therapy for Elderly with Schizophrenia:
Discriminating between Active and Passive Aspects
Aspects of Horticultural Therapy
Takuya Kenmochi1), 2)
1) Department of Physical and Occupational Therapy, Graduate School of Medicine, Nagoya University, Nagoya, Japan
2) Department of Rehabilitation, HINAGA General Center for Mental Care, Mie, Japan

Introduction
Large number of psychiatric hospitals in Japan faced withproblem of aging their inpatients caused by the patients who
have been hospitalized for a long time. The data reportedby Ministry of Health, Labor and Welfare showed that
51.5 % of psychiatric inpatients were at the age of 65 or overin 2012 [1]. Therefore, intervention for these patients tomaintain physical and mental function is required.
Horticultural Therapy (HT) is practiced in not a few
medical and welfare institutions, mainly for elderly becauseof its mild effect of enhancing physical and mental healthstates, both in Korea and Japan [2], [3]. Although theresearch concerning about effects of HT has been alreadystarted in early 1990s, there are few reports that shows theevidence of HT [4].
Figure 1 shows an example of HT’scomponents.
In general, HT’s components wereconceptually divided into two: active and passive [5]. The
fact that it is difficult to discriminate various components of
HT, and its intervention methodology depends on thetherapists, prevents HT research to establishing evidence ofthe effects. Hence, the study that distinguishing the effectsof each components is currently demanded. The aims ofthis study were to examine the effect of HT intervention
programs consisted by active components HT (A-HT) andpassive components HT (P-HT) respectively and generate
hypothesis to explain the effects of HT for elderly withschizophrenia.

Materials and Methods
Participants
Twenty elderly with schizophrenia were randomly recruitedfrom the inpatients of a psychiatric hospital. The inclusion
criteria were as follows: (1) aged 65 years or older, (2) chronic
phase of schizophrenia, (3) normal cognitive function (score of
HDS-R was higher than 20), (4) ability to communicate andmake their wish known, and (5) good physical function toparticipate the program regularly.
Informed consent was
obtained from each participant before the study.
Intervention
Participants were divided into two groups in matching age,sex and experience of HT. They participated in 45 minutes
group HT program once a week for 10 weeks. Crossovercomparison study was adopted (Figure 2).
A-HT: Participants cultivated vegetables in planters: seeding
Japanese radish and Boston lettuce, observing their growth, andfertilizing them. After harvested, participants cooked themand enjoyed eating. After the each program, participants
recorded the growth of plants by taking a note.
P-HT: Therapist brought some flowers and vegetables, andfacilitated participants to talk about them reflecting participants’
own experiences with touching, sniffing and eating them every
time.
Data collection
A combined quantitative and qualitative study was adopted.
Quantitative data: The evaluation we used were as follows:
Positive and Negative Syndrome Scale (PANSS) for evaluating
the severity of schizophrenia, Philadelphia Geriatric Center
Morale Scale (PGC Moral Scale) for evaluating subjective
quality of life, and Experimental Time Perspective Scale for
evaluating standpoint for the future. These evaluations wereconducted three times: baseline, interval between A-HT and PHT, and the endpoint of all programs.
Qualitative data: Semi-structured group interviews wereconducted three times: a week before the first intervention(baseline), interval between A-HT and P-HT, and the endpointof all programs. The contents of the baseline interview were:
impression before participating HT program, and the things forpleasure in daily life. On the other hand, the contents of theinterval and final interviews were: review of attending A-HT or
P-HT, and the things for pleasure in daily life.

-54-with them.”
During both programs, participants always looked forward toparticipating the program.
Furthermore, a number ofparticipants’ final statements regarding goals of daily life wereincreased comparing to contents of first semi-structured
interviews.

Data analysis
Qualitative analysis: For the analysis of the effect ofparticipating HT, the Wilcoxon singed rank test was used tocompare the scores of PANSS, PGC Morale Scale, andExperimental Time Perspective Scale between before andafter participate of each HT program.
Statisticalsignificance was set at p < 0.05 and 0.01.
Qualitative
analysis:
Modified-Grounded
TheoryApproach proposed by Kinoshita was used to analyzetranscribed data obtained by the group interviews [6].

Discussion
In terms of quantitative analysis, scores of Positive and
Negative Syndrome Scale, especially, general psychopathology
scale decreased significantly after the intervention of active
horticultural therapy program.
This result shows thetherapeutic effect of active horticultural therapy programs in
reducing general symptoms of schizophrenia. Besides, interms of qualitative analysis, several specific characteristics ofactive horticultural therapy and passive horticultural therapy
were revealed by participants’ statements. Active horticultural
therapy brought participants surprise and pleasure at growing
plants. These positive emotions possibly improve the modalityof time perspective. In contrast, passive horticultural therapy
facilitated comfortable communication with peers.
Whileprevious study showed that people with schizophrenia havesome difficulties spending time and communicating with others[7], participants can be relaxed and interact each other byintervening plants.

Results
Eighteen participants’ data were analyzed. Twoparticipants’ data were excluded because they could notcontinue to participate this study by their physical problems
etc.
Quantitative analysis: The score of PANSS was improved
significantly after practiced A-HT. On the other hand, there
were no significant differences neither other test scales in AHT nor any test scales in P-HT (Table 1). In detailcomparison of PANSS sub scales, General pathology scale of
PANSS was only improved significantly. However, there
were no significant differences in other sub scales: Positive
scale and Negative scale (Table 2).
Table 1 Comparison of positive and negative syndrom scale(PANSS), phiradelphia geriatric center morale scale (PGC
morale scale), time perspective scale between baseline andpost intervention
A-HT (N=18)

P-HT (N=18)

Average(±SD)

Average(±SD)

baseline

86.9

17.0

84.7

15.6

post

82.4

14.9

84.5

15.2

baseline

11.2

3.9

10.8

3.8

post

11.3

3.9

11.7

3.5

baseline

51.9

9.3

51.9

12.1

post

52.3

12.3

52.7

9.9

PANSS

*

Conclusions
Our study showed the possibility of the usefulness ofhorticultural therapy as a non-invasive therapeutic methodology.
Therefore, further study is required to clarify our hypothesis,
such as multicenter study.

PGC Moral Scale

Time perspective
scale

Wilcoxon signed rank test (*p<.05)

Table 2 Detail comparison of PANSS in A-HT
A-HT (N=18)
Average(±SD)

baseline

18.6

5.5

post

18.0

5.6

baseline

24.7

6.6

post

23.7

5.7

baseline

43.7

post

40.7

Positive scale

Negative scale
Generalpsychopathology
scale

7.4
**

5.9

Wilcoxon signed rank test (**p<.01)

Qualitative analysis: Several specific characteristics of AHT and P-HT were revealed by participants’ statements. In
A-HT, participants were surprised and pleased at growing
plants. For example, one participant stated “It was very
fun…and surprising for me to observe the growth of radish
and lettuce.” In P-HT, on the other hand, they enjoyedinteracting with members each other. For example, one
participant stated “Well... chatting with peers about thevegetables you (therapist) brought was so nice, especiallyabout cooking. I really enjoyed interacting and chatting

References[1] Mental Health Welfare Information. National Institute of
Mental Health, 2012. [Online]. Available: http://www.ncnp.
go.jp/nimh/keikaku/vision/pdf/data_h24/h24_630_sasshitai.
pdf. [Accessed: 08-Sep-2015].
[2] S.A. Park, K.C. Son, and W.K. Cho.
Practice of Horticultural Therapy in South Korea.
Acta Horticulturae. 2012;954:179-185.
[3] S. Koura. Present Status of Horticultural Therapy and
Future Possibilities in Japan. Horticultural research.
2013;12(3):221-227.
[4] H. Kamioka, K. Tsutani, M. Yamada, H. Park, H. Okuizumi,
T. Honda, S. Okada, S.J. Park, J. Kitayuguchi, T. Abe, S.
Handa, and Y. Mutoh. Effectiveness of horticultural therapy:A systematic review of randomized controlled trials.
Complementary Therapies in Medicine. 2014;22:930-943.
[5] Y. Takaesu. Horticultural therapy memorandum forunderstanding and practice of horticultural therapy.
1997.pp70-71. Japan Horticultural Therapy Society.
[6] Y. Kinoshita. Analytical techniques of M-GTA by steps:
Practice of Modified Grounded Theory Approach. 2003.
pp.87-252. Kobundo.
[7] G. Hiruta. Behavior Characteristics of the Patients with
Schizophrenia: Support and ICF. 2007.pp65-68. Kongo
Shuppan.
Author address
E-mail: kemmochi.takuya@h.mbox.nagoya-u.ac.jp-55-

Heart rate variability in anorexia nervosa
Tatsuya Omori
Department of Occupational Therapy, School of Health Sciences, Nagoya University, Nagoya, Japan

Introduction
Anorexia nervosa (AN) has been known as an eating
disorder, which is characterized by abnormally low bodyweight with intense fear of gaining weight and abnormal
body perception. Besides various metabolic and hormonal
abnormalities reported [1], autonomic dysfunction has beenreported in AN [2].
One major complication was
cardiovascular dysfunction due to hyperactivity ofparasympathetic system, which could contribute to the higher
rate of sudden death in patients with AN [3]. Patients with
AN in critical state with extremely low body weight less than
30 kg often requires inpatient hospitalization, although theeffectiveness of additional treatment to the diet control has
been unclear [4].
Occupational therapy (OT) has been also applied topatients with AN [5], and in the psychiatric department of
Nagoya University Hospital has been provided OT in therecovery phase after critical state of AN. During the OT forthe patients in the recovery phase, cardiovascular trouble
with autonomic dysfunction should be avoided. However,
little has been known regarding recovery of autonomic
function after acute phase of AN. In the present study, heart
rate variability was measured during the acute and recovery
phases, and during OT in the recovery phase in the patientswith AN to clarify the physical condition of patients during
OT.
Heart rate variability (HRV) is calculated from thefluctuation of heart rate, and it indicates sympathetic andparasympathetic activity applicable to various physical andmental disorders [6]. The HRV can be obtained noninvasively simply by recording hear beat orelectrocardiogram, and the calculation has been convenientwith computational development.
Materials and Methods
Subjects: Four inpatients with AN (all females, age range
17-53 years old) were participated in the study. All patientswere diagnised by DSM-VI, and they were addmitted to
Nagoya University Hospital because of theier critical weightloss and were given intensive nutritional treatment. Eachpatient, during recovery phase of AN after critical state, gave
informed consent prior to evaluation of HRV from the recordof electrocardiogram recorded during acute and recovery
phases.
Patients with severe psychological symptom,
physical complication, or drug abuse were excluded. The
present study was approved by the Ethical Committee of
Nagoya University, School of Health Science.
Experimental Procedures: HRV was obtained by two
methods, electrocardiography (ECG) and pulse oxymeter,
during acute and recovery phase of AN, respectivery. All
patients were monitored their heat rate by mobile ECG in theintensive care units during acute phase of AN, which werestored in a data recorder. During the recovery phase of AN,
including during OT, heart rate was obtained by a wearable
pulse oxymeter (OxyTrue, Bluepoint Medical, Germany, Fig.
1), since the patients in recovery phase were not monitored
by ECG, and some patients hesitated to wear the ECG
monitor with electrodes. The pulse oxymeter collected heartbeats throught a tip of infrated light sensor attached on a earlobe
or finger tip. The heart beats obtained from the ECG monitor or
pulse oxymater were stored in a data recorder (Voice-trec V801, OLYMPUS,Japan). Heart rate was recoreded for 10
minutes in acute and recovery phase at rest on bed and in sitting
position, respectively, and during OT in sitting position.

Figure 1: Pulseoxymeter used in the present study. Peripheral
pulse was obtained from a sensor attached on the finger tip (left)or earlobe (right).
A series of OT was provided for the patients. The OT
included sewing, japanese crape work, beadwork , and knitting
activities for 60 minutes on OT room in sitting potision.
Data analysis: The heart beats was expressed as events on asoftware (Spike2, CED, UK), and each inter-events interval
between adjacent heart beats was measured. After fast Fourier
Transformation (FFT) of the intervals, low (LF) and high (HF)
frequency HRV were calculated. The LF and HF was a valueof HRV between frequency of 0.05-0.15, and 0.15-0.40,
respectively. The HF indicates parasympathetic activity, and aratio LF/HF indicates for sympathetic activity [7].
Results
Figure 2 shows a trend of heart beats, inter-beats interval,
and FFT analysis recorded from a patient. The HF and LF/HF
changed during the state of patients (Figs. 3, 4), The LF/HF
value was more during OT than those values during acute andrecovery phases at rest. Mean body weight of the patients wasincreased from 29.05 kg in the acute phase to 35.88 kg in therecovery phase.
Discussion
In the present study, the HRV values was changed between
acute and recovery phase. During the OT intervention during
the recovery phase, change in HRV suggested that the
cardiovascular responses might be appeared by the time for theintervention. In patients with AN, abnormal HRV [8] and highmortality rate with cardiovascular dysfunction [9] were reported.
Sympathetic activity revealed by HF was changed among
condition, but the parasympathetic activity was relatively
unchanged to the sympathetic activity in the present study.
Although the HRV might be abnormal even in the recovery
phase of the patients, change in HRV might be indicator for the-56-

recovery phase after critical state of AN. Decrease HRV, i.e.,unchanged HRV values, suggested a risk factor of sudden
death in cardiovascular and neurological disorders [10].
Since the HRV recording is convenient and non-invasive, therecording might be informative during rehabilitation tomonitor the patient’s condition. Amount of rehabilitation,
including OT intervention, should be re-considered whenpoor response in HRV during rehabilitation was observed
during the intervention.
The indicator for the tentative goal of treatment in
hospitalization for patients with AN is a body weight morethan 65 ％ of normal weight in our University Hospital.
However, as Lachish et al. [11] reported, the patients withAN showed sustained abnormality in HRV, i.e., hyperactivityof parasympathetic system, after tentative weight gain. Thechange in HRV reflected not only physical state, but also
emotional and psychiatric conditions [12]. Since one of
psychiatric problems in patients with AN was abnormal
emotional function [13], HRV might be psychiatric indicator
for the patients with AN.
The present study was limited in number of patients andin duration for observation. Long-term follow-up of HRV
during daily living outside hospital might give information
for physical and emotional recovery from AN [14].

Fig. 2: Signals of heart beats transferred from thepulseoxymeter (B). An arrow indicates each heartbeat, andthe vertical line indicates threshold to calculate an interbeats interval (A).

Fig. 3: High frequency HRV (HF) recorded from the patientwith AN. Sympathetic activity, revealed by HF, wasrelatively higher during OT (Recovery OT).

Author address
E-Mail: oomori.tatsuya@j.mbox.nagoya-u.ac.jp

Fig. 4: Ratio of High (HF) and low (LF) frequency HRV
recorded from the patient with AN. Parasympathetic activity,
revealed by LF/HF seemed unchanged among conditions.
References[1] Fazeli PK, Klibanski A. Anorexia nervosa and bone metabolism.
Bone. 2014;66:39-45.
[2] Takimoto Y, Yoshiuchi K, Ishizawa T, Yamamoto Y, Akabayashi A.
Autonomic dysfunction responses to head-up tilt in anorexia nervosa.
Clinical Autonomic Research. 2014;24(4):175-181.
[3] Suárez-Pinilla P, Peña-Pérez C, Arbaizar-Barrenechea B, CrespoFacorro B, Del Barrio JA, Treasure J, Llorca-Díaz J. Inpatient
treatment for anorexia nervosa: a systematic review of randomized
controlled trials. Journal of Psychiatric Practice. 2015;21(1):49-59.
[4] Matusevich D, García A, Gutt S, de la Parra I, Finkelsztein C.
Hospitalization of patients with anorexia nervosa: a therapeutic
proposal. Eating and Weight Disorders. 2002;7(3):196-201.
[5] Martin JE. Occupational therapy in anorexia nervosa. Journal of
Psychiatric Research. 1985;19(2-3):459-463.
[6] McCraty R, Shaffer F. Heart Rate Variability: New Perspectives on
Physiological Mechanisms, Assessment of Self-regulatory Capacity,and Health risk. Global Advances in Health and Medicine.
2015;4(1):46-61.
[7] Zaza A, Lombardi F. Autonomic indexes based on the analysis ofheart rate variability: a view from the sinus node. Cardiovascular
Research. 2001;50(3):434-442.
[8] Rauscher G, DeGiorgio AC, Miller PR, DeGiorgio CM. Sudden
unexpected death in epilepsy associated with progressive
deterioration in heart rate variability. Epilepsy and Behavior.
2011;21(1):103-105.
[9] Takimoto Y, Yoshiuchi K, Ishizawa T, Yamamoto Y, Akabayashi A.
Autonomic dysfunction responses to head-up tilt in anorexia nervosa.
Clinical Autonomic Research. 2014 Aug;24(4):175-181.
[10] Koschke M, Boettger MK, Macholdt C, Schulz S, Yeragani VK,
Voss A, Bär KJ. Increased QT variability in patients with anorexia
nervosa--an indicator for increased cardiac mortality? The
International Journal of Eating Disorders. 2010;43(8):743-750.
[11] Lachish M, Stein D, Kaplan Z, Matar M, Faigin M, Korsunski I,
Cohen H. Irreversibility of cardiac autonomic dysfunction in female
adolescents diagnosed with anorexia nervosa after short- and longterm weight gain. World Journal of Biological Psychiatry. 2009;10(4Pt 2):503-511.
[12] Rommel D, Nandrino JL, De Jonckheere J, Swierczek M, Dodin V,
Logier R. Maintenance of parasympathetic inhibition following
emotional induction in patients with restrictive type anorexia nervosa.
Psychiatry Research. 2015;225(3):651-657.
[13] Cardi V, Corfield F, Leppanen J, Rhind C, Deriziotis S,
Hadjimichalis A, Hibbs R, Micali N, Treasure J. Emotional
Processing, Recognition, Empathy and Evoked Facial Expression in
Eating Disorders: An Experimental Study to Map Deficits in Social
Cognition. PLoS One. 2015;10(8):e0133827.
[14] Nakai Y, Fujita M, Nin K, Noma S, Teramukai S. Relationshipbetween duration of illness and cardiac autonomic nervous activity inanorexia nervosa. Biopsychosocial Medicine. 2015;9:12.

-57-

The Relationship Between Participation and Health Related Quality of Life (HRQoL) in
Persons with Spinal Cord Injury
Yejin Lee1), B.H.Sc., O.T., Lee, Joo-Hyun1), M.S., O.T., Park, Ji-Hyuk2), Ph.D., O.T.
1) Department of Occupational Therapy, The Graduate School, Yonsei University2) Department of Occupational Therapy, College of Health Science, Yonsei University

Introduction
Life expectancy for persons with spinal cord injury (SCI)
has improved significantly during the last two decades [1].
Research has moved from survival to long term
consequences such as quality of life including Health-Related
Quality of Life (HRQoL) [2]. Persons with SCI also face
problems across various participation domains, such as workand leisure activities [3]. In rehabilitation, therefore, bothparticipation and HRQoL are discussed as the ultimate goals
for persons with SCI [4]. Participation is a multifaceted
process resulting from interactions and transactions among
persons and occupations within physical, social, cultural, andpolitical environments and communities [5]. On the other
hand, HRQoL indicates the restrictions related to a specifichealth condition [6]. HRQoL refers to the specific impact ofan illness or injury, medical treatment, or health care policy
on an individual’s well-being and functioning [7]. Thus,
participation needs to be considered as the different concept
with HRQoL. However, in some studies, participation wasmeasured merely as a part of the general HRQoL concept [8].
Also, there were some measurements of HRQoL focusing on
the individual’s satisfaction which is a similar concept withparticipation [9] Although participation and HRQoL areessential concepts, little is known about the relationshipbetween participation and HRQoL [10]. Consequently, thepurpose of this study is to examine the relationship between
participation and HRQoL in persons with spinal cord injury
using K-USER-P and K-LHS.
Methods
Participants : In South Korea, A total of 112 persons with
SCI living in community were recruited for this study. The
participants were gathered from an athletics competition forpeople with SCI for 2 days in June, 2014 in South Korea.
Inclusion criteria were persons with SCI and ability to readand comprehend the questionnaire written by Korean.
Exclusion criteria were persons have diagnosis with otherneurologic or psychological disorders such as stroke anddepressive disorders etc.
82 questionnaires were included in the final analysis,
excluding 29 questionnaires of insufficient responses and 1
respondent as not diagnosed with SCI but with limb
amputation. 82 participants were aged between 24 and 75
years and an average age was approximately 46 years(46.48±11.23). The majority of participants was male (n=70,
85.4%). In level of injury, cervical injury was 25 (30.5%),
thoracic injury was 47 (57.3%), and lumbar was 5 (6.1%).
Participants with complete injury were 47 (57.3%) while 32
participants were incompletely injured (39.0%). More detailsof demographic features are displayed on table 1.

Table 1. The general characteristics of participants
CharacteristicsN%

Mean (SD)

Age

-

-

46.48 (11.23)

Male
FemaleLevel of injury
CervicalThoracicLumbar
UnawarenessCompleteness of injury
Complete
Incomplete
UnawarenessEducation
Middle school
High school
University
OthersEmployment
Employed
Unemployed
Marital status
Married or living as
marriedNot living as married
Assistive device
None
Manual wheelchairPowered wheelchair

70
12

85.4
14.6

25
47
5
5

30.5
57.3
6.1
6.1

47
32
3

57.3
39.0
3.7

9
41
29
3

11.0
50.0
35.4
3.6

49
33

59.8
40.2

40

48.8

42

51.2

1
74
7

1.3
90.2
8.5

Gender-

Procedure : This study is the cross-sectional study. Participants
were provided with instructions about the purpose andprocedures of the study and agreed to participate this study
voluntarily before they were requested to fill out thequestionnaires. The questionnaires, consisted of The Korean
version of Utrecht Scale for Evaluation of Rehabilitation–
Participation (K-USER-P), The Korean version of London
Handicap Scale (K-LHS) and Korean version of the World
Health Organization Quality of Life assessment instrumentBREF (K-WHOQOL-BREF), were explained by two
occupational therapists and one student studying occupational
therapy in the university. The participants were handed out thequestionnaires individually.
Mesurements : K-USER-P and K-LHS were applied to examine
participation as the independent variables. We also used KWHOQOL-BREF for HRQoL as a dependent variable.
Data analyses : All statistical analyses were conducted using
IBM SPSS 21.0 on windows. Descriptive analyses were carriedout for the general characteristics. Pearson’s correlation
efficient was used for the correlation among HRQoL, K-LHS
and the three scales of K-USER-P. And Hierarchical multiple
regression analysis was applied to examine the most predictablefactors for HRQoL. The total score of K-WHOQOL-BREF wastreated as the dependent variable. The independent variables
were the three scales of K-USER-P and the total score of KLHS. Significance level was set at 0.05.

-58-examine the most important factor of HRQoL, participation was
regressed on HRQoL. The total score of K-LHS was in Step 1.
The frequency scale, the restrictions scale and the satisfaction
scale of K-USER-P were entered in Step 2, 3 and 4 respectively.
The results of hierarchical multiple regression analyses indicatethat model 4 showed higher explanatory power than othermodels. Its statistically significant contribution added another
6% to the previous model, so that the final variance of the model
was 11% (p<0.05). More specifically, of these variables, thesatisfaction scale of K-USER-P was the strongest predictor of
HRQoL (p<0.05) (Table 5).

Results
Correlation between participation and HRQoL : Before we
proceeded with the regressions, the correlations was applied tothe data. Pearson correlations between participation and HRQoL
were shown in table 2. Results showed that the 3 scales of KUSER-P had a significant negative correlation with the total
score of K-LHS(r=-0.34~-0.46, p<0.01). The satisfaction scaleof K-USER-P was only significantly correlated with the total
score of K-WHOQOL-BREF (r=0.23, p<0.05).
Hierarchical multiple regression analyses examining thethree scles of K-USER-P and K-LHS in predicting HRQoL : To
Table 2. Correlation between participation and HRQoL`
K-LHS

Total score
Frequency
Restrictions
Satisfaction

K-USER-P

K-LHS
Total score1- 0.34**- 0.52**- 0.46**

K-USER-P
Restrictions- 0.52**0.45**
1
0.59**

Frequency- 0.34**1
0.45**
0.45**

K-WHOQOL-BREF
Total score
-0.14
0.19
-0.20
0.23*

Satisfaction-0.46**
0.45**
0.59**
1*p<0.05, **p<0.01
Table 3. Hierarchical multiple regression analysis : HRQoL regressed on Participation
Model 1Model 2Bβt
BβTotal Score
-0.46
0.35
-1.30
-0.29
-0.09
K-LHS
Frequency
K-USER-P

0.23

0.19

t
-0.79
1.69

Restrictions

B
-0.57

Model 3
β
-0.18

t
-1.39

B
-0.40

0.30

0.24

2.00

0.21

0.15

1.37

-0.13

-1.05

-0.16

-0.28

-2.05*

0.32

2.31*

0.24
1.69

t
-0.33

-0.07

Satisfaction
F

Model 4
β
-0.13

2.86

1.99

3.17*

R2

0.02

0.04

0.05

0.11

Adjusted R2

0.01

0.02

0.02

0.07`

Change in R2

0.02

0.04

0.01

0.06

B, Unstandardized regression coefficients; β, Standardized regression coefficients*p<0.05
Dependent variable : The total score of K-WHOQOL-BRE

Conclusions
Both subjective and objective perspective of participation areof important for participation. It was found from this study that
subjective participation (satisfaction of participation) was
related with HRQoL while objective participation was not.
Therefore, participation and HRQoL are distinctive constructs.
The most predictable factor on HRQoL was the subjective
participation. It is expected that subjective participation need tobe contributed to plan for HRQoL in persons with SCI inrehabilitation.

Although these are important findings, this study had some
limitations. First, the participants were gathered from anathletics competition for people with SCI. So, generalizability
could be limited. Furthermore, in this study, we considered theglobal HRQoL based on the total score of K-WHOQOL-BRFE.
However, HRQoL is divided into mental and physical area. The
relationship between participation and HRQoL may vary withmental area or physical area of HRQoL. Therefore, futurestudies are needed to address such shortcomings.
References[8] Tyszka, A.C. and R.S. Farber, Exploring the relation ofhealth-promoting behaviors to role participation and healthrelated quality of life in women with multiple sclerosis: apilot study. Am J Occup Ther, 2010. 64(4): p. 650-9.
[9] Lidal, I.B., et al., Health-related quality of life in persons
with long-standing spinal cord injury. Spinal Cord, 2008.
46(11): p. 710-5.
[10] Cieza, A. and G. Stucki, The International Classificationof Functioning Disability and Health: its development
process and content validity. Eur J Phys Rehabil Med, 2008.
44(3): p. 303-13.

[1] Groah, S.L., et al., Spinal cord injury and aging:challenges and recommendations for future research. Am J
Phys Med Rehabil, 2012. 91(1): p. 80-93.
[2] McColl, M.A., et al., Aging, gender, and spinal cord injury.
Arch Phys Med Rehabil, 2004. 85(3): p. 363-7.
[3] Noonan, V.K., et al., Measuring participation among
persons with spinal cord injury: comparison of three
instruments. Topics in Spinal Cord Injury Rehabilitation,
2010. 15(4): p. 49-62.
[4] Garma, S.I., et al., Health-related quality of life after
pediatric spinal cord injury. J Pediatr Psychol, 2011. 36(2):p. 226-36.
[5] Mallinson, T. and J. Hammel, Measurement ofparticipation: intersecting person, task, and environment.
Archives of physical medicine and rehabilitation, 2010.
91(9): p. S29-S33.
[6] Saúde, O.M.d., Classificação internacional defuncionalidade, incapacidade e saúde. 2003, Edusp São
Paulo.
[7] Strand, C.V. and A.S. Russell, WHO/ILAR Taskforce on
quality of life. J Rheumatol, 1997. 24(8): p. 1630-3.

Author address

E-Mail: handle0205@naver.com-59-Effectiveness of occupational therapy for improving participation: A systematic review
Kim, Yeonju1), B.H.Sc., O.T., Kim, Moon-Young1), B.H.Sc., O.T.,
Park, Hae Yean2), Ph.D., O.T.
1) Department of Occupational Therapy, The Graduate School, Yonsei University2) Department of Occupational Therapy, College of Health Science, Yonsei University
Introduction
In the International Classification of Functioning,
Disability, and Health (ICF), 'Participation' is one of thecomponents, which is defiend by one's involvement in life
situation[1]. Restricted participation is derived from several
functional impairments of individuals with stroke [2],traumatic brain injury [3], multiple sclerosis [4], or agerelated vision loss [5] who is the clients of occupational
therapy. Christiansen, Baum, and Bass-Haugen reported thatthe occupational therapists have to focus on improving the‘participation’ [6]. Therefore, It is essential to list andanalyze the information about interventions for improving
participation. So, the purpose of this study is to summarize
that information and establish evidence to clinicians forhelping the clinical reasoning.
Materials and Methods
Data sources: For the main key-words of a databasesearch, “Participation AND Occupational therapy AND
Intervention“ were used. We systematically examined papers
pulished in journals from January 2005 to April 2015, using
Scopus, PubMed, and Google scholar. First, the 718 articles
were searched. After the screening of titles and abstracts
based on the 1st exclusion criteria (non-English, overlapped
articles among databases, either ‘participation‘, and‘intervention‘ were not in the abstract), 48 articles wereretrieved. And then 2nd screening based on exclusion
criteria: 1)single-subject design, case study (n=15), 2)
systematic review, meta-analys (n=4), 3) no use of measurefor participation (n=2), 4) no intervention (n=6), 5) different
meaning of participation based on ICF definition (n=7),
measuring participation at one spcific point ot for pre-postcomparision (n=2). Finally, 12 studies were included in the
final reveiw (figure 1).

Analytical methods: The 12 articles were appraised using
the hierarchy of levels of evidence for evidence based practicefor 5 different levels. The details of each study weresummarized according to the author (year), participants,
intervention,intervention
intensity/duration,
dependent
variables, measurement for the participation, and the results.
Results
The results were about level of quality and trend of eachstudy, types of intervention, environments provided theintervention, participants’disease, applied tools, dependent
variables measured with the participation. The quality andquantity of studies are improving. And the interventions were
mostly provided on chronic conditions in a form of selfmanagement program in community setting. The tools wereused by researchers following their researcher’s intention. The‘Quality of Life (QoL)’was the most frequently measured withparticipation.
Table1. Level of Quality Among Each Study
Evidencelevel⇩
12 studies were includedin the final review

7 (58.3)

Ⅱ

Two groups non-randomized studies

0 (0.0)Ⅲ

One group non-randomized studies

5 (41.7)

Single subject designs

Ⅳ

Surveys0 (0.0)Case reports
Ⅴ

Narrative literature reviews

0 (0.0)Qualitative researches
Total
Table 2. Types of Intervention for Participation

12(100.0)

Types
Self-management program
Exercise program
Client-centered approach
Intervention using digital device
Complex intervention
Total

N (%)
Frequency
6 (50.0)
2 (16.7)
2 (16.7)
1 (8.3)1 (8.3)12 (100.0)

Table 3. Environments Provided the Intervention
on Participants
Environments
Community
Hospital
both community and hospital
Total

N (%)
Frequency
10 (83.4)
1 (8.3)
1 (8,3)12(100.0)⇩⇩ ⇦Meta-analyses
Randomized controlled trials

Screening of titles and abstracts based on exclusion criteria
Excluded 670 articles (48 full articles retrieved)
Excluded1) Single-subject design, Case study, series (n=15)2) Systematic review, meta-analysis (n=4)3) No use of measures for participation (n=２)4) No intervention (n=6)5) Different meaning of 'participation' based on ICF
definition (n=7)6) Measuring participation at one specific point notfor pre-post comparison (n=2)

Frequency

Systematic reviews
Ⅰ

Search key terms: “Participation AND Occupational therapy AND
Intervention” Total 718 articles⇩

Definition

N (%)

Figure 1. Search Process-60-

Table 4. Classification of Participants’Disease
Classification of disease
StrokeMultiple chronic conditions
Amyotrophy
Arthritis
Multiple Sclerosis
Older adults with age-related vision loss (ARVL)
Traumatic Brain Injury (TBI)
Total
Table 5. Analysis About Applied Tools
for Participation
Applied measurement tools for participation
Frenchay Activities Index (FAI)
Reintegraton to Normal Living Index (RNLI)Stroke Impact Scale (SIS) -‘social
participation’domain
Activity Card Sort (ACS)
Craig Handicap Assessment and Rating
Technique-Revised (CHART-R)
Canadian Occupational Performance Measure(COPM)
Impact Participation and Autonomy (IPA)
Occupational Gaps Questionnaire (OGQ)
Physical Activity Scale for Individuals with
Physical Disabilities (PASIPD)
Social/ Role Limitation Scale
Total
Table 6. Dependent Variables Measured With
the Participation
Variables measured with the participation
Quality of life
Emotional status (depression, anxiety)Self efficacy
Functional independence in ADL
Occupational performance
Total

N (%)
Frequency
5 (41.7)
2 (16.7)
1 (8.3)1 (8.3)1 (8.3)1 (8.3)1 (8.3)12 (100.0)

N (%)
Frequency
2 (15.4)
2 (15.4)
2 (15.4)
1 (7.7)1 (7.7)1 (7.7)1 (7.7)1 (7.7)1 (7.7)1 (7.7)13 (100.0)

N (%)
Frequency
5 (26.3)
4 (21.1)
4 (21.1)
3 (15.8)
3 (15.8)
19 (100.0)

References[1] World Health Organization. (2001). Internationalclassification of functioning, disability and health: ICF.
Geneva, Switzerland: Author.
[2] Kubina, L. A., Dubouloz, C. J., Davis, C. G., Kessler, D., &Egan, M. Y. (2013). The process of re-engagement inpersonally valued activities during the two years following
stroke. Disability and Rehabilitation, 35, 236-243.
doi:10.3109/09638288.2012.691936[3] Cifu, D. X., Keyser-Marcus, L., Lopez, E., Wehman, P.,
Kreutzer, J. S., Englander, J., & High, W. (1997). Acutepredictors of successful return to work 1 year after traumaticbrain injury: A multicenter analysis. Archives of physicalmedicineandrehabilitation,78,
125-131.
doi:10.1016/S0003-9993(97)90252-5[4] Chaudhuri, A., & Behan, P. O. (2004). Fatigue inneurologicaldisorders.
Lancet,363,
978-988.
doi:10.1016/S0140-6736(04)15794-2[5] Tejeria, L., Harper, R. A., Artes, P. H., & Dickinson, C. M.
(2002). Face recognition in age related macular degeneration:
Perceived disability, measured disability, and performancewith a bioptic device. British Journal of Ophthalmology, 86,
1019-1026. doi:10.1136/bjo.86.9.1019[6] Christiansen, C. H., Baum, C. M., & Bass-Haugen, J. (2005).
Occupational therapy: Performance, participation, and wellbeing. Gloucester, NJ: Slack Inc.
[7] Lorig, K. R., & Holman, H. R. (2003). Self-management
education: history, definition, outcomes, and mechanisms.
Annals of behavioral medicine, 26(1), 1-7.
Author address

E-Mail: otkimyeonju@gmail.com

Discussion
When we examine the result about the trend in level ofevidence of intervention for participation by separated thetwo terms from 2005 to 2015, there was improving of quality
and quantity of articles. These trends support the repot of
Christianse, Baum, and Bass-Haugen’s that the primary
purpose of rehabilitation was getting focus on theparticipation after publishing the ICF [6]. The mostfrequently used intervention was Self-management programin the community setting on the people with stroke. Except
the stroke, the interventions were for people with multiple
chronic conditions, amyotrophy, arthritis, multiple sclerosis,
older adults with age-related vision loss, traumatic brain
injury who need to long-term manage of disorders. Selfmanagement, in fact, is lifelong occupation and important forpeople with chronic condition.
This study had a limitation because we excluded thedomestic study and case study. So we couldn’t include all thearticles about intervention improving participation.
Conclusions
Through this systematic review, we could find and understandthe trend of occupational therapy service for participation. In the
future, based on this study, the research about intervention forimproving participation might be more developed.

-61-

Activities Outside the Home of
the Parents of Children with Movement Disorders
Asuka Suzuki
Department of Physical and Occupational Therapy, Graduate School of Medicine,
Nagoya University, Japan

Introduction	  Previous studies reported that the parents of children withdisabilities had lower quality of life (QOL) and more stresses
than the parents of typically developing children. Thesestudies also suggested that part of the factors affecting QOL
and stress of the parents was a degree of social participation,and support from family, community or officials[1]–[3].	
  In
addition, the relationship between parents and their children,
especially the mother-and-child relationship is significantly
important from the perspective of attachment theory.	
 Accordingly, it is also important to support not only children
with disabilities,	  but also their parents.	
  In this study, we
focused on the performance of activities outside the home
(AOH) of the parents of children with movement disorders(CWMD).	
  A qualitative approach was taken to explore theproblems and self-solving processes regarding the current
status of AOH, and to develop questionnaire regarding thecurrent status of AOH for the parents of CWMD.
Significance of the study	  It is possible for this study to clarify the role of community	
 based institutes such as development support center bycomprehending the actual situation of AOH of the parents of
CWMD.	
  Furthermore, the developed questionnaire could
also be used to garner information easily at these institutes,
schools or other facilities.
Materials and Methods
Participants: 15 parents of CWMD (under age 18) wererecruited in this study.
Data collection: The data were collected via semistructured interviews.	
  The questions were determined byliterature review.	
  The articles published between 2001 andJuly 2014 were searched online, Japan Medical Abstracts
Society, with keywords of cerebral palsy with activities
outside home, support or family.	
  From the articles selected,
phrases related to the problems and needs of AOH wereextracted, and they were categorized by similarities.	
  The
categories were used as questions in the interview guideline.	
 All interviews were recorded with an informed consent.
Data analysis: All recorded data were transcribed wordby word.	
  Since there were two objectives: to explore theproblems and self-solving process regarding the current
status of AOH, and to develop questionnaires regarding thecurrent status of AOH for the parents of CWMD, the data
were analyzed using qualitative and quantitative cording
method [4] respectively.
I.	
  Exploring the problems and self-solving process	  For the first step, the transcripts were examined line byline.	
  Important contents, and meanings of the sentenceswere extracted with taking the reasons into consideration.	
 These data were categorized as subcategories. 	
  For thesecond step, these developed subcategories were divided

into 5 groups according to the children’s ages and motor
function. 	
  Then, the similarities of the subcategories were
examined and the final categories were developed bycondensing similar subcategories. 	
  Moreover, conceptual
diagrams were created to explore the correlations between eachcategory.
II.	
  Developing questionnaires for the parents of CWMD	  First, the transcripts were examined line by line.	
  Second,
the phrases from the transcripts were extracted with titles.	
 These data were examined by similarities of the titles, andsubcategories were developed.	
  Then, the similarities of thesubcategories were examined and the final categories weredeveloped by condensing similar subcategories.	
  The processesof the cording are as follows (Figure 1).	
  Types of parents’
AOH were divided into two. 	
  One was AOH with theirchildren (Type I) and the other was AOH without the children(Type II).	
  In Type I, AOH were grouped into productive
activities (PA), leisure activities (LA).	
  In addition,	  therewere some problems and self-solutions of AOH that had
common characteristics in both PA and LA (it was named
common characteristics: CC).	
  Categories were arranged into
five items of the processes of going out.
	  In type II, AOH were divided into three: the child is in school(or other institutions for education), the child is in day care,someone’s house etc., and the child stays at home.	
 For Productive Activities(PA)
For Leisure Activities(LA)

I. Going out
with child

Common Characteristics(CC)

Processes of going out
1Motivate to go out
2Choose here to go
3Plan4Move to destination
5Perform the activityChild is in school
II. Going out
without childChild is in day care,someone’s house etc.
Child stays at home

Figure 1	  Processes of cording	  Trustworthiness: one experienced supervisor who is familiar
with qualitative research collaborated the analysis.	
 Additionally, five parents of CWMD will be recruited to checkthe conceptual diagrams and questionnaires for internal validity.
Results
	  14 participants’ data were analyzed. One participant’s data
did not cover all part of interview guideline questions.
I.	
  Exploring the problems and self-solving processes	  Total number of subcategories; problems, self-solutions,
received support, and necessary support were as follows
respectively: 153, 83, 55, and 22.	
  After dividing into fivegroups, the similarities of the subcategories were examined andthe final categories were developed by condensing similarsubcategories. 	
  Then, conceptual diagrams were createdrespectively.	
  Finally, integrated conceptual diagrams werecreated. The number of developed categories; problems, selfsolutions, received support, and necessary support were as
follows: five, two, one, two.
II.	
  Developing questionnaires for the parents of CWMD	  Table 1 shows the number of categories and examples ofType I. 	
  These developed categories will be used asquestion items for the further study.	
  In total, 53 problems
and 25 self-solutions were developed.	
 Table 1	  Number of categories and examples of Type I
Processes of Number ofgoing out
categories

PALA

CC Examples of categories

Problems011

Decrease motivation for going out
because of physical burdens for caring childSelf-solutions

0

0

3

Remade the entrance into barrier free

Problems

041

Lack of options of where to go because of bad weather

Self-solutions

2

0

0

Choose the place where it is accessible to wheelchairs

Problems

05

1

Restriction because of child's medical careSelf-solutions

0

4

1

Gather the information about the place

Problems

00

19 Physical burden of transferring childSelf-solutions

0

0

4

Have no luggage when transferring child

Problems

498Lack of restroom for people with disabilities

Self-solutions

2

5

4

Pay attention to child's safety and sign of ill-health

1

2

3

4

5

Besides, six categories of problems and one category of selfsolution were developed in Type II.	
  In addition to this, nine
categories of necessary support for AOH regarding bothType I and II were developed.	
  In total, the number ofcategories developed by this analysis was 96.
Discussion
I.	
  Exploring the problems and self-solving processes	  Integrated conceptual diagram (Figure 2) describes
parents’ physical burdens for caring their children andpsychological burdens for caring their children regardless of
the ages of parents and children, the child’s motor function,and family background.	
  Moreover, these burdens cause acollateral problem: anxiety of going out.	
  To solve thisproblem, parents make an effort to reduce the number oftimes going out for productive activities such as going to a
grocery store with their children. 	
  In addition to thisphysical solution, parents also solve this problem bychanging their mindset, for example, trying to get used to the
problems as they are, and feeling supported by people aroundthem when they go out (Positive).	
  On the other hand, someof the parents regard the anxiety of going out as stress(Negative). 	
  These results show the significance ofdeveloping
individualized
andflexible
support.	
 Furthermore, irrespective of the parents personality, most ofthem complain of anxiety about the future.	
  To solve thisissue, parents think it is necessary that the government provides
excellent respite services which meet these parents’ needs.	
 This represents that current respite services in Japan do not meetparents’ needs and they are quantitatively deficient.
II.	
  Developing questionnaires for the parents of CWMD	  The categories developed in parents’ activities outside thehome with their children cover the entire range of going out
processes from one to five. 	
  The categories of problems
developed in parents’ activities outside the home without theirchildren also cover the whole processes: the child is in school(or other institutions for education), the child is in day care,someone’s house etc., and the child stays at home.	
  Comparedto the number of problem categories, the number of selfsolution categories was few; this might reflect the current
situations that parents have no way of solving the problems bythemselves.
For the further study	  The categories developed will be used as question items.	
 After assessing the internal validity of the questionnaire by fiveparents of children with movement disorders, three-rounds ofDelphi’s method will be conducted at the children’s facilities or
hospitals all over the country.	
  Question items that validated by
Delphi’s method will be adopted as question items of thequestionnaire regarding the current status of activities outside
the home for the parents of children with movement disorders.
References[1]	
  A. Basaran, K. I. Karadavut, S. O. Uneri, O. Balbaloglu,
and N. Atasoy, “ The effect of having a children withcerebral palsy on quality of life, burn-out, depression andanxiety scores: a comparative study.,” Eur. J. Phys. Rehabil.
Med., vol. 49, no. 6, pp. 815–22, Dec. 2013.
[2]	
  S. A. Hayes and S. L. Watson, “The impact of parenting
stress: a meta-analysis of studies comparing the experience ofparenting stress in parents of children with and without
autism spectrum disorder.,” J. Autism Dev. Disord., vol. 43,
no. 3, pp. 629– 42, Mar. 2013.
[3]	
  V. C. Terra, R. M. Cysneiros, J. S. Schwartzman, M. C. T.
V Teixeira, R. M. Arida, E. A. Cavalheiro, F. A. Scorza, andM. de Albuquerque, “Mothers of children with cerebral
palsy with or without epilepsy: a quality of life
perspective.,” Disabil. Rehabil., vol. 33, no. 5, pp. 384–8,
Jan. 2011.
[4]	
  L. Richards, Handling Qualitative Data: A Practical Guide,
vol. 2. SAGE Publications, 2008.
Author address

E-Mail: suzuki.asuka@a.mbox.nagoya-u.ac.jp

Physical burdens
for caring a child
Promote barrier-freeenvironment

Anxiety of going out

Reduce going out for productive
activities with a child

Psychological burdens
for caring a child

Problems

Self solutionsPositiveSupportive settingMothers’ way of thinking
Negative

From official services

From family and friends

Anxiety about the futureProvide excellent
respite services

Figure 2	
  Integrated conceptual diagram

Received support

Necessary support

Effect of Home Modification and Caregiver Education on Activity Performance of Person with
Early Dementia: Case Study
Lee, Changdae1), B.H.Sc., O.T., Kim, Jaenam1), B.H.Sc., O.T., Lee, Yejin, B.H.Sc., O.T.
Jung, Minye2), Ph.D., O.T.
1) Department of Occupational Therapy, The Graduate School, Yonsei University2) Department of Occupational Therapy, College of Health Science, Yonsei University
Introduction
Participation in activities has close relationship with aging.
To elderly people, participation in activities mean not only
leisure but satisfaction of their lives[1]. Neverthelessdementia experience difficulties of performance goaldirected occupation because of decreased cognitive
function[2]. Restricted participation of activities of dailyliving and community living derives depression anddeterioration of cognition[3]. Furthemore psycologicalproblem such as depression and anxiety cause mental burden
to care geivers[4]. People with dementia need individualintervention in accordance with deterioration of cognitiven
function. The purpose of this study was to investigate effectof home modification and caregiver education on activity
level changing of person with mild dementia in homeenvironment by selecting items for intervention by using
client centered approach and confirming approach method
according to cognitive level of client.

Allen Cognitive Level Screen Test (ACLS)
ACLS based cognitive disability frame of reference(FOR),means cognitive state causes functional state. To this study,
assess cognitive level and search intervention method suit toclient cognitive state. Figure 1 is process of the research.
Intervention
Result from COPM and AHA(table 1), managing stairs,
getting in/out of house, bathing/showering, using toilet, washing
hair, walking indoors, using bed/bedclothes, taking medication,using household appliances, and controlling indoor lights activities
were selected as target intervention. ACLS was used to assess
cognitive level of client, home modification and caregiver education
were confirmed as intervention method according to the result. The
effectiveness of intervention was assessed by AHA.
Table 1. Modification Required Activities
Selection standard
ADL

Materials and Methods
Participants: 84-years old woman who diagnosed
alzhheimer’s dementia. She lives in community with her
spouse. General cognition assessed by MMSE-K and CDR
and got scores 17 means definite dementia and 1 means mild
dementia. Caregiver report she still maintain her ADL but
have difficulties with her IADL.
Evaluation
Canadial Occupational Performance Measure (COPM)
COPM is Client-centered assessment which format semistructured interview understanding performance of self-care,productive activities, leisure. To this study, COPM used to
select target activities.
Assessment of Home-based Activities (AHA)
AHA assess independent, difficulty, safety scales of 26
items include ADL, IADL, Leisure. To this study, selectactivities which need improvement or modify.

Activities
Bathing/showering
Taking medication

COPM
IADL

Watching TV
Using household appliances
Managing stairs
Getting in/out of house
Bathing/showering

ADL

Using toilet
Washing hair

AHA

Walking indoors
Using bed/bedclothes
Taking medication
IADL

Using household appliances
Controlling indoor lights

Analytical methods: To understanding effectiveness of home
modification and caregiver education on activity performance of
person with early dementia, we assess AHA pre-postintervention also evaluate 6 month after intervention.
Results
Persons with mild dementia has been declining in
independence level of activities are required higher cognitive
level. Throughout the intervention, however, the score of AHA;
independence, difficulty, and safety, was improved and theeffect of intervention was still maintaining after 6 months.

-64-

Table 2. Home Modification for Person with Mild Dementia
Selection
Modification place
Purchase
Modification
Standard: Method and Education
MethodBADLBath Chair

BADL

Non-slip tape

BADL

Non-slip mat

BADL

Non-slip
socks

BADL

Grab bar

BADL

Folding bed
rail

IADL

Transparent
container

IADL

Pill case

IADL

Sticker

Etc.
Planning

White
board

Bath: Placing a bath chair to prevent
accidents could be happened while
standing and sitting and also occur
of musculoskeletal disorders.
Stair: Installing non-slip tape toprevent falling due to decrease of
depth perception arising from low
vision and aging.
Front of doorway and bathroom:
Installing non-slip mat to prevent
falling due to slip or level difference
between floors.
Indoor: Buying non-slip socks toprevent falling could be happened
while walking on the slippery floor

Bed: Installing rails to prevent
falling from bed while sleeping
because of client’s sleeping habits.
Refrigerator: Changing containers totransparent container to help client
on discriminating between side
dishes and other foods.
Table: Buying pill cases and setting
an alarm to help client on taking
proper drugs with proper dosage atproper time.
TV remote controller: Writing down
channel numbers the clients usually
watch on the controller. Marking
with sticker to help client on using
number pad of controller.
Micro wave: Marking with sticker
to prevent confusion with otherbuttons, on a button is frequently
used.
Light switch: Marking with sticker
to prevent confusion with other lightswitches, on switches are frequently
used.
Indoor: Installing time table to help
planning what kinds of activities
does the client wants to do and to
train the client performing those
activities independently.

Price(￦)

LCIA

27,450

Personal

27,400LCIA

8,550 × 3
= 25,650

LCIA

720×6
= 4,320

LCIA

9,540
(T form)×2+11,740(L form)=30,820

Personal

60,500 × 2= 121,000

Personal

3,000×10= 30,000

Personal

1,000×2= 2,000

Side of toilet and sink: Installinggrab bars to prevent falling could be
happened while using toilet or bathroom.

Discussion
In this study, we select intervention using client-centeredapproach such as COPM and AHA that give information which
activities are important and meaningful to client. The results
give us more information about how she doing well in her ADL
situation.
In addition ACLS score show the client needs help the way
compensation not the remediate approach. When we examine
the result from pre intervention AHA cognitive activities scoreis more decreased than physical activities. It was just likeprevious research result that person who has more decreased
cognitive function perform activities with difficulty which needhigh cognitive level. However activities already show decreased
performance improved and maintain activity performing by
individual intervention.
It was meaningful to examine cognitive intervention withphysical factors to dementia client. For future study, we expectthat providing intervention not only client-centered approach
but also caregiver education program will show better result
about increased performance and maintaining the effectiveness.

Personal

500

Personal

6,800

Conclusions
Occupational Therapist have to provide intervention to not
only person with dementia but also their caregiver to improveand maintain activity performing level of person with dementia.

References[1] Hwang, J. N., Kwon, S. M. (2009). The relation between theparticipation in social activity and cognitive function among
middle-aged and elderly population. Jounal of the Korea
Gerontological Society, 29(3). 971-986.
[2] Law, M., Steinwender, S., & Leclair, L. (1998). Occupation,
health and well-being. Canadian Journal of Occupational
Therapy, 65(2), 81-91. doi: 10.1177/000841749806500204[3] Andersen, C. K., Wittrup-Jensen, K. U., Lolk, A., Andersen,
K., & Kragh-Sørensen, P. (2004). Ability to perform
activities of daily living is the main factor affecting quality oflife in patients with dementia. Health and quality of life
outcomes, 2(1), 52. doi:10.1186/1477-7525-2-52[4] Dunkin, J. J., & Anderson-Hanley, C. (1998). Dementia
caregiver burden A review of the literature and guidelines forassessment and intervention. Neurology, 51(1), S53-S60.
doi:10.1212/WNL.51.1_Suppl_1.S53

LCIA=Long-term Convalescence Insurance for the Aged
Table 3. Result of Changes in COPM Score
Item

ImportanceTaking medication
Bathing/showering
Watching TV
Using household appliances

8
8
7
3

Performance

Satisfaction

Author address

Pre
1
6
5
3

Pre
1
6
5
2

E-Mail: Pie_lee@yonsei.ac.kr

Post
3
7
5
5

Post
3
8
5
7

Table 4. Pre-Post Result of AHA Score
Item
Managing stairs
Getting in/out of house
Bathing/showering
Using toilet
Washing hair
Walking indoors
Using bed/bedclothes
Taking medication
Using household appliances
Controlling indoor lights
Average Score

Independence(3 points)
6m
Pre
Post
Post
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
1
1
1
1
2
2
3
3
3
2.6
2.7
2.7

Difficulty(4 points)
Pre

Post

2
2
3
3
3
3
3
1
2
3
2.5

2
2
3
3
4
3
3
2
2
3
2.7

Safety (4 points)
6m
Post
2
2
4
4
4
3
4
1
2
3
2.9

Pre

Post

2
2
3
3
3
2
3
2
2
3
2.5

3
3
3
3
3
3
3
2
2
3
2.8

6m
Post
3
3
4
4
3
3
4
2
3
3
3.2

-65-

Abstracts

Biomedical Laboratory Science-66-

2015 Yonsei-Nagoya University Joint Symposium on
Biomedical Laboratory Science
11:00~11:10 Opening Session

Prof. Jong-Bae Kim (Yonsei Univ.)

11:10~11:55

Session I

11:10~11:30

Theranostic Aptamer-conjugated Liposomal Nanoparticle for Triple

Chair: Prof. Takaaki Kondo and Jong-Bae Kim

Negative Breast Cancer
Min Woo Kim (Yonsei Univ.)
11:30~11:50

Influence of adipose-derived stem cell administration on cytotoxic
T lymphocyte-mediate liver injury in mice
Kenta Nakagiri (Nagoya Univ.)

12:00~14:00

Lunch

14:00~16:30

Session II

14:00~14:20

Enterotoxigenic Bacteroides fragilis-based wild type mouse model

Chair: Prof. Tetsuhito Kojima and Bo Young Jeonof colorectal cancer
Soon Jae Hwang (Yonsei Univ.)
14:20~14:40

Association of Meteorological Factors with Ambulance Transports
for Ischemic Heart Disease between 2002 and 2007 in Nagoya,Japan
Ryosuke Fujii (Nagoya Univ.)

14:40~15:00

Trends of Antibiotic Resistance Rate of Helicobacter pylori Isolates
from 2009-2010, 2011-2012, and 2014-2015 in a Single Center in
Korea
Ji Yeong Yang (Yonsei Univ.)

15:00~15:30

Coffee break

15:30~15:50

Human Exposure to Neonicotinoid Pesticides Has Increased theLast Two Decades
Arisa Aoi (Nagoya Univ.)-67-

15:50~16:10

Use of hTERT and HPV E6/E7 mRNA RT-qPCR TaqMan Assays in
Combination for Diagnosing High-Grade Cervical Lesions andMalignant Tumors
Sun Young Park (Yonsei Univ.)

16:10~16:20

Closing Remark

16:20~16:30

Group Photos

Prof. Takaaki Kondo (Nagoya Univ.)※ 15 minutes presentation and 5 minutes Q&A-68-

Theranostic Aptamer-conjugated Liposomal Nanoparticle for
Triple Negative Breast Cancer
Min Woo Kim1†, Hwa Yeon Jeong1, Seong Jae Kang1,
In Ho Jeong1, Moon Jung Choi1 and Yong Serk Park1
Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju, Gangwon-do
220-710, Republic of Korea

1Introduction
Breast cancers are clinically classified depending on
their expressions of estrogen receptor (ER),progesterone receptor (PR), and epidermal growth
factor receptor 2 (HER2/neu). Usually HER2-positive
breast cancer patients could be benefited fromendocrine and HER2-targeted therapies. However, incase of triple-negative breast cancers (TNBCs), theirlack of HER2 expression and aggressive progression
make it difficult to utilize HER2-targeted therapeutics.
An application of previously synthesized our cationiclipid, O,O’-dimyristyl-N-lysyl glutamate (DMKE)
combining with aptamer oligonucleotides specific toepidermal growth factor receptor (EGFR) could be anoble strategy to solve this concern. In order to achieveeffective siRNA complexation and provide with invivo target specificity, the cationic liposomes werePEGylated in two different steps.
Here, we synthesized quantum dot-incorporating
cationic liposomes (QCLs), which were thencomplexed with gene silencers such as Bcl-2 siRNAand PKC-λ/ι siRNA. Both siRNAs in QCLs wereeffectively and specifically transfected to TNBCs,
resulting in apoptosis and reduced migration of thecells. In this study, we concluded that EGFR aptamerconjugated QCLs can be utilized as a useful theranostic
agent for TNBCs.

Materials and Methods
Preperation of liposome : Quantum dotsincorporating
cationic liposomes (QCLs) wereprepared according to the lipid thin layer methods.
O,O’-dimyristyl-N-lysyl
glutamate(DMKE,
previously synthesized cationic lipid) (48 mol%),cholesterol (48 mol%), 1,2-distearoyl-sn-glycero-3phosphoethanolamine-N-[methoxy(polyethylene
glycol)2000] (DSPE-mPEG2000, Avanti Polar Lipids)(4 mol%) and quantum dots (CdSe/ZnS, Nanosquare)(5:1, w/w) were dissolved in a chloroform andmethanol mixture (2:1, v/v). The organic solvent wasevaporated under a stream of N2 gas, followed by
vacuum desiccation for 1 h. The dried films (0.5 mg
lipids) were hydrated in 1 ml of normal saline and thencontinuously vortexed and sonicated. The therapeutic
Bcl-2, PKC-λ/ι siRNA (Bioneer, Daejeon, Korea),and prepared QCLs were gently vortexed (4:1 N/P ratio)
at 500 rpm for 1 h.
To prepare immuno-QCLs, Cetuximab, a chimericantibody against EGFR, was thiolated by reaction with
Traut’s reagent (Thermo Scientific, Rockford, IL, USA),and then conjugated to the maleimide group of 1,2distearoyl-sn-glycero-3-phosphoethanolamine-N[maleimide(polyethylene glycol)-2000] (DSPEPEG2000-mal). Thiolated aptamer (Postech, Pohang,
Korea) was also conjugated to the distal termini of DSPEPEG2000-mal. Each of prepared EGFR targeting lipids(0.4 mol%) were post-inserted into QCLs complexedwith therapeutic siRNAs at 60 ℃ for 1 h.
Cell lines and cell culture
MDA-MB-231 cell (Human breast adenocarcinoma) and
MDA-MB-453 (human breast carcinoma), well known as
triple negative breast cancer (lack of ER, PR, HER2
antigen), were maintained in DMEM (Gibco, Carlsbad,USA). The culture media were supplemented with 10%
fetal bovine serum (Gibco, Carlsbad, USA), and 1%
penicillin-streptomycin (Gibco, Carlsbad, USA).
Analysis of cell binding test in MDA-MB-231 and
MDA-MB-453 cells
FACS analysis was performed with MDA-MB-231 and
MDA-MB-453 cells treated with EGFR-Cetuximab
labeled with Alexa fluor 488 and EGFR-aptamers labeledwith Cy3.
To evaluate transfection efficiency, the various QCLs
were complexed with fluorescein-labeled siRNA andtransfected to both cells in serum-free media for 4 h.
Then change of fluorescence shift in transfected cells
were determined by FACS analysis.
RT-PCR analysis of in vitro gene silencing by various
QCLs
To evaluate in vitro gene silencing by small interfering
RNA, MDA-MB-231 cells (5 ⅹ 105 cells per well) weretransfected with various formulations of QCLs containing
various concentration of the therapeutic Bcl-2, PKC-λ/ι
siRNAs in serum-free media for 4 h. The transfected cells
were then incubated in medium containing 10% FBS
media for 24 h. The mRNA level of both targets intransfected cells were determined by RT-PCR.

-69-

Figure 3. cell binding test in MDA-MB-231 and
MDA-MB-453 cells
FACS analysis was performed with MDA-MB-231 and
MDA-MB-453 cells treated with EGFR-Cetuximab
labeled with Alexa fluor 488 and EGFR-aptamers labeledwith Cy3..
50% FBS

Serum free
100

Percent Gated (%)

80
60
40
20

EGFR Antibody

EGFR Aptamer

MDA-MB-231

MDA-MB-453

EGFR

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60

ak
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80
60
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TP
-Q
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Figure 4. In vitro siRNA transfection efficiency ofvarious QCLs.
The various QCLs were complexed with FITC-labeledsiRNA and then were added to MDA-MB-231 cells.
After 4 h incubation, the transfection of FITC-labeledsiRNA to the cells were measured by FACS analysis.
.
Conclusions
In this study, we have developed a novel theranostic
liposomal siRNA delivery system specific to EGFRexpressing MDA-MB-231 cells, one of triple negative
breast cancers.
At 4:1 N/P ratio, QCLs exhibited the highest siRNA
encapsulation and showed an appropriate particle size andzeta potential.
Bcl-2 and PKC-λ/ι siRNAs in the anti-EGFR-QCLs wereable to significantly suppress the expression of thecorresponding genes in MDA-MB-231 cells.

References
1. Emmanuel A. Ho., et al., Characterization ofLong-Circulating Cationic Nanoparticle
Formulations Consisting of a Two-Stage
PEGylation Step for the Delivery of siRNA in a
Breast Cancer Tumor Model. J Pharm Sci, 2013.
102(1): p. 227-36
2. A Paul., et al., PKC λ/ι signaling promotes
triple-negative breast cancer growth andmetastasis. Cell Death Differ, 2014. 21(9): p.
1469-81Control
EGFR knock-down

40

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Figure 2. Determination of optimal N/P ratio of
siRNA & QCLs.
Scrambled siRNA were complexed with QCLs invarious N/P ratios and then incubated for 1 h with
continuous vortexing at room temperature. Optimal
N/P ratio was estimated by gel retardation assay (A)and their band intensities (B).

Percent Gated (%)

100

MDA-MB-453

60

0

0

Figure 1. Schematic illustration of Anti-EGFRQCLs.
Anti-EGFR-QCLs were prepared by post-insertion of
DSPE-mPEG2000 conjugated to antibodies or
aptamers into quantum dot-encapsulating cationicliposomes, followed by siRNA complexation.

80

on
tr
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20
00

MDA-MB-231

Percent Gated (%)

100

C

ResultsET
A
B

Analysis of Fluorescence imaging in MDA-MB-231
cells
MDA-MB-231 cells were transfected by various
QCLs containing fluorescein-labeled siRNA and thefluorescences images were observed by confocal
microscope (×400) 4 h later.

Author address
nanodream@yonsei.ac.kr-70-

Influence of adipose-derived stem cell administration on cytotoxic T lymphocyte-mediatedliver injury in mice.
Kenta Nakagiri, Tomomi Ohara, Eri Nanizawa, Fumika Hirano, Yumi Hayashi, Tetsuya Ishikawa
Department of Medical Laboratory Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
Introduction
Cell therapy with mesenchymal stem/stromal cells (MSCs),
has received much attention because these cells possess
immunomodulatory properties as well as multilineage
differentiation potential [1,2]. While bone marrow has beenoriginally reported to be the source of MSCs, adipose tissue
has been demonstrated to be the source of MSCs as well [3].
Adipose tissue-derived MSCs (ASCs) have shown to possess
immunomodulatory properties that are comparable withthose of bone marrow-derived MSCs (BSCs) [4,5]. ASCs
may be better candidate of cell therapy, since they could be
easily obtained with minimal invasive procedure and growfaster than BSCs [6,7]. Actually, the effects of ASCs onvarious inflammatory disease models have been
demonstrated, and the trials for clinical applications of ASCsin various immune disorders, such as graft-versus-hostdisease (GvHD), are now in progress.
Fulminant hepatic failure (FHF) could be one of the targets
for ASC therapy, since FHF is an incurable disease withsignificant mortality, composed of massive destruction ofhepatocytes caused by excessive immune responses [8,9],
and orthotopic liver transplantation is the only way to
improves the survival rate.
We and others have demonstrated the therapeutic effectsof ASCs on acute liver injury in mice models, such asconcanavalin A (ConA)-induced and carbon tetracloride(CCl4)-induced liver injury models, both of which arerecognized as the models of FHF in human [10,11]. However,
little is known about the effects of ASCs on cytotoxic T
lympocyte (CTL)-mediated liver injury; most prevalent causeof FHF as seen in hepatitis virus infection-related FHF.
In the current study, therefore, we evaluated the effects
and influences of ASCs on CTL-mediated acute liver injury
using hepatitis B surface antigen (HBsAg)-transgenic miceand HBsAg-specific CTLs.
Materials and Methods
Mice: HBsAg-transgenic mice, lineage 107-5D (official
designation Tg[Alb-1,HBV]Bri66), (inbred B10.D2, H-2d) inwhich the HBsAg coding region is under the control of themouse albumin promoter [12], were subjected for theexperiments in age of 8 to 10 week. Six- to 8-week-old
B10.D2 mice with same background as 107-5D were used as
the source of ASC administration and splenocytes. All themice were housed in a controlled environment and fed astandard diet with water ad libitum. The experiments wereapproved by the Nagoya University Animal ExperimentCommittee.
HBsAg-specific CTLs: The CD3+, CD4-, CD8+ CTL clone(designated 6C2) were used in the study. 6C2 is Ld restricted,
recognizes an epitope (IPQSLDSWWTSL) that is locatedbetween residues 28-39 of HBsAg, and secretes IFN- andTNF- after antigen stimulation in vitro [13]. They weremaintained by weekly restimulation with mitomycin (MMC)treated P815 cells (murine mastcytoma cell line, H-2d) thatstably express HBsAg (designated P815preS(1)).
Preparation of ASCs: Subcutaneous adipose tissues weretaken from 6- to 8-week-old B10.D2 mice, placed in DMEM
containing 10% FBS, and minced, adding Hank’s balanced

salt solution to prevent drying. These tissues were incubated in
HBSS containing 0.1% collagenase, suspended with DMEM,
passed through 100µm mesh, and resulting cell suspension wascollected in 50mL tube. After centrifuge, the precipitated cells
were washed twice with DMEM, and resuspended in a complete
medium, 3:2 mixture of DMEM and MCDB 201 medium
containing 20% FBS, supplemented with linoleic acid-albumin,
Insulin-Transferrin-Selenium (ITS), ascorbic acid phosphateester, and antibiotics. The cells were seeded in fibronectincoated flask, and attached fibroblast-like cells were cultured as
the progenitors of ASCs. The medium was changed every 1 or 2
days. When the cells grew confluent, they were treated with 1
mM EDTA-containing 0.25% trypsin, and the detached cells
were replated on a new flask for further expansion, or used forthe experiments [14].
Proliferation assay for CTLs co-cultured with ASCs: One ×
105/well 6C2s were placed in a 96-well plate, with 1 × 105/well
P815preS(1)s as stimulator cells and 1 × 106/well B10.D2
splenocytes as feeder cells, with or without 5 × 104/wellsyngeniec ASC (CTL:ASC=2:1), and incubated for 24 h. Then,
BrdU incorporation assay was performed to assess proliferative
responses of CTLs. As a control experiment, 1 × 106/well
B10.D2 splenocytes stimulated with 5 µg/mL ConA were
cultured with or without 5 × 104/well syngeneic ASC(splenocyte:ASC=20:1), incubated for 24 h, and subjected to
BrdU incorporation assay.
Cytotoxicity assay for CTLs co-cultured with ASCs: Two ×
105 or 1 × 106/well 6C2s (effector cells) were cultured with 2 ×
105/well carboxyfluorescein diacetate succinidyl ester (CFSE)labeled P815preS(1)s (target cells, effector to target ratios are
1:1 and 5:1, respectively) in a 24-well plate, with or without 1 ×
105/well ASC (CTL:ASC=2:1 and 10:1, respectively). The cells
were incubated for 4 h, non-adherent cells (except for ASCs)
were collected, fixed with 4% paraformaldehyde (PFA), andsubjected to the analysis with flow cytometer (LSRFortessa X20 Analyzer, Becton, Dickenson, abd Co.). Mean fluorescenceintensity (MFI) of target cells was determined, and % specifickilling was calculated as follows: [(MFI of labeled target cells
in control sample – MFI of labeled target cells in test sample)/(MFI of labeled target cells in control sample)] × 100. Control
sample indicates target cells incubated without effector cells,
and test sample indicates target cells incubated with effector
cells.
CTL-induced liver injury model and treatment with ASCs:
Eight- to 10-week-old male 107-5D mice were intravenously
injected with 5 × 106 6C2s of 5 d after the last stimulation,suspended in 200 L PBS. In ASC-treatment group, 1.0 × 106
ASCs in 200 µL PBS with heparin were intravenously injected
to mice, 30 m before 6C2 transfer. Control group (without ASC
treatment) were injected with PBS with heparin at the same time
point. At 48 h after 6C2 transfer, the mice were sacrificed aftercollecting sera, and liver tissue specimens were resected. ALTlevels in the sera were analyzed with by BBx system (Nittobo
Medical Co.,Ltd, Tokyo, Japan). Liver specimens were stainedwith hematoxylin and eosin (H&E), and the extent ofinflammation was asssessed under microscope. Eachexperimental group consisted of 3 to 4 mice.
Cytokine/Chemokine analysis for culture supernatants andmice sera: Cytokine and chemokine levels (IL-6, IL-10, MCP-1,-71-

IFN- TNF, IL-12p70) in the culture supernatants of 6C2s
stimulated with P815preS(1) with or without ASC
cocultivation, and in the sera of 107-5D mice 48 h after 6C
transfer (with or without ASC transfer), were measured using
Cytometric Bead Array (CBA) Mouse Inflammation Kit(Becton, Dickenson, abd Co.) according to the manufacture’s
instruction.
Results and Discussion
Influence of ASCs on CTL proliferation and cytotoxicity:
As a control experiment, we examined the effect of B10.D2
ASCs on ConA-stimulated proliferation of syngeneic
splenocytes. ASCs markedly suppressed proliferation of
splenocytes to one-tenth of that without ASC cocultivation,
indicating ASCs used in the study had immunomodulatory
function compatible to that reported previously. When ASCs
were cocultured with antigen (P815preS(1))-stimulated 6C2s,
however, they did not effectively suppress proliferation of
6C2s: the reduction rate of proliferation was only 12%. Next,
we tested the influence of ASC cocultivation on cytotoxic
activity of 6C2 using P815preS(1) as target cells. WithoutASCs, 6C2s effeciently killed targets: % specific killing was
80% at E/T ratio of 1 and 96% at E/T ratio of 5. In the
coculture experiment with ASCs, % specific killing of 6C2
was 79% at E/T of 1, and 96% at E/T of 5, showing almost
no suppresive effect of ASCs on cytotoxicity of 6C2s. The
differenct effects of ASCs on ConA-stimulated splenocytes
and antigen-stimulated CTLs may be explained by thecharacteristics and potentials of the individual cells. Namely,
the splenocytes are heterogenious and include non-sensitive
cells to ConA stimulation, such as B cells, macrophages, etc.,
while 6C2 is a CTL clone with strong proliferative andcytotoxic activity. On the other hand, Karlsson et al. reported
that ASC did not have regulatory funcrtion on cytotoxic
activity of CTL [15]. There are differences in experimental
condition and characteristics of cells between the two studies,
however, it may explain the results of our study as well.
Influence of ASCs on CTL-mediated liver injury: Then,we examined the in vivo effects of ASCs in CTL-mediatedliver injury model, in which HBs-Ag-specific CTLs (6C2s)
were transferred into HBsAg-transgenic mice (107-5D):transfer of the designated amount of CTLs (5 × 106) causes
FHF-like liver injury (the peak of ALT elevation on d 2 to 3)
in this model. The amount of ASCs (1 × 106) transferred tothe mice was enough to alleviate liver injury in FHF models
with ConA and CCl4 administration. In the mice transferredwith 6C2s alone, ALT levels on d 2 (48 h) were 3700±2107
U/L. In the mice transferred with 6C2 and ASCs, ALT levels
on d 2 were 5713±3543U/L, indicating that the immunoregulatory effect of ASCs was not observed. Histologicalanalysis also showed that ASC transfer did not relieve
inflammation in the livers of mice. Serum cytokine/chemokine analysis showed increase in IL-6 and MCP-1
levels in the mice with 6C2 and ASC transfer compared tothe mice with 6C2 transfer alone. From the results of in vitro
study, we did not expect that CTL-mediated hepatocyte
apoptosis was protected by ASCs, while we expected that
inflammatory responses of antigen-nonspecific cells
following CTL activation were lessened by ASCs. However,
the results indicated that there was no relief of liver
inflammation both antigen-specific and nonspecific levels.
Elevation of serum IL-6 and MCP-1 in the mice transferredwith 6C2s and ASCs may explain this phenomenon. Since
the increases of IL-6 and MCP-1 levels in the supernatant of
6C2 and ASC cocultivation were also confirmed, the serum
elevations of the both factors in the mice were possibly
caused by the interaction of 6C2s and ASCs in vivo.

Although the reason why ASC could not exert regulatory
function in CTL-mediated liver injury was not evident, it ispossible that elevations of these inflammatory cytokine/chemokine played some roles in disturbing immune-regulatory
function of ASCs.
Conclusions
The use of ASC in treating FHF should be careful, since theimmune-regulatory function of ASC may not be exerted as
expected depending upon the etiology of FHF. More detailed
analyses are necessary to elucidate actual influence of ASC on
CTL-mediated cytotoxicity and diseases, using other CTL
clones or CTL cell lines, since the current study used only asingle CTL clone.
References
1. Augello A et al. Cell therapy using allogeneic bone marrowmesenchymal stem cells prevents tissue damage in collageninduced arthritis. Arthritis Rheum. 2007; 56: 1175–86.
2. Aggarwal S, Pittenger MF. Human mesenchymal stem cells
modulate allogeneic immune cell responses. Blood. 2005;
105:1815–22.
3. Zuk PA et al. Multilineage cells from human adipose tissue:
implications for cell-based therapies. Tissue Eng. 2001;7:
211–28.
4. Puissant B et al. Immunomodulatory effect of human adipose
tissue-derived adult stem cells: comparison with bonemarrow mesenchymal stem cells. Br J Haematol. 2005;129:
118–29.
5. Yoo KH et al. Comparison of immunomodulatory propertiesof mesenchymal stem cells derived from adult human tissues.
Cell Immunol. 2009;259:150–6.
6. Kern S et al. Comparative analysis of mesenchymal stem
cells from bone marrow, umbilical cord blood, or adipose
tissue. Stem Cells. 2006;24:1294–301.
7. Wagner W et al. Comparative characteristics of mesenchymal
stem cells from human bone marrow, adipose tissue, andumbilical cord blood. Exp Hematol. 2005;33:1402–16.
8. Bernal W et al. Acute liver failure. Lancet 2010; 376:190-201.
9. Dhawan A et al. Human hepatocyte transplantation: current
experience and future challenges. Nat Rev Gastroenterol
Hepatol. 2010;7288-98.
10. Kubo N, et al. Efficacy of adipose tissue-derived
mesenchymal stem cells for fulminant hepatitis in miceinduced by concanavalin A. J Gastroenterol Hepatol.
2012;27:167-72.
11. Yukawa H, et al. Monitoring transplanted adipose tissuederived stem cells combined with heparin in the liver byfluorescence imaging using quantum dots. Biomaterials.
2012;33:2177-86.
12. Ando K, et al. Mechanisms of class I-restricted
immunopathology. A transgenic mouse model of fulminant
hepatitis. J Exp Med 1993;178 :1541-54.
13. Ishikawa T, et al. Polyclonality and multispecificity of the
ctl response to a single viral epitope. J Immunol 1998;
161:5842-5850.
14. Iwashima S et al. Novel culture system of mesenchymal
stromal cells from human subcutaneous adipose tissue. StemCells Dev. 2009;18:533–43.
15. Karlsson H, et al. Mesenchymal stem cells exert differential
effects on alloantigen and virus-specific T-cell responses.
Blood 2008;112:532-41.
Author address
E-Mail: nakagiri.kenta@j.mbox.nagoya-u.ac.jp-72-Enterotoxigenic Bacteroides fragilis-based
wild type mouse model of colorectal cancer
Soonjae Hwang, Chang Gun Lee, Sun-Yeong Gwon, Samnoh Hwang, Hye Chin Yi, Eungi Kim, Jisoo Han,
Myung Sook Kim, Ki-Jong Rhee*
Department of Biomedical Laboratory Science, College of Health Sciences, Department of Biomedical Laboratory
Science, Yonsei University at Wonju, Korea.

Introduction
Colorectal cancer is a major cause of death in the developed
countries. Colorectal cancer develops spontaneously as aresult of genetic mutation or as a long-term complication ofchronic bowel inflammation such as in Crohn’s disease andulcerative colitis. Since the past, many scientists have beenusing azoxymethane (AOM) with dextran sulfate sodium(DSS) in order to study pathogenesis of colorectal cancer (1).
AOM is a DNA alkylating agent, a chemical carcinogen.
DSS is a chemical which is used to induce colonicinflammation in rodents. IL-6, one of inflammatory cytokines
produced for inflammation, triggers the up-regulation oftranscription factors such as c-myc and cyclin D1 throughphosphorylated STAT3 (2). Therefore DSS is used toaccelerate colonic tumor formation and progression (3).
However, AOM/DSS system is primarily influenced bycondition of each animal facility. Same protocol applied to
specific strain of mouse sometimes show different colonictumorigenesis such as the number of colonic polyp and tumor
progression. So researchers needs to try and adapt known
protocol and method of AOM/DSS system in each laboratory.
We developed an enhanced and very highly reproducible
Bacteroides fragilis-applied mouse model with AOM/DSS
system compared to prior AOM/DSS mouse model.
Bacteroides fragilis is a gram-negative and facultative
anaerobe. B. fragilis is a human colonic commensal andknown to be one of the most commonly isolated species fromhuman intestine. Some strains of B. fragilis secretes
Bacteroides fragilis toxin (BFT) and those strains are named
as Enterotoxigenic Bacteroides fragilis (ETBF). The
prevalance of ETBF colonization is 4~30% and the clinicalmanifestation of most ETBF carrier is asymptomatic. BFT is
a 20 kDa secreted metalloproteinase. BFT induces
ectodomain E-cadherin cleavage in vitro and in vivo, thereby
inducing colitis in murine model (4, 5). Also, BFT activates
beta-catenin signaling, MAPK pathway and NF-B pathway
in colonic epithelial cell lines.
Recently, it has been shown that ETBF infection increases
colonic tumorigenesis through T helper type 17 immune
response in APC/Min mice which are characterized byspontaneous tumor formation in small and large bowel inmouse starting at the time of 4~6 weeks age (6). In addition,
studies using human stool samples indicated that an increase
rate of detection of bft gene of ETBF in colorectal cancer
patients when compared to control groups (7). Additionally,other study showed that ETBF-secreted nanoparticles induce
secretion of the S1P containing exosome from colonicepithelium, thereby inducing T helper type 17 immune
response in colonic mucosa in mouse (8). T helper 17 cell isregarded is as an aggravating factor of pathogenesis andprogression of colorectal cancer (9). Here we explored anovel method of ETBF-based AOM/DSS mouse model. We
show that ETBF infection showed enhanced colonictumorigenesis in AOM/DSS-treated mice through enhanced
colitis.

Materials and Methods
Animal and Treatment. 8 week-old female Balb/c mice
were purchased from Raonbio and housed in a temperaturecontrolled environment (23°C ± 1) with a 12-h light/darkcycle. After an acclimation period of 1 wk, the mice were
injected i.p with AOM (10 mg/kg). Control animals received
saline as vehicle control. DSS 2% solution was substituted foranimal drinking water 5 days after bacterial inoculation. One
cycle consists of 5 day of DSS treatment and 16 days of
distilled water.
Bacterial strains. Enterotoxigenic Bacteroides fragilis (WTETBF, B. fragilis 86-5443-2-2) expressing a biologically
active BFT-2 was used in this study. Bacteroides strains usedin this study are resistant to gentamicin and clindamycin.
Mouse Infection. All mice (Balb/c, female) were given waterwith clindamycin (100 mg/L) and gentamicin (300 mg/L) to
promote colonization of B. fragilis. Antibiotics-containing
water was initiated 7 days prior to bacterial inoculations.
Bacteria were washed with sterile phosphate-buffered saline
and adjusted to 2 x 10ˆ8 CFU/ml for mouse oral inoculations.
Fecal analysis. B. fragilis colonization (CFU / g stool) wasmonitored by diluting stool in brain heart infusion agar
(BHIA) containing gentamicin and clindamycin. BHIA plates
were cultured in an anaerobic chamber at 37°C for 2 days.
Thereafter, ETBF colonies were enumerated.
Histology. Formalin-fixed (10%), paraffin-embedded
intestinal tissues were sectioned (5 μm) and stained withhematoxylin and eosin (H&E). Spleen weight was measured
by an electronic scale. Colon length was measured by a ruler
from the beginning of the cecum to the end of the rectum.
Images were taken using a Leica camera and rendered using
Adobe Photoshop.
Data analysis. For statistical analysis, the Mann-Whitney U
test was used to compare between-group distributions for
unpaired data. All other data are presented as means ±standard errors of the means. A P value of ≤0.05 wasconsidered statistically significant.

Results
Histologic grade of colonic polyps from AOM/DSS-treatedmice generally showed low grade dysplasia and adenoma. In-73-contrast, colonic tumor histology of AOM/DSS/ETBFtreated mice indicated mostly aberrant hyperplasia, highgrade dysplasia, adenoma and carcinoma in situ. AOM/DSS
protocol was reported that colonic adenocarcinoma
progresses in colon of mice treated with AOM/DSS.
However, there was no invasion of colonic tumor throughout
basement membrane in all groups. There was also no
metastasis in liver and lung in AOM/DSS/ETBF group.
Additionally, we performed immunohistochemistry for
identifying the properties of tumor such as strong betacatenin reactivity, Cox-2 and iNOS in order to verify
characteristics of colonic polyps. Almost most of polyps ofmice from AOM/DSS/ETBF group showed representativestrong beta-catenin, Cox-2 and iNOS

Merit of AOM/DSS method is the easy accessible availability ofwild type mouse, which means that researchers can start in vivo
study anytime if wild type mouse, AOM and DSS are ready foruse. Typical AOM/DSS protocol is easily reproducible but mostpolyp size is so small that researchers might miss micro polyps.
Therefore some drugs with a minimal effect for colon cancer
can be ignored in AOM/DSS system. AOM/DSS/ETBF method
presented here could have significantly accelerated the colonictumorigenesis compared to control group of AOM/DSS. A
human commensal-applied AOM/DSS mouse model provides a
powerful framework for investigating the mechanism of tumor
initiation, progression and promotion of colitis-associatedcancer.
References

A

1.
ETBF+
AOM/DSS

2.
AOM/DSS

3.
B

4.

5.

6.

7.

8.

Figure 1. ETBF-based AOM/DSS protocol showed strongcolonic tumorigenesis compared to conventional AOM/DSS
mouse model.
A. Gross of large intestine of mice. B. Number of polyps
in large intestine of mice. ***, P<0.001 Bar, median

9.

De Robertis M, et al. (2011) The AOM/DSS murine
model for the study of colon carcinogenesis: Frompathways to diagnosis and therapy studies. Journal ofCarcinogenesis 10:9.
Grivennikov S, et al. (2009) IL-6 and Stat3 arerequired for survival of intestinal epithelial cells anddevelopment of colitis-associated cancer. Cancer Cell
15(2):103-113.
Tanaka T, et al. (2003) A novel inflammation-relatedmouse colon carcinogenesis model induced byazoxymethane and dextran sodium sulfate. Cancer
Science 94(11):965-973.
Rhee KJ, et al. (2009) Induction of persistent colitis
by a human commensal, enterotoxigenic Bacteroides
fragilis, in wild-type C57BL/6 mice. Infection and
Immunity 77(4):1708-1718.
Wu S, Lim KC, Huang J, Saidi RF, & Sears CL(1998) Bacteroides fragilis enterotoxin cleaves thezonula adherens protein, E-cadherin. Proceedings of
the National Academy of Sciences of the United Statesof America 95(25):14979-14984.
Wu S, et al. (2009) A human colonic commensal
promotes colon tumorigenesis via activation of T
helper type 17 T cell responses. Nature Medicine
15(9):1016-1022.
Boleij A, et al. (2015) The Bacteroides fragilis toxin
gene is prevalent in the colon mucosa of colorectal
cancer patients. Clinical Infectious Diseases
60(2):208-215.
Deng Z, et al. (2015) Enterobacteria-secreted particles
induce production of exosome-like S1P-containing
particles by intestinal epithelium to drive Th17mediated tumorigenesis. Nature Communications
6:6956.
Miossec P, Korn T, & Kuchroo VK (2009)
Interleukin-17 and type 17 helper T cells. The New
England Journal of Medicine 361(9):888-898.

Conclusions
Discussion
Representative mouse models for colon cancer are
APC/Min mice and AOM/DSS-treated mice. APC/Min
mouse model is dependent on loss of Apc function and moresensitive system than AOM/DSS, which means that we canobserve target effects of drug and factor as long withsensitively feasible formation of colonic polyps. However,
the effects and costs of breading and separating heterogenous
APC/Min mice mouse are highly laborious and expensive.
Additionally, polyp formation also arises in small intestinewhich region is not common in most of colon cancer patients.

In this study, we demonstrated that ETBF plays a role inenhancing colonic tumor number and progression in
AOM/DSS-treated Balb/c mice in vivo. Consequently,
Bacteorides fragilis harboring bft gene could be used as a noveland sensitive tool in AOM/DSS-based wild type rodent model.
Author address
Soonjae Hwang, E-Mail: yoyosong1@naver.com
Ki-Jong Rhee, E-Mail: kjrhee@yonsei.ac.kr-74-

Association of Meteorological Factors with Ambulance Transports for Ischemic Heart
Disease between 2002 and 2007 In Nagoya, Japan
Ryosuke Fujii, Hiroki Michishita, Yuuya Tatsuno, Chiharu Sudo, Takaaki Kondo
Department of Pathophysiological Laboratory Sciences,
Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction
Forecasting health fron weather pattern has attracted awide attention, particularly because information of weatherrelated risks for illness seems to be a useful tool of building
strategy for disease prevention. Ever-accumulated evidence
revealed the influence of weather factors on occurrence ofischemic heat disease (IHD) since the proposal by Rose G in
1966 [1]. According to the Hiroshima Prefectural Medical
Association, acute myocardial infarction (AMI) has been
likely to occur frequently in a day with mean ambient
temperature of less than 10℃ and mean barometric pressureof less than 1005hPa [2]. In Helsinki, AMI mortality rateincreased in the coldest day, and the number of incidents washigher when the barometric pressure quickly dropped,
whereas ambient temperature was not significantly
associated with AMI [3]. This Swedish study also indicatedthat AMI usually occurres on the day with low temperature,high humidity and low atmospheric pressure. Other Swedish
researchers previously found no relationship between
weather and lethal AMI [4]. Chinese researchers
demonstrated that AMI increased at high atmospheretemperature, high relative humidity and low atmospherepressure in summer [5]. These results suggest that therelationship between IHD and weather parameters is notconsistent. Presumably, weather-related risks affects disease
occurence from region to region, because otehr health-relatedrisks such as the pattern of lifestyle and environmental
situation tottaly vary. Therefore, investigation into theassociations of weather condition with IHD onset in aparticular area is warranted to design an area-specificprevention plan.
This study firstly aimed to summarize the frequency of
IHD ambulance transports by every season, month, day of
the week in Nagoya, and then to investigate the association
between the emergency transports for IHD andmeteorological factors.
Materials and Methods
Study site: Our study targeted Nagoya City, which is the
fourth largest city in Japan (latitude 35 ̊11'N, longitude136 ̊55'E). Its population size is approximately 2.2 million asof October 1st in 2010.

Figure 1. The daily mean ambient temperature by month in
Nagoya, 2002-2007
Nagoya is located in the central part of the JapaneseArchipelago and faces onto the Pacific Ocean. In terms of theclimate of Nagoya, most days in winter are cold, dry and clear,
while it is steamy in summer.
Meteorological data: The daily meteorological data from2002 to 2007 were obtained from the Japan Meteorological
Agency. At present, the data during 1872-2014 can be freely
downloaded as a CSV-formatted file from the website of theJapan Meteorological Agency. Our study simply used thefollowing meteorological variables for investigating therelationship between IHD and meteorological factors; mean
barometric pressure (hPa), ambient temperature (℃) (mean,
highest and lowest), intraday temperature difference (℃), meanvapor pressure (hPa), mean relative humidity (%), lowest
relative humidity (%), mean wind speed (m/s), mean cloud
cover, sunlight duration (hrs), global solar radiation (MJ),
precipitation (mm).
Ambulance transports data: The information of emergency
transports to the hospital, over the years 2002-2007, wasprovided by the Nagoya public ambulance emergency service.
This data set includes 20 variables for each emergency
transport; patients’ demographic data (e.g. age, gender andresidential area) and the date and time of emergency call andinformation of illness (e.g. presence of patient’s consciousness,degree of the injury and coded name of illness). The name of
disease was coded according to the diagnosis by the physician
who first examined tha patient. If the name of disease wasunidentified at the initial visit, it was coded later. In this study,
we regarded angina and myocardial infarction (MI) as“ischemic heart disease (IHD)”. The total number of transferred
for IHD, angina and MI during the period of 6 years was 9,253,
5,279 and 3,974, respectively.
Statistical analysis: The data of meteorogical variables wereshown as mean ± standard deviation. We regarded March,
April and May as “Spring”, June, and July and August as“Summer”, September, Octorber and November as “Autumn”,
and December, January and Febrary as “Winter”. One-way
analysis of variance (ANOVA) was used to confirm thedifferences of emergency transports for IHD between every
season, month and day of the week. After ANOVA, Tukey’s
multiple comparison test was performed to examine all pairwise
differences of means. Backward stepwise Poisson regression
analysis by Akaike’s information criterion was carried out toselect meaningful meteorological parameters and determine
how much weather factors were related to IHD transports. A pvalue of less than 0.05 was considered as statistically significant.
R-3.2.2 was used for all statistical analysis in this study.
Results
The summary of meteorological data from 2002 to 2007 isshown in Table 1. Average ambient temperature for 2,191days-75-was 16.2±8.5 (℃). The fluctuation of daily average airtemperature by every years is plotted in Fig. 1.
Table 1. Meteorological parameters during the period of
2002-2007 in Nagoya, Japan

In comparisons of IHD emergency transports by every
season, month and day of the week, there were significant
seasonal and monthly differences (both p < 0.01), while novariability was observed among 7days of the week (p = 0.71)(data not shown). The number of IHD ambulance transports
in winter was significantly higher than that of spring andsummer (both p < 0.01). More emergency IHD visits wereobserved in December than in May and June (both p < 0.05).
The result of Poisson regression analysis with the
backward stepwise method is shown in Table 2. Daily mean
humidity, actual sunlight duration and precipitation weresignificantly related to IHD emergency transports.
Furthermore, intraday temperature difference and global
solar radiation showed marginal association with the IHD
occurrence, whereas daily mean ambient temperature had no
significant influence on IHD.
Table 2. Effects of meteorological parameters on
emergency transports for IHD in Nagoya, Japan, 20022007, by backward Poisson regression analysis

Discussion
In this study, we firstly examined the number of
emergency transports for IHD by season, month and day of
the week. As some researchers reported, we also observed asurge in the number of ambulance IHD visits in winter and asecond peak in summer. The between-month comparison
showed that December had the highest IHD transports,
whereas May and June had a lower number. This result fellin line with previous studies concerning seasonal differenceof IHD [6-9]. Kinoshita N also reported that AMI onset
significantly increased in winter compared with summer [10].
One of the conceivable reasons for seasonal and monthly
difference is that colder weather induced an increased bloodpressure, which is a well-known risk factor of IHD [11,12].
Additionally, some researchers have argued that clotting islikely to occur in cold weather due to the increase in
fibrinogen, platelet count and plasma viscosity [13]. We
found no significant relationship between the day of the week
and IHD emergency transports. A previous study that
focused on the incidence pattern of AMI showed nosignificant relationship during the week, while only women
had a higher incidence rate in Saturday [14]. Therefore, weneed to further investigate the association of IHD incidents
with the weekly pattern by stratification.

As a main part of this study, we explored which
meteorological factor was related to the number of ambulance
IHD transports. We observed mean relative humidity had apositive relationship with IHD occurrence. The results regarding
the association of daily humidity and AMI admissions were
controversial. Some studies showed a significant relationshipbetween the number of AMI admissions and either maximal
ambient humidity [15] or low humidity [16], although anotherfound no such associations [17]. A possible hypothesis for ourconsequence could be that lack of sweating function hinderedby high humidity may be lead to the defects in the automatic
system of internal temperature control, thus increasing burden
for heart. Our study indicated that the longer sunlight durationand small amount of rain were significantly related to the higher
number of IHD. Further research should be needed to elucidate
the influence of precipitation and sunshine duration on IHD
because our evidence is inconsistent with previous findings interms of precipitation and sunlight hours. In this study, amarginal significant relationship between IHD and intraday
temperature difference was observed. A Japanese researcher
demonstrated that intraday temperature change is a predictive
factor for AMI [18]. However, the mechanisms have not been
elucidated. One reason could be that a rapid change in air
temperature is associated with an increased risk for
cardiovascular spasm.
There are some limitations should be discussed. Firstly, thename of disease might be different from the final diagnosis
because it was coded according to the first diagnosis. Secondly,
there is some possibility of over-counting the number of IHD
patients for angina and MI because we could not exclude
recurrent cases in this dataset.
Conclusions
We confirmed the seasonal and monthly variability of thenumber of ambulance transports for IHD. Daily mean humidity,
actual sunlight duration and precipitation were significantly
associated with IHD emergency visits in Nagoya.
References[1] Rose G. Brit J Prev Soc Med. 1966;20:97-100.
[2] Wang H, et al. J Cardiol. 2007;49:13-21.
[3] Sarna S, et al. Ann Clin Res. 1977;9:222-32.
[4] Messener T, et al. Int J Circumpolar Health. 2002;61:2017.
[5] Li QB, et al. Zhonghua Hu Li Za Zhi. 1997;32:621-4.
[6] Stefanadis CI. Hellenic J Cardiol. 2007;48:317-8.
[7] Madrigano J, et al. Epidemiology. 2013;24:439-46.
[8] Spencer FA, et ai. J Amer Coll Cardiol. 1998;31:1226-33.
[9] Loughnan ME, et al. Int J Health Geogr. 2008;7[10] Kinoshita N, et al. Circ J. 2005;69:1170-5.
[11] Kunes, et al. Am J Hypertens. 1991;4:422-6.
[12] Woodhouse PR, et al. J Hypertens. 1993;11:1267-74.
[13] Eldwood PC, et al. Br Heart J. 1993;70:520-3.
[14] Kinjo K, et al. Heart. 2003;89:398-403.
[15] Abrignani MG, et al. Int J Cardiol. 2009;137:123-9.
[16] Cheng TO. Clin Cardiol. 1985;8:510.
[17] Dobson AR. BMJ. 2004;329:760.
[18] Hirasawa K, et al. J Cardiol. 1990;20:797-805.
Author address

E-Mail: fujii.ryosuke@j.mbox.nagoya-u.ac.jp-76-Trends of Antibiotic Resistance Rate of Helicobacter pylori Isolates
from 2009-2010, 2011-2012, and 2014-2015 in a Single Center in Korea
Ji Yeong Yang1, Byoung Rak An2, Min Park1, Hyun Jun Woo1, Min Ho Lee1, Hyun Woo Kim1, Hye Jin
Kwon1, Min Ji Yeon1, Cheol Moon3, Sa-Hyun Kim3, and Jong-Bae Kim1
1

Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju
26493, Korea
2

3

Department of Laboratory Medicine, Yong-In Severance Hospital, Yong-In 17046, Korea

Department of Biomedical Laboratory Science, Semyung University, Jaecheon 27136, Korea

Introduction
Helicobacter pylori has been well known as oneof the most important human pathogens, infecting
more than half of the mankind. As H. pylori isparasitic on human gastric mucous membrane formany years, it causes various gastrointestinal
diseases; slight asymptomatic gastritis, chronic
gastritis, peptic ulcer, mucosa associatedlymphoid tissue (MALT) lymphoma, and gastriccancer. H. pylori colonization should be
eradicated in patients with peptic ulceration
because eradication helps ulcer healing andprevents ulcer relapse. For eradication of H.
pylori infection, standard triple therapy with aproton-pumpinhibitor,
amoxicillin,
andclarithromycin remains the drugs of choice. Whentreatment failure occured, remedy is substituted
for tetracycline, metronidazole, and levofloxacin.
However, recently, antibiotic resistance is one of
the main factors affecting H. pylori eradication.
Also, it has been reported quite widely dependent
on the geographic locations. In order to examine
the changing trends of antibiotic resistance, we
compared 5 antibiotics resistance rate from 20142015 with 2009-2010 and 2011-2012 in a single
center in Korea.

2015. H. pylori strains, isolated from 61 patients
conducted gastroscopic examination to confirm theinfection of H. pylori, were evaluated.
H. pylori isolation and culture
The gastric biopsy specimens were completely
homogenized and directly inoculated onto Brucellaagar culture plates (10% bovine serum
supplemented with 10 μg/mL vancomycin, 25
μg/mL nalidixic acid, 1 μg/mL amphotericin B and
8 IU/mL polymyxin B). Plates were incubated under
microaerophilic and 100 percent humidity
conditions at 37℃ and inspected after three to fivedays. Strains were identified as H. pylori by colonymorphology analysis and urease test. The H. pylori
ATCC 43504 strain was cultured as a reference
using the same methods described above for quality
control.

Materials and Methods

Susceptibility tests
The minimal inhibitory concentrations (MICs) for
clarithromycin,
amoxicillin,
tetracycline,
metronidazole, and levofloxacin were determinedusing a slightly modified agar dilution method(Mueller-Hinton agar base containing 10% bovine
serum). Cut-off values of resistance were defined as≥ 1 μg/mL for clarithromycin, ≥ 1 μg/mL for
amoxicillin, ≥ 4 μg/mL for tetracycline, ≥ 8 μg/mL
for metronidazole, and ≥ 1 μg/mL for levofloxacin.

Patients and collection of clinical specimens
Specimen collection was conducted at Yong-In
Severance Hospital attached to Yonsei University
College of Medicine, from May 2014 to June

Statistical analysis
Data of antibiotic resistance was analyzed using theChi-square test. P<0.05 was considered statisticallysignificant.

-77-

Results

Table 3. Comparison of multi-drug resistanceover 3 time periods*

Table 1. Clinical characteristics of patients

Values are presented as number or mean±SD.
Abbreviations : PUD, peptic ulcer disease; NUD, non-ulcer
disease.

Table 2. Distribution of MICs of H. pylori
clinical isolatesAbbreviations : TET, tetracycline; MET, metronidazole;
LVX, levofloxacin; AMO, amoxicillin; CLA, clarithromycin.
Cut-off values of resistance were defined as ≥ 4 μg/mL for
TET, ≥ 8 μg/mL for MET, ≥ 1 μg/mL for LVX, ≥ 1 μg/mL
for AMO and ≥ 1 μg/mL for CLA.

*Isolates were defined as resistant to clarithromycin (CLA),
amoxicillin (AMX), metronidazole (MET), and levofloxacin(LEV), when the MICs were ≥1, ≥1, ≥8, and ≥1 μg/mL,
respectively.

Discussion
In this study, the antimicrobial susceptibility test
was conducted for H. pylori strains isolated from asingle center over 3 periods. Among the H. pylori
clinical isolates from 2009 to 2015, antibiotic
resistance of H. pylori against amoxicillin has been
increased from 2.8% to 37.7% (p<0.001). The rateof clarithromycin resistance tended to continuously
increase from 7.0% to 19.7% although there was no
statistical significance (p<0.1). The rate of
metronidazole resistance was decreased from 45.1%
to 31.1% (p<0.01) although it had been slightly
increased from 2011-2012. Multi-drug resistance for
2 or more antibiotics was more frequent in theisolates from 2014-2015 (32.7%) than in the isolates
from 2009-2010 (16.9%) and 2011-2012 (23.4%),
but there was no statistical significance (P<0.102).
Conclusions
This result suggested that periodic monitoring of
antimicrobial susceptibility is necessary forselection of an appropriate antibiotic regimen.

Figure 1. Resistance rate of antibiotics in H.
pyloriisolatedfrompatients
withgastrointestinal diseases during 2009-2010,2011-2012, and 2014-2015. Increased antibiotic
resistance was notable in amoxicillin, but
metronidazole resistance was decreased.

References
Byoungrak An, Byung Soo Moon, Heejung Kim,
Hyun Chul Lim, Yong Chan Lee, et al. Antibiotic
Resistance in Helicobacter pylori Strains and its
Effect on H. pylori Eradication Rates in a Single
Center in Korea. Ann Lab Med 2013;33:415-419.
Author address
clever1088@nate.com-78-

Human Exposure to Neonicotinoid Pesticides Has Increased During the Last Two
Decades
Arisa Aoi, 1 Jun Ueyama,1* Kouji H. Harada,2 Akio Koizumi,2 Yuka Sugiura,1Takaaki Kondo,1 Isao Saito,3 Michihiro Kamijima4
Affiliations:1
Department of Pathophysiological Laboratory Sciences, Field of Radiological and Medical Laboratory Sciences,
Nagoya University Graduate, School of Medicine, Nagoya 461-8673, Japan.
2
Department of Health and Environmental Sciences, Kyoto University Graduate School of Medicine, Yoshida, Kyoto
606-8501, Japan.
3
Food Safety and Quality Research Center, Tokai COOP Federation, Nagakute 480-1103, Japan.
4
Department of Occupational and Environmental Health, Nagoya City University Graduate School of Medical Sciences,
Nagoya 467-8601, Japan.
*Corresponding author. E-mail: ueyama@met.nagoya-u.ac.jp (J.U.)
Introduction
Pesticides have had a broad spectrum of use in agricultural
settings, and in areas such as public health, commerce, andindividual households throughout the world for pest control(1), and have been a ubiquitous component of daily life (2).
Of the pesticide classes, neonicotinoid (NEO) insecticides
are now playing a key role in controlling agricultural pests
which developed tolerance to traditional insecticide
pyrethroids and organophosphates (OPs). Seven NEOs acetamiprid (ACE), clothianidin (CLO), dinotefuran (DIN),
imidacloprid (IMI), nitenpyram (NIT), thiacloprid (THD),
and thiamethoxam (THM) – have so far been introduced tothe market and have reduced labor-intensive pesticide
spraying and risk of chemical exposure due to their low
volatility, high permeability and highly selective insecticidal
properties (3).
These advantages have resulted in apronounced increase in NEO application in the world,
especially in developed countries (4-6). In general, NEOs
are considered good candidates for replacing OPs.
Recently, some concerns about the effect of NEOs on theecosystem and mammals have been reported. The mostrepresentative ones associate NEO use with the deteriorationof bee colony growth and the decline of insectivorous birds(7, 8). In vivo studies to identify the possible hazards ofNEOs have proven that THM and CLO may induce
dopamine release in rat striatum, as detected by a brain
microdialysis study (9), and that THD increases thyroid
hormone levels in rat plasma after a high-dose administration(10). However, health risks of NEO exposure in daily life
have rarely been investigated in human studies except forcase reports focused on suicide attempts or occupationalsettings (11, 12). First of all, epidemiological evidence
available about the level of environmental NEO exposure
encountered by the human body in daily life is scarce,
although it is absolutely required for making a risk
assessment of NEO.
Here we show that the NEO exposure level in the humanbody rose steadily in Japan from the mid-1990s when
farmers started to use it in their fields.

Graduate School of Medicine and Nagoya City University
Graduate School of Medical Sciences approved the study
protocol.
Urinary NEOs and DAPs analyses. The concentrations ofNEOs and DAPs in urine were measured according to themethods reported previously (14, 15). Two ‘‘quality control’’urine samples were used in the urinary NEO and DAP assay.
Urine samples were collected from three healthy volunteers who
had neither received medication nor had been occupationally
exposed to OP or NEO beforehand, and pooled for quality
control urine; then, a standard NEO and DAP solution dissolvedin acetonitrile was added. NEOs in urine are stable at -80ºC atleast 1 year.
Determination of creatinine in urine. Urinary creatinine
concentrations were measured by high-performance liquid
chromatography equipped with a UV detector according to areference method established by the Japanese Committee forClinical Laboratory Standards (16). Ten microliters of urine
samples was diluted with 990 L H2O in a HPLC vial, andstandard creatinine solutions were prepared at 2, 4, 6 mg/dL
with H2O in HPLC vials. Analysis was performed using the
LaChrom Elute System from Hitachi (Tokyo, Japan). The
apparatus used for HPLC consisted of the following: pump, L2130; auto sampler, L-2200; column oven, L-2300, diode array
detector, L-2455. The HPLC operating conditions were as
follows: HPLC column, CAPCELL PAK SCX (Shiseido,
Tokyo, Japan), 35 mm × 4.6 mm i.d., 5 m; mobile phase, 10mmol/L phosphate buffer (pH 5.75) containing 100 mmol/L
sodium sulfate; flow rate, 0.7 mL/min; oven temperature, 40°
C; photo diode array, 234 nm; injection volume, 10 L. Withinand between-day precisions were 0.24% and 1.27%,
respectively.
Data analysis. All statistical analyses were conducted using
the JMP Pro Statistical Software, Version 11 (SAS Institute Inc.,
Cary, NC), and 2-sided P values of <0.05 were considered
statistically significant.
Undetectable urinary DAP
concentrations were estimated as the value of the LOD divided
by the square root of 2 (17), when geometric means (GM) were
calculated.

Methods
Study subjects. All participants who attended healthcare
checkup programs conducted in 1994, 2000, 2003, 2009 and2011 were asked to donate a spot urine specimen to be stored
at -80°C until analysis in the Kyoto University Human
Specimen Bank (13). Random sampling from the stored
specimen taken from female residents aged over 45 in Kyoto
and the surrounding areas was conducted using statistic
software JMP Pro 11. The Ethics Committees of the Nagoya
University Graduate School of Medicine, Kyoto University

Results
Indisputably, the detection rates of NEOs generally increased
over the period while each NEO was not detected before it cameinto the market. Of the 7 NEOs, higher detection rates were
found for THM and DIN in 2011, while the rates of CLO andNIT were relatively low compared to the other NEOs. The ratesof THM and DIN were positively correlated to the sampling
years. Along with the increase in the rates, individual total
concentrations of urinary NEOs (Σ NEO, nmol/g creatinine)
also clearly increased, suggesting that the levels of NEO-79-

exposure in the Japanese increased over the period as well.
Moreover, significantly positive correlations between theamount of domestic shipments of DIN and THM in Japanand detection rates of urinary DIN and THM were found. By
contrast, there was an inverse relationship between thegeometric mean of urinary dimethylphosphate (DMP)
concentration and the sampling years.
However,
concentrations of other minor OP
metabolites:
diethylphosphate (DEP), dimethylthiophosphate (DMTP) anddiethylthiophosphate (DETP), remained stable during theperiod.
Discussion
We recently reported that NEO could be detected in urineof Japanese adults, suggesting that they are likely exposed toseveral NEOs in their daily lives (14, 15). This finding is not
surprising because NEOs are widely used today. However,
the time when NEO started to be detected in human urine andhow much people were exposed to it in their daily lives haveremained unclear. The shipment of NEO ingredients has
progressively increased over the past 20 years, except for thatof IMI, ACE and NIT (4). In contrast, roughly 6 thousand
tonnes of OP used in Japan have been consistently reduced toaround 2 thousand tonnes for ten years since 2000. Thus, thetrends of urinary NEO and OP metabolite levels during about
15 years starting from 1994 in Japan could reflect theamounts released into the environment in Japan.
Unfortunately, well-designed surveys for detecting changeover time of NEOs in the environment are limited. Thus, it isdifficult to discuss the relationship between environmental
NEO contamination, such as pesticide residue in water andfood, and human exposure to NEO from a historical angle.
However, a survey performed by the Japanese Ministry ofAgriculture, Forestry and Fisheries showed that DIN was themost frequently-detected NEO in fruits and vegetables in2011 (18). Yamamoto and colleagues (6) have reported thatthe highest geometric mean was found in DIN in watercollected from rivers in Osaka City, which is southwest of
Kyoto. Given that the median concentration level anddetection rates of DIN in human urine in 2011 were higher
than those of other NEOs, it might be concluded that human
exposure levels to NEOs reflect their environmental
contamination levels, even though the main exposure
pathway into the human body is still unclear.
Conclusions
Our results show that detection rates of urinary NEOs in
Japanese women increased significantly between 1994 and2011, suggesting that intakes of NEOs into the human bodyrose during that period. In contrast, exposure to OP
pesticides decreased steadily according to a finding thatgeometric
meansofurinary
dimethylphosphate
These
concentrations kept diminishing considerably.
changes may well reflect amounts of NEOs and OPs released
into the environment in Japan.
References[1] P. G. Bardin, S. F. van Eeden, J. A. Moolman, A. P.
Foden, J. R. Joubert, Organophosphate and carbamate
poisoning. Arch. Intern. Med. 154, 1433-1441 (1994).
[2]M. C. Alavanja, J. A. Hoppin, F. Kamel, Health effects ofchronic pesticide exposure: cancer and neurotoxicity.
Annu. Rev. Public Health 25, 155-197 (2004).
[3] P. Jeschke, R. Nauen, M. Schindler, A. Elbert, Overview
of the status and global strategy for neonicotinoids. J.
Agric. Food Chem. 59, 2897-2908 (2011).
[4]National Institute for Environmental Studies, WebKis-

Plus database, http://w-chemdb.nies.go.jp (2014).
[5]M. L. Hladik, D. W. Kolpin, K. M. Kuivila, Widespreadoccurrence of neonicotinoid insecticides in streams in a highcorn and soybean producing region, USA. Environ. Pollut.
193, 189-196 (2014).
[6]A. Yamamoto, T. Terao, H. Hisatomi, H. Kawasaki, R.
Arakawa, Evaluation of river pollution of neonicotinoids inOsaka City (Japan) by LC/MS with dopant-assisted
photoionization. J. Environ. Monit. 14, 2189-2194 (2012).
[7]P. R. Whitehorn, S. O'Connor, F. L. Wackers, D. Goulson,
Neonicotinoid pesticide reduces bumble bee colony growthand queen production. Science 336, 351-352 (2012).
[8]C. A. Hallmann, R. P. Foppen, C. A. van Turnhout, H. deKroon, E. Jongejans, Declines in insectivorous birds areassociated with high neonicotinoid concentrations. Nature
511, 341-343 (2014).
[9]I. M. de Oliveira, B. V. Nunes, D. R. Barbosa, A. M. Pallares,
L. R. Faro, Effects of the neonicotinoids thiametoxam andclothianidin on in vivo dopamine release in rat striatum.
Toxicol. Lett. 192, 294-297 (2010).
[10]V. Sekeroglu, Z. A. Sekeroglu, E. Demirhan, Effects ofcommercial formulations of deltamethrin and/or thiacloprid
on thyroid hormone levels in rat serum. Toxicol. Ind. Health30, 40-46 (2014).
[11]P. C. Lin, H. J. Lin, Y. Y. Liao, H. R. Guo, K. T. Chen,
Acute poisoning with neonicotinoid insecticides: a casereport and literature review. Basic Clin. Pharmacol. Toxicol.
112, 282-286 (2013).
[12]M. Forrester, Neonicotinoid insecticide exposures reported
to six poison centers in Texas. Hum. Exp. Toxicol. 33, 568573 (2014).
[13]A. Koizumi, K. H. Harada, K. Inoue, T. Hitomi, H. R. Yang,
C. S. Moon, P. Wang, N. N. Hung, T. Watanabe, S. Shimbo,
M. Ikeda. Past, present, and future of environmental
specimen banks. Environ. Health Prev. Med. 14, 307-318(2009).
[14]J. Ueyama, I. Saito, A. Takaishi, H. Nomura, M. Inoue, A.
Osaka, Y. Sugiura, Y. Hayashi, S. Wakusawa, H. Ogi, K.
Inuzuka, M. Kamijima, T. Kondo, A revised method for
determination of dialkylphosphate levels in human urine bysolid-phase extraction and liquid chromatography withtandem mass spectrometry: application to human urine
samples from Japanese children. Environ. Health Prev. Med.
19, 405-413 (2014).
[15]J. Ueyama, H. Nomur, T. Kond, I. Saito, Y. Ito, A. Osaka,
M. Kamijima. Biological monitoring method for urinary
neonicotinoid insecticides using LC-MS/MS and its
application to Japanese adults. J. Occup. Health 56, 461-468(2014).
[16]Japan Society of Clinical Chemistry, Committee on
Biochemical Constituents and Their Analytical Reagents.,
2012. Recommended Method for Determination ofCreatinine in Serum by HPLC. Recommendation method
Omnibus 2012 edition Clinical Chemistry 383-392.
[17]R. W. Hornung, L. D. Reed, Estimation of average
concentration in the presence of nondetectable values. Appl.
Occup. Environ. Hyg. 5, 46-51 (1990).
[18]Ministry of Agriculture, Forestry and Fisheries of Japan,
MonitoringofPesticide
Residue,
http://www.maff.go.jp/j/nouyaku/pdf/23betu3.pdf(inJapanese) (2011).
Author address

E-Mail: aoi.arisa@j.mbox.nagoya-u.ac.jp-80-Use of hTERT and HPV E6/E7 mRNA RT-qPCR TaqMan Assays
in Combination for Diagnosing High-Grade Cervical Lesions and Malignant Tumors
Sunyoung Park1, Hye-young Wang2, Sunghyun Kim3, Dongsup Lee5 ,Geehyuk Kim1, Yeun Kim1, Kwang Hwa
Park4*, Hyeyoung Lee1*
1

Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Wonju, Republic of
Korea
2
M&D, Inc., Wonju Eco Environmental Technology Center, Wonju, Gangwon, Republic of Korea
3
Clinical lab Science, Catholic University of Pusan,Pusan, Republic of Korea
4
Department of Pathology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
5
Department of Clinical Laboratory Science, Hyejeon College, Hongseoung, Republic of Korea

Introduction
Human Papillomavirus (HPV) is a majorcausative factor of cervical cancer, the third of themost common cancer in women. About 16 HPVs
(HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59,
66, 68 and 69) are known to be main causes of cervicalcancer, so for clinical settings in Korea, DNA chips for
HPV genotyping are being used. However, eventhough the HPV DNA genotyping has 20%-50%
higher sensitivity than Pap cytological diagnosis for
cervical cancer, the specificity is 50% - 85% in thecells with normal cytology results, indicating limited
usefulness of viral DNA marker. Therefore, inprevious study we developed RT-qPCR E6/E7 of highrisk HPV subtypes. Nevertheless, the positivity rate forthe assay to diagnose high grade cervical lesions was
91%, implying the need for additional biomarker.
Since E6 of HPV activates telomerase which induces
immortalization and progression of cervicalcarcinogenesis, we developed an RT-qPCR targeting
human telomerase reverse transcriptase (hTERT)mRNA, and evaluated the performance of the assay
using with 545 ThinPrep® Pap samples. Subsequently,
the combination of RT-qPCRs targeting hTERTmRNA and high risk group HPV E6/E7 were applied
to the same 545 clinical samples, and the usefulness of
combinational assay for diagnosis of high grade
cervical lesion was evaluated.

mRNA RT-qPCR was Ct 40. hTERT mRNA expression
levels relative to reference gene GAPDH wereautomatically calculated using the comparative Ct
method by CFX Manager Software v1.6 (Bio-rad). Cutoff value for distinguishing between positive and negative
results was the relative hTERT mRNA expression level
10. hTERT mRNA expression levels relative to reference
gene GAPDH were automatically calculated using thecomparative Ct method by CFX Manager Software v1.6
(Bio-rad). Cut-off value for distinguishing between
positive and negative results was the relative hTERTmRNA expression level 10.

Materials and Methods

Table 1. Comparison of HPV E6/E7 and hTERT m RNA
RT-qPCR in cytological diagnosis

Clinical sample: A total of 545 Liquid-based
cytology samples were collected with ThinPrep PAP
test (Hologic, MA, USA) (January 2010 and December
2011 from Yonsei University Wonju Severance
Christian Hospital).
Total RNA isolation and cDNA synthesis: Total
cellular RNA was isolated with the Isol-RNA Lysis
Reagent (5 Prime, TEX, USA) according to the
manufacturers’ instructions. Complementary DNA(cDNA) was synthesized by M-MLV Reverse
Transcriptase kit (Invitrogen, CA, USA) and random
hexamers (Invitrogen, CA, USA) according with
manufacturer’s recommendations.
HPV E6/E7 and hTERT mRNA RT-qPCR assay:
HPV E6/E7 mRNA RT-qPCR assay are able to detect
16 high risk HPV groups (HPV 16, 18, 31, 33, 35, 39,
45, 51, 52, 53, 56, 58, 59, 66, 68 and 69), withmultiplex RT-qPCR. Cut off value of HPV E6/E7

Results
The positivity for the HPV E6/E7 messenger RNA(mRNA) assay was 94.4%, 95.2%, 82.4%, 46.5%, 25.0%,
and 1.1% in squamous cell carcinomas (SCC), high-grade
squamous intraepithelial lesions (HSILs), atypicalsquamous cells— cannot exclude HSIL (ASC-H), lowgrade squamous intraepithelial lesions (LSIL), atypicalsquamous cells of undetermined significance (ASC-US),and normal cytology samples, respectively. Five cervicalintraepithelial neoplasia grade 2+ samples were notdetected by the HPV E6/E7 mRNA assay, but they
exhibited positive signals in the hTERT mRNA assay(Table 1). Notably, the hTERT mRNA expression level
was increased in high-grade cervical lesions but was very
low in all 288 normal samples.

hTERT positive cases

hTERT negative cases

Cytology

HPV E6/E7
positivecases (%)

HPV E6/E7
negativecases (%)

HPV E6/E7
positivecases (%)

HPV E6/E7
negativecases (%)

SCC

15/18
(83.3)
20/21(95.2)
14/17(82.4)
17/101(16.8)
9/100
(9)
0/90
(0)
0/198
(0)

1/18*
(5.6)
1/21*
(4.8)
3/17
(17.6)
21/101(20.8)
31/100
(31)
0/90
(0)
0/198
(0)

2/18
(11.1)
0/21
(0)
0/17
(0)
30/101(29.7)
16/100
(16)
3/90
(3.3)
0/198
(0)

0/18
(0)
0/21
(0)
0/17
(0)
33/101(32.7)
44/100(44)
87/90(96.7)
198/198
(100)

HSIL
ASC-H
LSIL
ASC-US
Normal
(HR-HPV+)
Normal
(HR-HPV-)

Abbreviations; SCC: squamous cell carcinoma, ADC: adenocarcinoma, HSIL:
high grade squamous intraepithelial lesion, ASC-H: atypical squamous cellscannot exclude HSIL, LSIL: low grade squamous intraepithelial lesion, ASC-US:-81-

atypical squamous cells of undetermined significance. HR DNA+: high risk
DNA genotypes positive, HR DNA- : high risk DNA genotype negative

Conclusions
The sensitivity and specificity of HPV E6/E7mRNA RT-qPCR were 91% and 96.7% when wecompared with the cytological diagnoses. HPV E6/E7mRNA RT-qPCR assay had advantage that all of 16
high risk HPVs, which are associated to cervicalcancer. Combined application of HPV E6/E7 andhTERT mRNA RT-qPCR assay showed 100%
sensitivity. Among 56 high grade cervical lesions,which include SCC, HSIL, and ASC-H samples, 49(87.5%) were HPV E6/E7 and hTERT mRNA positive,
2 (3.6%) were HPV E6/E7 mRNA positive only, and 5(8.9%) were hTERT mRNA positive only.
These data suggest that the combination of HPV
E6/E7 and hTERT mRNA expression levels could be
used in a complementary manner in diagnosing highgrade cervical lesions and malignant tumors and might
be useful as a predictive marker in monitoring lowgrade cervical lesions.
References[1]Wang, H.Y., Park, S., Kim, S., Lee, D., Kim, G.,
Kim, Y., Park, K.H., Lee, H., 2015. Use of hTERT
and HPV E6/E7 mRNA RT-qPCR TaqMan assays
in combination for diagnosing highgrade cervicallesions and malignant tumors. Am. J. Clin. Pathol.
143 (3), 344–351 (Mar).
[2] Munkhdelger, J., Kim, G.,Wang, H.Y., Lee, D., Kim,
S., Choi, Y., Choi, E., Park, S., Jin, H., Park,K.H.,
Lee, H., 2014b. Performance of HPV E6/E7mRNA RT-qPCR for screening and diagnosis of
cervical cancer with ThinPrep Pap test samples.
Exp. Mol. Pathol. 97 (2), 279– 284 (Oct).
Author address
E-Mail: angelsy88@gmail.com-82-

Abstracts

Radiological Technology-83-

2015 Yonsei-Nagoya University Joint Symposium onRadiological Technology

11:00~12:20

Session I

11:00~11:20

Monte Carlo Modeling of The LEKCELL GAMMA Knife PERFECTIONTM

Chair: Prof. Akiko Ihori

for Small Field Dose Validation using Geant4
Hyun Joon Choi (Yonsei Univ.)
11:20~11:40

A Study on the Analysis of Cortical Thickness in Adolescents with
Internet Addiction
A Reum Min (Yonsei Univ.)

11:40~12:00

Differences of Structural Brain Network Properties Between Patientswith Obstructive Sleep Apnea and Healthy Subject
Min-Hee Lee (Yonsei Univ.)

12:00~12:20

Development of Radiation Portal System based on Energy Weighted
Algoritm
Hyun Cheol Lee (Yonsei Univ.)

12:20~14:00

Lunch

14:00~15:20

Session II

14:00~14:20

Characteristics of Liquid Crystal Display

Chair: Prof. Kuniharu Imai

Akiko Ihori (Nagoya Univ.)
14:20~14:40

Study of Physical Image Properties on a Direct-type CMOS Imager
with Conventional Mammography Devices
Chizuru Okamoto (Nagoya Univ.)

14:40~15:00

Verification of Multi-point Source Method to Assess Annual Effective
Dose by Usage of NORM Added Consumer Products
Do Hyeon Yoo (Yonsei Univ.)

15:00~15:20

Development of a Patient Dose Calculation Algorithm Using TOPAS
Monte Carlo Toolkit for Passive Scattering Proton Therapy
Wook-Geun Shin (Yonsei Univ.)

15:20~15:40

20 Minute Coffee Break

15:40~17:00

Session III

15:40~16:00

Adaptation of Effective Atomic Number for Proton Therapy

Chair: Prof. Chul Hee Min

Ryota Shimokomaki (Nagoya Univ.)
16:00~16:20

Appearance of Stochastic Resonance on Computed Tomography andits Application
Yuki Yamamoto (Nagoya Univ.)

16:20~16:40

Gate Monte Carlo Simulation Study on 6 MV Photon BeamCharacteristics for Dual Head LINAC Modeling
Han Kyeol Song (Yonsei Univ.)

16:40~17:00

Feasibility Study for Spectral Unfolding of Clinical Megavoltage Phton
Beams with Transmission Method
Hyo Jun Park (Yonsei Univ.)※ 15 minutes presentation and 5 minutes Q&A

Monte Carlo Modeling of the Leksell GammaKnife PerfexionTM for Small Field Dose
Validation using Geant4
Hyun Joon Choi1), Wook-Geun Shin1), Do Hyeon Yoo1), Jason W. Sohn2), Chul Hee Min1)
1) Department of Radiation Convergence Engineering, Yonsei University, Wonju, Korea
1) Department of Radiation Oncology, Case Western Reserve University, Cleveland, USA

Introduction
Radiation therapy using small-filed photon-beam such asstereotactic radiosurgery have the advantage of impartingradiological damage to the target while minimizing dose toadjacent healthy tissue. The Leksell Gamma Knife
PerfexionTM (LGK-PFX) is a stereotactic radiosurgery device
that is used for the treatment of tumors or malfunctioning
nerves or blood vessel defects, especially small targets in thebrain. However small photon beams have increased theuncertainties in clinical dosimetry because of steep dose
gradients and very small dose distribution leading to the lossof lateral electronic equilibrium and the various perturbations
in detector. Monte Carlo (MC) method is a promisingalternative option for small field dosimetry because it allows
a detector size of zero, eliminating spatial effects, and it ispossible to eliminate the perturbing effects of dose
measurement. The aim of this study is to develop the LGKPFX radiosurgery system using Monte Carlo method toaccurately assess the dose distribution in the small field..
Materials and Methods
The Elekta LGK-PFX radiosurgery system was modeledin Geant4 toolkit by simulating the collimation system and
192 Cobalt-60 sources.

elements of this geometry and used a boolean volume(G4SubtractionSolid) to put the pipes in a complex shape of thewhole collimation system. The spherical polystylene water
phantom with a diameter of 16 cm used for LGK-PFX
dosimetry. For the measurement of dose distribution, tworadiochromic films were used and two planes (coronal, sagittal)of dose distribution in the water phantom were measured.
In this study, we used the Geant4 toolkit (ver. 4.10.00.p02)
developed with the C++ programming language with objectoriented techniques. Geant4 have great advantage of adding ourown descriptions of processes freely. Therefore LGK-PFX
radiosurgery system was designed calculating dose distribution
by one sector changing each sector settings eight times
automatically according to the initial settings. Because thephotons emitted isotropically from cobalt sources reach thenarrow holes in collimator with only a negligible fraction ofthem, we employed some direction biasing as a variancereduction technique. For the time-effiective simulation, photons
are targeted into a 5 degree cone shape. The phase-space file
was recorded on the spherical plane of 0.1 mm thickness ininner cavity of LGK-PFX system. Total 4.8x109 primarygammas were used for calculation of each dose distribution in 4,
8, 16 mm settings and it took almost 300 CPU-hours for thesimulation of each collimator. For three-dimensional dose
distribution, 4.5 cm x 4.5 cm x 4.5 cm box with 100 x 100 x 100
grid was placed at the center of the phantom and scoring meshwhich is the standard command-based scoring of Geant4 wasused.
Results and Discussion

Figure 1. The LGK-PFX radiation unit (left) and modeled
Gamma Knife in Geant4 (right).
The Elekta LGK-PFX contains 192 Cobalt-60 sources
distributed in eight sectors. Each sector composed of 24
sources can be moved independently and each source placed
over narrow collimator of three different sizes (e.g. 4mm,
8mm, 16mm). The holes and sources are targeted at one
point, the isocentre, forming a ellipsoidal dose distribution
with a narrow penumbra. All sources are modeled as acylinder 17 mm long, 1mm in diameter and 1.17, 1.33 MeV
radiation emitted in the uniform cylindrical distribution
randomly. We assumed that each cobalt pellets are of thesame dimensions and activity. The axis of source is perfectlyaligned only with 4 mm hole collimation; sources slightly
rotate and shift from the axis of 8, 16 mm hole collimation.
The collimators are composed of multiple sections withcylindrical shape. We modeled 72 pipes composed of 5different cylinder with holes of different size to describe

Figure 2. Three radiochromic film images used in measurement(top row) and calculated dose distribution planes from eachcollimator (bottom row).
The calculated three-dimensional dose distributions in 4.5
cm x 4.5 cm x 4.5 cm scoring box show that collimation system
is at least roughly aimed properly. We obtained relative dose
profiles along x, y, z axis for all collimator size and those arecompared to measurement data. Usually LGK-PFX dosimetry
uses the film because it is well-suited for dosimetry of the 4 mm
collimator if it is positioned properly. For the appropriate dose-86-evaluation, the resolution of the scanner should be good todescribe sharp gradient of profile. The resolution of the film
scanner was 0.0847 mm . Three radiochromic films show themeasured dose distribution. The films are punched at thecenter for accurate positioning and the sharp peaks of therelative dose profiles are caused by the hole at the center ofthe film. For the comparison between calculate and measured
dose profile, calculated profile was normalized to the averagevalue in the plateau region of the measured relative dose
profile except sharp peaks. The full widths at half maximum(FWHM) of each profiles were evaluated by the reference
values provided by Elekta. The reference FWHMs for 4, 8
and 16 mm collimators are 6, 10.8 and 21.3 mm, respectively.
FWHMs of calculated and measured dose profiles agreeded
well within 0.7 mm in all cases.
According to the different combination of beam size, thedose distribution calculated by in-house developed Gamma
Knife radiosurgery system in Geant4 was compared to that
calculated by commercial TPS. As a result of comparison, we
found that overall tendency of dose distribution was almost
same.

simulation for the Leksell Gamma Knife Perfexion
radiosurgery system: homogeneous media." Physica
Medica 29.6 (2013): 656-661.
[3]Benmakhlouf, Hamza, et al. "Monte Carlo calculated andexperimentally determined output correction factors forsmall field detectors in Leksell Gamma Knife Perfexion
beams." Physics in medicine and biology 60.10 (2015): 3959.
[4]Mancosu, Pietro, et al. "Evaluation of a synthetic singlecrystal diamond detector for relative dosimetry on theLeksell
Gamma
Knife
Perfexion
radiosurgery
system." Medical physics 42.9 (2015): 5035-5041.
[5] Ma, Lijun, et al. "Clinical Realization of Sector Beam
Intensity Modulation for Gamma Knife Radiosurgery: A
Pilot Treatment Planning Study." International Journal of
Radiation Oncology* Biology* Physics 91.3 (2015): 661668.
Author address
E-Mail: chmin@yonsei .ac.kr

Figure 3. Relative dose profile comparisons between
measurement and calculation in Geant4 for each collimatoralong the x, y axes.
Conclusions
The Elekta LGK-PFX was modeled and radiosurgery
system was developed using Geant4. As a result of
evaluation of MC calculated dose and measured dose,
FWHMs of dose profiles agreed well with reference value
within 0.42, 0.7 mm, respectively. Therefore, our MC
simulation study showed potential to accurately determine
the dose distribution in Gamma Knife radiosurgery. In the
future, we will focus on absolute dose in small field and dose
distribution in diverse MR-based phantoms throughmeasurement and commercial TPS.
References[1]Best, Ryan CM. Monte Carlo modeling of the Gamma
Knife Perfexion™. Diss. Wake Forest University, 2010.
[2]Battistoni, Giuseppe, et al. "FLUKA Monte Carlo-87-

A Study on the Analysis of Cortical Thickness in Adolescents with Internet Addiction
A Reum Min1), Min Hee Lee1), Yoon Ho Hwang1), Dong Youn Kim1), Bong Soo Han2) and Hyung Suk Seo3)
1) Department of Biomedical Engineering, College of Health Sciences, Yonsei University, Gangwon-do, Republic of
Korea
2) Department of Radiological Science, College of Health Sciences, Yonsei University, Gangwon-do, Republic of
Korea
3) Department of Radiology, Korea University Ansan Hospital, Ansan, Republic of Korea

Introduction
Adolescence is very important period. That isencompassed by alterations in psychological and social
development [1]. The relatively immature cognitive control
ability makes this period a time of vulnerability andadjustment and may lead to a higher incidence of affective
disorders and addiction among adolescents[2,3]. As on of thecommon mental health issue is internet addiction (IA). IA
called pathological or problematic internet use. Thisphenomenon may eventually result in marked distress andfunctional impairments of general life such as social
interaction, academic performance and behavior problems[4].
Unfortunatly, there is currently no standardized diagnosis
and treatment for IA due to the lack of a clear understandingof the mechnism underlying this disease[5]. To date, few
neuroimaging studies had been founded brain structural andfunctional alteration associated with IA[6]. Therefore, we
compared differences in IA group and healthy control groupby measuring the cortical thickness.

between IA and control group. For the statistical analysis, weused one-way ANOVA.
Results
The results presented more reduction cortical thickness ofboth hemipsheres in patient with IA group than healthy control
group. In both hemispheres, significant cortical thickening was
found lateral orbito frontal, rostral middle frontal, superior
frontal, precuneus, lingual, and superior parietal regions. In left
hemisphere, significant cortical thickening was found inferiorparietal, precuneus, superior temporal and cuneus regions. In
right hemisphere, significant cortical thickening was foundprecentral, superior parietal, insula, caudal anterior cingulate
and entorhinal regions (Figure.1 and Table.1).

Materials and Methods
Subjects: We compared 15 subjects (7 female) with IA
and 15 healthy control subjects (7 female). Age range of all
subjects is 11-18 years old. Each subject was matched for age
and handedness. In this study, we employed Internet
Addiction Test to classify the subjects into IA or control
group.
Data acquisition: Magnetic resonance imaging was
performed on a 3 Tesla scanner (Simens, Erlangen,Germany). T1-weighted images were obtained by amagnetization prepared rapid acquisition gradient echo
(MPRAGE) sequence for cortical thickness measurementswith the following parameters: TR =2000 ms, TE = 3.55, flip
angle = 8°, slice thickness = 1mm, acquisition matrix =256 x 256.
Image processing: The Freesurfer 5.3.0 package wasused to make a cortical surface of 3D model for measuringcortical thickness. This package that provides a semiautomated method to investigate brain morphometry. The
surface based stream involves (1) nomalization of brain
signal intensity, (2) skull-stripping, (3) delineation of thegray-white interface (inner surface) and (4) tracing of thepial(outer surface)[7,8]. The distance between equivalentvertices in these two surfaces represents the cortical
thickness. We investigated differences in cortical thickness

Figure 1. Significant differences between patient with IA
and healthy control group (p<0.05)
Discussion
Our results showed reduced cortical thickness in the bothhemispheres orbito frontal cortex (OFC). The OFC is related indecision making and reward function[9]. This result
demonstrated that the abnormal structure of the OFC wasassociated with impaired executive function among adolescentswith internet addiction[4]. Also, IA decreased visualcortex(lingual and cuneus regions) and motor cortex(superior
frontal and precentral regions). This result may be associated-88-with the excessive exposure to excessive visual stimulation
and repetitive mouse click during the internet online gameplay[10].
Conclusions
In this study, we found differences between patientwith IA group and healthy control group in OFC,
motor and visual cortex of the reduced cortical
thickness. Our findings suggested that the cortical
thickness abnormalities of these regions may beaffected in the compulsive internet use.
References[1] B. J. Casey, R. M. Jones and T. A. Hare, “The adolescent
brain,” Annals of the New York Academy of
Sciences., 1124(1), 111-126 (2008)[2] L. Steinberg, “Cognitive and affective development inadolescence,” Trends in cognitive sciences, 9(2), 69-74(2005)[3] D. S. Pine, P. Cohen and J. S. Brook, “Emotional
reactivity and risk for psychopathology among
adolescents,” CNS spectrums, 6(01), 27-35 (2001)[4] K. Yuan, W. Qin, G. Wang, F. Zeng, L. Zhao, X. Yang, ...
and J. Tian, “Microstructure abnormalities in adolescentswith internet addiction disorder,” PloS one,. 6(6), e20708,(2011)[5] C. Flisher, “Getting plugged in: an overview of internet
addiction,” Journal of paediatrics and child health, 46(10),557-559 (2010)[6] Y. Zhou, F. C. Lin, Y. S. Du, Z. M. Zhao, J. R. Xu and H.
Lei, “Gray matter abnormalities in Internet addiction: avoxel-based morphometry study,” European journal ofradiology, 79(1), 92-95 (2011)[7] A. M. Dale, B. Fischl and M. I. Sereno, “Cortical surfacebased
analysis:I.
Segmentation
andsurfacereconstruction,” Neuroimage, 9(2), 179-194 (1999)[8] B. Fischl, M. I. Sereno,and A. M. Dale, “Cortical surfacebased analysis: II: inflation, flattening, and a surface-based
coordinate system,” Neuroimage, 9(2), 195-207. (1999)[9] G. Schoenbaum, M. R. Roesch and T. A. Stalnaker,“Orbitofrontal
cortex,decision-making
anddrug
addiction,” Trends in neurosciences, 29(2), 116-124 (2006)[10] D. H. Han, I. K. Lyoo and P. F. Renshaw, “Differential
regional gray matter volumes in patients with on-line gameaddiction and professional gamers,” Journal of psychiatricresearch, 46(4), 507-515 (2012)
Author address

E-Mail: naniyaah@gmail.com-89-Differences of Structural Brain Network Properties Between Patients with Obstructive
Sleep Apena and Healthy Subjects
Min-Hee Lee1), Chang-Ho Yun2), Yoon Ho Hwang1), Areum Min1), Seung Ku Lee3), Dong Youn Kim1), Bong Soo Han4)
and Chol Shin3)1) Department of Biomedical Engineering, Yonsei University, Wonju, Korea
2) Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
3) Institute of Human Genomic Study, College of Medicine, Korea University Ansan Hospital, Ansan, Korea
4) Department of Radiological Science, Yonsei University, Wonju, Korea

Introduction
Obstructive sleep apnea (OSA) is a common clinicalsleep disorder. Patients with OSA are characterized byexposing intermittent hypoxia which causes injuries in someregions of the brain tissues and show the deficits ofautonomic, cognitive and mood functions [1]. It is
understood that the structural connectivity of the brain
underlies the brain functions may be affected from theregional abnormalities of the brain [2]. Injuries of brain
tissue are not clearly identified by T1-, T2-weighted images[3].
Diffusion tensor imaging (DTI) facilitates modeling thehuman brain as a network of brain regions connected byanatomical tracts defined by tractography. Network analysis
can help to investigate assumed abnormalities of connectivity
in neurological and psychiatric disorders and allows thequantitative analysis of network organization, describing theconnections of the brain as a collection of nodes (brain
regions) that communicate by connecting edges (white matter
tracts) [4]. This analysis has been used beneficially forneurological and psychiatric disorders.
In this study, we examined the regional abnormalities inwhite matter of patienst with OSA using fractional
anisotropy (FA) and revealed the regional alterations of thebrain connectivity in patients with OSA.
Materials and Methods
Data acquisition and pre-processing: DTI data werecollected using 1.5 Tesla MRI scanner (General Electric)
with the following acquisition parameters: TR = 15000 ms,
TE = 93.8 ms, diffusion gradients along 15 non-collinear
directions with b = 1000 s/mm2 after the acquisition of b = 0
s/mm2 image. We analyzed DTI data from a total of 32
subjects, including 16 healthy subjects and 16 patients with
OSA, matched for age, sex, education, apoE genotype. Eachdiffusion image was corrected for some distortion using FSL.
We used nonlinear tensor image registration algorithms for
spatial normalization, and performed tractography using theFiber Assignment Continuous Tracking algorithm.
Network Construction: To observe the regional
characteristic, we constructed the brain network using dataset
derived from tractography. For this, we used the automatedanatomical labeling template which was parcellated into 90
regions of cerebrum, each representing a node of the brain
network [4]. Two nodes (i.e., brain regions) were connectedby an edge (i.e., tracts) if any endpoints of fiber exist in bothregions. Constructed brain network is shown in Fig. 1.

Figure 1. Visualization of structural brain network
Fractional anisotropy: The FA indicates the microstructural
integrity of the white matter. We firstly calculate the FA foreach voxel and then the FA maps were smoothed (full widthhalf maximum = 8 mm). To analyze FA in white matter, weused a white matter mask segmented from standard space andFA values greater than 0.2. We then compared FA values at
each voxel between healthy subjects and patients with OSA. In
this comparison, the statistical threshold for significance was p< 0.001 and the minimum cluster size was set at 15 contiguous
voxels.
Regional efficiency: The regional efficiency of any node idefined as inverse of the harmonic mean of the minimum path
length between an node i and all other nodes in the network.
The regional efficiency measures the average path length
between any node and the remainder nodes in the network andreflects the integration of each node. We compared regional
efficiency for each brain region to determine the abnormal
regions in subjects with OSA.
Results
Patients with OSA showed lower FA compared with healthy
subjects in some brain regions, including right inferior frontal
gyrus (Fig. 2(b)), bilateral thalamoparietal fibers passing
through parietal white matter (Fig. 2(a),(c)). On the other hands,
right capsula interna (Fig. 2(d)) are showed higher FA inpatients with OSA.
In the comparisons of regional efficiency, we found thatpatients with OSA showed significant lower regional efficiency
in right precentral gyrus, left insula, posterior cingulate, inferior
occipital gyrus, and bilateral supplement motor area, and higher
in right orbitofrontal, superior frontal gyrus, precuneus, leftthalamus and bilateral temporal gyrus than healthy subjects (p <0.05; Fig. 3).

-90-

problems due to the disturbance in the limbic system, including
cingulate gyrus and insula [3]. Insula is related to breathlessness
and plays an important role on the regulation of emotions
including anger, sadness, and fear [6].
Sleep-disordered breathing is high risk factor of
cardiovascular disease [7]. Cardiovascular regulations are
related to cingulate, prefrontal cortex [3]. Additionally, theimportant role of thalamus is regulation of the sleep-wake cycle
and alterations of these cycle may induce irregular bloodpressure rhythms or increase of the cardiovascular mobidity.
Motor cortices have functional connections with the brainstemand ventrolateral medulla which control heart, blood pressure
and breathing [8]. Moreover, the structural alterations inprecentral gyrus and supplementary motor area result inincreasing the load of upper airway and respiratory muscles,
which appears to be related to the repetitive pauses of breathing
during sleep and OSA may, therefore, become more serious.

Figure 2. The comparison results of FA. Regions with
reduced FA in OSA involved bilateral thalamoparietal
fiber (a) (c), right inferior frontal lobe (b). Right capsulainterna (d) with increased FA in OSA.

Figure 3. Alteration of regional property in OSA. Bluecircles present reduced regional properties in OSA andred circles present increased regional properties in OSA.

Discussion
From VBA of FA, we found the abnormalities in rightinferior frontal gyrus and bilateral thalamoparietal fibers
pathway between parietal lobe and thalamus. Decrease of FA
means that brain tissues were injured and it is considered tobe related to alterations of pathway passing through injured
brain regions. Additionally, increment of FA was observed inright capsular interna. It is considered to be related to thehigher myelination and less branching in neural level and thefibers from thalamus to the frontal lobe pass through the rightcapsular interna.
In the network analysis for the regional property, we
found increase and decrease of regional efficiency in patientswith OSA. This result denotes that the structural brain
networks undergo rewiring during the course of the illness.
Our results provided the evidence for the altered structuralconnection of the brain which may affect the cognitive,
emotional functions and autonomic regulations explained in
the following paragraphs.
Patients with OSA frequently show mild cognitive
impairment and high incidence of dementia [5]. The
cognitive impairment associated with OSA may result fromabnormality of brain regions in cingulate, prefrontal,
temporal [3]. Patients with OSA also showed emotional

Conclusions
We studied the regional neural damages in the OSA
patients’ brain using VBA of FA and changes of the structuralconnection using network analysis. OSA patients showed the
injuries of white matter in four regions and increase or decreaseof regional network properties in various brain areas. Since ourfindings provide the relation between the regional properties
and typical OSA symptoms, brain network analysis can be used
to disclose potential functional deficits in OSA patients.
References[1] V. Castronovo, P. Scifo, A. Castellano, M. S. Aloia, A.
Ladanza, S. Marelli, S. F. Cappa, L. F. Strambi, and A. Falini,"White Matter Integrity in Obstructive Sleep Apnea before andafter Treatment," Sleep., 37:1465-75 (2013)[2] G. Gong, Y. He, L. Concha, D. W. Gross, A. C. Evans, andC. Beaulieu, "Mapping Anatomical Connectivity Patterns of
Human Cereb Cortex Using In Vivo Diffusion Tensor Imaging
Tractography, " Cerebral cortex., 19:524-36 (2009)[3] P. M. Macey, R. Kumar, M. A. Woo, E. M. Valladares, F. L.
Yan-Go, and R. M. Harper, "Brain Structural Changes in
Obstructive Sleep Apnea," Sleep., 31:967-78 (2008).
[4] M. Rubinov, and O. Sporns, "Complex network measures ofbrain connectivity: Uses and interpretations," NeuroImage.,
52:1059-69 (2010)[5] N. Canessa, V. Castronovo, S. F. Cappa, M. S. Aloia, S.
Marelli, A. Fallni, F. Alemanno, and L. F. Strambi, "Obstructive
sleep apnea: brain structural changes and neurocognitive
function before and after treatment, " Am J Respir Crit Care
Med., 183:1419-26 (2011)[6] A. von Leupoldt, T. Sommer, S. Kegat, H. J. Baumann, H.
Klose, B. Dahme, and C. Büchel, "The Unpleasantness ofPerceived Dyspnea Is Processed in the Anterior Insula andAmygdala," Am J Respir Crit Care Med., 177:1026-32 (2008)[7] A. B. Newman, F. J. Nieto, U. Guidry, B. K. Lind, S.
Redline, E. Shahar, T. G. Rickering, and S. F. Quan, "Relationof Sleep-disordered Breathing to Cardiovascular Disease Risk
Factors: The Sleep Heart Health Study, " Am J Epidemiol.,
154:50-9 (2001)[8] O. Viltart, O. Mullier, F. Bernet, P. Poulain, M. H. S. Ba,
and H. Sequeira, "Motor Cortical Control of Cardiovascular
Bulbar Neurones Projecting to Spinal Autonomic Areas, " J
Neurosci Res., 73:122-35 (2003)
Author address
E-Mail: MinHLee@yonsei.ac.kr-91-

Development of Radiation Portal Monitoring System based on Energy
Weighted Algorithm

Lee, Hyun Cheol1)1)Shin, Wook-Geun1) Lee, Han Rim2) Choi, Chang Il3)
Kim, Hong Suk3) Min, Chul Hee1,*)

Park, Chang Su3)

Department of Radiation Convergence Engineering , Yonsei University, Wonju, Republic of Korea
2) Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
3)
Korea Institute of Nuclear Safety, Republic of Korea

processing and presenting energy spectrum wasdeveloped (Fig. 1).
In measurement, 133Ba, 137Cs, and 60Co (> 80μCi) were used and source to detector distancewas 100 cm with 2 minute of measurement time.

Introduction
To prevent and restrain nuclear terrorism, many
radiation portal monitoring (RPM) system have been
installed and operated on main ports of South Korea
such as port of Incheon, Busan, and Pyeong-taek [1].
In RPM system, plastic scintillation detectors areusually included, because of their easy figuration andlow cost for large detection area, but there is limit onradionuclide analysis by its poor energy resolution[2].
In previous study, energy weighting algorithm
was developed using the Monte Carlo method andsmall plastic scintillation detector to discriminate
natural isotopes and artificial isotopes [3]. In
measured energy spectrum through the plastic
scintillation detector, counts on each bin were
multiplied with its energy of bin and the method wasable to discrimination of radionuclide by changing
the Compton edge of isotope to clear peak in recalculated spectrum (energy weighted spectrum).
But small plastic scintillation detector showed
limitation of detection efficiency, so we constructed
test RPM system based on large sized plastic
scintillation detector and evaluated the energy
weighted algorithm in this study.

Fig. 1. (A): PVT plastic scintillator combined withlight guide and PMT (B): Graphic user interface.

For the energy calibration, the Monte Carlo
method and Gaussian broadening method wasapplied [4, 5].
The measured energy spectrum wasconverted to the energy weighted spectrum
through the following equation:

Material and Methods
For the verification of the energy weighted
algorithm, polyvinyl toluene (PVT) (BC-408,
Saint-Gobain Ind.), plastic scintillation detector,of 50×100×5 cm3, light guide (BC-802, SaintGobain Ind.), photo-multiplier tube (9266B, ET
enterprises Ltd.), pre-amplifier (Ortec 113,
Ametek Inc.), amplifier (Ortec 575A, AmetekInc.), and digitizer (PXI-5105, National
Instrument
Inc.)
were
connected
forconstruction of test RPM system. And using
LabVIEW (Ver. 2014, National Instrument Inc.),user interface which can realize signal

CEW,i = Ci × Ei,

where CEW,i is the energy-weighted count of the ithbin of the optical photon distribution, and the original
optical photon count and the energy in the ith bin are
Ci and Ei, respectively.

And peak location in energy weighted
spectrum was compared with theoretical
Compton edge of each radionuclide to evaluate
the energy weighted algorithm.
Results and Discussions
In this study, module test of RPM system was-92-

performed about PMT, pre-amplifier, amplifier, anddigitizer for appropriate signal processing. By
comparing with energy spectrum measured fromcommercial used multi-channel analyzer (Ortec
digiBASE, Ametek Inc.), the optimal parameter of
each module was decided as 1.0 kV of high voltage,
100 pF input capacitance of pre-amplifier, 0.5 μsec
shaping time and 160 gain of amplifier.

In this study, test RPM system consist of plastic
scintillation detector, signal processing device,
and user interface based on LabVIEW forchecking energy spectrum was constructed.
Through energy spectrum measurement of
133
Ba, 137Cs, and 60Co, the energy weighted
algorithm
showedgood
discriminating
performance of radioisotopes by comparing thepeak location error of energy weighted spectrumwith the Compton edge energy in energy
spectrum.
References[1] Kwak et al. (2009). A study on current status

of detection technology and establishment of
national
detection
regimeagainstnuclear/radiological terrorism. Journal of
Radiation Protection. 34 (3), 115-120.
[2] Burr et al. (2007). Alarm criteria in radiation
portal monitoring. Applied Radiation andisotopes. 65 (5), 569-580.
[3] Shin et al. (2015). A monte carlo study of anenergy-weighted algorithm for radionuclide
analysis with a plastic scintillation detector.
Applied Radiation and isotopes. 101, 53-59.
[4] Ashra and Gol (2011). Energy calibration of thinplastic scintillators using Compton scatteredgamma-rays. Nuclear Instruments and Methods inPhysics Research Section A: Accelerators,
Spectrometers, Detectors and AssociatedEquipmet, 642 (1), 70-74.
[5] Lee et al. (2014). Development of signal
processing modules for double-sided silicon strip
detector of gamma vertex imaging for proton
beam dose verification. Journal of Radiation
Protection. 39 (2), 81-88.
Fig. 2. (A) Measured energy spectra of 133Ba, 137Cs
and 60Co, and (B) its energy weighted spectra.

Author address

133

Ba,
Cs, and Co, and the spectra have low
statistical fluctuation because of highFigure 2-(A) is showing energy spectra of137

chmin@yonsei.ac.kr

60

radioactivity of 80 μCi and large detection area.
Also, in the energy weighted spectra converted
from energy spectra, the peak location of 133Ba,
137
Cs, and 60Co were 0.204, 0.485, 1.065 MeV,
respectively, those have error of 0.48%, 0.42%,
and 0.29% with theoretical Compton edge
location.
Conclusions-93-Characteristics of liquid crystal display
displays
ays
A. Ihori and Y. Kodera
Department of Radiological Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction
Medical image diagnostic systems are shifting fromhard copy to soft copy. Especially because of the verysmall size of detected calcifications in mammography
diagnosis, digital images require a fine pitch and a large
matrix size. Therefore, liquid crystal displays (LCDs)
with 5 million (5M) pixels are recommended for theinterpretation of a mammogram. In clinical practice,
however, it is not uncommon for radiologists to observe
mammography images using LCDs with 2 million (2M)or 3 million (3M) pixels for multi-modality
workstations.
It is important to evaluate the characteristics ofdisplays and to carry out maintenance management inmedical facilities that use LCDs. Therefore, as one
factor of the image quality of a display, a modulationtransfer function (MTF) was measured to evaluate the
sharpness of the image.
We also visually evaluated mammography images
displayed on LCDs with different numbers of pixels,
which are commonly used in hospitals. The purpose of
our study is to determine whether the detection rate ofimages using a reduced pixel size of 2M and 3M isdecreased compared to that of the recommended 5Mpixel LCD. In addition, a variety of interpolation
methods can be used to reduce image sizes but themethod currently used in the medical field is generally
the bilinear method. In this study, images were reduced
using bilinear interpolation and other methods ofinterpolation to determine a method that does not reduce
the signal detectability even for a high reduction ratio.
Ⅰ．Physical evaluation
Materials and Methods
The method used here is based on “a periodic rectangle
wave composition of a fundamental frequency andharmonics, which are sine waves” [1] as shown in Fig.
1.

The bar pattern was displayed at the center of the display,
and a photograph was taken with a digital camera equippedwith a macro lens. We took pictures of the bar pattern inhorizontal (portrait) and vertical (landscape) directions.
The data for exact integer cycles of the bar patterns wereextracted from an output waveform. The amplitude valueof a fundamental frequency of the bar pattern was
calculated and the MTF was computed. We usedmonochrome LCDs with 1M, 2M, 3M, and 5M pixels. The
displays with 2M pixels used two different systems, an inplane switching (IPS) system and a vertical alignment(VA) system [2], for which the liquid crystal operation
mode differs. The monochrome LCDs with 3M and 5M
pixels were examined with and without a protective filter.
Two or three displays are used for each system. Table 1
shows specifications of the monochrome LCDs.
Table 1 Specifications of monochrome LCDs.
LCDs

Number of pixels
of LCDs

Pixel pitch
[mm]

1M

1280×1024

2M

3M

5M

Liquid crystal
operation mode

FilterNumber

0.2805

IPS

－

2

0.255

VA

○

3

0.270

IPS

○

3

－

3

0.207

IPS

1600×1200

2048×1536

2560×2048

0.165

○

3

－

3

○

3

IPS

Results & Discussion
For the horizontal direction of the monochrome LCDs,
the MTF of the 5M-pixel display is the highest, decreasing
proportionally for the lower-resolution displays. No
difference was seen when using a protective filter. For the
monochrome LCDs, the MTF in a horizontal direction was
higher than the MTF in a vertical direction. Figure 2 showsthe enlargement of the pixel when displaying a bar with
one pixel on the monochrome 3M LCD. The yellow
squares indicates one pixel. An individual display pixel
consists of six sub-pixel regions.

Gate Line
Horizontal direction

Fig. 1. Outline of the MTF measurement method
using frequency analysis of a bar pattern image.

Fig. 2. Enlargement of the pixel when displaying a bar
with one pixel on the monochrome 3M LCD.

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For the horizontal direction, a bar with one pixel andgate line become parallel but for the vertical direction,
they become perpendicular. Therefore, the width of abar with one pixel in the horizontal direction was
effectively narrower than the width of a bar in thevertical direction.
Conclusions
We measured the MTFs of monochrome displays. The
MTFs of the LCDs were affected by the difference inpixel size and shape, the structure and operation modeof the liquid crystal, and the number of pixels.

Ⅱ．Visual evaluation
Materials and Methods
We examined the influence of differences in LCD
image-reduction rates on the signal-detection
performance by observational experiments. Since aphase contrast mammography (PCM) image has thelargest numbers of pixels among medical images, weused a PCM image as the original image in this study.
The PCM images of the tissue-equivalent phantom
model 011A, manufactured by Computerized Imaging
Reference Systems (CIRS, Norfolk, VA, USA), wererecorded using the PCM equipment at 28 kV and 50
mAs. The phantom is realistically shaped and has thetissue properties of an average, firm breast. Breast detailcomponents closely mimic the radiographic properties
and shapes of normal and pathological breast structures,as shown in Fig. 3.

Fig. 3. Certification phantom CIRS, model 011-A
used for experimental tests. We observed sevenmasses, five fibers, and six groups of six calcifications.
The phantom image was reduced using bilinear,bicubic, and nearest-neighbor interpolation methods,
pictured in Fig. 4. The image-reduction rate, shown in
Table 2, was calculated as the ratio of the number ofpixels per LCD to that of the reduced image when thephantom image was displayed on LCDs of 2M, 3M, and5M pixels. The reduced images were displayed on a 5Mpixel LCD using the ImageJ software program, and thesignal-detection performance with each interpolation
method was examined. The observers were ten
radiological technologists with two to 10 years ofexperience in the mammography field. They observed

the reduced images and reported whether any signals could
be detected. The observers followed the detailed
procedures outlined in the ACR’s Mammography Quality
Control Manual[3] to score phantom images.

Fig. 4. Interpolation functions for (a) nearest-neighbor,(b) bilinear and (c) bicubic methods.

Table 2 Image-reduction rate
LCDs

Number of pixels
of LCDs

Reduction rate

Number of pixels of
reduced images

2M

1200×1600

16.87%

1194×1599

3M

1536×2048

21.60%

1529×2047

5M

2048×2560

27.00%

1911×2559

5M(split-screen display)

1024×2560

14.46%

1023×1370

Results & Discussion
The mass detection rate was the highest for the bilinear
reduction of the 3M-pixel image. The signal disappeared
when the image was small, and the signal to noise ratio(SNR) of the signal was low when the image was large.
The detectability of calcifications decreased as the image
size reduced. The difference in reduction rate had a minor
impact on the detectability of fibers. For most sizes, thebilinear method increased the detection rate and thenearest-neighbor method had the lowest detection rate.
Conclusions
When displaying PCM images on LCDs that have a small
number of pixels, the signals of calcification disappear.
The visibility deteriorates and the display size of the mass
is too small or too large. The bilinear method could be used
to calculate the mean of neighboring pixels, thus providing
a smoothing effect. As the noise is decreased by smoothing,
the rate of detection with the bilinear method is increased.
References[1] Ichikawa K. and Fujita H., “An MTF Measurement
Method of a Medical Image Viewer Using a Bar Pattern.”
Journal of Photographic Science and Technology 67,
184-190, 2004.
[2] Mitsuhiro Koden” Wide Viewing Angle Technologies
of TFT-LDEs.” SHARP Technical Journal, 74(8), 5559, 1999.
[3] Hendrick RE, Bassett L, Botsco MA, et al.
“Mammography quality control manual.” Reston (VA):
American College of Radiology, 1999.
Author address
E-Mail: ihori@met.nagoya-u.ac.jp-95-Study of Physical Image Properties on a Direct-type CMOS Imager
with Conventional Mammography Devices
C. Okamoto and Y. Kodera
Department of Radiological Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan

Introduction
Cancer is one of the most prevalent killers ofJapanese people and is recognized as a national disease.
Breast cancer is the most common form of cancer to bediagnosed in Japanese women, and ranks fifth in thenumber of deaths caused by cancer that women sufferfrom [1]. These numbers are increasing year by year.
However, if we enable early detection and treatment,
we will be able to achieve a high cure rate. Breast
cancer examinations and screening mammography are
essential for the early detection and prevention ofbreast cancer.
Mammography is an effective technique in thedetection of small masses and calcification. Whilesome calcifications have nothing to do with cancer,
one common early sign of cancer is microcalcification
depicted lightly, and it is necessary to perform highly
accurate screenings to recognize them. Therefore, theuse of high quality detectors with high spatial
resolution is essential. A detector with an extremely
small pixel size has recently been developed and isused in clinical applications. The smallest pixel size indetectors which meet the specification standards of theJapan Radiological Society (JRS) is 50 microns [2],and is equipped in mammography devices used inclinical.
In this study, we examined the physical image
properties of a detector with a pixel size of 50 microns
developed for mammography. There are many highdefinition mammography devices equipped withdirect-type flat panel detectors (FPD). Amorphousselenium (a-Se) film is used in direct-type FPD. The aSe film is known to be inferior in its temperature
properties. However, new a-Se film was developed,
which has superior heat resistance and is fit for highelectric field driving. We considered the applicabilityof the detector using the a-Se film with complementary
metal oxide semiconductor (CMOS) integrated circuit
for clinical use. First, we calculated the detective
quantum efficiency (DQE) with changing applied
voltage to the a-Se film. Secondly, we compared thephysical image properties of this detector with those of
the conventional mammography systems.
Materials and Methods
Proposed mammography system: The direct-type
flat panel detector (FPD) developed by the Electron
Tube Division, HAMAMATSU PHOTONICS K.K
was used. The CMOS integrated circuit is used(referred to as the CMOS imager). We used the X-ray

unit (Mermaid, KONICA MINOLTA) and set the CMOS
imager on the table of X-ray unit.
For comparison: We used the conventional systems
AMULET Innovality (FUJIFILM Corporation) andMicroDose SI (Philips). The equipped detector in
AMULET is a direct-type FPD of current integrationmode, and is a silicon (Si) detector of photon counting
type in MicroDose. Tungsten (W) is used as an anodematerial in both. The filter is rhodium (Rh) plate in
AMULET and aluminum (Al) plate in Microdose. Bothpixel sizes are 50 microns.
The geometries of the CMOS imager and theconventional imager are shown in Fig. 1.
Collimation: Al plates, 1 mm thickness × 2

SID*
59 cm

CMOS
imagerSID*
65 cm

detector(a)(b)
Fig. 1 Geometries of(a) the proposed mammography system, and(b) conventional mammography for comparison.
*SID: source-image receptor distanceStudy items: 1. Physical image properties of CMOS
imager with changing applied voltage: We measured
about the difference of the applied voltage to the detector
elements (-0.5, -0.8, -1, -2, and -3 kV). To calculate the
DQE, we measured the pre-sampled modulation transfer
function (MTF), Wiener spectrum (WS) and the numberof incident photons per unit area.
(1)

It is difficult to measure directly the number ofincident photons. Therefore, we used the coefficientreferring totheInternational
ElectrotechnicalCommission (IEC) 62220-1-2 standard to calculate thiseasily. The coefficient is set in the quality of radiation,
which is decided by half value layer (HVL). We
measured HVL with the dosimeter (Radcal Corporation
Ltd. Model: 9015 Chamber: 10 × 5 - 6M).

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12 cm

12 cm

SCD**
59 cm
Chamber

Chamber

6
cm

Table

Table

Fig. 2 Geometry for the decision of radiation quality**SCD: source chamber distance
Next, we selected the RQA-M2 condition and used
4981 photons per mm2 ･μGy in this study. The selected
tube voltage was 30 kV. In this condition, we
measured the input-output characteristic curves tocalculate MTF and WS with an X-ray exposure from apixel value. These were plotted using the time scale
method. The MTF was measured using the edge
method with the tungsten edge, and the WS was
calculated using the two-dimensional Fouriertransform method referring to the IEC 62220-1
standard. Also, we calculated the DQE from themeasured MTF, the WS value, and the number ofincident photons.
2. Comparison of MTF with conventional systems:
We measured the input-output characteristic curves
and pre-sampled MTF using the same method as thatof the above CMOS study. AMULET was set to 28 kV
and Microdose was set to 32 kVResults & Discussion
1. CMOS study: The input-output characteristic
curve shows a strong linearity between the incident Xray exposure and the pixel value for each applied
voltage. However, it was found that the linearity could
not be maintained over a pixel value of 3500. The
difference in the applied voltages in both the horizontal
and vertical directions has no influence on the MTF
and WS. In the low-frequency domain of Fig. 3, theDQE value is observed to be approximately 0.6. Thisvalue indicates this system has high detection
efficiency.
0.8- 0.5 kV
- 0.8 kV
- 1.0 kV
- 2.0 kV
- 3.0 kV

DQE

0.6

0.4

0.2

0
0

2
4
6
8
Spatial frequency [cycle/mm]

10Fig. 3 DQE about the difference of applied voltage

2. Comparison of MTF with conventional systems:
The input-output characteristic curve shows strong
linearity between the exposure dose and the pixel value ineach device. The AMULET shows strong linearity to thelogarithmic exposure dose. On the other hand, theMicroDose shows strong linearity to the exposure dose.
In the MTF of the Microdose, however, there is an
important difference between the horizontal and verticaldirections, as shown in Fig. 4. We guess that this isbecause the MTF in the vertical direction depends on the
pixel pitch, while the MTF in the horizontal direction
depends on the effect of the continuous scan movement.
The MTFs of AMULET and MicroDose reported here aresimilar to the literature values [3] [4] of previous
generation models and thereby may be taken as accurate.
From the comparison, the CMOS imager shows thehighest definition of the three.
1
CMOS
horizontal and vertical directions

0.8
MicroDose vertical direction

MTF

Collimation

0.6

AMULET horizontal direction
AMULET vertical direction

0.4

MicroDosehorizontal direction

0.2
0
0

5
10
15
20
Spatial frequency [cycles/mm]

25

Fig. 4 MTF of three devices
Conclusions
The CMOS imager has very high definition and ahigh detection efficiency. Also, it seems to be
independent to the voltage applied to the a-Se film. The
physical image properties are superior to those of theconventional devices. In future, we wish to obtain andstudy breast phantom images with proper exposure doses.
References[1] Cancer Information Service, National Cancer Center,Japan[2] Japan Radiological Society (JRS) and JapaneseSociety of Radiological Technology (JSRT),
Mammography Guideline third edition expanded
version. 2014 April: p. 32[3] Rivetti S, Lanconelli N, and Bertolini M, et al.
Physical and psychophysical characterization of anovel clinical system for digital mammography,
Medical Physics, 2009 November; 36(11): pp. 51395148[4] Monnin P, Gutierrez D, and Bulling S, et al. A
comparison of the performance of digital
mammography systems Medical Physics, 2007 March;
34(3): pp. 906-914
Author address
E-Mail: okamoto.chiduru@e.mbox.nagoya-u.ac.jp-97-Verification of Multi-Point Source Method to Assess Annual Effective Dose by Usage of
NORM Added Consumer Products
Do Hyeon Yoo1), Wook Guen Shin1), Jae Kook Lee2), Yeon Soo Yeom3), Chan Hyeong Kim3) and Chul Hee Min1)
1) Department of Radiation Convergence Engineering, College of Health Sciences, Yonsei University, Gangwon-do,
Republic of Korea
2) Korea Institute of Nuclear Safety, Daejeon, Republic of Korea
3) Department of Nuclear Engineering, Hanyang University, Seoul, Republic of Korea
Introduction
Naturally Occurring Radioactive Material (NORM) arecommonly found in food, soil, rocks and minerals of theearth`s crust (such as 40K, 13C, and 238U) [1]. NORM are
responsible for the majority of an average person’s yearlyradiation dose, however the dose levels are very low andtherefore they are not usually considered of any special
health or safety significance [2]. When NORM areconcentrated
throughtechnologicalactivities
theTechnologically-Enhanced (TENORM) may be used.
Uncontrolled activities associated with TENORM cancontaminate the environment and pose a potential risk tohuman health. Typical examples are the radon concentration
inside buildings that can increase by about a hundred times
compared to the natural concentration or the level of theradium from an oil well that may lead to considerable buildup. In Korea, in order to regulate the exposure dose of thegeneral public from NORM and TERNORM, a law called‘Act on safety control of radioactive rays around living
environment’ was passed. In this work we investigated aseries of commercial products (pillows, accessory, waist
supporters, and mattresses) containing NORM that arecommonly found on the market. In most cases, the additionof NORM to commercial products results from thecontroversial theory of radiation hormesis, which predicts
that a small dose of ionizing radiation can be beneficial forhuman health. In this study we developed a more flexible
source model named “multi-point source model” in whichradioactive sources are uniformly distributed directly in thephantom skin over the areas in contact or proximal to theconsumer product. We benchmarked our new model against
the real shape modeling by comparing the exposure dose
performed due to the usage of NORM added consumer
products.

Materials and Methods
Monte Carlo (MC) simulations were performed using theGeant4 code and a computational human phantom in order toevaluate the exposure dose from the usage of NORM-added
consumer products. Specifically, we used the Polygonsurface reference Korean Man and Woman (PSRK-Man,
PSRK-Woman) phantom [3] that is composed of highresolution polygons to accurately model 27 organs as shownin figure 1. The PSRK-Man and PSRK-Woman wasdeveloped based on the reference Korean body with height
and weight of 171 cm, 68 kg, 159 cm and 54 kg,
respectively. Each polygon is defined by the three coordinateof the vertexes as shown figure 2.

Figure 1. Graphic rendering of the PSRK-Man male
phantom.

Figure 2. Enlargement of on polygon of the PSRK-Man.
In the multi-point source model particle sources were placed on
the center of each polygon on the skin-area in contact orproximal to the consumer product. In this study, for evaluate theexposure dose from the usage of NORM added consumer
products, the source consisted of 0.6 MeV gammas emitted
isotropically on each point source. The effective dose and organ
equivalent dose by each skin-point-source was compiled into
database for 0-2 MeV with 0.1 MeV interval. For the various
consumer products, the annual effective dose were assessedwith the usage scenario for each product obtained from theStatistics Korea like table 1. To validate the skin point source
method, the real shape of the product was simulated and for thesame energy gammas the effective dose was compared with thatby skin-point-source.

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Table 1. Exposure scenario.
Consumer products
Pillow
Accessory
Belt
Sleeping mattress

Usage location
Back of the head andneck
Neck and wrist
Waist and abdomen
Waist, abdomen, thighand hip

Usagetime
7 h 50 min
8 h 7 min5 h 1 min7 h 50 min

Results
Multi-point sources of the pillow products were determinednear the head and neck area consist of 233 weight center
point on the PSRK-Man as shown in Figure 3. For thecomparison purpose, the realistic pillow also modeled with arectangular parallelepiped shape of width, length, and heightof 30 cm, 50 cm, and 13 cm, respectively.

Figure 3. Multi-point source (a) and realistic shape model(b) of the pillow.
Figure 4. shows the organ equivalent dose with the initial
gammas of 107 with 0.6 MeV isotropically emitted from theboth sources. The organ equivalent dose of the modelingsource of the bone and skin distributed to the whole body
were evaluated as higher than that of the multi-point sources;that is, increasing the distance between the source andcomputational phantom increase the potential effective angle
to the organs distributed in a whole body.

Figure 5. Annual effective dose with 0.6 MeV of gammas forthe six consumer products with modeling and multi-point
sources.
Discussion
Our simulation study shows that the skin-point-source shows
similar organ dose compare to that by the realistic shape sourceof the TENORM added consumer products. For the most case,
two times higher effective dose was assessed with skin-pointsource, because the sources are closer to the organs than the
product shape source. Finally our results demonstrate thepotential that with the database obtained from skin-point-source
could be used to efficiently assess the effective dose just bydefining the product usage location in PSRK-Man, PSRKWoman and its activity without additional Monte Carlosimulation.
Conclusions
The current study showed the effectiveness of the multipoint source on the computational human phantom to evaluateannual effective dose by usage of TENORM added consumer
products. The point source method could also be used for theother field for radiation protection to calculate the effective dose.

References[1] Kathren, Ronald L. "NORM sources and their
origins." Applied radiation and isotopes 49.3 (1998): 149168.Potential Environmental and Regulatory Implications of
Naturally Occurring Radioactive materials (NORM)[2] Join, S. P. E. "Naturally occurring radioactive materials."
[3]
Kim,
Chan
Hyeong,etal.
"A polygonsurface
reference
Koreanmale
phantom(PSRKMan) and its direct implementation in Geant4 Monte Carlo simu
lation.” Physics in medicine and biology 56.10 (2011): 3137.
Author address

E-Mail: bleem131@yonsei.ac.kr
Figure 4. Organ equivalent dose with 0.6 MeV gamma
energy.
Finally, the annual effective dose due to the usage of the
TENORM added consumer products was evaluate based on
the usage time and organ equivalent doses as shown in figure
5. The annual effective dose with the multi-point source washigher than that of modeling source. Especially, 2.5 times
higher annual effective dose was assessed in mat productusing multi-point source. The annual effective dose over six
products was evaluated less than 1 mSv, even though theemployment of conservative point source method.

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Development of a Patient Dose Calculation Algorithm Using TOPAS Monte Carlo Toolkit
for Passive Scattering Proton Therapy
Wook-Guen Shin1), Do Hyeon Yoo1), Mauro Testa2), Jong Hwi Jeong3), Se Byeong Lee3), Yeon-Joo Kim3)
and Chul Hee Min1)*
1) Department of Radiological Science, College of Health Sciences, Yonsei University, Gangwon-do, Republic of
Korea
2) Industry-Academic Cooperation Foundation Office of Research Affairs, Yonsei University, Gangwon-do,
Republic of Korea
3) Proton Therapy Center, National Cancer Center, Goyang, Republic of Korea

Introduction
In proton therapy, accurate dose calculation is the mostimportant for radiation treatment planning (RTP) in clinicalsituation. Currently, pencil beam algorithm (PBA) is
employed to calculate dose because of fast calculating time,
however, it is reported that PBA has many physicaldisagreement such as nuclear interaction and multiple
Coloumb scattering in inhomogeneous material. There aremany challengeable researches such as Analytical
Anisotropic Alorithm (AAA), Collapse Cone Convolution
algorithm (CCC), Acuros XB (AXB), Simplified Monte
Carlo (SMC). However, the accuracy of the Monte Carlo(MC) is more than these algorithms. So MGH and the otherhospitals employes Monte Carlo method to validate patient
dose. The purpose of this study is to develop a patient dose
calculation platform using tool for particle simulation(TOPAS) based on Monte Carlo method, and to validate thepatient dose in internal mammary node (IMN) and abdomen(ABD) cases.
Materials and Methods
Modeling and Validation of the Proton Beam Nozzle: In
previous study, we developed proton beam nozzle code forpassive scattering proton therapy using Geometry andTracking4 (Geant4) MC tool. Figure 1 is the visualized
proton beam nozzle. The code was emigrated to TOPAS, andwas validated by comparing axial percent depth dose (PDD)
in a virtual water phantom with measured data by Markus
ionization chamber. The dimension of water phantom was 30
X 30 X 30 cm3 and the center line of the water phantom weredivided into 5 X 5 X 0.1 cm3. PDDs of 8 beam options werecompared with measured data (4.73 – 24.01 cm), snout size
is 250 mm (SNT-250), and source to surface distance (SSD)
is 300 cm. 107 primary protons were employed for
calculating PDD in each beam option.

Figure 1. Schematic illustration of proton beam nozzle
and a water phantom modeled by TOPAS.

Automatic Algorithm for Patient Dose Calculation: In thisstudy, an algorithm for patient dose validation was developedwith TOPAS by automatically importing the patient data suchas the beam delivery conditions and patient image through
DICOM file. Figure 2 shows a flowchart of automatic patient
dose calculation algorithm by using TOPAS. First, nozzle
parameter was determined by range and modulation width
measured by quality assurance (QA) process. Second, phasespace file was generated to reduce calculation time. The
information of neutrons and protons which pass through virtual
plate at downstream of the compensator was recorded. At last,
patient dose was calculated based on CT data and phase-space
file. Schneider model was employed to convert CT data to CT
phantom.

Figure 2. Flowchart for automatic dose calculation
algorithm by using TOPAS.
Validation of the Patient Dose Calculation Algorithm: To
validate the dose calculation algorithm, IMN case and ABDcase were employed. Both patients were treated by passive
scattering proton therapy at National Cancer Center (NCC), andboth simulations calculated 109 primary protons totally. 300
CPU-hours were taken for each case and dose-to-water was
calculated to compare same physical quantity with RTP dose.
We employed the supercomputer called TACHYON supported
by Korea Institute of Science and Technology Information(KISTI) for reduction of simulation time with parallel
calculation and Matlab was employed to analyze our simulation
results.

-100-

Results
For MC-commissioning, PDDs calculated by TOPAS
beam nozzle code were compared with experimentallymeasured PDDs. Figure 3 shows an example of SOBP whichhas 4.73 cm range. The agreement between MC simulations
and measurements show the difference of 0.1 mm range error
and 0.2 mm modulation width error.

Figure 5. DVHs for ABD case (upper) and IMN case (lower).
Solid line indicates dose calculated by Eclipse RTP anddashed line indicates dose calculated by TOPAS Monte
Carlo tool.
Figure 3. PDD of 4.73 cm range proton beam measuredby Markus ionization chamber (blue) and calculated by
TOPAS (red).
ABD case and IMN case represent homogeneous andinhomogeneous materials, respectively. The dose distribution
show close relationship between RTP and MC as shown in
Fig. 4. Minimum 99% of 3D gamma passing rate for most of
the organs was assessed with 3 mm of distance to agreement(DTA), 3% of dose difference (DD), and 20% of threshold.
However, in the IMN case, lung dose show relative highdifference (96% of gamma passing rate) because of theinhomogeneity.

Figure 5 shows difference of DVHs between RTP and MC.
Because of statistical fluctuation, the MC-DVH curve for target
volume is more gradual than RTP-DVH curve. And the relative
high fraction of low dose in bladder can be generated by dosefrom secondary particles.
Discussion
The results of two patient cases show good agreement
between RTP and MC. However, in the inhomogeneous case(IMN), lung dose shows relative high difference of 96% gamma
passing rate. In this study, we determined 109 primary particles
for patient dose calculation, however, still statistical fluctuation
is most limitation. In further study, experimental validation ofpatient dose calculation algorithm will be performed in various
conditions which show difference from plan such as
disequilibrium inhomogeneous materials, range degradation,and small field. In addition, graphic user interface interlockedwith patient management system at the NCC will be developed.
Conclusions
In this study, proton beam nozzle for passive scattering
proton therapy installed at NCC was modeled by using TOPAS
which employs MC method. In addition, patient dose
calculation platform was constructed and validated bycomparing with dose distribution assessed by RTP. This study
demonstrates the reasonability of patient dose calculation using
MC method.
References[1] H. Paganetti, "Range Uncertainties in Proton Therapy andthe Role of Monte Carlo Simulations", Phys. Med. Biol.,
57:R99-R117 (2012).
[2] H. Paganetti, H. Jiang, K. Parodi, R. Slopsema, and M.
Engelsman, "Clinical Implementation of Full Monte Carlo Dose
Calculation in Proton Beam Therapy", Phys. Med. Biol.,
53:4825-4853 (2008).

Figure 4. Dose distributions of ABD (left) and IMN(right) case calculated by Eclipse RTP (1st row) and
TOPAS Monte Carlo tool (2nd row) in the isocenter plane,
and gamma plot representing the difference between RTP
and MC (3rd row).

Author address

E-Mail: wgshin@yonsei.ac.kr-101-

ADAPTATION OF EFFECTIVE ATOMIC NUMBER FOR PROTON THERAPY
R. Shimokomaki1), M. Komori1), C. Omachi2), H. Shibata2), T. Toshito2), T. Kamomae3), H. Oguchi1)1) Department of Radiological Sciencies, Graduate School of Medicine, Nagoya University, Nagoya, Japan
2) Nagoya Proton Therapy Center, Nagoya, Japan
3) Department of Therapeutic Radiology, Graduate School of Medicine, Nagoya University, Nagoya, Japan
Introduction
Proton therapy can deliver a high radiation dose to target
tumor without giving that to healthy organs because of the
Bragg Peak. To maximize the advantage we need accurate
calculation for stopping power.
To calculate dose deposition for human body, the valueof electron density of each tissue is needed. Electron density
can be estimated as electron density ratio (EDR) to water byusing computed tomography (CT) images because the CT
numbers expresses the ratio of attenuation coefficient ofmaterial to water. Therefore stopping power is always
determined as stopping power ratio (SPR) to water. In a caseof particle beam therapy, the differences of elemental
compositions complicate the calculation of dose distribution
for each tissue or organ in comparison to x-ray radiotherapy
because mean excitation energy of target molecule is needed
to the precise calculation of SPRs. The most popular method
for calibration of CT numbers to SPRs is called“stoichiometric calibration method”, Schneider et al [1]proposed. In this method, a calibration curve is used todetermine SPR by CT number. Later, Kanematsu et al [2]showed a simpler method by poly-binary tissue model thathave accuracy equal to Schneider’s method. However, thesemethods are thought to have potential error because ofelemental differences between patient body and referencematerials which used when make a calibration curve. The
differences appear as the errors of EDR and mean excitationenergy.
In recent study, there are several reports using dual
energy CT (DECT) for calculating SPRs. The biggest
advantage of using DECT is that it can derive effective
atomic number (EAN) and EDR with high accuracy byscanning at two different x-ray spectra. The accuracy of EDR
greatly affects to that of SPR. Further, EAN can be adapted
to calculate SPR accurately in particle therapy because it
have so close relationship with mean excitation energy. Fromthese reasons, the methods to calculate SPRs by DECT havemore accuracy than Schneider’s and Kanematsu’s method.
The main purpose of this study is to evaluate theextraction accuracy of EAN, EDR and SPR for a phantom byusing two different x-ray tube voltage of single energy CT
that used in clinical treatment planning. We simplify Landry
et al [3] to extract EAN, and EDR is obtained by solving
equation, discussed below, and finally calculate SPRs.
Materials and Methods
In this study, we scanned two different electron density
phantoms; CIRS (Computerized Imaging Reference System,
Norfolk, VA) phantom and Gammex RMI 467 (Gammex,
Middleton, WI) phantom, which have some rod-shaped tissue
substitutes made of known different elemental compositions
and densities.CIRS phantom was regarded as a calibration
phantom and Gammex phantom as a human body.
The ratio of linear attenuation coefficient 𝜇 of a material
to water at a certain x-ray tube voltage (kVp) is expressed as𝜇()= 𝜌𝑒 × ( 𝐴𝑘𝑉𝑝 + 𝐵𝑘𝑉𝑝 × 𝑍1.86
𝜇𝑤𝑎𝑡𝑒𝑟 𝑘𝑉𝑝+ 𝐶𝑘𝑉𝑝 × 𝑍 3.62 ).

(1)

where 𝜌𝑒 and Z shows EDR and EAN respectively.𝐴𝑘𝑉𝑝 , 𝐵𝑘𝑉𝑝 and
𝐶𝑘𝑉𝑝 represent the coefficient for incoherent scattering, coherent
scattering, and photoelectric effect respectively [1]. Left hand inequation (1) is obtained from CT measurements by a CT scanner(TOSHIBA Aquilion LB). Both phantoms were scanned at two
different tube voltage (80 kVp and 135 kVp) at 400 mAs, 2mm
thickness. Two kinds of equation (1) were obtained from the CT
measurements for CIRS phantom at each tube voltage. 𝐴𝑘𝑉𝑝 , 𝐵𝑘𝑉𝑝
and 𝐶𝑘𝑉𝑝 at each tube voltage were calculated by least square fit
between HUkVp and EAN for each rod. EAN for each rod ofphantoms were calculated using information of their elemental
composition.
After determining 𝐴𝑘𝑉𝑝 , 𝐵𝑘𝑉𝑝 and 𝐶𝑘𝑉𝑝 in equation (1) for
each tube voltage, the ratio between 80 kVp and 135 kVp of the
80 kVplinear attenuation coefficient ratio to water μ|135 kVp was obtained
as following equation [1]80 kVpμ|135 kVp
𝐴80 𝑘𝑉𝑝 + 𝐵80 𝑘𝑉𝑝 × 𝑍1.86 + 𝐶80 𝑘𝑉𝑝 × 𝑍 3.62=
𝐴135 𝑘𝑉𝑝 + 𝐵135 𝑘𝑉𝑝 × 𝑍1.86 + 𝐶135 𝑘𝑉𝑝 × 𝑍 3.62

(2)

Since equation (2) can be regarded as a calibration curve between
80 kVp
EAN and μ|135 kVp , the EAN for each pixel of Gammex phantom
can be determined by the calibration curve. By using thedetermined EAN, EDR of each pixel can be calculated by solving
equation (1) for each x-ray spectrum;𝜇)𝜌𝑒,𝑘𝑉𝑝 = (𝜇𝑤𝑎𝑡𝑒𝑟 𝑘𝑉𝑝
×1( 𝐴𝑘𝑉𝑝 + 𝐵𝑘𝑉𝑝 × 𝑍1.86 + 𝐶𝑘𝑉𝑝 × 𝑍 3.62 ).

(3)

We determine EDR as average of 𝜌𝑒,80 𝑘𝑉𝑝 and 𝜌𝑒,135 𝑘𝑉𝑝 .
Calculated EAN was converted to mean excitation energy.
Figure 1 shows the relationship between EAN (calculated by
𝛽=3.3) and natural logarithm of mean excitation energy for thereference tissues from ICRU report 44 and 46 such as adipose,liver, brain, cortical bone, etc. We approximate by 5-orderequation among minimum and maximum EAN (6.23 and 13.63
respectively). In the approximation, we did not include thyroid
tissue because it has specific mean excitation energy value by thecontent of iodine. Outside of the fitting region, the linear
extrapolation of the fitted function gave the EAN.
SPR for each pixel of Gammex phantom was calculated using
the following Bethe-Bloch formula [2],SPR = EDR ×ln[2𝑚𝑒 𝑐 2 𝛽2⁄𝐼(1 − 𝛽2 )] − 𝛽2,ln[2𝑚𝑒 𝑐 2 𝛽2⁄𝐼𝑤𝑎𝑡𝑒𝑟 (1 − 𝛽2 )] − 𝛽2(4)where 𝑚𝑒 , I, and 𝑐𝛽 show electron mass, mean excitation energy
and velocity of proton beam.
Calculated EAN, EDR, mean excitation energy and SPR wererepresented as images respectively. In each image, region ofinterests (ROI) are set at each rod and the mean values andstandard deviation (SD) in each ROI are obtained. The mean valueof each ROI is evaluated as relative error to their theoretical value
defined by-102-

Relative Error(%) =𝑂𝑏𝑡𝑎𝑖𝑛𝑒𝑑 𝑉𝑎𝑙𝑢𝑒 − 𝑇𝑟𝑢𝑒 𝑉𝑎𝑙𝑢𝑒
× 100.
𝑇𝑟𝑢𝑒 𝑉𝑎𝑙𝑢𝑒(5)

In addition, the SPRs from our method were compared withthat from stoichiometric calibration method, performed at
120 kVp, by equation (5) and root mean square (RMS) error
defined by∑𝑁 (𝑒𝑞. 5)2
RMS error(%) = √ 𝑖=1
,
𝑁

(6)

where N means the number of rods.

Figure 2. Calibration curve from CIRS phantom and CT
measurements of Gammex phantom.
(b)
(a)

(c)

Figure 1. The relationship between effective atomic
number (EAN) and logarithm of mean excitation energy(LnI) for reference tissues from ICRU report 44 and 46.
Results
Figure 2 shows the calibration curve from CIRS phantom
and CT measurement data plot of Gammex phantom at eachrod with SD. CT measurement data for Gammex phantom
well agree with the calibration curve from CIRS phantom
especially soft tissue substitutes, except lung substitutes(EAN are 7.60 and 7.62). Figure 3 (a), (b) and (c) show
relative error between outputs and theoretical values formean EAN, EDR and natural logarithm of mean excitationenergy with SD at each rod. All outputs have critical large
SD, so we focus on the mean value. The largest error ofmean value among the rods is 26.11% for EAN, 9.22% for
EDR, and 11.37% for mean excitation energy.
Figure 3 (d) shows relative error for SPR with SD at eachrod. Red circle plots are stopping power ratio from our
method and blue triangle plots are stopping power ratio fromstoichiometric calibration method. The largest error is 9.51% for SPR from our method, and -6.12% for fromstoichiometric calibration method. RMS error is 3.67% forfrom our method, and 2.12% for from stoichiometriccalibration method.
Discussion
When we focus in mean value, we can find from figure 3(d) that our method is equal to or more accurate thanstoichometric calibration method at the region whose SPR isclose to 1.0. However, at the lung and bony tissue regions,
our method have less accuracy.The result represents that our
calculation of EDR is not accurate at the regions thanstoichiometric calibration method because the accuracy of
SPR calculation greatly depends on the accuracy of EDR
calculation, which depends on the accuracy of EAN
calculation. Figure 3 (a) and (b) show that we could not
calculate EAN and EDR accurately for lung tissues. This isbecause lung tissues are greatly deviated from the calibration
curve as shown in figure 2. In addition, in figure 3, there arelarge errors at high EAN region, even for the rods whose
EAN errors are small. This means that the approximation
showed in figure 1 is incorrect especially at high EAN range
and occurs the inaccuracy of SPR calculation.

(d)Figure 3. The results of relative error. (a): effective
atomic number (EAN). (b): electrom density ratio(EDR). (c): rogarithm of mean excitation energy (LnI).
(d):stopping power ratio (SPR) from stoichiometriccalibration method and from EAN and EDR.
More importantly, figure 2 and 3 show that the outputs fromour method have greatly large SD, which is equal to noise, thenour method to calculate SPR is exceedingly less reliable thanstoichiometric calibration method. We need to decrease the noise,
derived from the noise of CT measurement, to perform a correct
evaluation.
Conclusion
Our method could calculate SPRs equal to or more accurately
than stoichiometric calibration method except lung or bonyregions. It indicates the possibility that EAN and EDR can beadapted to calculate SPR accurately. However, the results havecritical problem for the SD. Therefore our next step is to decrease
the noise to obtain a reliable results. In addition, we have toevaluate the dose exposure by CT measurement simultaneously.
References[1] Schneider U, Pedroni E, and Lomax A. Phys. Med. Biol. 1996;
41: 111-24[2] Kanematsu N, Matsufuji N, Kohno R, Minohara S and Kanai T.
Phys. Med. Biol. 2003; 48: 1053-64[3] Landry G, Seco J, Gaudreault M and Verhaegen F. Phys. Med.
Biol. 2013; 58: 6851-66[4] Yang M, Virshup G, Clayton J, Zhu X R, Mohan R and Dong
L. Phys. Med. Biol. 2010; 55: 1343-62
Author address
E-Mail: shimokomaki.riyouta@d.mbox.nagoya-u.ac.jp-103-Appearance of Stochastic Resonance on Computed Tomography and its Application
Y. Yamamoto 1), K. Igarashi 1), K. Naito 1), K. Fujii 1), C. Kawaura 1) M. Mori 2), M. Ikeda 1), K. Imai 1)
1) Department of Radiological Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Division of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
Introduction
Image noise on Computed Tomography (CT) is oneof the important factors degrading image quality, andmany studies about noise reduction have been
conducted. On the other hand, noise can have positive
influence on some nonlinear systems. Thisphenomenon is called “Stochastic Resonance (SR)”.
This SR has been applied for various researches suchas neuroscience and optical research. Gammaitoni et al.
reported that SR caused by adding optimal noiseprovided improvement of a system response (e.g.
signal-to-noise ratio) [1]. Thus, SR can be applied for
improving signal detectability on X-ray digital images.
However, at least to our knowledge, it has not beenreported that SR has appeared on CT images. The aimof this study is to verify whether SR appears on CT
images and improves signal detectability.
Materials and Methods
I. CT image acquisition
Figure 1 illustrates target object used to measurehigh contrast resolution (Catphan528; The Phantom
Laboratory). The phantom was scanned with a 64-row
multidetector CT scanner (LightSpeed VCT; GE
Healthcare). The scan parameters were as follows: tube
voltage of 140 kVp, tube current of 180, 250, 320, and
400 mA. All images were reconstructed with standard
kernels for brain.
II. Verification of SR on CT images
CT images displayed on 8-bit gray scale based onprocess of windowing have nature of nonlinearity. In
this study, white Gaussian noise of zero-mean andstandard deviation (SD) denoted by  representing
noise intensity from 50 to 1000 Hounsfield Unit (HU)
was added to CT images obtained with 140 kVp, 180mA or 400 mA. For these CT images, a window widthand window level were set to 40 HU and 100 HU,
respectively. We have subjectively assessed theappearance of SR on these CT images.

III. Quantitative evaluation of signal detectability on SR
imagesRousseau et al. reported that SR was represented by the
curve with a peak SNR at the optimal noise intensity [2].
Thus, we have quantitatively evaluated the differences inthe signal detectability for added noise intensity  withthe following two physical indices: i) Michelson’scontrast and ii) Contrast-to-Noise Ratio (CNR).
Michelson’ s contrast is given by,

Contrast Psignal  Pbackground(1)

Psignal  Pbackgroundwhere Psignal and Pbackground are mean pixel values ofsignal (bars) and background areas, respectively. Then,the contrast at each spatial frequency was normalized to
1.0 at 1 LP/cm.
CNR is defined as follows;

CNR 

Psignal  Pbackground(2)

NoiseSD

where NoiseSD is standard deviation of backgroundarea.
Results and Discussion
I. Verification of SR on CT images
Figure 2 (a) shows original CT image obtained with140 kV and 400 mA and noise-added CT images Whenthe noise intensity was 300 HU, bars on noise-added CT
images appeared to be separated, indicating high-contrast
resolution of 3 LP/cm. Moreover, the dark-band artifacts

Original

=300 HU(a) 140 kV, 400 mA

=1000 HU

=300 HU
=1000 HU(b) 140 kV, 180 mA
Fig. 2 Original CT and noise-added CT images
Original

Fig. 1 Target object (Catphan528)-104-

on original CT image were found to be reduced byadding noise. However, when the noise intensity was1000 HU, bars on noise-added CT images appeared to
be separated, whereas bars looked buried in noise.
Thus, the addition of optimal intensity of noise to CT
image provided a substantial improvement of signal
detectability. Thus, this result verified that SR occurs
on CT images.
Figure 2 (b) shows original CT image obtained withlower tube current (180 mA) and noise-added CT
images. As shown in this figure, SR also appeared on
the images with lower tube current and with added
white Gausian noise, and provided a substantial
improvement of signal detectability. This result
indicated that appearance of SR was independent onamount of noise on original CT images.

Contrast-to-Noise Ratio

0.8

0.6

0.4
Tube Voltage 140 kV：Tube Current 400 mA：Tube Current 320 mA：Tube Current 250 mA：Tube Current 180 mA

0.2

0

0

100

200
300
400
Noise Intensity σ (HU)

500

Fig. 4 CNR at 3 LP/cm as a function of noise intensity
II. Quantitative evaluation of signal detectability on
SR images
Figure 3 shows spatial frequency characteristics ofMichelson’s contrast for various noise intensities. For
original CT image, the contrast decreased with theincrease in spatial frequency and dropped to almost
zero at 3 LP/cm. On the other hand, for noise-added
CT images, the contrasts at 1-6 LP/cm were improved
with the increase in noise intensity up to 300 HU,
leveling off at higher noise intensity.
The results of Michelson’s contrast showed thecontrast at 3 LP/cm was substantially improved byadding noise to original CT image. Figure 4 shows
CNR at 3 LP/cm as a function of noise intensity. CNR
took the maximum value at the noise intensity of
approximately 300 HU, and decreased for higher noise
intensity. However, CNR did not significantly varywith tube current. This result indicated that CNR was
not dependent on amount of noise on original CT
images, but changed with noise intensity added to the
CT images. Thus, these results showed that appearanceof SR on CT images was quantitatively verified andcontrast resolution and CNR of CT images wereincreased by adding optimal intensity of noise.

Conclusion
We have verified appearance of SR on CT images byadding white Gaussian noise, and have quantitatively
evaluated improvement of signal detectability on the CT
images with two physical indices of Michelson’s contrast
and CNR. Our results suggested that application of SR on
CT images can be clinically useful for detection of sulcal
effacement such as acute ischemic stroke.
Acknowledgement
This study was supported by JSPS KAKENHI Grant
Numbers 26461821 [Grant-in-Aid for Scientific Research(C)].
References[1] L Gammaitoni, P Hänggi, P Jung and F Marchesoni,
Stochastic resonance. Rev. Mod. Phys. Vol. 70, No. 1,
p. 223-287, Jan. 1998
[2] D Rousseau, F Chapeau-Blondeau, Suprathresholdstochastic resonance and signal-to-noise ratio
improvement in arrays of comparators. Phys. Lett. A.
Vol. 321, No. 5-6, p. 280-290, Feb. 2004

Normalized Contrast

Author address
E-Mail: yamamoto.yuuki@b.mbox.nagoya-u.ac.jp
Tube Voltage: 140 kV
Tube Current: 400 mA：σ= 0：σ= 50：σ= 100：σ= 300：σ= 400

1

0.5

0
1

2

3
4
Spatial Frequency (LP/cm)

5

6

Fig. 3 Spatial frequency characteristics of Michelson’scontrast for each noise intensity-105-

GATE Monte Carlo Simulation Study on 6 MV Photon Beam Characteristics for Dual Head
LINAC Modeling
Han Kyeol Song1), Yong Hyun Chung1), Seung Woo Park2), Young Hoon Ji2)
1) Department of Radiological Science, College of Health Sciences, Yonsei University, Wonju, Rebulic of Korea
2) Research Center for Radiotherapy, Korea Institute of Radiological and Medical Sciences, Seoul, Republic of Korea

Introduction
In order to design the purposed dual head LINAC
system, 6 MV photon beam was simulated and evaluatedquantitatively with GATE Monte Carlo code for apreliminary study. The generated 6 MV photon beam wasdemonstrated from a sing head simulation in terms of thePercent Depth Dose (PDD) and cross-line profile. Then, thedual head was simulated and deposited dose was measured
according to irradiation time, field size and the shpae of aphantom.
Materials and Methods
The geometrical and material properties were
derived from a VARIAN's manufacturer specified layout for
VARIAN 2300EX. The simulated components were primary
collimator, target, mirror, ion chamber, X-Y jaws and water
phantom.
The simulation was separated by two stages. The
first stage was to generate 6 MV photon beam. At the firststage, a single LINAC head was modeled with GATE
platform. The properties of head which were geometry,
dimension, material and density were defined from the
manufacturer information and described as precisely as
possible. The electron source was placed within the primary
collimators and it generated 6 MeV electrons. To be exact,
the electron source generated 6.1 MeV electron to fit theconventional 6 MV photon spectrum with given geometry.
The electrons hit the target and 6 MV photon spectrums weregenerated. The simulated photons were stored within a Phase
Space (PhS) which saved entering particles' information interms of position, direction, energy, etc. The PhS was
attracted to predetermined volume and placed above the X
jaws (Secondary collimators). The number of primaryelectron was 108.

this stage, the photon spectrum was irradiated to water phantom
after passed through X-Y jaws with given field size. The fieldsize was set by 5×5 and 10×10 cm2 depending on the jaws
location and shape. The Source to Surface Distance(SSD) was
80 cm.
The simulated photon spectrum was irradiated to thewater phantom below the lower jaws. The shape of the phantom
was box with 50×50×30 cm3 of dimension. In the water
phantom, cross-line profile and PDD were measured to verify
the simulation quantitatively. The line profile was evaluated at
the surface of the phantom and had 100×1×1 resolution with
5×500×500 mm3 of voxel size. After verify the single head andspectrum, the dual heads were described and both of the heads
irradiated 6 MV photons with various field size. One head wasstationary and the other head was rotated by 45o and 90o to
describe one arbitrary treatment moment. At the center of thedual heads, water phantom was placed and various shape of thephantom was modeled. As the result, the deposited dose within
the phantom was measured. We compared the deposited dose
for given time which was described in terms of the number ofparticles on the single head case and the dual head case,respectively . In addition, the deposited dose of whole volume
was also compared at both cases.
Results
The mean energy of the specturm was 1.303 MeV and6.1 MeV of maximum energy was observed. In orter to evaluate
the X-ray beam generated from the simulated head, cross-line
profile and PDD were measured within the water box phantom.
Figure 2 showed the measured cross-line profile on the water
phantom with 10×10 cm2 of field size. On the cross-line profile,
field flatness and symmetry were 4.65% and 0.115%,
respectively.
Cross-line profile

1.20E-007

Intensity(A.U)

1.00E-007

8.00E-008

6.00E-008

4.00E-008

2.00E-008

0.00E+000
-150

-100

-50

0

50

100

150

Transverse(mm)Figure 2. Cross-line profile(10×10 cm2 field)

Figure 1. LINAC head geometry on the GATE simulation

The dual head irradiation was compared to single head
irradiation in terms of the deposited energy which corresponded
to treatment time. Both simulations were performed with 2×108
particles which were from PhS file. Figure 4 and Figure 5
showed the deposited dose at box and sphere phantom,
respectively. The efficiency was calculated that deposited dosefrom dual heads was divided by the dose from single head.

In the second stage, PhS was acted as the photon
source at the same location. In other words, the simulation
was begun at top of the secondary collimators and the source
was located at the same space with a PhS record volume. In

-106-

1.1

photon beam using GATE/GEANT4" Phys. Med. Biol., 56:903918(2011)

PDD

1.0
0.9

Author Address
E-Mail : shg2848@yonsei.ac.kr

0.8

D(%)

0.7
0.6
0.5
0.4
0.3
0.2
0

5

10

15

20

25

Depth(cm)Figure 3. Percent Depth Dose curve(10×10 cm2 field)
At all condition, dual head showed higher treatment
efficiency. Efficiency was increased about 40 to 60%. The
efficiency variation was caused by phantom geometry andphoton energy which penetrated the phantom. The photons
were not fully deposited within the phantom due to nocompensator and actual planning.
175

8.00E-008
Efficiency
Dual
Single170

7.50E-008
7.00E-008

165

6.50E-008

160

6.00E-008
5.50E-008

150
5.00E-008

145
4.50E-008

140

Dose(Gy)

Efficiency(%)

155

4.00E-008

135

3.50E-008

130

3.00E-008

125

2.50E-008

120

2.00E-008
5x5, 45 deg, box

5x5, 90 deg, box

10x10, 45 deg, box

10x10, 90 deg, box

Simulation Conditions

Figure 4. Comparison of the deposited dose and its
efficiency at box phantom
8.00E-008

175

Efficiency
Dual
Single170

6.50E-008

160

6.00E-008

155

5.50E-008
150
5.00E-008
145
4.50E-008
140

Dose(Gy)

Efficiency(%)

7.50E-008
7.00E-008

165

4.00E-008

135

3.50E-008

130

3.00E-008

125

2.50E-008

120

2.00E-008
5x5, 45 deg, sphere

5x5, 90 deg, sphere

10x10, 45 deg, sphere

10x10, 90 deg, sphere

Simulation Conditions

Figure 5. Comparison of the deposited dose and its
efficiency at sphere phantom

Conclusion
In this study, in order to validate the feasibility of adual heads LINAC system, GATE Monte Carlo simulation
has been employed and it was estimated. LINAC headmodeling was evaluated with a single head and the geometry
and property were extended to the dual head system. In the
dual head LINAC, it showed the improved deposited dose
which could be corresponed to the faster radiotherapy and thehigher degree of freedom to treatment planning than a single
head LINAC system. However, this study was not concerned
the actual planning and patient's information, therefore, it
was required to be estimated with the practical condition in
the future.
References[1] L. Grevillot*, T. Frisson, D. Maneval, N. Zahra, J. N.
Badel, D. Sarrut, "Simulation of a 6 MV Elekta Precise Linac-107-

Feasibility Study for Spectral Unfolding of Clinical Megavoltage Photon Beams withTransmission Method
Hyo Jun park1), Hyun Joon Choi1), Do Hyeon Yoo1), Chul Hee Min*1)
1) Department of Radiation Convergence Engineering, Yonsei University, Wonju, Korea

Introduction
In radiation therapy, it is required to determine beam
quality such as energy spectrum to accomplish accurate
treatment planning and dosimetry. For this, direct
measurement of energy spectrum from the linear accelerator(Linac) is prefered. However, it is physically difficult toestimate the photon energy spectrum directly because of very
high intensity of radiation from Linac. Typically, beam
quality from Linac have been estimated by matching percent
depth-dose (%dd) and profile data that are measured. As
considering attenuation coefficients of materials that consis
of human body, however, it is required to measure accurate
photon energy spectrum.
Among the methods suggested to calculate photon
energy spectrum from Linac, method determining energy
spectrum with the transmission data, which is called as
unfolding energy spectra, showed its potential with high cost
efficiency and relatively easy measurements setup.
In this study, the possibility of unfolding photon
spectrum was proved by using Monte Carlo (MC) simulation
and a program called as HEPROW which is designed to
calculate energy spectrum.
Materials and Methods
Transmission: Transmission is the ratio of chargetransferred to ion chamber with and without attenuator.
Theorectically, transmission with the attenuator of certain
thickness is defined as a integral function of multiplicationsof energy transferred to ion chamber and the exponentialconsidering attenuation expressed as below.

In the equation above, T(x) and M(x) mean transmission
and ion chamber signal with attenuator of certain thickness, x,
respectively, and F(E) is the fractional signal of the photon
spectrum, and R(E) means response fuction of ion chamber.
Simulation setup: To obtain transmission data, Geant4
simulation tool-kit was used. Elekta Linac and PTW farmertype ion chamber were modeled in the simulation. In thesimulation, to increase simulation efficiency, only sensitive
volume of ion chamber was modeled. Also, Aluminum (Al)Alloy 1100 was selected as the attenuator material and Lead
(Pb) secondary collimator was modeled to detect only
straight radiation that reaches ion chamber. Figure 1 below
shows overall setup of transmission measurement simulation.
In the simulation, Al attenuator and ion chamber werelocated at the distance of 1 m and 3 m respectively from thezero point and secondary collimator was located at 275 cm
from the zero point.
With the simulation, ideal energy spectrum andtransmission curve of Linac were calculated. Also, chamber

response matrix which is one of important input factor of
HEPROW is calculated.

Figure 1 Simulation setup of transmission measurement
Energy spectrum calculation: In this study, HEPROW
which calculate energy spectrum through series of iterations
using least-square method was selected to obtain photon energy
spectrum by analysing transmission curve of 6 MV photon
beam from Linac. HEPROW was designed to calculate original
energy spectrum from measured one based on the equation
below.

In the equation, z refers detected spectrum which is input
values of HEPROW, R(E) is response function depends on thephoton energy E, and Φ(E) is the fluence of photon of theenergy E.
Results
The relative curve of transmission of photons from Linac
through thicknesses of Al Alloy 1100 attenuators was measured
by using farmer-type ion chamber and the energy spectrum wasreconstructed by using HEPROW from the transmission curve.
Figure 2 is the plot of transmission curve obtained fromthe simulation. To see the curve, it has a shape of exponential
curve that is mathematically reasonable because the baseformual of transmission curve explained at Maetrials andMethods, which has variable of attenuator thickness, x, is
exponential function.

-108-

Figure 2 Transmission curve obtained from MC
simulation
Figure 3 shows the comparison between the spectra
obtained with HEPROW and MC simulation. In Figure 3,
diamonds(◆) indicate energy spectrum obtained from MC
simulation and asterisks(*) indicate energy spectrum oftained
from using HEPROW. Energy spectrum obtained from
HEPROW underwent 3,000 iterations using least-square
method. To see the spectra, they show similar tendency,
similar peak energy and spectral shape. Also, difference
between mean energies of each energy spectra was calculated
as 1.5% from the energies of 1.98 MeV and 1.95 MeV for
HEPROW and MC simulation, respectively.

reconstruction of high energy photon beams for kernel baseddose calculations. Medical Physics. 2002;29(8):1789-1796.
[4]MATZKE, Manfred. The HEPROW program system.
NEA1666/01. 2004.
Author address

E-Mail: chmin@yonsei.ac.kr

Figure 3 Comparison between energy spectra obtained
from MC simulation and HEPROW
Discussion
In this study, we calculate transmission curve of 6 MV
photon beam from Linac and obtain energy spectrum byusing the transmission curve and HEPROW program. In the
results, overall tendencies of the spectra from MC and
HEPROW seem to be similar. However, there is difference
between the spectra in slope of each spectra. This problem
seems to be solved by increasing iteration tries of HEPROW
but it didn’t work because more iterations resulted more
distortions of shpe of energy spectrum, especially, values ofhigh energy region were increased. And, considering peaklocations of energy spectra and mean energy, it seems thatdifference between the spectra is resulted from using a single
attenuation material, Al. Therefore, additional researches onthese problems are needed for further study.
Conclusions
We unfolded energy spectrum from Linac by MC
simulation and HEPROW employed in this study anddemonstrated the possibility of unfolding energy spectrum
from Linac. Additional study to develop in-house unfoldingcode is needed based on the results of this study. For
advanced research, experimental studies for validation of theresults on this study and optimization of measurement setup
are needed.
.
References[1]E. S. M. Ali and D. W. O. Rogers. An improved physicsbased
approachforunfoldingmegavoltage
bremsstrahlung spectra using transmission analysis.
Medical Physics. 2012;39(3):1663-1675.
[2]E. S. M. Ali and D. W. O. Rogers. Functional forms forphoton spectra of clinical linacs. Physics in Medicine andBiology. 2012;57(1):31-50.
[3]Hinson, William H., and J. Daniel Bourland. Spectral-109-

List of Participants – Yonsei University
Name

Name

(Korean)(English)김종배Jong Bae Kim

Medical홍인수

In Soo Hong

Professor

Medical공인덕

In Deok Kong

Professor

Nursing박소미

So Mi Park

Professor

Nursing김기연Gi Yon Kim

Professor

Nursing김기경Ki Kyong Kim

Professor

Nursing송희영Hee Young Song

Nursing최지혜Ji Hea Choi전혜선

Hye-Seon Jeon

Professor

이충희Chung Hwi Yi

Professor

조상현Sang Hyun Cho

Professor

신현석Heon-Seock Shin

Professor

유성현Sung-Hyun You

Professor

Department
Biomedical
Lab. Science

Physical
Therapy
Physical
Therapy
Physical
Therapy
Physical
Therapy
Physical
Therapy-110-

Position
Professor& DeanAssociate
Professor
Associate
Professor

Occupational정민예

Min Ye Jung

Professor

유은영Eun-Young Yoo

Professor

김종배Jong Bae Kim

박지혁Ji-Hyuk Park박혜연Hae Yean Park김정란Jung-Ran Kim

전보영

Bo Young Jeon

Professor

한봉수Bong Su Han

Professor

민철희Chul Hee Min

Nursing고진화

Jin Hwa Koh

Nursing이슬기

Seul Gi Lee

Nursing정용주Yong Ju Jung전인철In Cheol Jeon

박주희

Joo-Hee Park손재익Jae Ik Son

Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Biomedical
Lab. Science
RadiologicalTechnology
RadiologicalTechnology

Physical
Therapy
Physical
Therapy
Physical
Therapy-111-

Associate
Professor
Assistant
Professor
Assistant
Professor
Assistant
Professor

Assistant
Professor
Graduatestudent
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
StudentPhysical
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Occupational
Therapy
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science차영주Young Joo Cha

이주현

Joo Hyun Lee

안시내

Si Nae Ahn

김정현Jeong Hyun Kim

김서은

Seo Eun Kim

황보승우Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student

Seung Woo

Graduate

HwangboStudent

이예진(A)Ye Jin Lee (A)변은진

Eun Jin Byun

이예진(B)Yei Jin Lee (B)김문영Moon Young Kim

김연주Yeon Ju Kim

박상미Sang Mi Park양지영Ji Yeong Yang

권혜진

Hye Jin Kwon

연민지

Min Ji Yeon

-112-

Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student

Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
Biomedical
Lab. Science
RadiologicalTechnology
RadiologicalTechnology
RadiologicalTechnology
RadiologicalTechnology

강성재Seong Jae Kang김민우

Minu Kim최문정

Mun Jeong Choi황순재

Sun Jae Hwang

권선영

Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student

Seong Yeong

Graduate

Kwon

Student이창근Chang Geun Lee김정호Jeong Ho Kim

박선영Seon Yeong Park김수진

Soo Jin Kim

김남경

Nam Gyeong Kim

세짐

Jim Se이민희

Min-Hee Lee민아름Areum Min송한결

Han Kyeol Song유도현Do Hyeon Yoo-113-

Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student

RadiologicalTechnology
RadiologicalTechnology
RadiologicalTechnology
RadiologicalTechnology이현철Hyun Cheol Lee신욱근

Wook-Geun Shin최현준Hyun Joon Choi박효준

Hyo Jun Park

-114-

Graduate
Student
Graduate
Student
Graduate
Student
Graduate
Student

List of Participants – Nagoya University
Departments

Name(English)Nursing

Modori Asano

Nursing

Hiroe Yamamoto

RadiologicalTechnology
RadiologicalTechnology
PathophysiologicalLab. Sciences
PathophysiologicalLab. Sciences
PathophysiologicalLab. Sciences

Kuniharu Imai

Akiko Ihori

Professor
Assistant
Professor

Professor

Yumi Hayashi

Sachiko Lee

Therapy

Professor

Takaaki Kondo

Physical Therapy

Occupational

Assistant

Professor

Sumio Yamada

Therapy

Professor

Testuhito Kojima

Physical Therapy

Occupational

Position

Makoto Chishima

Junichi Uemura

Nursing

Akiyo Tsuji

Nursing

Shigeyoshi Maki

-115-

Assistant
Professor
Professor
Assistant
Professor
Professor
Assistant
Professor
Graduatestudent
MC2
Graduatestudent
MC2

Nursing
RadiologicalTechnology

Tsubasa Aoyama

Yuki Yamamoto

Graduatestudent
MC1
Graduatestudent
MC2Radiological

Ryota

Graduatestudent

Technology

Shimokomaki

MC2RadiologicalTechnology
PathophysiologicalLab. Sciences
Pathophysiological
Lab.Sciences
Pathophysiological
Lab.Sciences
Physical Therapy

Chizuru Okamoto

Ryosuke Fujii

Kenta Nakagiri

Arisa Aoi

Occupational
Therapy
Occupational
Therapy
Occupational
Therapy

Graduatestudent
MC2
Graduatestudent
MC1

MC1

Naomi Yamada

Therapy

DC1

Watanabe

Physical Therapy

Occupational

Graduatestudent

Graduatestudent

Masaki Katou

Therapy

MC2

Tatsunori

Physical Therapy

Occupational

Graduatestudent

Haruko Kashiwagi

Tatsuya Omori

Asuka Suzuki

Takuya Kemmochi

Kilchoon Cho-116-

Graduatestudent
MC2
Graduatestudent
MC2
Graduatestudent
MC1
Graduatestudent
MC2
Graduatestudent
MC2
Graduatestudent
MC2
Graduatestudent
MC2