Yonsei–Nagoya University
Research Exchange Meeting on Health Sciences
2023
Program & Proceedings

November 10-11, 2023
Nagoya University
Nagoya Japan

Welcome Letter
Dear Professors and students of Yonsei and Nagoya Universities,
I am very pleased to invite you to the 2023 Yonsei-Nagoya University Research
Exchange Meeting on Health Sciences. We are planning to hold our exchange meetingat Nagoya University this year. After the experience of COVID-19, hybrid holding
techniques have become commonplace for us. Therefore, we decided to hold a hybrid
meeting this year so that professors and students from Yonsei University could
participate. We expect an active exchange between both universities again.
Sincerely,

Minoru Hoshiyama
Chairperson, School of Health Sciences, Nagoya University

Acknowledgement
This exchange meeting is financially supported by SAKURA SCIENCE
Exchange Program, Japan Science and Technology Agency.

This exchange meeting includes program of Convolution of Informatics and Biomedical
Sciences on Glocal Alliance (CIBoG) Program, WISE Program, Nagoya University, withfinancial support.

November 11, Saturday

Yonsei-Nagoya University Research Exchange Meeting on Health Sciences 2023
Prenary session: Main Hall, East-Building, Daiko-campus, Nagoya University
10:00
10:20

Registration
Opening
Moderator
Opening hostremarks
Guest remarks(Video message)

10:40

Prof. Kuniharu Imai

NagoyaProf. Kuniharu Imai

Prof. Minoru Hoshiyama

NagoyaSchool of Health Sciences, Nagoya University

Prof. Eun Woo Nam

YonseiTo College of Software and Digital Healthcare Convergencecommemorative gifts

To Wonju College of Nursing

Information

Prof. Kuniharu Imai

Nagoya11:00

Group photo

All participants

Yonsei/Nagoya

11:00-12:00

Paperwork

Sakura Science Students

Yonsei

12:00-13:00

Lunch

Students

Yonsei/Nagoya

Professors

Yonsei/Nagoya

13:30～

University

Presentation of

10:50

12:00-13:00

Dean of College of Software and Digital Healthcare Convergence, Yonsei

Bissiness meeting on
Lunch
Department sessions

Nursing: Main hall（East building 4F)
13:30

Opening remarks

Prof. Naoko Nishitani

NagoyaGuest greetings

Prof. So-Mi Park

YonseiNatsuki Nakayama

NagoyaProf. Kazuteru Niinomi

NagoyaPresentation 10minutes + Discussion 5minutes

13:50

Misao Kurita

NagoyaImpact Of Gum Chewing In Daily LifeOn Autonomic Nervous System Activity

14:05

Chiyo Iwata

Nagoya

14:20

Momoka Niihara

Nagoya

14:35

Jae Yeon Lee

Yonsei

14:50

Sounantha Phanthadala

Yonsei

Factors associated with exclusive breastfeeding: Aliterature review

Dr. Maki Tanaka

NagoyaPresentation 10minutes + Discussion 5minutes

15:30

Mika Kawabata

Nagoya

15:45

Ayako Nakayama

NagoyaFactors Associated with Dementia Worry among Middle-Aged or Older Adults

16:00

Chinzaya Boldoo

Yonsei

Factors related to nurse turnover Intention: A literaturereview

16:15

Odbayar Delgerekh

Yonsei

Factors related to nurses’ organizational commitment: Aliterature review

16:30

Woori Lee

Yonsei

Generations of Nurses in Korea: A Scoping Review

13:45

Openingannouncement

Session Ⅰ
Chair

15:05-15:30

Impact of Gum Chewing on the Autonomic NervousSystem and Work
Efficiency
Early mobilization in patients undergoing laparotomy inJapan: A literature
review
Hospital infection control education programto improve nurses' infection
control awareness andperformance: A literature review

Intermission

Session II
Chair

16:45
16:55

General comments
Closing
Closing remarks

Prof. Natsuki Nakayama
Prof. Midori Asano

NagoyaDeveloping and testing the reliability and validity of asupport scale for family
caregivers’ appraisal

Impact Of Gum Chewing In Daily Life
On Autonomic Nervous System Activity
Misao Kurita1), Natsuki Nakayama1), Yuki Kuno2),
Chiyo Iwata1), Sota Okabe1), Momoka Nihara1), Yoshimi Moriwaki1)
1) Department of Integrated Health Sciences, Nursing Sciences, Graduate School of Health Science, Nagoya University
2) Nagoya University Hospital
Introduction
Among the various effects of mastication exercises, there
have been many studies on the effects of chewing gum onhumans. Several studies on changes in heart ratevariability during gum chewing have been conducted;
however, masticatory motor stimuli were controlled in thelaboratory or by metronomes [1] [2]. Little is known about
the influence of mastication on autonomic nervous
activity in daily life. Therefore, this study aimed toinvestigate the influence of gum chewing on heart ratevariability in daily life and to elucidate some aspects ofthe significance of the act of mastication.
Methods
The participants were undergraduate and graduate
students aged 20 years or older. Exclusion criteria werepeople who had allergies to gum ingredients, ongoing
dental treatment, and a history of temporomandibular joint
problems.
They completed a questionnaire about their date of birth,sex, height, weight, gum chewing habits, and the reasonsfor chewing gum.
To capture autonomic nervous activity indices, we fitted
each participant with a Holter electrocardiograph andbegan the recording. The participants were asked to rest ina sitting position for 5 min without doing anything andthen to chew gum for 5 min. Then, recording with theHolter electrocardiograph was completed. To account forthe differences in blood glucose levels during meals, theexperiment was conducted at least 2 h after a meal.
The normal RR interval was extracted from ECG data.
Frequency analysis was then performed using the Mem
method, and low-frequency power [LF ( range: 0.04–0.15
Hz )] and high-frequency power [HF ( range: 0.15–0.4
Hz )] were obtained. The average heart rate (HR), HF, andLF/HF values were calculated for 5 min of rest and 5 minof gum chewing. HF indicates parasympathetic activity;
LF/HF, sympathetic activity [3]. The Wilcoxon signed-

rank test was used to evaluate the differences between
autonomic nervous activity indices with and without gum
chewing. Statistical significance was set at p < 0.05.
This study was approved by the Bioethics Review
Committee of the Nagoya University Graduate School of
Medicine (Approval no. 21-144-2).
Results
Nineteen men and women who agreed to participate in the
study were analyzed (Table 1).
The HR at 5 min of rest was 77 (55–99) bpm, and that at
5 min of gum chewing was 74 (60–101) bpm. The HR
during gum chewing was significantly lower than thatduring no gum chewing (P = 0.027). The HF during 5 minof gum chewing was 503 (35–1977) ms², while the HF
during 5 min of rest was 1042 (57–9695) ms². Therefore,
HF with gum chewing was not significantly different fromthat without gum chewing (P = 0.445). LF/HF at 5 min ofrest was 3.7 (0.7–6.8), while LF/HF at 5 min of gum
chewing was 2.9 (0.5–5.5). The LF/HF with gum chewing
showed a significant decrease compared to the LF/HF
without gum chewing (P = 0.036).
Discussion
In the present study, 5 min of gum chewing did not
significantly change the HF but significantly decreased
the LF/HF. This suggests that gum chewing does not havean impact on HF but suppresses sympathetic activity andconsequently increases parasympathetic activity.
A previous study reported that the alpha wave activity
increased after gum chewing, which brought aboutrelaxation [4] [5] [6]. In the present study, inhibition of
sympathetic nerve activity by gum chewing was observed,
which may have resulted in a relaxing effect.
However, a previous study reported an increase insympathetic nerve activity after 6 min of gum chewing [1].
In the present study, the HR was significantly decreased
by gum chewing, and sympathetic nerve activity wassuppressed. In the previous study, the experiment was
conducted after lunch, whereas in this study, theexperiment was conducted more than 2 h after the meal.
Therefore, it is likely that HR did not undergo a
postprandial compensatory mechanism that affected theincrease in HR [7] in this study.
One limitation of this study is that the participants werelimited to healthy young men and women. Therefore, togeneralize the results of this study, it is necessary to
examine the results for people of various ages andsociodemographic characteristics. In addition, because theduration of gum chewing in this study was only 5 min, theeffects of longer chewing on autonomic nervous system
activity should be investigated in the future.
Conclusion
Gum chewing for 5 min did not change parasympathetic
nerve activity but decreased HR and suppressed
sympathetic nerve activity. Gum chewing for 5 min in
daily life is expected to have a relaxing effect bysuppressing sympathetic nerve activity.
Table 1: Summary of participant datan(%)

median( range )21( 21 – 22 )height160( 146 - 182 )weight50( 44 - 69 )

age
sex

frequency
chewing

manofgum everyday

shape of gum

6( 31.6 )0(0)about 3 days
per week2( 10.5 )about 1 day
per week2( 10.5 )about 1 day
per month3( 15.8 )little12( 63.2 )granular18( 94.7 )plate1( 5.3 )

time to chew a piece ofgum
taste of gum

Author address
E-Mail: kurita.misao.s8@s.mail.nagoya-u.ac.jp
25

mint

12

( 63.2 )Fruit

5( 26.3 )other

2( 10.5 )reason for gum chewing sleepy

5( 26.3 )given

2( 10.5 )clear one’s
mouth

4

( 21.0 )study

3( 15.8 )concentration

1( 5.3 )

hunger3( 15.8 )class

1( 5.3 )

References[1] Hasegawa Y, Sakagami J, Ono T, et al. Circulatory
response and autonomic nervous activity during gum
chewing. Eur J Oral Sci. 117(4): 470-473, 2009[2] Ishiyama T, Suzuki M, Sato M, et al. [Evaluation of
sympathetic and parasympathetic nervous system activity
during mastication by heart rate variability, salivarycomponents and EEG] Shimpakuhendo daeki seibunoyobi noha ni yoru soshakuji kokan hukukokansinkeikei
katsudo no hyoka (in Japanese). Japanese Society for
Mastication Science and Health Promotion. 16(2): 55-69,
2006[3] Malik, M., Bigger, J. T., Camm, A. J., et al. Heart ratevariability Standards of measurement, physiologicalinterpretation, and clinical use. European Heart Journal,
17(3): 354–381.1996.
[4] Otsuka K, Kudo T, Takiguchi T, et al. [Relaxation
effect on the cerebrum by gum chewing] Gum chewing ni
yoru daino heno relax koka (in Japanese). JapaneseSociety for Mastication Science and Health Promotion.
7(1): 11-16, 1997
[5] Banquet, J.P. Spectral analysis of the EEG in
meditation. Electroencephalography and Clinical
Neurophysiology. 35: 143-151, 1973
[6] Batty, M.J, Bonnington S, Tang, B.K, et al. Relaxation
strategies and enhancement of hypnotic susceptibility,
EEG neurofeedback, progressive muscle relaxation andself- hypnosis. Brain Research Bulletin. 71(1-3): 83–
90,2006[7] Hashidume M, Sakurai K, Doi T, Konishi K, et al.
[Changes in postprandial hemodynamics] Shokugo no
junkandotai no hendo nit suite (in Japanese). Japanesephysical therapy academic conference abstract. 40(2),2013( 5 - 60 )

Impact of Gum Chewing on the Autonomic Nervous System and Work Efficiency
Chiyo Iwata, Natsuki Nakayama,
Sota Okabe, Momoka Nihara, Yoshimi Moriwaki
Department of Nursing, Graduate School of Medicine, Nagoya University
Introduction
Chewing gum affects both sympathetic andparasympathetic nerves [1]. In addition, chewing
gum has been reported to reduce stress [2], increase
short-term memory [3], and reduce subjective
fatigue in computing tasks [4]. It has been shownthat the effects of gum chewing on the sympathetic
nervous system and the positive effects on
calculation tasks are related [5,6]. However,whether the influence of gum chewing on theparasympathetic nervous system is related to its
impact on task performance remains unclear. In
addition, it is not clear how many minutes of gum
chewing are required to achieve these effects, as
the duration of gum chewing varies among theprevious studies. Furthermore, calculation tasks
incorporated as work tasks in many studies havebeen less representative of contemporary
professional activities, where massive calculation
tasks are less common. Therefore, in this study, weinvestigated the effects of chewing gum at various
time points on autonomic nervous activity
indicators and typing tasks in healthy adults.
Methods
Initially, the participants were equipped with a
Holter monitor and completed a questionnaire
regarding their age, sex, height, weight, and gum
chewing habits. Measurements with gum chewing
were performed using the following protocol:
After 5 min of resting in a sitting position, the firsttyping session was conducted without gum
chewing. After completing the first 5-minutetyping session, participants began chewing gum
and continued until the completion of the third
typing session. Five minutes after the start of gum
chewing, a second typing session was initiated andlasted 5 min. After typing was completed,participants remained seated in a resting state.
Finally, the third typing session commenced 20
min after the initiation of gum chewing. After thethird typing session, the Holter monitor was
removed and the experiment was concluded.
Measurements without gum chewing were
performed using the same protocol as those with
gum chewing, except for the gum chewing process.

We recorded the total number of types (counts) andrate of correct types (%) after each typing session.
Participants were randomly divided into twogroups, with half of them undergoingmeasurements without gum chewing, followed by
a 20-minute break, and then measurements with
gum chewing. The other half started withmeasurements with gum chewing, followed bymeasurements without gum chewing after a 20minute break.
Results
Basic characteristics of participants
Eighteen participants (12 females and six
males) from Nagoya University were included in
the analysis. The participants were 21 (21-22)
years old, 160.0 (146-182) cm tall, and had a BMI
of 20.5 (17.1-27.2). Regarding gum chewing
habits, more than a half of the participants (66.7%)
answered that they rarely chew gum.
Parasympathetic nerve activity index (HF)
The HF during the first 5 min after the initiationof the third typing session with gum chewing was
significantly higher than that during the first 5 minafter the initiation of the first typing session before
gum chewing (361 (32-1933) ms2 vs. 341 (431718) ms2, p = 0.044).
Total typing count
The typing count of the third typing session
with gum chewing increased significantly
compared with that of the first typing session
before chewing gum (631 (461-906) times vs. 596(439-932) times, p =0.006). Without chewing gum,the typing count was significantly higher in thesecond typing session than in the first (644 (476933) times vs. 642 (458-935) times, p =0.027).
Correct typing count
The correct typing count of the third typing
session with gum chewing was significantly higher
than that of the first typing session before gum
chewing (576 (429-813) times vs. 535 (406-846)
times, p =0.013).
Discussion
Parasympathetic nerve activity index (HF)

A study by Hashizume et al. suggested thatchewing gum for 5 min leads to greater stress
reduction within 10 min after chewing gum
compared to drinking water or simply having gum
in the mouth without chewing [7]. Additionally,
Ishiyama et al. reported that 6 min of gum chewing
led to sympathetic nervous system activation
during gum chewing and parasympathetic nervous
system activation after gum chewing [1]. Thesestudies have shown that the parasympathetic nerve
activity is activated after at least 5 min of chewing
gum, resulting in a relaxing effect. In the present
study, based on HF fluctuations, it was consideredthat during the third typing session, 20 min after
the start of gum chewing, the parasympathetic
nervous system was still activated similarly to thestate after gum chewing. Therefore, it ishypothesized that 20 min of gum chewing
increases HF and induces relaxation compared to
not chewing gum.
Total typing count and correct typing count
Sasaki et al. showed that the work output decreasedin calculation tasks because of the distraction of
having something in the mouth [4]. In the present
study, the total typing count did not increasesignificantly after 5 min of gum chewing,suggesting that 5 min of gum chewing may notaffect work efficiency.
Hirano et al. suggested that chewing enhances
concentration during chewing and promotes theprocessing of working memory [8]. Fantozzi et al.
reported that chewing gum for 2 minutes increased
the speed of extracting specific numbers from asequence, both immediately after and 30 minutes
after chewing [9]. Furthermore, Tojo et al. foundthat calculation task performance during gum
chewing tended to be higher in a group that chewed
gum than in a group that did not, although thedifference was not significant [6]. Ishiyama et al.
showed that 6 min of gum chewing activatedsympathetic nerve activity during gum chewing
and parasympathetic nerve activity after the end of
gum chewing [1]. The improvement inconcentration and working memory processing
during chewing shown by Hirano et al. and theimprovement in performance on a calculation task
shown by Tojo et al. are considered to be
associated with the activation of sympathetic
nerves. In our study, HF increased after 20 min ofgum chewing but did not increase after 5 min ofgum chewing. In addition, both total and correct
typing counts increased after 20 min of chewing;
they did not increase after 5 min of gum chewing.
This suggests that chewing gum for 20 minutes iseffective in increasing work efficiency and isassociated with an increase in HF. In conclusion,
gum chewing for 5 min does not affect work
efficiency; however, gum chewing for 20 min is
expected to activate the parasympathetic nervous
system and enhance work efficiency.
References[1] Ishiyama I, Suzuki M, Matsubara S: Functionof sympathetic and parasympathetic nerves during
gum chewing. Journal of Japanese Society for
Masticatory Science and Health Promotion 8;1;4252 1998
[2] Nakajo N, Tomioka S, Eguchi S: Gum
Chewing may Attenuate Salivary Alpha-Amylaseof Psychological Stress Responses. Journal ofJapanese Dental Society of Anesthesiology
35;346-353 2007
[3] Tomita M, Nakamura K, Fukui K: The effect ofmastication on short-term memory. Journal of theJapanese Stomatological Society 56;4;350-355
2007[4] Sasaki A, Sakuma Y, Kanoya Y, Sato C: The
Effects of Gum Chewing on Work Efficiency and
Fatigue: a Preliminary Study. Journal of Japan
Health Medicine Association 18;1;24-30 2009:[5] Otsuka K, Kudo T, Takiguchi H: The Relaxing
Effect of Gum Chewing. Journal of JapaneseSociety for Masticatory Science and Health
Promotion 7;1;11-16 1997
[6] Tojo Y, Nagaoka Y, Kobayashi T: Influence ofgum chewing timing on psychological andphysiological responses and task performance.
Journal of the Faculty of Human studies, Bunkyo
Gakuin University 15;273-283 2014[7] Hashizume S, Kawano K, Kokubo H: Effect ofchewing on stress reduction (Research Papers, The
35th Symposium on Life Information Science).
Journal of International Society of Life
Information Science 31;1;40-41 2013[8] Hirano Y 、 Onozuka M ： Chewing and
Attention: A Positive Effect on Sustained
Attention、BioMed Research International 367026
2015[9] Fantozzi M. P. 、 Cicco V. D. 、 Barresi M. ：Short-Term Effects of Chewing on Task
Performance and Task-Induced Mydriasis:
Trigeminal Influence on the Arousal Systems 、Frontiers in Neuroanatomy 00068 2017:

Early mobilization in patients undergoing laparotomy in Japan: A literature review
Momoka Niihara, Natsuki Nakayama, Iwahara Marina
Department of Integrated Health Sciences Nursing Sciences
Graduate School of Health Sciences, Nagoya University

Introduction
Early mobilization after laparotomy is consideredeffective in preventing postoperative complications,promoting wound healing, and reducing the length of
hospital stay [1][2]. In Japan, emphasis on the importanceof early mobilization as an integral part of acuterehabilitation for post-laparotomy patients is needed toreduce medical costs.
Nursing interventions play a crucial role in facilitating
the early mobilization of patients undergoing open
laparotomy. Nonetheless, Nakanishi et al. have shown that
postoperative early mobilization methods vary based on
the nurses’ years of experience [3]. Moreover, Sato et al.
reported cases wherein early mobilization for patients
undergoing laparotomy did not proceed as intended. The
patients expressed concerns such as, “Is it safe to move sosoon after surgery?” and the nurses expressed assumptions
and subjective judgments such as, “The patient is in pain,
so he will not be able to move” [4]. Hanamura et al. foundthat postoperative pain is exacerbated by the strain exerted
on the abdominal muscles when transitioning from thesupine to sitting positions [5]. This finding suggests thatearly mobilization after laparotomy is particularly
difficult because of wound pain. However, no studies inJapan have identified the interventions for early
mobilization after laparotomy.
This study aimed to identify effective strategies forpromoting early mobilization in patients undergoing open
laparotomy in Japan through a literature review.

Methods
The literature search was conducted using the Central
Medical Journal (Ichu-shi Web), which covers all nursing
literature in Japan. We searched for original articles
published between 2015 and 2020, using the research
keywords “early mobilization” and “laparotomy,” whichyielded 18 articles. The studies excluded were those that
did not discuss postoperative mobilization, whose target
operation was not laparotomy, that described thebiological effects of early mobilization, and that discussed
inhibitors for early mobilization. Seven articles were
included in this analysis.

Results
There were two articles on the effects of preoperative
care on postoperative early mobilization. They included“family orientation” and “preoperative rehabilitation.”
There were four articles on nursing care and focus
points for getting out of bed.
There was one article on the effects of perioperative
rehabilitation.

Discussion
1. Standardized perioperative protocols
Of the seven articles examined, most focused on the
preoperative interventions by the medical staff andpostoperative care provided by the nurses. Only one
article discussed standardized perioperative protocols, andthose were for cancer patients. These results suggest thatcomprehensive perioperative protocols are yet to beestablished for all surgical patients in Japan. Hori et al.
reported that although the contents and methods of theinterventions varied previously, the introduction of
perioperative rehabilitation helped establish a unified caresystem and the promotion of early mobilization. In thenear future, validation of the effectiveness of
perioperative protocol interventions would be necessary
not only for cancer patients but also for other surgicalpatients.
Kato et al. compared an intervention group, receiving
preoperative rehabilitation by other medical professionals
and early mobilization immediately postoperatively, anda control group, which simply awaited postoperative
spontaneous mobilization [6]. The results showed thatcompared to the control group, the intervention group
showed earlier stabilization in water delivery balance,earlier normalization of the nitrogen balance, and earlier
restoration of the total lymphocyte count. Additionally,
the intervention group demonstrated inhibition of
aspartate aminotransferase elevation. These results
suggest that preoperative rehabilitation and early
postoperative mobilization promote the postoperative
recovery of metabolic functions.
2. Nurses' anxiety regarding the safety of early
mobilization
Several articles reviewed in the literature describedthat nurses are anxious when assisting patients because theward nurses have to decide when to start and stop the early
mobilization process [7]. This is an inhibitory factor forthe nurses in proceeding with early mobilization. Insteadof letting the ward nurses decide, we suggest establishingstandard criteria for starting and stopping the early
mobilization process. This will ensure safety and allow
nurses to assist in weaning without any concerns.
The Japanese Society of Intensive Care Medicine(JSICM) has formulated the “initiation criteria for early
mobilization and early active exercise” and “cancellation
criteria for early mobilization and early active exercise” inthe intensive care unit (ICU) [8]. Sato et al. reported theinitial weaning of ICU patients following these criteria
and evaluated their pain levels and vital signs [4]. Most
patients who were unable to meet the discontinuation
criteria or discontinued early mobilization showedworsened vital signs. These findings suggest that theimplementation of specific criteria can effectively
enhance the safety of early mobilization.
The discontinuation criteria for early mobilization
proposed by the JSICM targeted ICU patients and did not
apply to the hospital ward patients, where the ward nurses
have to make these decisions. Few studies have validated
the safety of early mobilization in hospital ward settings
based on the JSICM criteria. Therefore, proposing theinitiation and discontinuation criteria for early
mobilization in ICUs as well as hospital wards iswarranted while assessing the safety of these criteria.

Conclusion
We reviewed the literature to identify effective
strategies for early mobilization in patients undergoing
open laparotomy; however, no specific interventions wereidentified. In the future, the development of perioperative
protocols is warranted based on the biological responses
to ensure the safety of early mobilization. Specifically, we
should implement interventions with standardized timing
and content from the preoperative period and establish
postoperative criteria for initiation and discontinuation.

References[1] Yanaga K, et al. Clinical Surgical Nursing
Comprehensive Review. Igaku Shoin. 2019.
[2] Thompson JB, et al. Role of the transverse abdominal
incision and early ambulation in the reduction of postoperative complications. Arch Sung. 1949.
[3] Nakanishi Y, et al. Differences in post-operative
weaning intervention by nurses' years of experience.
Kagawa Academy of Nursing Journal. 6 : 32-36. 2015.

[4] Sato T, et al. The Issues identified from data analysis
of first-time weaning in post-operative laparotomy orthoracotomy patients. The Medical journal of Yuri
Kumiai Sogo Hospital. 29 : 36-39. 2019.
[5] Hanamura Y, et al. Relationship between Tension of
Postoperative Midline Wound of Abdomen andMovement of Elevation from Supine Position to Sitting
Position. Bulletin/Nagano College of Nursing. 6 : 19-25.
2004.
[6] Kato T, Miyata G, Kamei T. Early Ambulation after
Surgery and Perioperative Rehabilitation. Journal ofJapan Surgical Society. 116 (4) : 254-259. 2015.
[7] Ono Y, Kojima M. Focus of the Master Nurses when
Observing and Assisting Patients to Early Mobilization ;Paper simulation of a patient after laparotomy. Med J
Tokushima Munic Hosp.31 : 75-78. 2017.
[8] Evidence based expert consensus for earlyrehabilitation in the intensive care unit. J Jpn Soc
Intensive Care Med. 24 : 255-303. 2017.

Author address
E-mail: niihara.momoka.s8@s.mail.nagoya-u.ac.jp

Hospital infection control education program
to improve nurses’ infection control awareness and performance: A literature review
Jae Yeon Lee
Wonju College of Nursing, Yonsei University, Wonju, Korea
Introduction
Nurses have high frequency of direct contact withpatients and play critical role in hospital infection
spread prevention and control. It has been confirmedthat the more nurses have high infection control
awareness, the better they perform infection control[1, 2]. Nurses’ infection control performances
according to infection control education andinstruction not only reduces the risk of infection
among nurses but also provides patients a safer
hospital environment and has become an importantfactor to block infection spread [3].
The importance of hospital infection control
education program to improve a nurse’s infection
control awareness and performance has beenmagnified [4]. However, there is a lack of basic dataand evidences about hospital infection control
program’s characteristics and effect for improvementof infection control awareness and performance. The
purposes of this study was to 1) identify the nurses’
infection control awareness and performance of
hospital infection control education programs and 2)
identify the characteristics and effects of hospital
infection control education programs to improveawareness and performance through a literature
review.
Methods
1) Search Strategy
This literature review was searched from August
to September 10, 2023, through two electronic
databases: MEDLINE (via PubMed) and RISS. The
search was not limited to language, literature type, or
study design. The search strategy terms included thefollowing concepts: (1) ‘Nurse’ for population, (2)‘Infection control,’ and ‘Infection education program’for intervention, (3) ‘Awareness,’ and ‘Performance’for outcome, and (4) ‘Hospital’ for setting.
2) Eligibility Criteria
Inclusion criteria were as follows: 1) studies thatenrolled nurses working in hospitals as participants; 2)
studies published in all languages; and 3) studies
published between 2013 and 2023. Exclusion criteria
were as follows: 1) studies that did not use aquantitative design; and 2) studies that did not report
the study methods.
Results
1) Search Results

The search strategy identified 895 articles. A totalof 24 article titles and abstracts were reviewed. The
full texts of the 10 articles were reviewed for
eligibility. Finally, five studies were included in thereview.
2) Characteristics of Selected Studies andParticipants
The characteristics of five studies finally selected
were identified according to country, research design,setting, purposes, measures and outcomes. The threestudies [5-7] targeted nurses at inpatient ward and thetwo studies [8, 9] targeted nurses at intensive careunits (ICU). The two studies were cross sectional [5,7], one was a systematic review [6], and two werequasi-experimental studies [8, 9].
3) Nurses’ Infection Control Awareness andPerformance of Infection Control Education
Programs
According to the result of the one systematic
review study [6] and two cross-sectional studies [5, 7],
Hammoud et al. [5] identified that scores of infection
control awareness and standard prevention were at an
appropriate level but performance of healthcare
associated infections and hand hygiene were notproper. Alrubaie et al. [7] identified the nurses’
knowledge and performance of infection control of
100 nurses who directly contact patients in two private
hospitals in S-city of Yemen. The result showed thatthe nurses’ infection control knowledge andperformance were at a high level. Nasiri et al. [6]analyzed 18 studies to survey nurses’ knowledge,
performance, and attitude of infection control andstandard prevention. As a result, it has been identified
that nurses had appropriate knowledge and positive
attitudes about healthcare association infections but
their infection control performances were not good.
4) Effects of Infection Control Education Program
According to the result of the two quasiexperimental studies [8, 9], Lim [8] provided
education for multidrug-resistant bacterial infection
control 3 times for 30 minutes each course for 4
months targeting 65 nurses who were working in aneonatal ICU in a university hospital in Korea, byusing videos and educational materials. As a results,
not only knowledge but also hand hygiene
performance were improved. Specially, the rate ofmultidrug-resistant bacteria infection was reduced.

Galal et al. [9] provided infection control educationfor 1 month targeting 125 nurses who working inpediatric ICU of a university hospital in Egypt byusing presentation about infection control principle
and instruction, and video showing proper handhygiene. As a results, nurses’ knowledge and attitudeimproved after taking infection control programeducation.
Discussion
According to the two cross sectional studies [5, 7]
and one systematic review [6], it has been revealed
that nurses’ infection control knowledge level washigh but their infection control performance wasinefficient. In addition, it has been confirmed thatsatisfactory knowledge improvement resulted throughinfection control education. However, there is still thedemand for additional hospital infection control
education programs to improve performance.
According to the two intervention studies [8, 9],nurses’ infection control awareness [8, 9] andperformance [8] were meaningfully improved throughinfection control education programs. It has been
confirmed that nurses’ infection control performanceability could also be improved by improving nurses’
infection control awareness through effective infection
control education [8]. However, Galal [9] did not
check an infection control performance through aninfection control education program. Further studies
are needed to confirm the effectiveness of infection
control education programs through additional
searches through database expansion. Also, additional
intervention studies are needed to confirm theinfection control performance.
Even though the demand for hospital infection
control education targeting nurses has been increased,intervention studies have been insufficient. In
addition, due to the lack of verification of theeffectiveness of hospital infection control education interms of performance, following up efforts to evaluate
and improve the infection control education program’s
effectiveness are required. This study recommends
effective and various educational methods applied
hospital infection control education programs must be
developed for nurses’ improvement in infection
control awareness and performance.
Conclusion
This literature review identified that nurses’
infection control awareness was high but infection
control performance was insufficient. This study was
also confirmed that awareness and performance wereincreased through infection control education, butthere are still difficulties in identifying reasonableeffects in terms of performance. An infection control
education program needs to be developed to improvenurses’ infection control awareness and performance,
as nurses are critical medical workforces to preventand control infection spread within a hospital.
References[1] Lee, M. H., Kim, M. Y., Go, Y. J., Kim, D. R., Lim, H.
N., Lee, K. H., & Yang, S. Y. (2021). Factors influencing in
the infection control performance of COVID-19 in nurses.
Journal of Digital Convergence, 19(3), 253-261.
[2] Kim, S., & Song, R. (2018). Knowledge and practice of
middle east respiratory syndrome isolation precaution
among hospital nurses. Journal of Korean Academy ofFundamentals of Nursing, 25(1), 46-57.
[3] Kim, K. M., Cha, K. S., Lee, J. Y., Yoo, S. Y., Choi, O.
J., Wie, S. H., ... & Kang, M. W. (2004). Knowledge andperformance of infection control guidelines. Korean Journalof Nosocomial Infection Control, 9(2), 139-150.
[4] Lee, J. (2020). The present and future of infection
control policy in Korea. Korean Journal Healthc Assoc
Infect Control Prev, 25(2), 70-78.
[5] Hammoud, S., Khatatbeh, H., Zand, A., & Kocsis, B.
(2021). A survey of nurses' awareness of infection control
measures in Baranya County, Hungary. Nursing Open, 8(6),3477-3483.
[6] Nasiri, A., Balouchi, A., Rezaie-Keikhaie, K., Bouya, S.,
Sheyback, M., & Al Rawajfah, O. (2019). Knowledge,
attitude, practice, and clinical recommendation toward
infection control and prevention standards among nurses: A
systematic review. American journal of infection control,
47(7), 827-833.
[7] Alrubaiee, G., Baharom, A., Shahar, H. K., Daud, S. M.,& Basaleem, H. O. (2017). Knowledge and practices ofnurses regarding nosocomial infection control measures inprivate hospitals in Sana’a City, Yemen. Safety in Health,3(1), 1-6.
[8] Lim, J., Bang, K. S., Lim, J., & Bang, K. S. (2016).
Effect of education on infection control for multidrug
resistant organism on infection control by NICU nurses.
Child Health Nursing Research, 22(3), 172-181.
[9] Galal, Y. S., Labib, J. R., & Abouelhamd, W. A. (2014).
Impact of an infection-control program on nurses’
knowledge and attitude in pediatric intensive care units at
CAIRO university hospitals. The Journal of the Egyptian
Public Health Association, 89(1), 22-28.
Author address
E-Mail: wodus0318@yonsei.ac.kr

Factors associated with exclusive breastfeeding: A literature review
Sounantha Phanthadala1), SoMi Park2), Jihea Choi3), Ki Kyong Kim2)
1)

Master’s Student, Wonju College of Nursing, Yonsei University, Wonju, Korea
2)

3)

Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

Associate Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

BackgroundFigure 1. Flow chart of article selection.

Exclusive breastfeeding

provides immune

protection for infants and supports their growth anddevelopment [1]. It also reduces the risk of respiratoryand gastrointestinal infections, ultimately leading tolower mortality rates compared to infant formula
feeding. Globally, the rate of exclusive breastfeeding, as
measured by a 24-hour diet recall, increased from 24.9%
in 1993 to 35.7% in 2013 [2]. Numerous studies have
exploredthefactorsthat

influence

exclusive

breastfeeding. Therefore, the authors systematicallyreviewed potential factors associated with exclusive
breastfeeding, based on the results of previously
published research articles. This literature review aims
to enhance understanding of exclusive breastfeedingpractices and promote more effective encouragement ofResults
1. Characteristics of selected articles

exclusive breastfeeding in Laos.

Objective
This study aimed to identify the factors
associated with exclusive breastfeeding in mothers ofinfants.

Methods
The databases PubMed, Embase, CINAHL,
and Cochrane Library were searched using the key
words “exclusive breastfeeding” and ‘woman.”Descriptive studies published between 2013 and 2023 inEnglish were reviewed. In total, 751 references wereidentified by searching, but only 7 studies met our
inclusion criteria (Figure 1).

The publication years of the papers included inthis review ranged from 2017 to 2022, and the studies
were from 5 Asian countries and 1 African country. The
subjects of the study were mothers with infants aged 6
to 24 months, and the number of participants varied
from 80 to 3,541.

2. Identified associated factors
The variables that showed statisticallysignificant associations with exclusive breastfeeding
among mothers of infants included the mother's age atmarriage, maternal motivation, marital status,
occupation, breast complications, level of education,
type of delivery, income, socioeconomic status,
frequency of antenatal care visits, and wealth index.

3. Classification of associated factors based on thesocio-ecological model
Intrapersonal factors with statisticallysignificant associations with exclusive breastfeeding, asclassified based on the socio-ecological model, werematernal age at marriage, maternal motivation, maternal
status, mother occupation, type of birth, breast
complication, mothers' education, and mothers withpoor socioeconomic status. Region of residence was asignificant community/society factor.

Conclusion
Most of the significant variables identified inthis review were not maternal characteristics that could
be changed through a nursing intervention (e.g.,maternal age at marriage, mother’s occupation, andmother’s education). However, certain significant
variables, such as maternal breastfeeding knowledge
and motivation, as well as support from the husband,
could potentially be modified through nursing
interventions. Furthermore, the majority of these studies
were conducted in developing countries in Asia andAfrica.
This literature review demonstrates that toencourage exclusive breastfeeding among mothers ofinfants in Laos, it is crucial to offer tailored interventions.
These interventions should target modifiable maternal
factors in future studies, including information(knowledge), motivation (husband’s support), andbehavioral skills (self-efficacy), all of which are
grounded in the IMB model.

References[1] Victora CG, Bahl R, Barros AJ, França GV, Horton S,
Krasevec J, Lan‑ cet Breastfeeding Series Group, etal.
Breastfeeding in the 21st century: epidemiology, mechanisms,
and lifelong efect. Lancet. 2016;387 (10017): 475–90.
[2] Victora CG, Bahl R, Barros AJ, França GV, Horton S,
Krasevec J, Lan‑ cet Breastfeeding Series Group, etal.
Breastfeeding in the 21st century: epidemio- logy,
mechanisms, and lifelong effect. Lancet. 2016;387(10017):
475–90.
[3] Lyons KE, Ryan CA, Dempsey EM, Ross RP, Stanton C.
Breast milk, a source of beneficial microbes and associatedbenefits for infant health. Nutrients. 2020;12(4):1039.

[4] A. D. A, P., et al., Is Maternal Breastfeeding Motivationand Exclusive Breastfeeding Influenced by early Marriage
age? Journal of Nepal Pediatric Society, 2022. 42(2): p. 46-51.
[5] Adugna, B., H. Tadele, F. Reta, and Y. Berhan,
Determinants of exclusive breastfeeding in infants less than six
months of age in Hawassa, an urban setting, Ethiopia.
International Breastfeeding Journal, 2017. 12: p. 1-8.
[6] Durmazoğlu, G., Ö. Çiçek, and H. Okumuş, The effect of
spousal support perceived by mothers on breastfeeding in the
postpartum period. Turkish Archives of Pediatrics, 2021.
56(1): p. 57-61.
[7] Hossain, M., A. Islam, T. Kamarul, and G. Hossain,
Exclusive breastfeeding practice during first six months of an
infant's life in Bangladesh: a country based cross-sectional
study. BMC pediatrics, 2018. 18(1): p. 93.
[8] Jama, A., et al., Exclusive breastfeeding for the first six
months of life and its associated factors among children age 624 months in Burao district, Somaliland. International
Breastfeeding Journal, 2020. 15(1): p. 1-8.
[9] Sultania, P., et al., Breastfeeding knowledge and behavior
among women visiting a tertiary care center in India: A crosssectional survey. Annals of Global Health, 2019. 85(1).
[10] Bal, N., et al., How do the determinants of exclusive
breast-feeding change over time? A multi-survey quasilongitudinal study in Lao People's Democratic Republic.
Public Health Nutr, 2022. 25(9): p. 2380-2394.

Author address
E-Mail: sounanthaphone@yahoo.com

Developing and testing the reliability and validity of a support scale
for family caregivers’ appraisal
Mika Kawabata, Kaori Saeki, Ayako Nakayama, Marina Takikawa, Junko Hoshino
Division of Nursing, Department of Integrated Health Sciences
Postgraduate School of Health Sciences, Nagoya University
Introduction
Family caregivers of care-dependent people are at highrisk of experiencing psychological distress and depression[1]. At the same time, caregivers perceive a positive
impact from their caregiving experiences [2]. In addition,
positive appraisal of caregiving was associated withhigher life satisfaction [3]. Previous research has clarified
that the support of visiting nurses (e.g., collaborating withfamily caregivers in patient care) promotes positive
appraisal of family caregivers and controls negative
appraisal of caregiving (e.g., by alleviating associatedburdens) [4,5]. Family caregivers identified healthcare
professional advice as one of their significant needs [6].
However, few measures have examined support for family
caregivers’ appraisal. This study aimed to develop a
support scale based on family caregivers’ appraisal andexamine its reliability and validity.
Methods
1. Item generation
The initial item pool was compiled in three steps:
The first steps: A questionnaire was developed based on
previous studies describing the support that visiting nurses
offer family caregivers’ appraisal. The results showed that
there were 37 items.
The second step: Interviews were conducted with visiting
nurses, asking them about the support they provide tofamily caregivers’ appraisal. The scale initially consistedof 42 items.
Third step: Three nurses and two researchers formed anexpert panel. The panel examined 42 items individually,and similar items were grouped. Finally, 16 items wereprepared.
2. Study Participants
The study participants were 87 family caregivers
providing home-based care for a family member.
3. Data collection
Participants were selected from eight home-visit nursing
stations located in various areas of Japan. The home care
support offices agreed to our study after watching an
online study presentation by researchers. Visiting nurses
distributed the questionnaires to family caregivers.
The Ethics Committee of the Nagoya University Graduate
School of Medicine approved the study (Approval no. 21138-2)
4. Measures
Participants answered a self-administered questionnaire.

(1) Characteristics of the family caregiver and carerecipient. (e.g., gender, age, duration of care, andrelationship to the caregiver)(2) The 16-item “a support scale for family caregivers’
appraisal” The item scores (ranging from 0-3) thatbelonged to the domain were summed. Higher scoresindicated recognition of support from the visiting nurse.
(3) To assess criterion-related validity, we compared thequestionnaire against an existing scale for measuring
caregiver coping strategies. The scale was developed by
Okabayashi [7]. We selected one factor, “Formal Support
Seeking” from among five caregiver coping strategies.
5. Statistical Analysis
To verify the validity of our scale, we conducted an
exploratory factor analysis using the maximum-likelihood
method and varimax rotation. Criterion-related validity
was assessed by comparing the mean performance using
Pearson correlation coefficients. Confirmatory factor
analysis was conducted to determine the validity of thefactor structure. In the reliability testing, Cronbach's alphacoefficients were confirmed. Descriptive statisticalanalyses were performed using SPSS Version 28 andAmos Version 29 software.
Results
1. Caregiver and Care Recipient Characteristics
The mean age and SD of caregivers was 68.4±11.9 years;
30 (34.5%) were male, and 57 (65.5%) were female. The
mean age and SD of the care recipients were 80.8 ± 12.6
years. Most caregivers, 57 (69.5%), had less than five
years of caregiving experience.
2. Validity Analysis
The original 16 items were examined. Item 15 wasomitted as it subsumed multiple factors. In addition, its
factor loading exceeded 0.3. The item content of thefactors identified three subscales, “empathy andcollaboration in caregiving” (Factor 1), “support thatconsiders the caregiver’s and family’s wishes” (Factor 2),
and “provision of information and skills regarding therecipient’s care” (Factor 3). (Table 1)
The caregiver coping strategies scale (Formal Support
Seeking) was used to examine criterion-related validity. It
produced correlation coefficients (r) of 0.354–0.477.
Moreover, the confirmatory factor analysis of this model
was represented by GFI＝0.807, AGFI＝0.734, CFI＝0.807, and RMSEA＝0.095.(Figure1)

3. Reliability Analysis
The Cronbach’s alpha coefficient for the entire scale was
0.914. (Table1) The I-T correlations between the items
and the factor scores showed correlation coefficients of
0.5 or higher for all items and factors.
Discussion
The scale developed in this study was reliable and valid.
The support scale for family caregivers’ appraisal can help
identify how much support they received as viewed fromtheir perspective. Continuous implementation of this scaleis required based on the duration of caregiving.
References[1] Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H.
Impact of a disease management program upon caregivers ofchronically critically ill patients*. Chest. 128(6): 3925-36. 2005.
[2] Yamamoto, N., & Wallhagen, M. I. The continuation offamily caregiving in Japan. Journal of health and social
behavior, 38(2), 164–176. 1997.
[3] Jiang, N., Lu, N., Sun, Q., & Lou, V. W. Q. Positive andnegative experiences and life satisfaction among spousal
caregivers for frail older adults in urban China: a parallel processmodel. Age and ageing, 49(4), 622–627. 2020.
[4] Hiroki Fukahori H, Kubo N, Kawada. Associations between
among Visiting Nurses Encouraging Family Caregivers’
Positive Appraisal of their Caregiving and Work-related Stress.
Japanese Journal of Research in Family Nursing, 14(1), 68-76.
2008.
Table1[5] Takechi K, Nishizaki M, Hakarnada-Taguchi, R Nursing
Care to get positive appraisal of family caregivers by visiting
nurses, Journal of Japan Academy of nursing for home care, 8(2),87-94, 2020.
[6] Janet WH S., Thomas KS W., Michael C., et al. Stroke carein the home: the impact of social support on the general healthof family caregivers, Journal of Clinical Nursing (WileyBlackwell), 13(7), 816–824. 2004.
[7] Okabayashi H, Sugisawa H,et al. The factor structure of
coping strategies and their effects on burnout among primary
caregivers of impaired elderly person. Japanese Journal of
Psychology. 69, 486–493. 1999.
Author address
E-Mail: kawabata.mika.v8@s.mail.nagoya-u.ac.jp

GFI＝0.807 AGFI＝0.734 CFI＝0.807 RMSEA＝0.095.
Figure 1 Confirmatory factor model of a support scale
for family caregivers’ appraisal

The result of Exploratory factor analysis

Factor（Cronbach's alpha）
item

Factor Lodings

Empathy and collaboration in caregiving （α=0.883）

Factor1

Factor2

Factor3

0.877

0.247

0.263

0.84

0.204

0.323

10 Visiting nurses listened to me (caregiver).

0.682

0.307

0.294

14 Visiting nurses recognized me as being skilled in the art of caregiving.

0.669

0.099

0.364

5 I worked with a visiting nurse to care for care recipient.
16 Visiting nurses were assigned to or took over the care of care recipient in order to reduce theburden of caregiving.

0.505

0.185

0.193

0.381

0.290

0.226

9
8

Visiting nurses understood the difficulties of daily care.
Visiting nurses recognized the hard work I (caregiver) put into caring for care recipient (family
member).

Support that considers the caregiver’s and family’s wishes（α=0.817）
2

Visiting nurses told me about care recipient intentions and thoughts.

0.161

0.894

0.212

1

Visiting nurses encouraged care recipient to express his/her true feelings.

0.027

0.822

0.225

4

Visiting nurses told care recipient to convey my thoughts to him/her.

0.318

0.676

0.166

3
7

Visitng nurses listened to care recipient about his/her likes and hobbies before he/she became ill.

0.239

0.477

0.101

Visiting nurse helped us to do things at home that we could not do at the hospitals or facility(e.g., hold birthday parties).

0.224

0.319

0.115

12 Visiting nurses explained care recipient's current condition.

0.307

0.239

0.793

11 Visiting nurses informed me about care recipient's illness.

0.344

0.279

0.709

13 Visitng nurses taught me caregiving techniques.

0.288

0.173

0.679

6

0.374

0.212

0.448

Factor1

Factor2

Factor3

Provision of information and skills regarding the recipient’s care（α=0.849）

Visiting nurses established a path and direction on how to provide caregiving.

（Total α＝0.914）

3.46

2.80

2.42

ratio (％)

23.06

18.64

16.15

cumulatjve contribution ratio (%)

23.06

41.69

57.84

eigenvalue
contribution

Maximum likelihood and Varimax rotation

Factors Associated with Dementia Worry among Middle-Aged or Older Adults:
A Literature Review
Ayako Nakayama1, Mika Kawabata1, Marina Takikawa1, Natsuki Tanaka1
Mikako Sakai1, Kaori Saeki2, Junko Hoshino2
1

Division of Nursing, Department of Integrated Health Sciences,
Postgraduate School of Health Sciences, Nagoya University
2

Nagoya University Graduate School of Medicine

Introduction
With an aging global population, the number of people
with dementia is predicted to triple by 2050 [1].
Consequently, we should rapidly achieve not only
prevention or treatment of dementia, but also a society inwhich people with or without dementia live together.
Accordingly, recent studies have focused on the degreeof worry about developing dementia, “Dementia Worry(DW.)”
Furthermore, DW has just defined as an emotional
response to the perceived threat of developing dementia
and has been reported to vary from responses positioned
as concern or worry to those positioned as obsessions orphobias [2]. Moreover, this study [2] found that DW wasstrong in British middle-aged and older adults, and 31%
of British participants reported fearing dementia morethan fearing other serious health problems [2]. In
Germany, DW was also reported 55% had a little or some,
16% had a severe fear of dementia [3].
Some previous studies that focused on factors of people
with stronger DW suggested the following: they had
suicidal ideation [4], and their executive function was
decreased [5]. These findings suggest the existence ofpeople with stronger DW and obstacles in their lives, aswell as the need for support. If the factors of a stronger
DW can be accurately identified, effective supports can beprovided to them according to the evidence.
Therefore, this literature review aimed to clarify thefactors associated with DW among middle-aged or older
adults.
Methods
In September 2023, we conducted a literature review
using the Web of Science database, using search termswith a combination of “dementia,” “worry,” “anxiety,”“fear,” and “concern” (Figure1). We retrieved 399 articles
and surveyed their titles and abstracts. Finally, we focusedon articles that explored factors associated with DW andselected 12 articles for this review (Table1).

Figure1: selection of articles

Results
Our literature review revealed commonalities anddifferences in factors associated with DW among several
countries. From this perspective, the results are as follows.
1. Commonality of factors associated with Dementia
Worry
Previous studies have commonalities among several
countries regarding the factors associated with DW [6, 7,
8, 9, 10, 11, 12, 13, 14].
1.1 Perception of dementia etc.
In Germany and the United States, stereotypes ofdementia or aging, such as the belief that dementia ruins
their lives, are associated with DW [6, 7]. Similarly,
prejudices and ageism are associated with it among the
Chinese and Israelites [8, 9].
1.2 Psychological health status
Depression, loss of motivation, psychological distressand insomnia are associated with DW among theAmericans, Koreans, Germans, and Chinese [10, 11, 12,13]. In addition, concerns about one’s own memories andperceived memory changes are associated with DW in the
United States, Korea and Germany [10, 11, 12].
1.3 Social background
Exposure to people with dementia and a family historyof dementia is associated with DW in Americans andKoreans [10, 11]. In addition, decline in family
functioning or attachment and unmarried among Chineseand Korean is also associated with DW [8, 14].

Table1: Articles about factors associated with DW.
CountryYear

the United States 2016
2017
2020
2021
Germany
2019
2020
2020
Korea
2019
2021
China
2022
2023
Israel, Australia 2022

Reference
No.
[10]
[7]
[4]
[5]
[12]
[3]
[6]
[14]
[11]
[8]
[13]
[9]

2. Differences of factors associated with Dementia WorryOn the other hand of the above commonality, previous
studies conducted in various countries have revealed
differences in the factors associated with DW [3, 8, 10, 11,
12, 14].
2.1 Age
For the all-age groups over 40 years old, DW was
generally strongest in the 50–70 age group and weaker inthe younger age group of 40 years old and the older age
group of 80 years and older; it resembled mountainshaped curve for Germans [12]. Furthermore, for all ages
18 and older, DW was the strongest among 45–64-yearolds in China [8]. Although several studies have generally
found an association between middle to early age and DW,
as in these two articles, age was not associated with DW
for Americans [10].
2.2 Sex
In contrast to the stronger DW in females among
Germans [3], sex was not associated with DW among
Americans [10].
2.3 Health status
Although having chronic diseases were associated withstronger DW among Koreans [11], physical health was not
associated with DW among Germans [12].
2.4 Educational background
In Korea, one study reported that higher school education
was associated with stronger DW [11], while anotherreported that lower school education was associated withstronger DW [14].
Discussion
Although some aspects of the factors associated with
DW have been clarified, several factors show conflicting
results in different backgrounds. This suggests that DW isrelated to physical, psychological, and social factors in acomplex manner. Moreover, despite the accumulation ofprevious studies in a wide range of countries, including
Europe, the United States, and Asia, we have not yet
established a theory that can explain the factors associatedwith DW. Further research is needed to support people
with strong DW based on scientific evidence.

In particular, Japan has already witnessed rampant aging
and the aging rate is approximately 30%, the highest in theworld [15]. The number of people with dementia is
expected to further increase. When the factors associatedwith DW among Japanese people are clarified, theseresults can become scientific evidence for effective carefor people whose lives are affected by DW, and we will
be able to recommend this to society.
Japan needs to lead the world in developing measuresagainst DW or supporting people suffering from it andshare the results with other countries to contribute to theworld.
References[1] Nichols,E., Steinmetz,J.D., Vollset,S.E., et al. Estimation of
the global prevalence of dementia in 2019 and forecasted
prevalence in 2050: an analysis for the Global Burden of Disease2019. Lancet Public Health. 7(2): 105-125. 2022．
[2] Kessler,E.M., Bowen,C.E., Baer,M., et al. Dementia worry:a psychological examination of an unexplored phenomenon. Eur
J Ageing. 9: 275-284. 2012.
[3] Hajek,A., Koenig,H. Fear of Dementia in the General
Population: Findings from the German Socio-Economic Panel(GSOEP). J Alzheimers Dis. 75(4): 1135-1140. 2020.
[4] Cui,R.F., Maxfield,M., Fiske,A. Dementia-related anxiety
and coping styles associated with suicidal ideation. Aging Ment
Health. 24(11): 1912-1915. 2020.
[5] Caugie,C., Bean,P., Tiede,P., et al. Dementia Worry and
Neuropsychological Performance in Healthy Older Adults.Arch
Clin Neuropsychol. 36: 29-36. 2021.
[6] Hajek,A., Koenig,H. Determinants of Perceived Own Risk
for Developing Dementia and the Perception That Memory
Deterioration Is Preventable. Findings From the General Adult
Population in Germany. Front Med. 7. 2020.
[7] Molden,J., Maxfield,M. The impact of aging stereotypes on
dementia worry. Eur J Ageing. 14: 29–37. 2017.
[8] Liu,M., Sun,F., Lu,C., et al. The Influence of Dementia
Beliefs and Knowledge on Perceived Dementia Worry: An
Empirical Study Among Adults in Rural China. Am J
Alzheimers Dis Other Demen. 37. 2022.
[9] Werner,P., Kim,S. How Are Sociodemographic, Health,
Psychological, and Cognitive Factors Associated with Dementia
Worry? An Online Survey Study among Israeli and Australian
Laypeople. Int J Environ Res Public Health. 19. 2022.
[10] Kinzer,A., Suhr,J.A. Dementia worry and its relationship todementia exposure, psychological factors, and subjective
memory concerns. Applied Neuropsychology: Adult. 23(3):196-204. 2016.
[11] Joo,S.H., Jo,I.S., Kim,H.J., et al. Factors Associated With
Dementia Knowledge and Dementia Worry in the South Korean
Elderly Population. Psychiatry Investig. 18(12): 1198-1204.
2021.
[12] Bowen,C.E., Kessler,E.M., Segler,J. Dementia worry in
middle‑aged and older adults in Germany: sociodemographic,
health‑related and psychological correlates. Eur J Ageing. 16:
39-52. 2019.
[13] Dai,H.H., Qin,J.J., Huang,R. The serial mediating effects ofsocial isolation and resilience on the relationship between fear of
dementia and insomnia in community-dwelling older adults. J
Adv Nurs. 79(5): 1994-2003. 2023.
[14] Ryu,S.I., Park,Y.H. Factors Related to Dementia Worry,
Comparing Middle-Aged and Older Adults in South Korea，Res
Gerontol Nurs. 12(6): 299-310. 2019.
[15] United Nations, Department of Economic and Social
Affairs, Population Division. World Population Prospects 2022.
Retrieved from：https://population.un.org/wpp/. (2023/5/26).
Author address
E-Mail: nakayama.ayako.v2@s.mail.nagoya-u.ac.jp

Factors related to nurse turnover Intention: A literature review

Chinzaya Boldoo1), Junghee Kim4), Gi Yon Kim2), Jihea Choi3)
1)

Master’s Student, Wonju College of Nursing, Yonsei University, Wonju, Korea
2)

Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

3)

Associate Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

4)

Assistant Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

Introduction

encompassed various countries, including China,
Iran, South Korea, Japan, the United States, andothers. The sample sizes of nurses in these studies
ranged from relatively small samples of around 133
participants to larger cohorts exceeding 17,582
nurses. Factors related to nurse turnover weredivided into two categories: individual andorganizational factors. The individual factors were
further identified as biopsychosocial and jobrelated factors.

Nurse turnover intention has a significant
impact on the quality of patient care, the financial
costs borne by hospitals, productivity, and the job
satisfaction of nursing staff. This issue is a major
concern for healthcare organizations (1). Highturnover rates among nurses have been associatedwith negative impacts on patient safety and care
continuity (2), as well as significant financial
burdens related to recruitment, orientation, andtraining of new staff (3). In addition, frequent
turnover can reduce morale and job satisfaction
among the remaining nursing workforce,
potentially leading to burnout and decreased overall
staff retention (4). Nurse turnover in hospitals is
also recognized as a problem in Mongolia. The aimof this review is to evaluate the current literature to
identify factors related to nurse turnover intention.

Figure 1. Flow chart of study selection

Methods
Studies from CINAHL, ProQuest,
PubMed, and Embase were included. The review
was conducted between January 2013 and January2023 to ensure the inclusion of up-to-date
information on the issue. The search terms usedcombinations of keywords such as "nurse turnover"and "turnover intention."
Results
Initially, 827 studies were retrieved andabstracts were screened for content relevance,
resulting in the inclusion of 14 studies in thissummary review (Figure 1). All 14 studies (5-8) inthis review used a cross-sectional research design
with observational methodologies. These studies
1

Discussion

iew–an update. International journal of nursing studies, 49(7), 887-905.
[5] Chen, H., Li, G., Li, M., Lyu, L., & Zhang, T.
(2018). A cross-sectional study on nurse turnover
intention and influencing factors in Jiangsu Province,
China. International Journal of Nursing Sciences , 5 (4),396-402.
[6] An, M., Heo, S., Hwang, Y. Y., Kim, J., & Lee, Y.
(2022, June). Factors affecting turnover intention among
new graduate nurses: focusing on job stress and sleep
disturbance. In Healthcare (Vol. 10, No. 6, p. 1122).
MDPI.
[7] Kitamura, Y., & Nakai, H. (2023). Factors Associatedwith Turnover Intentions of Nurses Working in Japanese
Hospitals Admitting COVID-19 Patients. Nursing
Reports , 13 (2), 792-802.
[8] Lyu, X., Akkadechanunt, T., Soivong, P., &Juntasopeepun, P. (2022). Factors influencing intention
to stay of male nurses: A descriptive predictive study.
Nursing & Health Sciences , 24 (1), 322-329.
[9] Kim, S. O., & Moon, S. H. (2021). Factors
influencing turnover intention among male nurses in
Korea. International Journal of Environmental Researchand Public Health , 18 (18), 9862.
[10] Jiang, Nan, Xuan Zhou, Yanhong Gong, Mengge
Tian, Yafei Wu, Jiali Zhang, Zhenyuan Chen et al.
"Factors related to turnover intention among emergency
department nurses in China: A nationwide cross‐sectional
study." Nursing in Critical Care 28, no. 2 (2023): 236244.
[11] Mirzaei, A., Rezakhani Moghaddam, H., & Habibi
Soola, A. (2021). Identifying the predictors of turnover
intention based on psychosocial factors of nurses during
the COVID‐19 outbreak. Nursing Open , 8 (6), 34693476.
[12] Baek, G. L., & Lee, E. (2022). Impact of workplacebullying and resilience on new nurses' turnover intention
in tertiary hospitals. Nursing & Health Sciences , 24 (4),801-810.
[13] Mafula, Dluha; Martani, Hersinta Retno; Widyawati,
Widyawati
Psychiatry Nursing Journal / Jurnal
Keperawatan Jiwa, Mar2023; 5 (1): 16-22. 7p.
(Article - research) ISSN: 2656-3894 ,[14] Wubetie, A., Taye, B., & Girma, B. (2020).
Magnitude of turnover intention and associated factors
among nurses working in emergency departments ofgovernmental hospitals in Addis Ababa, Ethiopia: across-sectional institutional based study. BMC nursing ,19 (1), 1-9.
[15] Wang, X. X., Wang, L. P., Wang, Q. Q., Fang, Y. Y.,
Lv, W. J., Huang, H. L., ... & Zhang, Y. H. (2022).
Related factors influencing Chinese psychiatric nurses'
turnover: A Cross‐Sectional study. Journal of psychiatricand mental health nursing , 29 (5), 698-708.

Amongindividual
factors,
biopsychosocial elements such as age, gender,
education level, and sleep disturbances have beenfound to influence nurse turnover. Additionally,
job-related factors like job stress, satisfaction, andburnout are also linked to turnover. To reduce nurse
turnover, hospitals need to take into account thesebiopsychosocial
factorsand
implementinterventions aimed at reducing occupational stressand burnout. Organizational factors that have been
identified as influencing nurse turnover include
cultural aspects such as organizational leadership,professional opportunities, and conflicts. As such, it
is crucial to shift the hospital's organizational
culture in a positive direction. Healthcareorganizations in Mongolia must acknowledge theimportance of identifying and addressing these
related factors in order to maintain a stable andsatisfied nursing workforce.

Conclusion
Nurse turnover intention is a multifacetedissue that warrants further investigation andunderstanding. It is crucial to identify and address
the diverse factors contributing to nurse turnover
intentions, as this knowledge can inform thedevelopment of effective strategies. These
strategies can significantly influence healthcareorganizations and the quality of patient care.
Consequently, ongoing research and interventions
that consider a range of factors are necessary to
mitigate the issue of nurse turnover in Mongolia.

References[1] Hu, H., Wang, C., Lan, Y., & Wu, X. (2022). Nurses’
turnover intention, hope and career identity: the mediatin
g role of job satisfaction. BMC nursing, 21(1), 1-11.
[2] Peng, X., Ye, Y., Ding, X., & Chandrasekaran, A.
(2023). The impact of nurse staffing on turnover andquality: An empirical examination of nursing care within
hospital units. Journal of Operations Management .
[3] Kelly, L. A., Gee, P. M., & Butler, R. J. (2021).
Impact of nurse burnout on organizational and position
turnover. Nursing outlook , 69 (1), 96-102.
[4] Hayes, L. J., O’BrienPallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes,F., ... & North, N. (2012). Nurse turnover: a literature rev

2

[16] Choi, H., & Shin, S. (2022). The factors that affectturnover intention according to clinical experience: afocus on organizational justice and nursing corecompetency. International Journal of Environmental
Research and Public Health , 19 (6), 3515.
[17] Liu, Y., Duan, Y., & Guo, M. (2023). Turnover
intention and its associated factors among nurses: amulti-center cross-sectional study. Frontiers in Public
Health , 11 , 1141441.
[18] Yang, H., Lv, J., Zhou, X., Liu, H., & Mi, B. (2017).
Validation of work pressure and associated factors
influencing hospital nurse turnover: a cross-sectional
investigation in Shaanxi Province, China. BMC healthservices research , 17 , 1-11.
Author address
E-Mail: boldoochinzaya@gmail.com

3Factors related to nurses’ organizational commitment: A literature review

Odbayar Delgerekh1), Ki Kyong Kim 2), Jihea Choi3), SoMi Park2)
1) Master’s Student, Wonju College of Nursing, Yonsei University, Wonju, Korea
2) Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea
3) Associate Professor, Wonju College of Nursing, Yonsei University, Wonju, Korea

Introduction:
Organizational commitment (OC) is a crucial
element in the nursing field, significantly impacting
nurse turnover and work-related outcomes [1]. This
concept is multifaceted, with both attitudinal andbehavioral perspectives playing a role [2]. The
attitudinal perspective emphasizes an employee's
identification with the organization and their aspiration
to sustain a long-term relationship [3]. Conversely, thebehavioral perspective characterizes OC as anindividual's commitment to the organization,
demonstrated by the personal time they devote toorganizational activities [4].
Mowday et al. [5] defined OC as "the relative strengthof an individual's identification with and involvement
in a particular organization." Optimal nursing
performance
dependsupontheknowledge,
competencies, job satisfaction, and OC of individual
nurses [6].
Recognizing that factors related to OC may evolve
over time due to changing roles in nursing [7], it is
crucial for nurse managers to understand the factors
influencing OC within the current nursing workforce.
This review aims to evaluate these determinants aspresented in the current literature, shedding light on themultifaceted nature of nurses' OC in hospital settings.

PurposeThis study was conducted to identify anddescribe the factors relating to nurses' OC in publishednursing research.
MethodStudy Design: This study conducted athorough review of the research literature tocomprehensively investigate the factors related tonurses' OC.
Data Sources: The research commenced with anextensive search strategy across four major electronic
databases: CINAHL, Embase, PubMed, and Cochrane.
This choice of databases was designed to guarantee athorough and exhaustive investigation of the pertinent
academic
literature,
using
the
key
terms
“organizational commitment” and “nurses.”
Inclusion Criteria: To ensure the inclusion of up-todate and relevant research, this literature review
considered studies that met the following criteria:
1.

Publication from 2013 to 2023, thereby
encompassing recent developments in thefield.

2.

Focus on investigating factors that influenceor are related to nurses' OC.

3.

Studies published in the English language.

4.

Studies that used a cross-sectional design

Data Collection: A systematic and rigorous datacollection process was conducted for all studies
meeting the aforementioned inclusion criteria. This
involved the comprehensive extraction of pertinent
information from these studies.
Final Sample: The systematic search across fourelectronic databases yielded a total of 663 studies
relevant to the study topic. Following the application of
the inclusion criteria, as well as the completion of data
extraction and analysis, the ultimate sample for thisreview consisted of a total of 13 studies. These studies
met the inclusion criteria and provided valuable
insights into the factors relating to nurses' OC within
the specified timeframe (2013-2023).

Data Analysis: The data extracted from the selectedstudies were meticulously and thoroughly analyzed.
This process entailed the systematic categorization offindings pertaining to factors related to nurses' OC.
Figure 1: Flow chart of article selection for the review.

Results:
1. Characteristics of selected articles
The selected papers were categorized based on
several characteristics, including the author, year of
publication, country of origin, sample setting, variables,and significant factors.
2. Relevant characteristics according to category
2.1 The significant personal characteristics were age,gender (male), years of experience (5), religion(Muslim), participation in an ethics course,
departmental affiliation, monthly income, average
hours of sleep per day, level of dedication, job
satisfaction, passion, psychological empowerment,
self-determination, alignment with the organization'svalues(person-organization
fit),
perceived
overqualification (viewed negatively), symptoms ofanxiety (also viewed negatively), and psychologicalcapital.
2.2 The organizational characteristics were promotion(-), perceived empowerment, organizational climate,supervisor social support, vigor, absorption, internalmarketing, learning organization, and structuralempowerment.
Conclusion:

In this review, we analyzed 13 out ofidentified 663 studies to gain insight into the factors
influencing nurses' organizational commitment from2013 to 2023. Notable factors include job-related
elements such as job satisfaction, and psychosocial
factors like psychological empowerment, psychologicalcapital, and structural empowerment. Healthcareorganizations should concentrate on these areas toboost nurses' commitment, taking into account culturaland psychosocial variations. This review provides
valuable guidance for enhancing nurse commitment,
which benefits both healthcare systems and patient care.
The studies selected for this review collectively
contribute to a more profound understanding of the
intricate dynamics surrounding nurses' commitment totheir organizations. Further research should continue to
track these commitment dynamics beyond 2023. Thereis also a need for future research on the psychosocial
variables that influence nurses' organizational
commitment.
The limitation to studies published solely inEnglish suggests that we may have missed some valid
research. Further investigation is required into thepsychosocial factors influencing nurses' commitment totheir organizations.
References[1] Hayes LJ, O’Brien-Pallas L, Duffield C, Shamian J,
Buchan J, Hughes F, et al. Nurse turnover: A literature review.
Int J Nurs Stud. 2006;43:237–63.
[2] Zangaro GA. Organizational commitment: A concept
analysis. Nurs Forum. 2001;36:14–22.
[3] Blau GJ, Boal KB. Conceptualizing how job involvement
and organizational commitment affect turnover andabsenteeism. Acad Manage Rev. 1978;12:288–300.
[4] Price S. Future directions for career choice research innursing: A discussion paper. Int J Nurs Stud. 2009;46:268–76.
[5] Mowday RT, Steers RM, Porter LW. The measurement oforganizational commitment. J Vocat Behav. 1979; 14:224–47.
[6] Dinc M, Kuzey C, Steta N. Nurses’ job satisfaction as amediator of the relationship between organizational
commitment components and job performance. J Workplace
Behav Health. 2018;33(2):1–21.
[7] Carver L, Candela L. Attaining organizational
commitment across different generations of nurses. J Nurs
Manag. 2008; 16:984–91.
Author address
E-Mail: Ododko@gmail.com

Generations of Nurses in Korea: A Scoping Review

Woori Lee1)
1) Department of Nursing, Wonju College of Nursing, Yonsei University, Wonju, Korea

1. Introduction
According to a 2021 report published by King's College
in the UK, Korea ranked first among 28 OECD countries
in ideological, rich, gender, academic, political,
generational, and religious conflicts, and Korea's
generational conflict is high among OECD countries.
According to a recent 2023 survey conducted by Korea
Research, 80% of people felt that the generational conflict
was serious, and 49% felt that the seriousness of thegenerational conflict would be similar or increasingly
serious, up from 43% in 2022[1]. In addition, according toa 2020 survey conducted by the Korea Chamber ofCommerce and Industry, 6 out of 10 workers (63.9%) of
30 large and medium-sized companies feel the generation
gap, and the degree to which the generation gap negatively
affects their work has increased[2]. Over the past decade,as interest in generational conflicts has increased invarious fields, studies on generational differences andgenerational conflict among nurses in hospitals have also
increased. However, literature review studies on
generations of nurses in Korea were insufficient.
Therefore, it is necessary to examine research related toon generations of nurses in Korea and to identify overall
research to find ways to resolve generational conflicts inthe organization.
2. Purpose
This study aims to understand the general characteristics,
research methods, related variables, and characteristics ofresearch results of the study on generations of nurses in
Korea through a scoping review.
3. Methods
The research process was conducted to the five steps ofArksey and O'Malley(2005). The data were searchedbased on PubMed, Cochrane, CINAHL, EMBASE,KMBASE, KoreaMed, KISS, KISTI, NDSL, RISS, andDBpia. Studies published up to August 2023 were
included. The selected 8 studies were organized using
Zotero and Microsoft Excel.
4. Results
1) General Characteristics
The final selection of 8 studies revealed that there wereno publications between 2013 and 2019. However, there
were 4 studies published from 2020 to 2022 and another 4
studies published in 2023.

2) Research Design and Purpose
A total of 8 studies were all quantitative research,
consisting of 3 descriptive survey studies, 4 descriptive
correlational studies, and 1 structural model validation
study. The purposes of each study were as follows: 3
studies aimed to elucidate generational differences, 3
studies investigated the correlations among variables
related to generations, 1 study aimed to identify factors
influencing generational conflict in organization, and 1
study focused on constructing a structural model andvalidating the structural relationships among variables.
3) Participants Characteristics
The sample sizes ranged from 97 to 560. The participants
were classified into generations based on their birth years
in a total of 7 studies. Among them, 6 studies madedistinctions between X, Y, and Z generations as criteria,
while 1 study used the MZ generation as a criterion. Therewas 1 study that did not specify the criteria forgenerational classification.
4) Variables, Analysis Methods, and Research Results
The study encompassed a total of 20 variables related to
Korean hospital nurses' generations. Among thesevariables, the most frequently mentioned were Work
Values and Organizational commitment, each covered inthree studies.
Regarding the research methods, all eight selected articles
employed non-experimental research designs, consistingof five multiple regression analyses, one correlation
analysis, one chi-squared test, and one structural equation
modeling analysis.
When looking at the study results, a total of seven studies
examined generational differences by distinguishing
between generations based on birth years. Among these,
X-generation nurses showed higher Job Satisfaction andOrganizational Commitment than Y and Z-generation
nurses. Additionally, X-generation nurses exhibited apreference for intrinsic Work values and consideredfamily life and work to be important. Furthermore, Xgeneration showed higher Professional pride andOrganizational Commitment than Y- and Z-generation.
In contrast, Y and Z-generation nurses exhibited asignificant positive correlation between Work Values and
Job Satisfaction, primarily favored extrinsic Work values,
and tended to prioritize leisure time. They also placed
more importance on interest in their work compared to X-

generation nurses. Additionally, higher education levels,
specifically postgraduate education, were associated withincreased Job Embeddedness. The factors affecting
Retention Intension were found to be Job Embeddedness,
Nursing Practice Environment, and Job Esteem.
Among X and Y-generation nurses, their communication
Types were found to be more similar to each other than tothose of Z-generation nurses. X and Y-generation nurses
also tended to prioritize family life. In the case of Zgeneration nurses, Emotional Labor and Burnout were
found to have a greater impact on their Organizational
Commitment compared to X and Y-generation nurses.
Across all generations, Job Satisfaction andOrganizational Commitment displayed a strong positive
correlation. Factors such as financial benefits, job security,
and working environment were considered important.
Furthermore, Social Support was identified as the mostsignificant influencing factor on Organizational
Commitment.
5. Discussion
The limitations of this study include the very limited
number of final selected documents and the fact that the
PRISMA protocol guidelines were not followed in theliterature selection process. Furthermore, in the case of thescoping review, the absence of the ability to evaluate thequality of the literature may affect the validity andreliability of the research results. However, this study has
significance in exploring the scope and diversity of theresearch through the scoping review, providing a broader
understanding of research topics and issues. Additionally,it thoroughly examined the trends in research on thegenerational differences among hospital nurses in South
Korea, including the methods used for generational
categorization and the relevant variables. Moreover, thestudy's value lies in providing evidence and directions to
mitigate intergenerational conflicts in organizations.
6. Conclusion
This study suggests various approaches such as
qualitative research, literature reviews, and intervention
studies in research related to generations of Korean
hospital nurses. Secondly, there is a need for research
approaches that can distinguish generations through clear
terminology definitions and conceptual modeling. Thirdly,
it is necessary to investigate how the variables that reflect
generational differences among Korean hospital nurses
actually impact generational conflict in organization.
Furthermore, this research emphasizes the importance ofnursing organizations in understanding generational
differences, resolving intergenerational disconnects andconflicts, and fostering a supportive nursing practiceenvironment and organizational culture to enhance job
satisfaction and organizational commitment.

7. References[1] Korea Chamber of Commerce and Industry. Comprehensive
diagnosis of generational conflict and corporate culture in theworkplace. Retrieved June 10, 2022, fromhttps://www.korcham.net/nCham/Service/Economy/appl/KcciReportDetail.asp?SEQ_NO_C010=20120932732&CHAM_CD=B001[2] Kim, Y.S., & Hur, C.Y. Effects of generation conflict in public
institutions on job burnout: Mediating effect of job stress &moderating effect of clan culture. Korean Review of Management
Consulting, 13(4): 153-179. 2022.
[3] Arksey, H., & O'Malley, L. Scoping studies: Towards a
methodological framework. International Journal of Social
Research Methodology, 8(1): 19-32. 2005.
[4] Lee, S. A., & Lee, J. Differences in occupational values,
communication types, job satisfaction, and organizational
commitment among clinical nurses across generations. Frontiersin Psychology, 14, Article 1174197. 2023.
[5] Lee, S.H., & Yi, Y.J. Work values and communication styles
among Generation X, Y, and Z nurses: A cross-sectional
study. International Nursing Review. Published July 14, 2023,
from https://doi.org/10.1111/inr.12863[6] Lee, H.S., & Kim, Y.H. Generational differences in values of lifeand factors influencing turnover intention among Korean nurses.
Journal of Digital Convergence, 19(1): 217–228. 2021.
Ahn, S.M., & Lee, H.S. Generational differences between nurses
focus on work value and job engagement. Journal of Digital
Convergence, 18(9): 199-210. 2020.
[8] Seo, E.J., Yun, S.H., Kim, H.J., & Hong, E.H. Journal of the Korea
Safety Management & Science, 23(2): 1-8. 2021.
[9] Kwon, J.E., & Kim, E.Y. Impact of nursing organizational culture
and nursing practice environment on generational conflict inorganization among hospital nurses. Journal of Korean Academyof Nursing Administration, 29(1): 45-54. 2023.
[10] Jo, G.W., & Kim, E.J. Effects of generation on professional prideand organizational commitment among hospital nurses: The
mediating effects of individualism-collectivism tendency. Journalof Muscle and Joint Health, 30(1): 15-24. 2023.
[11] Chae, J. H., & Kim, Y. S. A structural equation model oforganizational commitment by hospital nurses: The moderating
effect of each generation through multi-group analysis. The
Journal of Korean Academic Society of Nursing Education, 28(3):305-316. 2022.
[7]

Author address
E-Mail: woori.2521@gmail.com

Radiological Science/Radiological Technology: Lecture room-1（Main building 2F）
13:30 ～ 14:30

Chair

14:30 ～ 14:40

10-minute break

14:40 ～ 15:40

Chair

Prof. Hirano Yoshiyuki

NagoyaJehyeong Yeon

YonseiHabin Kim

YonseiJi Won Choi

YonseiYoon Soo Chung

Yonsei

Directional radiation monitoring system using Artificial Neural Network

Prof. Chul Hee Min

YonseiPresentation: 10 min, discussion and questions: 5 min

Aoyama Kanako

NagoyaJiyong Shim

Yonsei

Honjou Haruto

NagoyaSoo Min Lee

YonseiPresentation: 10 min, discussion and questions: 5 min
Removal of gradient and pulse artifacts in simultaneous EEG-DTI dataacquisition: An AAS and ICA approach
Radiation-Hardened Preamplifier Design for Radiation Detector
Investigation of fetal dose from carbon radiotherapy during pregnancy - Monte
Carlo study

Evaluating nanoparticle candidates as radiation modifiers on DNA damages forradiation therapy
New Method for Dental Panoramic Reconstruction Using Cone-BeamComputed Tomography Projection Data
Simulation study of a bent crystal based monochromatic X-ray imaging with an
X-ray tube
Study on the Sewage Sludge Reduction and Solubilization Depending on Doseof Gamma Irradiation

Removal of gradient and pulse artifacts in simultaneous EEG-DTI data acquisition: An
AAS and ICA approach
Jehyeong Yeon1, Chang-Soo Yun1, and Bong Soo Han1*
Department of Radiation Convergence Engineering,1

College of Software Digital Healthcare Convergence, Yonsei University, Republic of Korea
Introduction
The glymphatic system(GS) is a waste clearance
system in the human brain that utilizes the influx of
cerebrospinal fluid (CSF) into parenchyma during sleep[1]. The intratissue influx of CSF affects the diffusion
properties of the brain tissue. Therefore, diffusion
tensor imaging (DTI) is a usful technique for noninvasively monitering the function of GS
Dynamic monitoring of GS function using DTI
requires information about the patient's sleep stages at
the time of the DTI data acquisition. This requires
simultaneous
acquisition
of
DTI
and
electroencephalgraphy (EEG).
However, simultaneous EEG-DTI is accompanied
by significant challenges, particularly in the quality of
EEG signal. Prominent among these challenges are thegradient artifact (GA) and pulse artifact (PA). The GA
is induced by the rapid switching of gradient magnetic
fields in MRI, with intensity being 10 to 100 times
larger than that of the EEG signal [2-4]. Concurrently,
the PA is caused by electrode movements within thestrong static magnetic field, influenced by the subject's
pulsating scalp and blood flow [5-7]. The averageartefact subtraction (AAS) technique has been widelyused for the removal of GA in simultaneous EEG-fMRI.
In this study, in order to use for identifying sleep
stages, we studied GA and PA removal from EEG
signals measured in simultaneous EEG-DTI using AAS
and Independent Component Analysis (ICA).
Methods
Participants (male, n = 4, age = 20 – 30) were
subjected to sleep deprivation. To facilitate the onset ofsleep within the MR environment, participants wereadministered a sedative.
EEG signals were measured outdie the MRI scanroom for 90 s for artifact-free EEG signal (EEGo).
During the experiment, EEG signals were measured
continuously and fifteen DTI scans were performed,
each scan after 90-second rest. EEG signal
simultaneously measured with DTI (EEGd) and EEG
signal measured during 90-second rest (EEGr) wereacquired.
GA and PA removal algorithms that incorporate theapproach proposed in [5] were included in in-housedeveloped MATLAB software (R2023a, MathWorks,
Natick, MA, USA). Given the inherent synchronization
challenges between EEGd, an novel synchronization

approach was used. The first EEGD was designated as
the reference. An arbitrary point within this EEGD was
picked, and subsequent EEGd was then correlated withthis reference. The starting point of each epoch was
identified by pinpointing the maximum correlation to
the reference, ensuring optimal alignment. Post
synchronization, AAS technique was employed toremove GA from EEGs. To remove the PA from EEGs
and EEGr, we employed ICA to accurately isolate andeliminate them.
After artifact removal, the resulting EEGd were
evaluated using spectral anlaysis. Since we analyzed
EEG signals measured in sleeping state, the EEG signal
power ratio of EEGd and EEGo were calculated fordelta (1 – 4 Hz), theta (4 - 7.5 Hz), alpha (8 – 14 Hz),and beta (14 – 30 Hz) waves.
Results
Table 1 shows the power spectral distribution ratiosof the Delta, theta, Alpha and Beta for each subject.
Theta and Alpha waves show a ratio close to 1,
indicating that GA and PA were well removed. To
minimize the difference between subjects, all epochs
without GA and with removed GA were compared. The
results for a total of subjects were delta wave: 0.443,
theta wave: 0.818, alpha wave: 0.968, and beta wave:
1.448.
Table. 1: Power spectral distribution ratios of the EEG signal
after AAS and ICA processing and the artifact-free EEG
signal GA for each subject.
Delta
Theta
Alpha
Beta
Subject 1
0.992
0.652
0.277
1.000
Subject 2
0.113
1.000
1.717
0.735
Subject 3
0.236
0.997
0.751
3.058
Subject 4
0.429
0.621
1.129
0.999
Total
0.443
0.818
0.968
1.448

Discussions
Simultaneous EEG/DTI measurements are essential
to monitering the GS function. In this study, we
employed both the AAS and ICA techniques to remove
the artifacts in EEG signal generated during
simultaneous EEG/DTI measurements.
We focused on delta, theta, alpha, and beta waves,which are essential for determining sleep states.
The power distribution of theta and alpha waves
indicates that GA and PA were well removed in thedelta and theta waves. the possibility of accurately

identifying sleep stages through EEGs. However, there
may be differences in low-frequency delta waves fromperson to person. If the onset timing of the gradient
field is different for each EEGd, GA removal may not
be effective above 15 Hz. When EEG-DTI is measured
simultaneously, the onset time of the gradient pulse is
not recorded, synchronizing the onsets of the GA
signals. However, the proposed method pinpoints thestarting signal of the gradient pulse and effectively
remove both GA and PA, especially below 13 Hz. Iflarge residual artifacts remained despite GA removal,
they were sometimes mistaken for beta waves. It has
been reported that residual artifacts in GA can beeffectively removed by increasing the number of EEGd[5]. Therefore, this study suggests that sleep stages canbe identified from the artifact-removed EEGs using the
proposed method if the number of simultaneous EEGDTI increases to greater than 25.
References[1] Xie, L., Kang, H., Xu, Q., Chen, M.J., et al. Sleep drives
metabolite clearance from the adult brain. Science,
342.6156: 373-7, 2013.

[2] GONÇALVES, S. I., et al. Artifact removal in coregistered EEG/fMRI by selective average subtraction.
Clinical Neurophysiology, 118.11: 2437-2450, 2007.
[3] NEGISHI, Michiro, et al. Removal of time-varying
gradient artifacts from EEG data acquired during continuous
fMRI. Clinical neurophysiology, 115.9: 2181-2192, 2004.
[4] MULLINGER, Karen J.; YAN, Winston X.;
BOWTELL, Richard. Reducing the gradient artefact insimultaneous EEG-fMRI by adjusting the subject's axial
position. Neuroimage, 54.3: 1942-1950, 2011.
[5] ALLEN, Philip J.; JOSEPHS, Oliver; TURNER, Robert.
A method for removing imaging artifact from continuous
EEG recorded during functional MRI. Neuroimage, 12.2:
230-239, 2000.
[6] SRIVASTAVA, Gaurav, et al. ICA-based procedures forremoving ballistocardiogram artifacts from EEG dataacquired in the MRI scanner. Neuroimage, 24.1: 50-60, 2005
[7] MULLINGER, Karen J.; HAVENHAND, Jade;
BOWTELL, Richard. Identifying the sources of the pulse
artefact in EEG recordings made inside an MR scanner.
Neuroimage, 71: 75-83, 2013.
Author address
E-Mail: yy77887@yonsei.ac.kr

Radiation-Hardened Preamplifier Design for Radiation Detector
Minuk Seunga, Habin Kimb, and Inyong Kwonc,*aCollege of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Koreab

Department of Radiation Convergence Engineer, Yonsei University, Wonju, Republic of Koreac

Department of Radiological Science, Yonsei University, Wonju, Republic of Korea

1. Introduction
In an era where electronic devices have become
indispensable components of our daily lives, thedemand for reliable, high-performance circuits hasreached unprecedented levels. Whether it's forcommunication,
data
processing,
medicalinstrumentation, or space exploration, electronicsystems must not only function flawlessly but also
endure the harshest of environments. One suchchallenging environment is radiation, which
encompasses a spectrum of ionizing and non-ionizing
radiation sources, including cosmic rays, solar radiation,and terrestrial radiation.
The effects of radiation on electronic circuits can be
detrimental, leading to data corruption, device
malfunctions, and even complete system failures. In
critical applications, such as those in aerospace, nuclear
facilities, and medical devices, the need for radiationhardened circuits is paramount. This has sparked athriving area of research and development dedicated tothe design and optimization of radiation-resistantelectronic circuits. This paper delves into the realm ofradiation circuit design, addressing the uniquechallenges and opportunities it presents. We explore thefundamental principles, strategies, and innovations thatenable circuits to operate reliably in radiation-richenvironments. With a focus on both ionizing and nonionizing radiation, we aim to provide a comprehensive
overview of the current state-of-the-art in radiationhardened electronics. We researched a study onradiation-hardened by design (RHBD) preamp designusing binary weighted current source (BWCS).
2. Methods
The radiation hardening strategy involves using a 6bit BWCS to compensate for changes in the current
level of the preamplifier to minimize the total
ionization dose (TID) effect. This preamp is designed
using a two-stage operation amplifier (OP-AMP),
which features low power, low noise, high speed, andproper gain.
The preamp proposed in Fig. 1(a) is designed tocompensate for the TID effect. In addition, theconfiguration of the OP-AMP consisting of the same
circuits as the CSA is used for the proposed pre-amp
consisting of self-bias circuits, transmissions. The gate

Fig. 1 (a) Block diagram of proposed preamplifier. The proposed
preamplifier consists of two parts: the CSA and replica. (b)Configuration of two-stage OPAMP used for proposed preamplifier.
The OPAMP has a 6-bit binary weighted current source (BWCS) tocompensate for TID effects.

Fig. 2 Configuration of the BWCS control circuit. The circuit consistsof a ring oscillator, counter control logic, and a 6-bit up-and-down
counter.

Fig. 3 Photograph of the proposed preamplifier circuit in 0.18μm
standard CMOS technology.
Table 1
Electrical parameters of the two-stage OPAMP with 6-bit BWCS.
Parameters (unit)

Value

Supply voltage (V)Miller capacitance (pF)Open loop gain (dB)
3dB BW (kHz)
GBWP (MHz)Phase margin (° )

1.8
1
66
112.5
217.1555

contains a 6-bit BWCS, as shown in Figure 1(b). RHBD
techniques can significantly improve theperformance of the system in a radiation environment.
The BWCS circuit consists of a ring oscillator, a 6-bit
up-and-down counter, and control logic, as shown in
Fig. 2. Depending on the output signal from the BWCS
circuit, supply current to the OP-AMP at the proposed
pre-amp in the range of 1I to 64I. By self-compensating
techniques for this current, the pre-emp can mitigatechanges in current induced by radiation effects.
The RHBD preamplifier was implemented in a
general-purpose complementary metal-oxide-siliconfield effect transistor (MOSFET) 0.18μm technology
process. A photograph of the fabricated chip is shownin Fig. 3. The active area of the proposed circuit
occupies 0.1208 mm2. Table 1 lists the electrical
specifications of the OP-AMP for the proposed
preamplifier.
3. Results and Discussions
The verification test was conducted by the Korea
Atomic Energy Research Institute (KAERI) using
cobalt-60 gamma-rays at a rate of 10.46kGy (SiO2) at a
rate of 230kGy (SiO2)/h. Experiments showed that thedigital code had a maximum value of 42 and aminimum value of 29 while the initial value was 39
before the test. The results indicate that the systemcurrent level tends to decrease as a result of radiation
effects. This phenomenon might have been related to
the leakage current increase. When the leakage current

Fig. 4 During irradiation test with gamma rays up to 230kGy (SiO2):(a) recorded output of CSA and(b) error rate of normalized amplitude of the preamplifier obtained asa maximum error rate of 2.39%

increased, the system current level also increased. Thus,
the BWCS was able to decrease the system current.
Fig. 4 shows the output of the preamp at 50kGy (SiO2)
intervals during the test. Changes in the output
amplitude may result from changes in the open-loop
gain. The open-loop gain was determined by thetransconductance and output resistance of the OP-AMP.
Fig. (b) depicts the error rate of the normalized
maximum amplitude of the proposed preamplifier. A
maximum error of 2.39% was observed at 100kGy(SiO2), with the digital code reaching 38.
4. Conclusion
The RHBD preamplifier can mitigate radiationinduced degradations, particularly TID effects, bycompensating the tail current of the OPAMP used forthe preamplifier using a 6-bit BWCS, through which awide range of current (1I to 64I) can flow. The replica
OP-AMP of the proposed preamplifier detects thechanges in the operating point caused by the total
radiation dose and generates a signal to control the
BWCS, aiming to minimize TID effects. The circuit
was fabricated using the 0.18μm CMOS process, andoccupied 0.1208 mm2. An irradiation test was
performed using a gamma-ray source up to 230kGy(SiO2) at a rate of 10.46kGy (SiO2)/h. The RHBD
preamplifier could be used in various sensor
applications, particularly radiation environments,
because the proposed circuit could maintain its
performance regardless of increased radiation exposure.
Acknowledgments
This work was supported in part by the Basic Science
Research Program through the National Research Foundationof Korea (NRF) funded by the Ministry of Science and ICT(RS-2022-00144419 and 2022M3F3A2A01072851)
Also, this work was supported by the Korea Institute ofEnergy Technology Evaluation and Planning (KETEP) andthe Ministry of Trade, Industry & Energy (MOTIE) of the
Republic of Korea (No. 20214000000070).

References[1] Minuk Seung, Jong-Gyun Choi, Wooyoung Choi, andInyong Kwon*, “Radiation-hardened-by-design preamplifier
with binary weighted current source for radiation detector,”
NuclearEngineeringandTechnology,
10.1016/j.net.2023.09.023, 2023.
Author address
Minuk Seung: E-Mail: mseung0409@yonsei.ac.kr
Habin Kim: E-Mail: vinny6780@yonsei.ac.kr
Inyong Kwon: E-Mail: ikwon@yonsei.ac.kr

Investigation of fetal dose from carbon radiotherapy during pregnancy- Monte Carlo study
Ji Won Choi1, Yongdo Yun2, Se Hyung Lee3, Choonsik Lee4, Min Cheol Han2*, Yeon Soo
Yeom1*, Jin Sung Kim2
12

Department of Radiation Convergence Engineering, Yonsei University, Republic of Korea

Department of Radiation Oncology, Yonsei Cancer Canter, Heavy Ion Threapy Research Institute, Yonsei
3
4
5

University College of Medicine, Republic of Korea

Department of Nuclear Engineering, Hanyang University, Republic of Korea

Division of Cancer Epidemiology and Gentics, National Cancer Institute, United States of America

Introduction
Radiotherapy for pregnant cancer patients is
considered when it is essential for the primary
treatment, or when surgery and/or chemotherapy are
insufficient [1]. Compared to conventional photon
therapy, particle therapy using proton or carbon ion
beams, which can improve dose conformity to thetarget by their unique dose distribution (i.e., Braggpeak), may provide a better focus on the tumor regionof the mother and reduce the dose for fetus [2]. A
successful case has been reported in which proton
therapy for craniospinal irradiation (CSI) was
administered to a pregnant woman with an atypicalteratoid/rhabdoid tumor [3]. Recently, a Monte Carlo(MC) study was conducted to systematically quantify
the amount of the fetal dose contributed by secondary
particles (neutrons and photons) produced by theinteraction of the proton beams within the body of themother treated with the CSI [4].
Radiotherapy with carbon ion beams which have a
sharper Bragg peak than proton beams has been
recently getting more attention. Carbon ion therapy,
therefore, can be also considered applicable for the CSI
treatment to pregnant patients while the detailed
information of the fetal doses is yet to be reported. To
fill this gap, we investigated fetal organ doses fromcarbon beam CSI during pregnancy by performing MC
dose calculations and compared to the fetal doses
estimated for the proton CSI in the previous study [4].
Methods
We employed the high-quality pregnant female
phantom series developed by University of Florida(UF) for eight gestational ages (8, 10, 15, 20, 25, 30, 35,
and 38 weeks) [5, 6]. The phantoms were converted
into
DICOM-RT(Digital
ImagingandCommunications in Medicine – Radiotherapy) format
by using a conversion program, DICOM-RT generator[7]. The converted DICOM-RT data were implemented
into a treatment planning system (TPS) with aprescribed dose of 36 Gy to create a carbon CSI plan,as shown in Fig. 1. TPS dose distributions on the
pregnant phantoms for 25-week from carbon therapy
are shown in Fig. 2. The carbon CSI plan (CT and beam
information) for each gestational age was simulated by
performing TOPAS (Tool for Particle Simulation) MC
based dose calculation system that were commissioned
to the carbon beam measurement data. We computed
organ/tissue-averaged absorbed doses for the following
28 organs of the fetus: bone, lungs, colon, stomach,breasts, testes, ovaries, urinary bladder, esophagus,
liver, thyroid, brain, salivary glands, skin, adrenals,
extrathoracic (ET) region, gall bladder, heart, kidneys,
muscle, oral mucosa, pancreas, small intestine, spleen,
prostate, uterus, thymus, and eye lenses.

Fig 1. 3D view of 25-week pregnant phantom
implemented in treatment planning system wherecarbon CSI is being planned.
Results & Discussion
The fetal whole-body dose for each gestational age
ranged from 6 mGy (30-week) to 99 mGy (20-week).
The organ/tissue doses for the 20 weeks showed thelargest variation ranging 7 mGy (thyroids) to 99 mGy(prostates), while the doses for 8 weeks showed thesmallest variation ranging from 21 mGy (gall bladder)to 30 mGy (brain). Table 1 shows the average,
minimum, and maximum doses for each gestational age.

Fig 2. Dose distribution on 25-week pregnant phantom
as a result of CSI plan using the TPS.
Table. 1: Fetal average doses, minimum doses, andmaximum doses for Carbon Ion Therapy.
Gestational Average dose
age
[mGy]

Minimum dose[mGy]

Maximum dose[mGy]

8-week26

21 (gall bladder)

30 (brain)

10-week17

11 (lung)

28 (brain)

15-week24

7 (oesophagus)

47 (bladder)

20-week37

7 (thyroid)

99 (prostate)

25-week20

6 (oesophagus)

31 (small intestine)

30-week28

6 (oesophagus)

58 (small intestine)

35-week37

13 (oesophagus)

88 (lens)

Figure 3 shows the comparison of fetal organ doses
between carbon ion therapy and proton therapy for eachgestational age. All the fetal organ doses from carbon
therapy were greater about 1.5 times to 47.3 times thanthose from proton therapy

Figure 3. Fetal organ dose ratios between carbon ion
therapy and proton therapy for each gestational age

Nevertheless, when accounting for the total process
in carbon therapy, including CT and X-ray scans, theaverage fetal dose was 91.5 mGy while the threshold of
100 mGy for significant risk of damage for the fetus isrecommended by AAPM Report No. 36 [8].
Conclusion
We conducted MC simulations of the carbon PBS
CSI on pregnant computational phantoms that include
high-quality fetal models and a TOPAS MC beamcommissioned to the carbon measurement data.
Considering the rapid expansion in carbon therapy
centers around the world, the result of the present work
would be considered as the informative data for one toestimate dose to the fetus as one of the first clinicallyinformative predictions just in cases that carbon
therapy during pregnancy should be consideredurgently.
References[1] Blommaert, J, De Saint-Hubert, M, et al. Challenges
and opportunities for proton therapy during pregnancy.
Acta Obstet Gynecol Scand. 00: 1-8, 2023.
[2] Hall E J, Intensity-modulated radiation therapy,
protons, and the risk of second cancers. Int. J. Radiat.
Oncol.*Biol.*Phys. 65: 1–7, 2006.
[3] Kalbasi A, Kirk M, Teo B-K K, et al. Protoncraniospinal irradiation during the third trimester ofpregnancy. Pract. Radiat. Oncol. 8: 213–6, 2018.
[4] Yeom YS, Griffin KT, Mille MM, et al. Fetal dosefrom proton pencil beam scanning craniospinal
irradiation during pregnancy: a Monte Carlo study.
Phys Med Biol. 67: 035003, 2022.
[5] Maynard M R, Geyer J W, Aris J P, et al. The UF
family of hybrid phantoms of the developing humanfetus for computational radiation dosimetry. Phys. Med.
Biol. 56: 4839–79, 2011.
[6] Maynard M R, Long N S, Moawad N S, et al. The
UF Family of hybrid phantoms of the pregnant female
for computational radiation dosimetry. Phys. Med. Biol.
59: 4325–43, 2014.
[7] Griffin K T, Mille M M, Pelletier C, et al.
Conversion of computational human phantoms into
DICOM-RT for normal tissue dose assessment inradiotherapy patients. Phys. Med. Biol. 64: 13NT02,
2019.
[8] Stovall M, Blackwell C R, Cundiff J, et al. Fetaldose from radiotherapy with photon beams: report of
AAPM radiation therapy committee task group No. 36
Med. Phys. 22: 63-82, 1995.
Author address
E-Mail: ysyeom@yonsei.ac.kr

Directional radiation monitoring system using Artificial Neural Network
Yoon Soo Chung, In Soo Kang, Min Kyu Baek, Seongyeon Lee, Juwan Kang, and Yong Hyun
Chung*
Department of Radiation Convergence Engineering, Yonsei University
Introduction
In January 2023, a radiation capsule containing
137
Cs was lost during transit in Australia. 137Cs has a
half-life of about 30 years, which could cause
overexposure damage to public if it went undetected
or lost permanently. In the event of such a radiation
accident, it is crucial to minimize the damage by
detecting radioactive material early, thereby protecting
public health and preserving the environment.
Therefore, the location of radioactive material must be
rapidly detected in order to take necessary actions [1].
A radiation detector capable of determining thedirection of the radioactive source is necessary toquickly and efficiently detect the location ofradioactive
material.
However,conventional
directional radiation monitoring systems have thedisadvantages of long measurement time due to anarrow field of view and reduced accuracy of
direction information for long-distance radioactive
sources [1-3].
Thus, a new structure of directional radiation
monitoring detector is proposed to compensate for thelimitations of conventional detectors. The proposed
detector is composed of four detector modules withexternally attached wall-type collimators. The field ofview of each detector module varies with the source
direction due to the geometry of wall-type collimator.
The count obtained from each detector module varies
according to the location of the source. To detect
directional information of the source, the countdifference between detector modules was analysedusing an artificial neural network algorithm (ANN).
In this study, we evaluated the performance of the
proposed directional radiation monitoring system. The
proposed detector was designed and optimized using
Monte Carlo simulation. The acquired data was usedas training, testing and validating datasets. The
performance of proposed detector and ANN algorithm
was verified by analysing the accuracy of source
direction detection.
Methods
As shown in Figure 1, the directional radiation
monitoring detector consists of four NaI(Tl) detector
modules (Φ 3" × 3") arranged in a counterclockwise

direction with a wide field of view of 360 degrees.
The wall-type collimator attached to the outside of thesystem was designed with 2 cm thick lead to cover a
photomultiplier tube (PMT). Due to this structure,each detector module acquires a different gamma
count according to the direction of radiation incidence.
Additionally, the use of the wall-type collimator
improves the accuracy of direction information ofradioactive source located at a long-distance.

Fig. 1. The geometrical structure of directional radiation
monitoring detector

The training and validation datasets of the ANN
was generated using the Geant4 Application for
Tomographic Emission (GATE) simulation toolkit [4].
The simulations were performed by moving the 137Cs(662 keV) source from 0 to 90 degrees at 5-degreeintervals around the system, as shown in Figure 2. The
distance between the source and system was set to 50
m, 100 m, 200 m, and 400 m, respectively. The
gamma count was acquired with a 20% energy
window at the source energy peak.

Fig. 2. Simulation conditions for obtaining count of eachdetector module according to the source direction

The ANN based algorithm was developed using
the Python programming language. A total of 1,200
datasets were used for training and validation. The
datasets were divided with a ratio of 70% for training
and 30% for validation, respectively. The ANN
algorithm consists of four input-layer nodes, 256
hidden-layer nodes, and one output-layer node. The
activation function of the hidden layer was set to a
ReLU function. The training and validation wereconducted based on the settings described above.
Results
Figure 3 shows the count rate of each module
according to the position angle between the source andthe detector modules at a distance of 50 m. The
obtained patterns were confirmed to have the same
trend for other distances.

Discussions
In this study, we designed and evaluated theperformance of the directional radiation monitoring
system composed of four NaI(Tl) detector modules
arranged in a rectangular shape with externallyattached wall-type collimators. The proposed system
was utilized with the ANN based algorithm to quickly
locate the direction of a radioactive source.
As a result of the study, it was verified that the
proposed detector has a different count rate for each
module depending on the direction of the radiation
source. The ANN was shown to have an average errorof 0.57 degrees for all datasets obtained at 5-degreeintervals, and was evaluated to be able to detect thedirection of the radioactive material with an error of atleast 5 degrees. The results show that the proposed
directional radiation monitoring system is feasible.
References

Fig. 3. The count rate of each module in the source direction

The Mean Absolute Error (MAE), a measure of a
trained neural network's performance, was calculated
to be 0.57. Figure 4 shows the result of predicted
angle of the source direction. The predicted angles,
based on the validation datasets obtained at 5-degreeintervals, showed a maximum error angle of 3.54
degrees.

[1] Marques, L., Vale, A., & Vaz, P., State-of-the-art mobile
radiation detection systems for different scenarios. Sensors,21(4), 1051. 2021.
[2] Hwang, Y. G., Song, K. Y., & Lee, N. H., Direction
detection technique of radioactive contaminants based on
rotating collimator. Journal of the Korea Institute ofInformation and Communication Engineering, 24(11),1519-1527. 2020.
[3] Gal, O., Jean, F., Lainé, F., & Lévêque, C., The
CARTOGAM portable gamma imaging system. IEEE
Transactions on Nuclear Science, 47(3), 952-956. 2000.
[4] Agostinelli, S., Allison, J., Amako, K. A., Apostolakis, J.,
Araujo, H., Arce, P., ... & Geant4 Collaboration.,
GEANT4—a simulation toolkit. Nuclear instruments andmethods in physics research section A: Accelerators,
Spectrometers, Detectors and Associated Equipment, 506(3),250-303. 2003.

Author address

E-Mail: chyoso1217@yonsei.ac.kr

Fig. 4. Correlation between predicted value and ground truth

Evaluating nanoparticle candidates as radiation modifiers on DNA damages for radiation
therapy
Kanako Aoyama, Katsunori Yogo, Masataka Komori
Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine

Introduction
Gold nanoparticles (AuNPs) have emerged aspromising radiosensitizers for medium- andhigh-energy photon therapies, such as γ-ray radiationin high-dose-rate (HDR) brachytherapy. However,achieving a clinically significant dose enhancement
necessitates using high AuNP concentrations. Ourprior research showed that the impact of positively (+)
charged AuNP on radiosensitization of plasmid DNA
damage induced by 192Ir γ-rays [1] and MV X-rays[2] at low concentrations, with a focus on DNA
targeting (Fig.1). The dose enhancement achieved
with low concentrations of +AuNPs is believed to be aconsequence of DNA binding or increasing local+AuNP concentration proximate to the DNA. This
study evaluated the radiosensitization effects of+AuNPs on plasmid DNA damage induced bytherapeutic particle beams, such as carbon ions andprotons. The selection of plasmid DNA assays for invitro investigations was predicated on their heightened
sensitivity
andcapacitytofacilitatethestraightforward detection of DNA damage [3].

dose-dependent increase, indicating the presence of
double-stranded breaks (DSBs) (Fig. 2).
Lower concentrations of +AuNPs (approximately
200–3,000 times lower) than those used in cellular
assaysyieldedacomparable
degreeofradiosensitization, generating both SSBs and DSBs.
The dose enhancement factor (DEF) for +AuNPs wasdetermined to be 1.3±0.2 and 1.5±0.4 for SSBs andDSBs, respectively, induced by photon beams [1,2].
However, SSBs and DSBs induced by carbon ions in
the presence of +AuNPs and –AuNPs did not show
significant differences. This observation may be
attributed to the higher linear energy transfer (LET)
associated with carbon ions than photon beams. Our
ongoing research endeavors include incorporating
additional data and exploring the effects of particle
beams on varying LETs.
Acknowledgments
We sincerely thank Ryoichi Hirayama from QST and
Toshiyuki Toshito from the Nagoya Proton Therapy Centerfor providing experimental support.

Methods
We observed DNA breaks when using low
concentrations of AuNPs. The pBR322 plasmidDNA, exposed to 64 ng/ml AuNPs, wassubsequently irradiated with carbon ion beams (290
MeV/u) at a 6 cm spread-out Bragg peak facility
located at the National Institutes for Quantum andRadiological Science and Technology (QST). We
employed 5- and 30-nm +AuNPs and -AuNPs forcomparison. The positive charges on AuNP were
Fig. 1 Improving the microscopic dose enhancement factor using low
introduced through surface modification with amine +AuNPs concentrations via +AuNP–DNA binding for carbon-ion beams.
groupsDNA breaks were identified by monitoringchanges in the plasmid conformation, andquantification was accomplished through agarose gelelectrophoresis. We conducted a comparative
analysis between positively (+) and negatively (-)
charged AuNPs to study the effect of surface charge
on dose enhancement.
Results and Discussion
The fraction of supercoiled DNA decreased withincreasing radiation doses, indicating an increase insingle-stranded breaks (SSBs). Figure 2 shows thefraction of the linear plasmid DNA exhibited

Fig. 2 Damage yields for plasmid DNA irradiated in the presence of AuNPs
as a function of carbon-ion dose.

References[1] Yogo K, et al. Effect of gold nanoparticle
radiosensitization on plasmid DNA damage induced byhigh-dose-rate brachytherapy Int. J. Nanomedicine.16: 359,
2021.
[2] Yogo K et al. Radiosensitization Effect of Gold
Nanoparticles on Plasmid DNA Damage Induced by
Therapeutic MV X-rays Nanomaterials. 12: 771, 2022.

[3] Yogo K et al. Potential Mechanisms for Protective Effectof D-Methionine on Plasmid DNA Damage Induced by
Therapeutic Carbon Ions Radiat. Res. 193: 513–519, 2020.

Author address
E-Mail: aoyama.kanako.u9@s.mail.nagoya-u.ac.jp

Study on the Sewage Sludge Reduction and Solubilization Depending on Dose ofGamma Irradiation
Soo Min Lee1, Bo-Wi Cheon1, Hyung-Joo Choi1, In Jae Jeong2, Mu Sun Lee2, Tae Kwon Lee2,and Chul Hee Min1, *1

Department of Radiation Convergence Engineering, Yonsei University

2

Department of Environment and Energy Engineering, Yonsei University

Introduction
Sewage sludge is a semi-solid slurry that can beproduced as a by-product during sewage treatment
processes. The accumulation of sewage sludge iscontinuously increasing, and the necessity fordeveloping sludge reduction technologies also arises.
Sludge has a high moisture content, is large involume, and contains pathogenic and hazardous
substances, which poses a high environmental risk, so
general treatment such as incineration and compostingis limited. The Ministry of Environment is proposing
anaerobic digestion-based sewage sludge reduction andbiogas conversion technology as a unit process in the
sewage treatment stage. Sludge solubilization
technology is needed to increase the digestibility of
sewage sludge and ensure highly efficient sludge
reduction.
The gamma irradiation is suggested as a sludge
solubilization technology that can destroy components
such as sludge floc, EPS (Extracellular Polymeric
Substances), and cell walls and convert sludge into
highly biodegradable substrates [1,2]. The sludge
reduction rate increases with gamma irradiation, by
reducing the moisture content of sludge and theincreasing biogas conversion rate. However, further
research focusing on the optimization of thistechnology is needed. In order to enable the effective
treatment of sludge, it is essential to assess the impactof doses.
In this study, we investigated the effect of radiation
for sludge depending on doses ranging from 1.6 to 23.3
kGy. Shielding materials of aluminium, lead, andacrylic was manufactured with width calculation using
Geant4 Monte Carlo simulation. The SCOD (Soluble
Chemical Oxygen Demand), DTN (Dissolved Total
Nitrogen), DTP (Dissolved Total Phosphorus), Scarbohydrate, and S-protein were measured to evaluatesolubilization.

directions. The source was defined for Co-60 emitting
gamma of 1.17 and 1.33 MeV in a 1:1 ratio. Total
number of primary particles produced in eachsimulation was 109.
The sludge used in this study was sourced from theTancheon Sewage Treatment Plant, and the same
sludge was used in all cases. Gamma irradiation was
conducted at Greenpia, a Co-60 irradiation facility
manufactured by Nordion. The sludge was irradiated at
14 dose points ranging from 1.6 kGy to 23.3 kGy
depending on the dose.
The dose absorbed into each sludge was confirmed
using alanine dosimeters, which could be used tomeasure doses from values in Gy up to hundreds of kGy.
The alanine signals were analyzed by the ESR system
which measures the numbers of free radicals producedby radiation interactions and converted into the doses
by use of a calibration curve. Each alanine pellet was
analyzed 10 times in the ESR system, and the dose wascalculated as the average value, and the error per
analysis was less than 3%.
The solubilization rate of sludge was evaluated using
the SCOD analyzed according to standard procedures[3], and DTN, DTP, S-carbohydrate, and S-protein
were also measured. The supernatants obtained bycentrifuging the sludge at 10,000 rpm for 15 min wereused to analyze the EPS. Carbohydrates and proteins
were measured using the anthrone-sulfuric acid method,
and the Lowry method, respectively [4].
The sludge solubilization rate was calculated withthe coefficient of particulate COD release ratio(PCODRR) using the following equation:

Materials & Methods
Shielding materials were manufactured to control thedose of sludge and composed of aluminum, lead, andacrylic considering the shielding rate. The thicknesses
were determined with Geant4 MC simulation.
Shielding materials were modeled on both sides of 6 cm
of sludge and gamma irradiation was simulated in bothResults and Discussions
The sludge was irradiated according to the dose andthe changes in its properties had compared each other.
The shielding materials were attached to both sides ofsludge in accordance with the irradiation direction of
the two-way irradiation facility. The dose irradiated to

𝑃𝑐𝑜𝑑 𝑅𝑅(%) =𝑆𝐶𝑂𝐷𝑑 −𝑆𝐶𝑂𝐷0
𝑇𝐶𝑂𝐷0 −𝑆𝐶𝑂𝐷0

100

(1)

where SCODt is the amount of SCOD at dose d, SCOD0
is the initial SCOD, and TCOD0 is the total COD in thesludge.

calculated evaluations. This solubilization result canalso mean how much sludge has been reduced bybreaking down the water content tightly bound to the
EPS matrix.
Figure 3. The sludge solubilization rate depending on the dose

129

Pcod RR (%)

the sludge was quantitatively measured using an
alanine dosimeter.
DTN, DTP, S-carbohydrate, and S-protein for the
gamma irradiated sludge were measured and comparedwith those for the control sludge in figure 1,2. Except
for DTP, it showed an increase trend as the dose
increased. The dose and amplitude of change were notcompletely proportional, but this can be accounted forwithin the standard deviation of the measurements.
This alteration in chemical properties indicates theextent to which EPS, encompassing proteins,carbohydrates, DNA, and other compounds, underwent
decomposition as the results of irradiation. DTP yielded
results that were not significantly dose-related,indicating that additional pretreatment conditions wererequired to break phosphorus-related bonds.

6

3

0
0

5

10

15

20

25

Absorbed dose (kGy)

It was confirmed that irradiation can decompose
non-decomposable substances, reduce the watercontent of sludge and reduce sludge. The study showedthat the solubilization rate increased as the dose
increased, and it is expected that dose optimization will
be possible in more detail through the anaerobic
digestion rate according to the dose.

Figure 1. Comparison of DTN and DTP between the gamma
irradiated sludge and control sludge

Figure 2. Comparison of S-carbohydrate and S-protein
between the gamma irradiated sludge and control sludge

The solubilization of irradiated sludge wascalculated using equation (1) and is shown in Figure 3.
PCODRRs are also large as the dose increased, and it isconsidered to be the comprehensive result of previously

Conclusion
In this study, we investigated the solubilization rate ofsludge that varies depending on the dose in sludge
treatment using radiation. The results of this study are
expected to be useful in the development of sludge
reduction technology using radiation.
References[1] Yin Y, Wang J. Biohydrogen production using waste
activated sludge disintegrated by gamma irradiation. Applied
Energy. 2015 Oct 1;155:434-9.
[2] Yin Y, Wang J. Enhancement of enzymatic hydrolysis ofwheat straw by gamma irradiation–alkaline pretreatment.
Radiation Physics and Chemistry. 2016 Jun 1;123:63-7.
[3] Apha. Standard methods for the examination of water andwastewater. Apha; 1985.
[4] Leyva A, Quintana A, Sánchez M, et al. Rapid andsensitive anthrone–sulfuric acid assay in microplate format toquantify carbohydrate in biopharmaceutical products:
Method development and validation. Biologicals. 2008 Mar
1;36(2):134-41.
Author address
E-Mail: shue0526@yonsei.ac.kr

Simulation study of a bent crystal based monochromatic X-ray imaging with an X-ray tube
Haruto Honjo
Department of Radiological and Medical Laboratory Sciences

Graduate School of Medicine, Nagoya University
Introduction
In synchrotron radiation experimental facilities,
monochromatic X-rays are used for phase contrast
imaging that utilizes quantification in objects.
Monochromatic X-rays are obtained by diffracting white
X-rays obtained from an accelerator under the Bragg
condition using a Si monochromator. The beam size ofsynchrotron radiation X-rays is small due to theirextremely high directivity, making it difficult to image
large objects. Monochromation using such X-ray optics is
possible because synchrotron radiation has high brillianceand directionality over a wide spectrum, while lowbrilliance and divergent X-rays from an X-ray tube cannot
provide a practical field of view or photon number.
To generate monochromatic X-rays with a large field ofview from an X-ray tube, a method using a thin bent Lauetype Si single crystal was proposed by Zhong et al. in 1997
[1, 2]. Normally, when a flat Si single crystal is irradiatedwith X-rays, X-rays with monochromatic energy
satisfying the Bragg condition diffract from the crystal,
but when it is irradiated with divergent X-rays, acontinuous X-ray spectrum diffracts from the crystal. If
the crystal is bent to a fixed angle, X-rays in all directions
can enter the crystal at the same angle of incidence to the
crystal surface, and the same X-ray energy can bediffracted in all directions. This method is expected toprovide a large monochromatic X-ray field of view, but it
was first proposed and has not been put into practical use
to date. It is difficult to curve thin crystals to the desired
curves; in the setup of Zhong et al. The shape of the curve
was calculated assuming that the light source was a point,
but the focal spot size of the light source used was 0.3×
1.0 mm2, which is considered to cause a large loss ofdiffraction intensity.
Our research group has been developing an X-ray opticalsystem made of thin Si single-crystals several tens of
micro-meters thick for high image quality in refractioncontrast CT[3], and has the technology to set up andcontrol thin crystals with high precision. If this technology
is used for setting up bent Si single-crystals, it may bepossible to generate a large, uniform field of view. In
addition, the diffraction intensity can be increased byusing a microfocus X-ray tube as a light source to diffract
characteristic X-rays with a narrow spectral width andhigh brightness.
In this study, to investigate whether the Zhong et al.
method can generate monochromatic X-rays that can beused for human imaging, the positional accuracy required
to obtain a wide field of view with flat X-ray intensity andthe number of X-ray photons generated under practicalimaging conditions are obtained through simulations.
Methods
Figure 1 shows the geometry of X-ray monochromation
using Laue-case bent Si single-crystals proposed by
Zhong et al. The x-axis is set horizontally and the y-axis
vertically to the light source. This figure illustrates only
X-rays in a two-dimensional plane, but because thediffraction planes of the crystal are aligned perpendicular
to the xy coordinate, similar diffraction occurs in the
direction orthogonal to the xy coordinate. The radius ofcurvature between the X-ray beam and the crystal curve isdefined by the following equation:𝑟(𝜃) = 𝑅exp(−tan⁡(𝜃𝐵 )𝜃),(1)
where θ is the angle between the x-axis and the directionof the beam, R is the distance between the light source andthe crystal surface when 𝜃 is 0 degree, and 𝜃𝐵 is the
Bragg angle. Since the incident angle of all X-rays
incident on this curve is 𝜃𝐵 , X-rays with a specific energy
can be diffracted. X-ray beams incident on the diffraction
plane of the crystal near the Bragg angle are divided into
forward-diffraction beam and diffraction beam at the backof the crystal. These diffraction intensities follow a
diffraction intensity curve that can be calculated
theoretically from the X-ray energy and crystal latticeplane. To investigate whether the curvature condition inequation (1) can be used to obtain monochromatic X-rays
that are practical for imaging, one-dimensional X-ray
intensity profiles in the diffraction direction obtained at
the back of a bent crystal are calculated by simulation. The
simulation conditions are determined as follows.
1. X-ray tube
The energy of the monochromatic X-ray extracted fromthe energy spectrum of the X-ray tube is 17479 eV(ΔE≈5.77 eV), which is the Kα1 ray of the characteristic
X-ray of the Mo target. The focal spot size is set to 1 μm,
assuming the use of a microfocus light source. The tube
voltage, tube current, and exposure time are set to 50 kV,
1 mA, and 1 second, respectively. The anode angle is 12
degrees. The energy spectrum from the X-ray tube is
obtained by using SpekPy, a toolkit that models an X-ray
tube.
2. Laue-case bent Si single crystal
The diffraction plane used in the Laue-case bent Si single
crystal is Si(111) with a thickness of 62 μm. The Bragg
angle 𝜃𝐵 for the energy of the Kα1 ray is 5.6 degrees. The

Fig.1: X-ray Monochromation Geometry

spectral width of the Kα1 ray and the intensity curve aretaken into account when determining the diffraction
intensity. The width of the diffracted beam produced at theback of the crystal is about 100 mm.
The pixel size for integrating the number of photons is
50 × 50 µm2, assuming the pixel size of a medical X-ray
system.
In the simulation, the following aspects will be investigated:
1. A fan-shaped X-ray beam generated by an X-ray tube
is injected into a flat crystal to obtain the X-ray
intensity profile in the diffraction direction. The
number of photons produced in the diffraction
direction is determined in this section. The number ofphotons of diffracted continuous X-rays other thancharacteristic X-rays, which can be a noise source, isalso obtained simultaneously.
2.

X-ray intensity profiles in the diffraction direction forbent crystals and the profiles when the light source isdisplaced in the x or y direction are obtained. Also,
the acceptable amount of displacement should bechecked.

Results
1. Diffraction intensity profile of plane crystal
The number of photons that can enter a 50 x 50 µm2 pixel
is about 220 photons per second for characteristic X-rays
and about 0.35 photons per second for continuous X-rays.
Although the number of photons is about three orders ofmagnitude lower than that of clinical X-ray systems, we
believe that a practical number of photons can be obtainedby extending the exposure time. Continuous X-rays,
which can be a source of noise, can be ignored because
they are about three orders of magnitude smaller thancharacteristic X-rays.
2. Diffraction intensity profile of bent crystal
The diffraction intensity obtained with the bent crystal
was about five times higher than that with the flat crystal.
This is considered to be due to the fact that the same Bragg
angle is satisfied in all directions by the curvature. The
relationship between the amount of misalignment in the xand y-directions and the intensity profiles show that theintensity changes more sensitively to misalignment in they-direction. This result suggests that a misalignment of±10 µm can be tolerated in the x-direction to obtain auniform field of view, but in the y-direction, the positionof the light source must be controlled to ±1 µm. The fieldof view is more than 10 cm by controlling the crystals andthe light source in detail, and can cover the whole body ofa human being.
Discussion
In this study, we reexamined the monochromatic X-ray
generation method proposed by Zhong et al. and examined
whether it is possible to generate monochromatic X-rays
that can be used for human imaging. In the future, we will
combine this monochromatic X-ray generation methodwith a phase-contrast imaging method and investigate ahigh-contrast imaging method using an X-ray tube.
References[1] Zhong, Z., et al. “A bent Laue crystal monochromator formonochromatic radiography with an area beam. “Nuclear
Instruments and Methods in Physics Research Section A:
Accelerators Spectrometers, Detectors and AssociatedEquipment 399.2-3 (1997): 489-498.
[2] Zhong, Z., et al. “Producing parallel x rays with a bent –crystal monochromator and an a – ray tube. “Medical
Physics 28.9(2001): 1931-1936[3] Sunaguchi, N, et al. “Crystal optics simulations fordelineation of the three-dimensional cellular nuclear
distribution using analyzer0based refraction-contrast
computed tomography. “Scientific Reports 12.1 (2022):
19595.
Author address
E-Mail: honjou.haruto.g8@s.mail.nagoya-u.ac.jp

New Method for Dental Panoramic Reconstruction Using Cone-Beam Computed
Tomography Projection Data
Jiyong Shim, Duhee Jeon, Hyesun Yang, and Hyosung Cho*
Department of Radiation Convergence Engineering, Yonsei University, Wonju, Republick of Korea
Introduction
In dentistry, panoramic radiography andcone-beam computed tomography (CBCT) are vitalfor diagnosis and treatment planning. Panoramic
radiography, while low in radiation and providing
ample tooth information in 2D, and CBCT, offering
highly detailed 3D data at a higher radiation dose, areessential tools. However, maintaining two separate
systems is costly and space requirements. Software
solutions have been explored to generate panoramic
images from CBCT data. This approach allows you toacquire panoramic images without hardware
modifications, but CBCT artifacts can affect image
quality.
This study introduces a method to extract
panoramic projection data from dental CBCT
projection data. Leveraging the fact that CBCT covers
panoramic scan trajectories, it identifies dental arches[1], determines a virtual panoramic scan trajectory,
extracts the relevant data, and reconstructs the
panoramic image. This method allows for an
optimized focal plane, independent of the CBCT
image, and is less affected by CBCT image quality,
making it a promising approach in dental imaging.
Material and Methods
The proposed methodology comprises a series ofkey steps, as illustrated in Fig 1. These steps
encompass.

Fig. 1. Simplified process of the proposed dental panoramic
reconstruction method

2.1. Dental Arch Detection
The CBCT image identifies dental arches, forming
the foundation for panoramic scan trajectory. This
paper introduces a method employing Bézier curves todetect teeth in CBCT images and establish the dental
arch. To obtain the dental arch, an axial CBCT slice
depicting overall tooth structure is selected through
MIP. The MIP process accumulates row intensities,
creating a graph. The MIP image is generated bydetermining top and bottom tooth positions based on a
threshold within a certain range of the highest graphvalue. In the MIP image, teeth regions are segmented
using a preset threshold, and a closing operation fills
in lost regions. A skeleton curve, which represents thecurve through the middle of the selected objects, isdefined. To create a smooth panoramic image, Bézier
curves, defined by control points, transform it into a
differentiable continuous function:𝑛𝑛𝑛𝑛� � 𝑡𝑡 𝑖𝑖 (1 − 𝑡𝑡)𝑛𝑛−𝑖𝑖 𝑃𝑃𝑖𝑖
𝑖𝑖=0 𝑖𝑖𝐵𝐵(𝑡𝑡) = �

Here, t ranges from 0 to 1, and n specifies control
points for Bézier curve optimization. The discreteskeleton curve is approximated as a continuousfunction through iterative control point adjustments tominimize differences between the two curves.
2.2. Panoramic Projection Acquisition
Following the acquisition of dental arch
information, the panoramic scan trajectory in CBCT
geometry is determined, mirroring the approach of
conventional panoramic systems. This involves
maintaining consistent source-to-object distance(SOD) and source-to-detector distance (SDD), withthe dental arch acting as the object and the panoramic
projection aligning with the dental arch direction.
However, CBCT projections may exhibit varying
magnification, necessitating correction. To address
this, panoramic projections are obtained by dividing
the optimized dental arch length into equal intervals.
Each sampled dental arch segment's normal vector is
calculated, a corresponding CBCT projection is
selected, and cropping is performed to derive apanoramic projection. The length of the panoramic
projection matches that of the sampled dental arch.
This process is repeated for all sampled dental arch
segments to generate panoramic projections.
2.3. Panoramic reconstruction & magnification
correction
The panoramic projection data obtained is utilized
to reconstruct the panoramic image. This
reconstruction utilizes the shift-and-add method [2]with auto-focusing. The width of the focal plane fromwhich the panoramic image is derived depends on theextent of shift applied in the shift-and-add method. As
the shift amount varies, the focal plane width adjusts
accordingly, akin to a tomosynthesis image. Since thepanoramic projections obtained from CBCT geometry
exhibit varying magnification, they may introduce
distortion during image reconstruction. To rectify this,magnification correction is applied. The magnificationof each panoramic projection is adjusted sequentiallyfor both vertical (MV) and horizontal (MH) dimensions
to align with a reference projection's magnification.
This iterative process culminates in the creation of the
final corrected panoramic image.
The proposed method integrates dental archdetection, panoramic projection acquisition, andpanoramic image reconstruction with magnification
correction. It addresses the challenges posed byvarying magnifications in CBCT geometry, ensuring
the production of high-quality panoramic images
tailored to individual patient characteristics.
Table. 1: Parameter used in simulation
Parameter
Dimension
No. of projection
720
Voxel dimension
512 × 512 × 512
Voxel size
1.0 (mm)
Pixel dimension
1268 × 276
Pixel size
0.8 (mm)
Source-to-object distance362.0 (mm)Source-to-detector distance724.1 (mm)Results and Discussion
3.1. Dental arch phantom
To validate proposed algorithm using a numericaldental arch phantom. The dental arch phantom used in
the simulation consisted of a tooth, the spine, and soft
tissue, with a few missing teeth in the mandible. Fig 2(a) shows a panoramic image reconstructed using
panoramic projections obtained from the CBCT
projection data. The magnification of each panoramic
projection is not the same, resulting in a distortion of
the panoramic image. Finally, a distortion-freepanoramic image was obtained by applying verticaland horizontal magnitude corrections. To compare theimage quality of the panoramic images reconstructedusing the proposed algorithm, we compared it to a
panoramic image acquired using a conventional
panoramic scan trajectory.

Fig. 2. Simplified process of the proposed dental panoramic
reconstruction method: (a) specifying patient's dental archfrom the CBCT image, (b) extracting panoramic projection
data from the CBCT projection data, (c) reconstructing apanoramic image, and (d) correcting image magnification.

3.2. Real bone phantom

To verify the performance of the proposed
algorithm in a real-world environment, we conducted
experiments using a real bone phantom. The phantom
used in the experiment is a real bone phantom madefrom real human bones and teeth. Compared with atypical head phantom, the real bone phantom makes it
possible to obtain radiographs of the same teeth andbones as in a clinical case. The dental arch detection
algorithm using Bézier function optimization
performed well on the experimental data. The
panoramic images reconstructed from the CBCT
projection showed good image quality.

Fig. 3. Experimental results: (a) dental arch extracted
through Bézier curve, and (b) proposed panoramic image
reconstructed using the CBCT projection data before
applying an appropriate image enhancement process.

Conclusion
In this study, we propose an effective method forreconstructing a panoramic image by extracting
panoramic projection data from dental CBCT
projection data, thereby eliminating the need for an
additional panoramic scan. This method involves
patient-adaptive dental arch detection using CBCT
projection data and (SAA) based panoramic
reconstruction through the acquisition of a panoramic
projection. The image quality of the proposed
panoramic image, based on CBCT projection, is
comparable to that of conventional panoramic images.
The introduction of this method is expected to assist
dental clinics in performing various procedures byenabling the acquisition of panoramic images without
requiring further modifications to the hardware ofexisting dental CBCT equipment.
References[1] P.H.J. Amorim, T.F. Moraes, J.V.L. Silva, H. Pedrini,
R.B. Ruben, Reconstruction of panoramic dental images
through Bézier function optimization, Frontiers in
Bioengineering and Biotechnology, 8 (2020) 794.
[2] D.S. Kim, H.S. Cho, Y.O. Park, U.K. Je, D.K. Hong, S.I.
Choi, Y.S. Koo, Adaptive panoramic tomography with acircular rotational movement for the formation of multifocal
image layers, Journal of the Korean Physical Society, 60(2012) 534 - 539.
Author address
E-Mail: jiyong2155@yonsei.ac.kr

Department sessions
Biomedical Laboratory Science/Medical Technology
13:30-13:40

Opening remarks

Prof. Mitsuo Sato

NagoyaChair

Prof. Tetsuya Ishikawa

Nagoya13:40-14:00

Miyu Isogai

Nagoya14:00-14:20

Jin HanYonsei

14:20-14:40

Chiharu Yamada

NagoyaProf. Jung-Yoon Yoo

Nagoya14:55-15:15

Jin-Seok Jung

Yonsei

15:15-15:35

Nanami Yoshida

NagoyaProf. Tsutomu Kawabe

NagoyaWoo-Seung Kim

Yonsei

Session I

Molecular characterization of three closely related species ofKlebsiella pneumoniae (K. pneumoniae, K. quasipneumoniae, and K. variicola)
Identification of Colorectal Cancer-related Biomarkers from Whole Blood using
Integrated Bioinformatics Analysis
ZNF384-fusion proteins upregulate RGS1, which may attenuate
CXCL12-CXCR4 signaling

Intermission (15 min)Session II
Chair

Identification of Molecular Mechanisms in the pathogenesis and developmentof Liver Fibrosis
Quercetin prefers to induce the expression of type 3 inflammatory chemokine
CXCL2 in macrophages

Session III
Chair
15:35-15:55

Identification of Regulatory Mechanisms of Colonic pH
in Enterotoxigenic Bacteroides fragilis Toxin Secretion15:55-16:15

Fuzuki Hayashi

NagoyaProf. Fumihiko Hayakawa

Nagoya

16:15

Closing remarks

16:25

Commemorative photographing

Analysis of immune responses in NC/Nga mice focusing on lymphocytes

Molecular characterization of three closely related species of Klebsiella pneumoniae(K. pneumoniae, K. quasipneumoniae, and K. variicola)
Miyu Isogai1), Masahiro Suzuki2), Tetsuya Yagi3), Kumiko Kawamura4)
1) Department of Integrated Health Sciences, Course in Radiological and Medical Laboratory Sciences (Field in
Pathophysiological laboratory sciences), Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Department of Microbiology, School of Medicine, Fujita health University, Toyoake, Japan
3) Department of Infectious Diseases, Nagoya University Graduate School of Medicine, Nagoya, Japan
4) Division of Host Defense Sciences, Omics Health Sciences, Department of Integrated Health Sciences,
Nagoya University Graduate School of Medicine, Nagoya, Japan
Introduction
Klebsiella pneumoniae is a Gram-negative bacterium
belonging to the order Enterobacterales, which iscommonly found in the human intestines andrespiratory tract. It is considered an opportunistic
pathogen, primarily causing urinary tract infections,
respiratory infections, bloodstream infections, and liverabscesses, especially in immunocompromised
individuals. In the medical environment, K.
pneumoniae has shown a trend towards multidrug
resistance due to daily exposure to antibiotics. The
World Health Organization is concerned about theincreasing prevalence of strains producing extendedspectrum β-lactamase (ESBL) and carbapenemresistant strains (Carbapenem-resistant K. pneumoniae,
CRKp), as well as the high mortality rate associatedwith infections caused by this bacterium [1].
Additionally, reports of outbreaks of highly virulent
hypervirulent K. pneumoniae (HvKp) with highviscosity have emerged in Asian regions, including
Taiwan [2], and their trends are being closely
monitored in Japan.
Advancements in the study with whole-genome
sequencing (WGS) in recent years have revealed thatclinical strains identified as K. pneumoniae include not
only K. pneumoniae but also closely related species
such as K. quasipneumoniae and K. variicola [3]. K.
quasipneumoniae has been reported to acquire drugresistance plasmids from environmental bacteria andtransfer them to other Enterobacterales, acting as avector [4]. K. variicola, on the other hand, exhibits
higher pathogenicity and tends to have a higher
mortality rate from bloodstream infections compared toK. pneumoniae [5]. While the importance of these nonK. pneumoniae species is becoming increasingly
evident, research on these species is scarce in ourcountry, and routine hospital diagnostics have yet toclassify these three closely related species.
Therefore, this study aims to elucidate the frequency
and molecular biological characteristics of K.
pneumoniae, K. quasipneumoniae, and K. variicola.

Materials and Methods
Bacterial strains and culture conditions
A total of 269 clinical strains collected from January
2015 and Jun 2021 at Nagoya University Hospital,
located in Japan. All these strains were obtained fromblood cultures and initially identified as K. pneumoniae
or K. variicola using matrix-assisted laser desorption
ionization-time-of-flight mass spectrometry (MALDITOF/MS). All strains were stored at -80 °C before use.
Sequencing reads of the clinical strains are available
under the BioProject accession numbers PRJDB14656.
WGS and assembly
Illumina short-read sequencing was performed on the
269 strains. Genomic DNA was extracted using the
Gentra Puregene Yeast/Bact.Kit (Qiagen, Germany)
then DNA concentrations were quantitated with the
QuantusFLUOROMETER(Promega,
WI).
Sequencing libraries were prepared using QIAseq FX
DNA Library kit (Qiagen, Germany) according to the
manufacturers' instructions, and the libraries weresequenced with Illumina NextSeq 2000 sequencer
using NextSeq 1000/2000 P2 Reagents (300 cycle).
Low-quality raw reads were trimmed using fastp andassembled by SPAdes version 3.13.1.
Identification of species
The species of 269 strains were determined using
OrthoANI based on the WGS data [6,7]. The reference
genomeswereK.
pneumoniae
HS11286(PRJNA78789), K. quasipneumoniae KqPF26(PRJNA683049), and K. variicola LEMB11(PRJNA541977). The cut-off values of averagenucleotide identity (ANI) for the identification ofbacterial species were set at 95%.
Identification of genotypes
Antimicrobial resistance genes (with 90% identity and
60% minimum length) were identified by the
AMRFinderPlus-3.11 version 3.11.18.
Virulence genes (with 90% identity and 60%
minimum length) and capsular genotypes wereidentified using BLASTn according to the online
database of the Pasteur Institute MLST for K.
pneumoniae.
Results and discussion
Ratio of K. pneumoniae, K. quasipneumoniae, and K.
variicola
First, we identified the isolation ratios among 269
clinical isolates. The 269 isolates were identified asfollows: K. pneumoniae 6% (n=190, 70.6%), K.
quasipneumoniae (n=32, 11.9%), and K. variicola(n=47, 17.5%). This distribution aligns with the results
reported by Imai et al. [8], implying that approximately
30% of K. pneumoniae isolates in Japan may
potentially belong to K. quasipneumoniae and K.
variicola.
Antimicrobial resistance genes
We confirmed the presence of β-lactamase genes,
including chromosomal genes, as an indicator of
antimicrobial resistance. Eight distinct of β-lactamase
genes were identified among K. pneumoniae strains,four were identified among K. quasipneumoniae strains,
and only two were detected among K. variicola strains.
Among these ESBL genes were observed in 38 out of
190 K. pneumoniae strains (20.0%) and 2 out of 32 K.
quasipneumoniae strains (6.3%), but were absent in K.
variicola strains. Regarding carbapenemase genes, they
were detected in only 2 out of 190 K. pneumoniae
strains (1.1%), while no presence observed in K.
quasipneumoniae or K. variicola strains. Previous
research has highlighted the role of antimicrobial
resistance plasmids in K. quasipneumoniae infacilitating gene transfer and plasmid rearrangement
within the hospital environment [4]. However, in thisstudy, relatively limited number of antimicrobial
resistance genes were observed among K.
quasipneumoniae strains.
Virulence genes
We identified the K1 and K2 capsular genotypes
commonly associated with highly virulence strains andverified the presence of genes related to virulence,
including capsule production, iron carrier, and type 3
pili. Strains exhibiting the K1 and K2 capsular
genotypes, were observed in 7 strains (3.7%) and 1
strain (0.5%) of K. pneumoniae respectively, but were
not found in any K. quasipneumoniae or K. variicola
strains. Regarding virulence genes, K. pneumoniae wasfound to harbor 21 distinct genes, while K.
quasipneumoniae possessed 12, and K.variicola
exhibited only 3. Although there have been reportssuggesting a high pathogenicity of K. variicola [5], inthis study, K. variicola had a relatively limited numberof virulence genes.

Conclusions
About 30% of K. pneumoniae clinical isolates in Japan
could be K. quasipneumoniae or K. variicola, whichhave fewer resistance and virulence genes than K.
pneumoniae. It is reported that K. quasipneumoniae isassociated with colonization, while K. variicola has ahigher 30-day mortality rate [9]. Therefore,
distinguishing these species and analyzing their genes
is crucial for understanding Klebsiella species.
References[1] World Health Organization. Global Priority Listof Antibiotic-Resistant Bacteria to Guide
Research, Discovery, and Development of New
Antibiotics. 2017.
[2] Liu, Y.M., et al., Clinical and Molecular
Characteristics of Emerging Hypervirulent
Klebsiella pneumoniae Bloodstream Infections in
Mainland China. Antimicrob Agents Chemother,2014. 58(9): 5379-85.
[3] Wyres, K.L., M.M.C. Lam, and K.E. Holt,
Population genomics of Klebsiella pneumoniae.
Nat Rev Microb, 2020. 18(6):344-359.
[4] Mathers, A.J., et al., Klebsiella quasipneumoniae
Provides a Window into Carbapenemase Gene
Transfer, Plasmid Rearrangements, and PatientInteractions with the Hospital Environment.
Antimicrob Agents Chemother, 2019. 63(6):e02513-18.
[5] Kiley J.L., et al., Resistance patterns and clinicaloutcomes of Klebsiella pneumoniae and invasive
Klebsiella variicola in trauma patients. PLoS
One, 2021. 16(8): e0255636.
[6] Lee, I., et al., OrthoANI: An improved algorithm
and software for calculating average nucleotide
identity. Int J Syst Evol Microbiol, 2016.
66(2):1100-1103.
[7] Sarangi, J., et al., Molecular Epidemiology ofEnterobacter cloacae Complex Isolates with
Reduced Carbapenem Susceptibility Recoveredby Blood Culture. Jpn J Infect Dis, 2022.
75(1):41-48.
[8] Imai, K., et al., Clinical characteristics in bloodstream infections caused by Klebsiellapneumoniae, Klebsiella variicola, and Klebsiellaquasipneumoniae: a comparative study, Japan,
2014–2017. BMC Infectious Diseases, 2019.
8;19(1):946.
[9] Martin, R.M. and Bachman, M.A., Colonization,
Infection, and the Accessory Genome ofKlebsiella pneumoniae. Front Cell InfectMicrobiol, 2018. 22;8:4.
Author address
E-Mail: isogai.miyu.w6@s.mail.nagoya-u.ac.jp

Identification of Colorectal Cancer-related Biomarkers from Whole Blood using
Integrated Bioinformatics Analysis
Jin Han, Jungchul Na, Hyeyoung Lee
Department of Biomedical Laboratory Science, College of Health Sciences, Yonsei University, Republic of Korea
Introduction
The gene expression Omnibus (GEO) database is acomprehensive resource for gene expression data
generated by numerous technologies, such as
microarrays, next-generation sequencing, and otherhigh-throughput methods. Researchers from aroundthe globe can submit their gene expression data to
GEO, making it accessible for further analysis andinvestigation by the scientific community. By
providing a centralized repository for gene expression
data, researchers are able to compare their own
findings with existing datasets to discover new
insights.
In addition, Human Transcription Factors (TF)
Database, expression quantitative trait loci (eQTL)
Gene Consortium, disease Gene Search Engine(DigSeE) database, and Colon Rectal Cancer Gene
Database (CoReCG) database can also provide a
wealth of cancer-related data.
In this study, we used Korean whole blood
samples and the above databases for obtaining novel
markers associated with colorectal cancer.
Materials and Methods
a. Retrieval of Blood Genome-Wide Transcriptomic
Datasets
Peripheral blood gene expression datasets wereretrieved from the Gene Expression Omnibus (GEO)
database.
b. Protein-Protein Interaction network analysis
The String App plugin (version 1.6.0) in
Cytoscape (version 3.8.2) was used to load theprotein-protein interaction (PPI) network from the
Search tool for the retrieval of integrating
genes/proteins (STRING, https://string-db.org). A PPI
network of DEGs from RNA sequencing analysis wasconstructed. And Network Analyzer plugin (version
4.4.6) in Cytoscape (version 3.8.2) was applied toevaluate the degree of interaction between nodes of
the PPI network.
c. Composing Korean CRC-related whole blood(KCRWB) dataset through RNA sequencing analysis
and differentially expressed gene (DEG) analysis
RNA sequencing analysis and DEG analysis wererequested at Macrogen in Seoul, Republic of Korea,
with 10 samples from each group to explore novel
RNA biomarkers in Koreans. Samples were analyzed
using Agilent 2200 Tape Station System (Agilent
Technologies, CA, USA) to assess the integrity of
total RNA. Only high-quality RNA samples with

RNA integrity number (RIN) greater than 7.0, wereused for RNA library construction. The DESeq2
package in the R software was used to identify DEGs
between each group. DESeq2 analyzes read-count datafrom RNA sequencing as one of the representative
methods of DEG analysis.
d. Statistical analysis
Statistical analysis was performed using thesoftware packages PRISM version 7.01 (GraphPad
Software, CA, USA) and 2022 Minitab 21.3(Minitab
Inc, Barbara F. Ryan Penn, USA). Student’s t-test was
performed to determine the statistical significance ofdifferences between groups. p-value < 0.05 wereconsidered statistically significant.
e. RT-qPCR method
Complementary DNA (cDNA) was synthesizedusing an M-MLV reverse transcriptase (Invitrogen,
CA, USA), random hexamers (Invitrogen), and dNTP
mixture (Intron Biotechnology, Seongnam, Republicof Korea) according to the manufacturer’s
recommendations. The expression of each gene
relative to that of glyceraldehyde-3-phosphate
dehydrogenase (GAPDH) gene was measured byquantitative polymerase chain reaction (qPCR) using
TaqMan probes in a CFX-96 real-time PCR system(Bio-Rad Laboratories, CA, USA).
Resultsa. Selection of the GEO dataset and pre-processing of
the dataset
Peripheral blood gene expression datasets wereretrieved from the GEO database by searching withthe keywords ‘Colorectal cancer’ and ‘Human whole
blood’. By manual inspection based on two criteria:(1) transcriptome data from whole blood samples and(2) availability of comparisons between CRC patients
before any treatment and healthy controls,
GSE164191 and GSE11545 datasets satisfying theabove criteria were used to identify CRC-related
genes.
b. Protein-Protein Interaction network analysis for
GEO datasets
Compare with these two datasets of GSE164191
and GSE11545 there were 8,966 common genes.
Subsequently, genes with p-value <0.05 andfold-change more than 1.5 times between CRC groupand control group were determined to be DEGs. This
selection process resulted in a reduced collection of956 genes.

We mapped 956 DEGs onto the PPI network and
166 genes were selected as the DEGHub dataset withmore than 10 interactions.
c. Identification of Blood CRC-related Genes using
five publicly available datasets (PADs)
As a result of performing an intersection analysis
between 956 DEGs from the GEO dataset andtranscripts from five PADs respectively, each PADs’intersection results were obtained. (Table 1)
Table. 1.The union results of GEO database and five PADs.

Accordingly, five circulating transcripts (DLG5,
NQO2, CD177, SH2D1B, KRT73) that exhibit same
expressions when compared to the GEO and KCRWB
dataset were chosen as a set of genes for clinicalvalidation.
e. Clinical validation for five circulating transcripts
with reverse transcription quantitative polymerase
chain reaction (RT-qPCR)
A total of 106 samples from the colorectal cancer(CRC) group and 123 samples from the healthy
control (HC) group were utilized for the RT-qPCR
analysis. The DLG5, CD177, SH2D1B, and NQO2
exhibited statistical significantly increased results inthe t-test analysis. The expression of KRT73 wasfound to be decreased in the colorectal cancer (CRC)
group. But the statistical analysis conducted using at-test did not yield significant results for the KRT73
variable (Figure 2).
Figure 2. The clinical validation results of five circulatingtranscripts

d. Selection of candidate genes for clinical validation
An intersection analysis between the PAD datasetsand the KCRWB dataset was conducted. There exists
a group of seven circulating transcripts that are shared
between two datasets: ADAMTS1, DLG5, NQO2,
CD177, SH2D1B, KRT73, and SLC26A8. To further
filtrate candidates, the expression tendency of sevengenes was investigated. (Figure 1)
Figure 1. The scatter plot of expression tendency of sevencirculating transcripts

an X-axis was a fold change value for the KCRWB dataset,and a Y-axis was a fold change value for the GEO dataset.
The middle of the center in the X and Y-axis was the zero
point, and the standard of zero point divided both sides as
negative change and positive change in gene expression
compared to the control group.

Discussion
According to the Clinical validation results, atleast four of these five circulating transcripts could be
useful as diagnostic markers for colorectal cancer. In
addition, we can infer that the method used toinvestigate biomarkers for colorectal cancer with
PADs was a valuable one because it incorporated
multiple environmental and genetic datasets.

Author address
E-Mail: kristenlovemom@naver.com

ZNF384-fusion proteins upregulate RGS1, which may attenuate
CXCL12-CXCR4 signaling
Chiharu Yamada, Kentaro Okada, Koya Odaira, Ami muraki, Mina Noura, Syuichi Okamoto,
Takahiko Yasuda, Shinobu,Tsuzuki, Fumihiko Hayakawa
Division of Cellular and Genetic Sciences, Department of Integrated Health Sciences, Nagoya
University Graduate School of Medicine, Nagoya, Japan

fig1. structures of Z-fusion proteins

MethodWe established two cell lines expressing TCF3ZNF384 (TCF3-Z) or TAF15-ZNF384 (TAF15-Z),
performed RNA-seq, and analyzed differentiallyexpressed genes (DEG) due to Z-fusion protein
expression. We also analyzed DEG between Z-fusion
gene-positive and negative ALL using the previous
RNA-seq data of 323 Japanese ALL patients. We
searched the direct transcriptional targets of Z-fusion
proteins using both DEG data and ChIP-seq dataobtained from ENCODE data base. Then, weinvestigated the binding of Z-fusion proteins to theregulatory regions of the candidate genes by ChIPqPCR. Finally, we tested the effects of the candidates
on cell proliferation and chemokine chemotaxis.
Results
We searched the direct transcriptional targets of Zfusion proteins using two DEG data. 272 genes wereupregulated by Z-fusion protein expression in LCL
trasnfectant and 187 genes showed higher expression in
Z-fusion gene-positive ALL than negative one. Out of
26 commonly upregulated genes, we selected 6 genes
to which ZNF384 strongly bound using ChIP-seq data.
The candidate genes were, CREB5, RGS1, RIN3,
PLEKHG1, CHST12 and TESK2 (fig2).
Screening by RNA-seq data
Upregulated gene in LCLtransfectant
TCF3-Z/LCL&TAF15-Z/LCL
vs. Control/LCL

272

Screening by ChIP-seq data

Upregulated gene in ClinicalsampleRNA-seq data of 323 Ph(-)ALL
Z-fusion gene (+)ALL
vs. Other ALL

Log2foldchange>1
adj-pvalue<0.01
basemean>100

Encode ChIP-seq data
GEO accession: GSM1003602
Cell: LCL
Antibody: anti-ZNF384 Ab
ChIP signal>100

Log2foldchange>1
adj-pvalue<0.01
basemean>500

26

CREB5
RGS1
RIN3
PLEKHG1
CHST12TESK2187

Candidate target genes

fig2. Seatch of transcriptional target genes

We examined the expressions of the candidate genes
by RT-qPCR. The expressions of all genes weresignificantly higher in Z-fusion-expressing LCL thanControl LCL. We performed ChIP-qPCR to examine
the binding of Z-fusion proteins to these genes in LCLtransfectants. TCF3-Z bound to all the target genes,
while TAF15-Z associated with only CREB5 and RGS1
10

Relative enrichment to Normal IgG

Introduction
B-cell acute lymphoblastic leukemia (B-ALL) is ahematological malignancy frequent in children andelderly, and is caused by the clonal proliferation of Blymphoid progenitor cells [1]. Recurrent cytogenetic
and molecular abnormalities have been shown to play
key roles in the pathogenesis of B-ALL.
ZNF384 fusion (Z-fusion) genes are recently
identified in B-cell acute lymphoblastic leukemia (BALL) and characteristically frequent in Asian adultpatients. The frequency is about 20% in Philadelphia
chromosome negative B-ALL. Several fusion partners
such as TCF3 and TAF15 are identified and whole
ZNF384 are fused to the C-terminal sides of the fusion
partner proteins in Z-fusion proteins (fig.1). Z-fusion
proteins are expected to be gain-of-function mutants of
ZNF384, a transcription factor. We and others
demonstrated the development of leukemia byintroducing a Z-fusion gene into mouse hematopoietic
cells, strongly indicating its leukemogenicity [2];however, detailed mechanisms of leukemogenesis by
Z-fusion proteins have yet to be clarified.
In the present study, we searched the transcriptionaltargets of Z-fusion proteins by analyzing the gene
expression profiles of Z-fusion gene transfected celllines andWild type
Fusionclinical ALL
proteinproteinsamples. And, ZNF384 C2H2-ZF
we did a516
functional
TCF3 TAD
TAD2 HL
TCF3-ZNF384
1
H
analysis of
1022
654
ZFtheseSYGQTAF15 rich RRM RanBP TAF15-ZNF384
transcriptional
590
677
targets.

**

ns

*

8

*

**
**

6

ns
ns

ns

**

*

**

4
2
0
CREB5

RGS1

Control/LCL

PLEKHG1 CHST12
TCF3-Z/LCL

TESK2

RIN3

TAF15-Z/LCL

fig3. Binding of Z-fusion proteins to candidate genes in LCL transfectants(fig3), indicating that CREB5 and RGS1were thecommon direct targets of Z-fusion proteins.
We examined the effect of the expression of CREB5and RGS1 on the survival of Z-fusion gene-positive
ALL cell line, JIH5, by knock down experiments;
however, Neither knock down of CREB5 nor RGS1
affected the survival of JIH5 (data not shown).
RGS1 is an inhibitor of CXCR4 signaling and it isreported that overexpression of RGS1 in pro B cell
impaired CXCL12-induced chemotaxis [3]. We
examined CXCL12-induced chemotaxis of TCF3Z/LCL by transwell assay. CXCL12-induced
chemotaxis was impaired in TCF3-Z/LCL, suggestingthat TCF3-Z induced RGS1 expression attenuate
CXCL12-induced chemotaxis (fig4).

CXCR4

GDP

Gα

Gγ

↓↓

↓

GTP

↓

RGS1

↓

Gβ

Chemotaxis
ProliferationDiﬀerentiation

fluorescence intensity [×105]

CXCL12

15

*

10
5
0
-

+

Control/LCL-+

CXCL12

TCF3-Z/LCL

fig4. CXCL12-induced chemotaxis was impaired in TCF3-Z/LCL

Discussion
Two methods have been reported to searchtranscriptional targets of Z-fusion proteins. The one
was selecting genes upregulated by the transduction ofEP300-Z gene to cell lines [4], and the other was
picking up DEG between Z-fusion gene-positive andnegative ALL samples [5]. These methods wereinsufficient because the genes upregulated in cell lines
might not be expressed in primary ALL cells and thegenes highly expressed in Z-fusion gene-positive ALL
might not be regulated by Z-fusion proteins. In thepresent study, we used both approach to screen thetranscriptional targets of Z-fusion proteins.
CXCL12 is thought to play important roles inretaining early B cells in bone marrow
microenvironment and supporting B cell differentiation
through CXCL12-CXCR4 signaling. It is reported thattargeted disruption of the CXCL12 gene isaccompanied by defects in B cell lymphopoiesis [6].
These findings raises a possibility that RGS1 highexpression induced by Z-fusion proteins impairs B celldifferentiation through inhibiting CXCL12-CXCR4
signaling.
References[1] Iacobucci I, Mullighan CG. Genetic Basis of Acute
Lymphoblastic Leukemia. Journal of Clinical Oncology.
2017;35(9):975-983.
[2] Yasuda T, et al. Recurrent DUX4 fusions in B cell acutelymphoblastic leukemia of adolescents and young adults.
2016 May;48(5):569-74[3] Joseph B O’Brien, et al. Regulator of G-protein signaling(RGS) proteins as drug targets: Progress and future potentials
2019 Dec 6;294(49):18571-18585[4] Yaguchi A, et al. EP300-ZNF384 fusion gene product upregulates GATA3 gene expression and induces hematopoietic
stem cell gene expression signature in B-cell precursor acutelymphoblastic leukemia cells. International Journal of
Hematology. 2017;106(2):269-281[5] Maoxiang Qian, et al. Whole-transcriptome sequencing
identifies a distinct subtype of acute lymphoblastic leukemiawith predominant genomic abnormalities of EP300 and
CREBBP. 2017 Feb;27(2):185-195[6] Takashi Nagasawa, et al. Defects of B-cell lymphopoiesis
and bone-marrow myelopoiesis in mice lacking the CXC
chemokine PBSF/SDF-1. Nature 1996;382:635
Author address
E-Mail: yamada.chiharu.h3@s.mail.nagoya-u.ac.jp

Identification of Molecular Mechanisms in the pathogenesis
and development of Liver Fibrosis
Jin-Seok Jung, Jung-Yoon Yoo
Department of Biomedical Laboratory Science, Colleage of Software & Digital Healthcare Convergence,
Yonsei University MIRAE Campus
Introduction
Liver fibrosis is a pathological condition characterized
by the abnormal accumulation of extracellular matrix(ECM) due to chronic liver disease, representing asignificant global health challenge [1]. There is asignificant unmet medical need for anti-fibrotic
therapies to prevent hepatic disease progression,
however, there is currently no approved therapy forliver fibrosis.
Elucidating the molecular mechanisms underlying theamelioration of liver fibrosis is of paramountsignificance. Recent studies have reported that
epigenetic dysregulation is a common factor in the
progression of human diseases, including fibrosis [2].
However, the precise mechanisms underlying theseprocesses still require further elucidation.
In this study, we have elucidated the significance ofthe molecular mechanism mediated by p300, a histone
acetyltransferase, in the progression of liver fibrosis.
Furthermore, we aim to elucidate another molecularmechanism underlying liver fibrosis by employing
these experimental techniques.
Methods
Mouse Experiments
All animal experiments were approved by Yonsei
University College of Medicine Institutional Animal
Care and Use Committee (IACUC No. 2019-0313).
C57BL/6 mouse group was fed a choline-deficient,
L-amino acid-defined, high-fat diet (CD-HFD) for 4
weeks to inducing liver fibrosis. Inhibitors wereadministered 3 times/weeks.

analysis
Total RNA was extracted from fresh liver tissues and
LX2 cell lines. Subsequently, qRT-PCR analyses wereconducted, with target gene expression levels
normalized by comparison to GAPDH expression
levels.
Liver histopathological staining
Mouse livers were isolated under anesthesia and fixedby formalin. After fixation, liver tissue was embedded
in paraffin and sectioned. Liver sections werede-paraffinized with xylene and rehydrated through100%, 90%, and 80% ethyl alcohol series prior tostaining(Masson's trichrome staining (MTS), Sirius
red staining, Immunohistochemical staining (IHC).
Results
We investigated regression of liver fibrosis in miceinduced by Choline-Deficient, High-Fat Diet
(CD-HFD) using p300-specific inhibitors, A6 andC646 (Fig 1A) [3]. CD-HFD mice induced liver
fibrosis displayed elevated p300 protein levels (Fig. 1
B, D). However, treatment with p300-specificinhibitors resulted in a significant improvement inhistological features (Fig. 1B, C). Western blot
analysis further revealed decreased levels of p300,
αSMA (alpha-smooth muscle actin), and COL1A(collagen type 1A) proteins in the liver tissues treatedwith p300 inhibitors (Fig. 1D). The reduction offibrosis after treatment with p300 inhibitors was also
observed in mRNA levels of fibrosis marker genes,

LX-2 cell culture
To induce fibrosis in vitro, LX-2 cells, human hepatic
stellate cells, were initially subjected to a 2-hour
period of serum starvation and subsequently
stimulated with 20 ng/ml of TGF-β1. Various
inhibitors were co-treated with TGF-β1, and and cell
harvesting was performed after 24 hours.
Western blot assay
Protein samples were prepared from cells and tissues
by lysis. Protein samples were separated andtransferred to PVDF membranes. Primary andsecondary antibodies were attached to membranes,
and chemiluminescence signals were visualized using
the Fusion SOLO S device.
RNA
isolationandquantitative
reversetranscription-polymerase chain reaction (qRT-PCR)

Figure 1. Amelioration of CD-HFD-induced liver fibrosis byp300 inhibitors.

experimental tools had facilitated the elucidating
molecular mechanism that p300 inhibition alleviatedliver fibrosis suppressing HSCs activation.
Based on these techniques, we aim to investigate
another molecular machanism in liver fibrosis. We
selected inhibitors affecting differnt molecularmachanisms and analyzed effects of fibrotic
progression in TGF-β induced LX2 cell. someinhibitors appeared to regulate the fibrotic progression(Fig. 3).
In future study, we intend to verify whether these
inhibitors and target molecules regulate fibrosis andhow they regulate the molecular mechanisms of liver
fibrosis utilizing above experimental tools.

Figure 2. Suppression of pro-fibrotic responses in
TGF-β1-stimulated LX2 cells via disruption by p300 inhibitor.

actin alpha 2, αSMA (ACTA2), tnascin C (TNC),
connective tissue growth factor (CTGF) and collagentype 1, alpha 1(COL1A1) and collagen type 3, alpha1(COL3A1) (Fig. 1E).
To elucidate the molecular mechanism of liver fibrosis
at the cellular level, we utilized human hepatic stellate
cells (LX2) treating TGF-β. Stimulation with TGF-β1
increased αSMA expression levels in LX2 cells, whichwere significantly reduced by p300 inhibitors (Fig. 2A,
B). Furthermore, treatment with p300 inhibitors
following TGF-β1-induced fibrosis ameliorated theelevated expression of fibrosis markers, including
COL1A, CTGF, fibronectin (FN), TNC, and periostin
induced by TGF-β1 (Fig. 2C, D).
Discussions
Liver fibrosis is life-threatening disease worldwide [1].
There are no approve drugs for the treatment of liver
fibrosis, therefore, it is crucial to elucidate themolecular mechanisms of liver fibrosis to propose
therapeutic strategies.
In this study, we demonstrated that molecularmechanism of in liver fibrosis via p300, analyzing
expression levels of fibrotic marker in CD-HFD
mouse model and TGF-β induced hepatic stellate cells(HSCs) model. The CD-HFD mouse model was
designed to enhance lipid uptake while diminishing
their release in liver, thereby inducing thedevelopment of liver fibrosis through Non-Alcoholic
Steatohepatitis (NASH) [4]. HSCs are myofibroblastprogenitor cells in the liver and key effector cells inliver fibrogenesis and fibrosis progression [1]. HSCs
induced by TGF-β are driving liver fibrosis. These

Figure 3. Effects of candidate inhibitors on Fibrotic Progressionin TGF-β-Induced LX2 Cells.

References[1] Roehlen N, Crouchet E, Baumert TF. Liver
Fibrosis: Mechanistic Concepts and Therapeutic
Perspectives. Cells. 9(4):875, 2020.[2] Xue T, Qiu X,
Liu H, Gan C, Tan Z, et al. Epigenetic regulation in
fibrosis progress. Pharmacol Res.173:105910, 2021.
[3] Hwang SY, Park SY, Hong JY, Lee SY, et al.
Field-based rational design of p300 histone
acetyltransferase inhibitor and systematic evaluation
as an anti-fibrotic agent. Chem Commun (Camb).
56(68):9795-9798, 2020.
[4] Ipsen DH, Lykkesfeldt J, Tveden-Nyborg P.
Animal Models of Fibrosis in Nonalcoholic
Steatohepatitis: Do They Reflect Human Disease?
Adv Nutr. 11(6):1696-1711, 2020.
Author address
E-Mail: js_jung@yonsei.ac.kr
Correspond to: jy_yoo@yonsei.ac.kr

Quercetin prefers to induce the expression oftype 3 inflammatory chemokine CXCL2 in macrophages.
Nanami Yoshida1), Miyoko Matsushima2), Ko Iwaki1), Yuki Hayashi1), Nodoka Shimasaki1), Hinata
Taniguchi1), Hina Kawashima1), Fuzuki Hayashi1), Sayaka Takagi1), Mitsuo Sato2), Tsutomu Kawabe2)
1) Department of Integrated Health Sciences, Course in Radiological and Medical Laboratory Sciences (Field in
Pathophysiological laboratory sciences), Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Division of Host Defense Sciences, Omics Health Sciences, Department of Integrated Health Sciences, Nagoya
University Graduate School of Medicine, Nagoya, Japan
Introduction
Flavonoids are organic compounds found in natural plants.
Quercetin is one of the flavonoids found abundantly infruits and vegetables. We have previously reported thatquercetin has various cytoprotective effects, including
anti-allergic, anti-inflammatory, and anti-oxidative effects
via nuclear factor E3 related factor 2 (Nrf2)-heme
oxygenase (HO)-1 pathway [1, 2, 3]. Nrf2 is one of thestress-sensing transcription factors and has an importantrole in cellular defence [4].
Immune responses are classified into three different
types depending on the species of pathogens, and the typeof effector T-cell and innate lymphoid cell (ILC) lineages[5, 6]. Type 1 response protects against intracellularpathogens through activation of Th1 cells, CD8⁺ cytotoxic
T cells, ILC1, and natural killer cells. Type 2 response
induces the activation of Th2 cells and ILC2 against
helminths and venoms. Type 3 response targets
extracellular bacteria and fungi, and Th17 cells and ILC3
perform significant functions in this response. During
these immune responses, chemokine produced by stromal
and inflammatory cells promote the recruitment ofpolarized T cells and specific effector cells at the local siteof inflammation.
Although quercetin suppressed the production of
inflammatory cytokines, such as TNF-α, IL-1β, and IL-6,
induced by various stimuli, we found that quercetin
induced the expression of CXCL2 (macrophageinflammatory protein-2, MIP-2), which triggered
neutrophil chemotaxis in a type 3 immune response.
However, it is unclear how quercetin regulates chemokine
expression and how it works on cells.
In this study, we investigated the effects of quercetinon chemokine expression acting on type 1, type 2, andtype 3 immune responses.
Materials and Methods
Cell culture
RAW264.7 cells were cultured in RPMI1640 culture
media containing 10% fetal bovine serum, 100 U/ml
penicillin, 0.1 U/ml streptomycin, 2.5 x 10⁻⁴ U/ml
amphotericin B, and 1 mM sodium pyruvate at 37℃ underhumidified 5% CO₂ conditions.
Establishment of HO-1 knock out (KO) RAW264.7 cells
by CRISPR/Cas 9 system

Two types of sgRNAs that recognized different sites in the
HO-1 gene sequence were used. Target-complementary
CRISPR RNA (crRNA) (100 μM) and trans-activating
crRNA (tracrRNA) (100 μM), were mixed with equalamounts (final concentration 50 μM), and then heated at
95 ℃ for 5 min. The temperature was slowly lowered to
25 ℃ to synthesize sgRNA. The RNP complexes weresynthesized by mixing the respective sgRNAs with Cas 9
enzyme (New England BioLabs, MA, USA) in a 2:1 ratio
and incubated at room temperature for 20 min. RAW264.7
cells (1.4 x10⁴ cells/μl) were reacted on ice for 5 min, andthen 15 μl each of the two RNP complexes were added.
The cells were then transferred to a 2 mm wide cuvette andelectroporated (Bio Rad Laboratories) at 250 V, 500 μF.
After electroporation, the cells were transferred to a 6-wellplate and incubated at 37 ℃, 5% CO₂ for 72 h. Single cellclones were isolated by limiting dilution using a 96-wellplate.
Quantitative real-time polymerase chain reaction
Total RNA was extracted from cells by using ISOGEN II(Nippon Gene, Toyama, Japan) or RNAiso Plus (Takara
Bio, Shiga, Japan) and transcribed into cDNA by
PrimeScript RT reagent kit (Takara Bio) or ReverTra
Ace® qPCR RT Master Mix (Toyobo, Osaka, Japan).
Quantitative real-time PCR was performed on a Thermal
Cycler Dice Real Time System II (Takara Bio). The
expression levels of each target gene were normalized withan endogenous reference gene (Gapdh or 18S rRNA).
Nitrite assay
Aliquots (50 μl) of culture supernatants were collected andincubated (in triplicate) with equal volumes of Griess
reagent (1% sulphanilamide, 0.1% naphthylethylenediamine dihydrochloride, 2.5% H₃PO₄) at room
temperature for 10 min. The plate was read at a wavelengthof 540 nm with a microplate reader. Nitrite (NO₂⁻)
concentration was determined by using sodium nitrite as astandard.
Western blotting
Subjected protein using SDS-PAGE transferred topolyvinylidene difluoride membranes. The membrane wasincubated with 2% skim milk for 1 h at room temperature.
The membrane was then incubated with primary
antibodies overnight at 4ºC. Subsequently, the membranewas incubated with secondary antibodies with horseradish
peroxidase for 1 h at room temperature. The specificprotein bands on the membrane were visualized.
Statistical analysis
Statistical comparisons among the groups were assessedby one-way analysis of variance (ANOVA). When F ratios
were significant (p<0.05), Scheffe’s post hoc tests
between two groups were done, and p<0.05 wereconsidered statistically significant.
Results and discussion
We first confirmed that quercetin induced cytoprotective
effects in RAW264.7 cells. The induction of IL-6 mRNA
expression and NO production by LPS/IFN-γ wasinhibited by quercetin. Quercetin increased the levels of
HO-1 expression at both mRNA and protein levels.
Moreover, deficiency of HO-1 cancelled the suppressionof IL-6 induced by quercetin, suggesting that Nrf2-HO-1
pathway would be important to exhibit the cytoprotective
effects of quercetin. However, the inhibitory effects ofquercetin were not completely recovered in HO-1 KO cells.
These observations suggest a possibility that othermechanisms might exist besides the enhanced expressionof HO-1 by quercetin.
To investigate the effects of quercetin on theexpression of chemokines, we examined whether
quercetin regulated the expression of CXCL10 (interferon
gamma-induced protein 10, IP-10), CCL17 (thymus andactivation-regulated chemokine/chemokine ligand 17,
TARC), and CXCL2 involved in type 1, type 2, and type
3 immune responses, respectively. While no significant
changes in the mRNA expression of CXCL10 and CCL17
were observed, quercetin induced CXCL2 expression at
dose-dependent manner. Our results suggest that quercetin
may act preferentially on a type 3 immune response. We
are now trying to examine time-dependent changes in
CXCL2 expression induced by quercetin. We are also
investigating the expression of other chemokines.
It is interesting to note that quercetin, which has antiinflammatory effects, induces CXCL2, an inflammatory
chemokine. One hypothesis is that quercetin may help
prepare the body for bacterial infection by inducing theexpression of CXCL2. Besides Nrf2-HO-1-mediatedcytoprotection, this may be a novel prophylactic
mechanism of quercetin against pathogens which induceda type 3 inflammation.
References[1] Matsushima M., et al., Heme oxygenase-1 mediates theanti-allergic actions of quercetin in rodent mast cells.
Inflamm. Res. 58: 705-715, 2009.
[2] Hayashi Y., et al., Quercetin protects against
pulmonary oxidant stress via heme oxygenase-1 induction
in lung epithelial cells. Biochem. Biophys. Res. Commun.
417 (1): 169-174, 2012.
[3] Takashima K., et al., Protective effects of
intratracheallyadministeredquercetinonlipopolysaccharide-induced acute lung injury. Respir. Res.
15: 150, 2014.
[4] Gerasimos P.S., et al., The role of the antioxidant andlongevity-promoting Nrf2 pathway in metabolic
regulation. Curr Opin Clin Nutr Metab Care. 14 (1): 4148, 2011.
[5] Annunziato F, Romagnani C, Romagnani S. The 3
major types of innate and adaptive cell-mediated effector
immunity. J. Immunol. 135 (3): 626-635, 2015.
[6] Kenneth M, Casey W. Janeway's Immunobiology 9thed. W.W. Norton & Co., Inc. 2016.
Author address
E- mail: yoshida.nanami.u4@s.mail.nagoya-u.ac.jp

Identification of Regulatory Mechanisms of Colonic pH in Enterotoxigenic
Bacteroides fragilis Toxin Secretion
Woo-Seung Kim and Ki-Jong Rhee
Department of Biomedical Laboratory Science
College of Software Digital Healthcare Convergence, Yonsei University at MIRAE Campus
Introduction
Enterotoxigenic Bacteroides fragilis (ETBF) is apathogenic bacterium that triggers colitis andcolorectal cancer in humans. The only known
virulence factor of ETBF is B. fragilis toxin (BFT).
BFT is an enterotoxin that induces E-cadherin
cleavage and subsequent shedding of intestinal
epithelial cell layer leading to diarrhea disease.
However, the environmental stimulus for BFT
expression is not still elucidated [1]. Furthermore,
ETBF-associated inflammation does not occur insmall intestine although ETBF is colonized in both
small and large intestines. We found that the pH of thesmall intestine is higher than the pH of the large
intestinal. Moreover, the most well-known biologicalactivity of BFT, E-cadherin cleavage did not occur inepithelial cells treated with supernatant cultured withETBF in alkalic environment. If BFT expression
mechanisms regulated by pH were elucidated, thisstudy would help to develop the therapy or drug thatcures enterotoxin-induced colitis without side effect.
Materials and methods
Bacterial strains and collection of bacterial
supernatants
The three strains of B. fragilis, wild-type ETBF
(WT-ETBF) expressing BFT, non-toxigenic wild-type
B. fragilis overexpressing a biologically active BFT(rETBF) and inactive mutated BFT (rNTBF) wereused. Three strains were cultured in BHI broth at 37°C
under anaerobic condition for another two days. The
bacterial supernatants were centrifuged and filtered.
Animal experiment and histology
The C57BL/6 mice were used in this study. The
mice were given water containing clindamycin andgentamicin for 5 days, inoculated with B. fragilis, andsacrificed after another 7 days. The gastrointestinal
tract was harvested and measured by micro pH meter.
The intestinal inflammation was examined by H&Estained sections per mouse.
Cell Culture
The HT29/c1, human colonic epithelial cells were
cultured in DMEM supplemented with 10% FBS, 20
mM HEPES and penicillin/streptomycin.
Western blot analysis

Western blot was performed using primary
antibody specific to E-cadherin. GAPDH was used as
an internal control.
Statistical Analysis
Data in the bar graphs are presented as mean±SEM.
All data were analyzed by unpaired t-test (*P < 0.05,**P < 0.01 and ***P < 0.001).
Results
ETBF induces acute inflammation in cecum andlarge intestine, but not in small intestine
To investigate where ETBF induces inflammationin the intestine, ETBF was orally administrated andwhole intestines were extracted. It was elicited thatETBF colonized the small intestine, cecum, and large
intestine, but inflammation was observed in cecum
and large intestine, not in small intestine (figure 1).

Fig. 1: (A) Images of whole cecum including distal
ileum and proximal colon (magnification X0.5). (B)No inflammation was detected in small intestine(magnification X10).
Small intestine has a higher pH than large intestine
We hypothesized that ETBF-induced colitis isdetermined by the intestinal pH. Initially, thegastrointestinal tracts were extracted and pH was
measured. The results demonstrated that the pH of thesmall intestine shifted increasingly alkaline as itprogressed proximally, while the pH of the largeintestine shifted more acidic (data not shown).
Furthermore, we infected mice with wild-type ETBF,
recombinant ETBF or recombinant NTBF and the pH
was measured. Respectively, the trend of alkalinity inthe small intestine and acidity in the colon was
identical with previous pH measurement (figure 2). In
addition, there was no significant difference in the
CFU of B. fragilis colonized in small and large
intestine.

Fig. 4: Western blot analysis of HT29/c1 cells treatedwith normal or pH-adjusted BFT solution.
ETBF restores BFT secretion when alkalization is
stoppedTo investigate whether BFT secretion ability iscompletely lost after pH adjustment, ETBF wasacidified pH to 5, 6, 7 and 8 after 24 hours of pH
adjustment. HT29/c1 cells were treated with thecultured supernatants and E-cadherin cleavage was
detected. ETBF restored BFT secretion ability.

Fig. 2: (A) Intestinal pH in seven parts was measured
after WT-ETBF infection for 7 days. (B) Intestinal pH
of rNTBF or rETBF-infected mice.
ETBF does not express toxin in alkalic
environment
To investigate whether BFT is secreted in an
alkaline environment, we cultured ETBF in BHI broth
medium adjusted to and alkaline pH. Subsequently,
HT29/c1 cells were treated with cultured supernatant.
It was observed that the cultured supernatant fromETBF under alkaline broth did not demonstrate Ecadherin cleavage (figure 3).

Fig. 5: Western blot analysis of HT29/c1 cells treatedwith cultured supernatant from ETBF with pH
restoration.
B. fragilis alters micro-environment acidic
To examine the pH of micro-environment, BHIB
was inoculated with rNTBF or rETBF, incubated for
48 hours and the pH was measured. It is determinedthat both strains acidified the pH of BHIB extensively
in exponential stage.

Fig. 3: Western blot analysis of HT29/c1 cells treatedwith cultured supernatant from normally cultured or
pH-adjusted WT-ETBF. There was no significant
difference in the number of CFU (ns, non-significant).

Fig. 6: Measured pH of rNTBF or rETBF-cultured
BHIB at indicated time points (6, 12, 24, 36 and 48
hours).

The previously secreted BFT is not influenced by
pH
To exclude the possibility that secreted BFT isdenatured by the alkaline pH of BHIB, the supernatantfrom normally cultured ETBF was harvested and the
pH was adjusted to 5, 6, 7 and 8, respectively. As aresult, it was determined by Western blot that thebiological activity of BFT exhibits in both acidic andalkaline environments.

Discussions
According to reported data thus far, regulatory
mechanisms by pH were restricted with several bacteria or
fungi. The current study identified ETBF, the most
responsible pathogen for colitis among microbiome, can be
regulated its enterotoxin secretion by environmental pH.
These results will help not only to understand themechanistic pathway of bacterial toxin secretion, but also todevelop the cure with pH adjustment without any side
effects.
References[1] Ezequiel V and Juliane Bubeck W. Good Gone Bad: One
Toxin Away From Disease for Bacteroides fragilis. J. Mol.

Biol. 432: 765-785. 2020.
Author address
E-Mail: redberry1245@yonsei.ac.kr

Analysis of immune responses in NC/Nga mice focusing on lymphocytes
Fuzuki Hayashi1), Miyoko Matsushima2), Hikaru Tsuzuki1), Iroha Matsuda1), Shino Ando1), Nodoka
Shimasaki1), Hinata Taniguchi1), Hina Kawashima1), Sayaka Takagi1), Nanami Yoshida1), Mitsuo
Sato2), Tsutomu Kawabe2)
1) Department of Integrated Health Sciences, Course in Radiological and Medical Laboratory Sciences (Field in
Pathophysiological laboratory sciences), Nagoya University Graduate School of Medicine, Nagoya, Japan
2) Division of Host Defense Sciences, Omics Health Sciences, Department of Integrated Health Sciences, Nagoya
University Graduate School of Medicine, Nagoya, Japan
Introduction
NC/Nga mice, an atopic dermatitis (AD) model,
spontaneously develop AD-like skin lesions when raised
under conventional environment. NC/Nga mice exhibit
type 2-prone immune response characterized byhyperproduction of IgE in association with thedevelopment of AD [1]. The B cells of NC/Nga mice also
have increased sensitivity to CD40 ligand and IL-4
stimulation, suggesting some modification factors toenhance a type 2 immunity. However, the mechanisms
how NC/Nga mice induce type 2-prone immune response
is poorly understood. In this study, we investigated thedifferentiation and proliferation of lymphocytes to explore
the basal immune status of NC/Nga mice.

Fig. 1. NC/Nga mice kept in specific-pathogen-free (SPF)
surroundings or conventional (CONV.) surroundings (J Immunol
2007;178:584-591).

MethodMice
Six- to eight-week-old male NC/Nga and C57BL/6 mice
were used. Animal experiments were approved by the
Animal Experiment Committee of Nagoya University
Graduate School of Medicine. All procedures were
performed in accordance with the Guidelines for Animal
Experimental Experimentation of Nagoya University.
Flow cytometric analysis of lymphocyte differentiation
Bone marrow cells and splenocytes were collected from
NC/Nga and C57BL/6 mice. Cells were washed andincubated with anti-CD16/32 antibodies at 4 ℃ for 15 min
to avoid unspecific binding to Fc receptors. Cells werethen stained with fluorescent-labeled antibodies at 4 ℃ for
20 min. The expression of cell-surface molecules wasanalyzed by FACSCanto Ⅱ flow cytometer (BDBiosciences). The data was analyzed and quantified
analyzed using FlowJo software program.
Flow cytometric analysis of lymphocyte proliferation
Splenocytes collected from NC/Nga and C57BL/6 mice
were labeled with 5 μM 5-carboxyfluorescein diacetate
succinimidyl ester (CFSE) (Life Technologies Carlsbad,
CA, USA). CFSE-labeled splenocytes were plated at 5 x
105 cells in a 24-well plate and stimulated with 1.0 µg/ml
lipopolysaccharide (LPS), 0.5 µg/ml concanavalin A (ConA), or anti-CD3ε/CD28 antibodies for 2-3 days. Cells werethen collected, incubated with Fc blocking antibody
against CD16/32, and stained with fluorescent-labeled
antibodies at 4 ℃ for 20 min. The CFSE signal of gated B
cells, CD4+ T cells, or CD8+ T cells was analyzed by flow
cytometry on FACSCanto Ⅱ flow cytometer. The data wasanalyzed and quantified using FlowJo software program.
Enzyme-linked immunosorbent assay (ELISA)
Splenocytes from NC/Nga and C57BL/6 mice were
stimulated with anti-CD3ε/CD28 antibodies for 2-3 days.
Supernatant was collected, and production of IL-2 wasassayed using a Mouse IL-2 ELISA Ready-SET-Go! Kit(eBioscience, San Diego, CA, USA) according to the
manufacturer’s recommendations.
Statistical analysis
Statistical comparisons among the groups were performed
using one-way analysis of variance (ANOVA). When F
ratios were significant (p<0.05), Scheffe’s post hoc tests
were performed between the two groups, and values of
p<0.05 were considered statistically significant. Statisticalanalyses were performed using StatView software (SASInstitute Inc., Cary, NC, USA).
Results and discussion
First, we examined the proportion of B cells and T cells in
splenic lymphocytes, and the number of each lymphocyte
subpopulation per spleen. Both the proportion and number
of T cells were decreased in NC/Nga mice, while there waslittle difference in the number of B cells between NC/Nga
and C57BL/6 mice. These results suggested that theincreased proportion of B cells in NC/Nga mice may be
due to the lower number of T cells. Moreover, there is apossibility that the proliferation and maturation of T cells
in the spleen might be impaired in NC/Nga mice. The
proportion of CD4+ T cells was increased and that of CD8+
T cells was decreased in NC/Nga mice, suggesting that adominant CD4+ T cell population may lead to a type 2prone immune responses in NC/Nga mice.
We next examined the proportion and number of B
cells at each stage of differentiation in the bone marrowand spleen. The proportion of mature B cells in bonemarrow was significantly increased in NC/Nga mice,
while the proportion of pre B cells was slightly decreased.
In the spleen, NC/Nga mice showed a marked decrease in
the proportion and number of transitional type 1 (T1) B
cells and T2 B cells, and a marked increase in the
proportion and number of marginal zone B (MZB) cells.
These results suggested that B cells in NC/Nga mice might
rapidly differentiate into mature B cells due to theirmodification of rate-limiting step. Furthermore, T2 B cells
might differentiate more dominantly into MZB cells in
NC/Nga mice.
Next, we investigated the proliferation of splenic
lymphocytes in response to LPS, Con A, or antiCD3ε/CD28 antibodies. Higher B-cell and T-cellproliferations in response to LPS or Con A were observedin NC/Nga mice, respectively. Moreover, NC/Nga mice
exhibited higher T-cell proliferation and IL-2 production
stimulated by anti-CD3ε/CD28 antibodies. Thesesuggested that increased production of IL-2 might enhancecell proliferation in NC/Nga mice compared to C57BL/6
mice.
In conclusion, our results suggest the possibility thata unique differentiation pattern and accelerated
proliferation of lymphocytes might cause potent type 2prone immune response in NC/Nga mice.
References[1] Matsumoto M., et al., IgE hyperproduction throughenhanced tyrosine phosphorylation of Janus kinase 3 in
NC/Nga mice, a model for human atopic dermatitis. J
Immunol. 162: 1056–1063, 1999.
[2] Pieper K., et al., B-cell biology and development. J
Allergy Clin Immunol. 131 (4): 959–971, 2013.
[3] Zhang M., et al., The pre-B cell receptor and its
function during B cell development. Cell Mol Immunol. 1(2): 89–94, 2004.
[4] Su T., et al., Signaling in transitional type 2 B cells is
critical for peripheral B-cell development. Immunol Rev.
197 (1): 161–178, 2004.
[5] Thomas M. et al., Regulation of peripheral B cellmaturation. Cell Immunol. 239 (2): 92–102, 2006.
[6] Singer A. et al., Lineage fate and intense debate:
myths, models and mechanisms of CD4- versus CD8lineage choice. Rev Immunol. 8 (10): 788–801, 2008.
[7] Zhu J. and Paul W., CD4 T cells: fates, functions, andfaults. Blood. 112 (5): 1557–1569, 2008.

[8] Lin J. and Weiss A., T cell receptor signalling. J Cell
Sci. 114 (2): 243–244, 2001.
[9] Davis M., A new trigger for T cells. Cell. 110 (3): 285–
287, 2002.
[10] Sprent J. and Surh C., Normal T cell homeostasis: theconversion of naive cells into memory-phenotype cells.
Nat Immnol. 12 (6): 478–484, 2011.
[11] Sakai T., et al., Decreased expression of MHC class
II and cathepsin E in dendritic cells might contribute toimpaired induction of antigen-specific T cell response in
NC/Nga mice. J. Med Invest. 59: 95–101, 2012.
Author address
E-Mail: hayashi.fuzuki.m1@s.mail.nagoya-u.ac.jp

Department sessions
Physical Therapy
Opening remarks

Prof. Hideshi Sugiura

NagoyaChair

Prof. Yasushi Uchiyama

NagoyaMasahiro Nishimura

NagoyaAkira Omi

NagoyaYumika Suzuki

NagoyaProf. Sanghyun Cho

Yonsei

Lingchao Xie

YonseiWonjun Oh

YonseiYunhwan Kim

YonseiProf. Sanghyun Cho

YonseiProf. Hideshi Sugiura

NagoyaSession I
13：30-14：30

COP COM Coordination Is Related to a Process of Acceleration Drive on Gait
Initiation in Community Dwelling Elderly People
Effects of auditory stimulation on gait orientation
Analysis of the molecular mechanisms underlying the cell surface localizationof M-cadherin during skeletal muscle regeneration

Intermission (20 min)Session II
14:45-15:50

Chair

Closing remarks
Awarding ofcertificatesAnkle Strategies for Step Aside Movement during Straight Walking
Who are the Best Candidates for Robotic Gait Training Rehabilitation in
Hemiparetic Stroke?
Long term Effects of Deep Learning Digital Therapeutics on Sustainable Painand Movement in Low Back Pain Management

COP-COM Coordination Is Related to a Process of Acceleration Drive on Gait Initiation in
Community Dwelling Elderly People
Masahiro NISHIMURA, Yasushi UCHIYAMADivision of Physical Therapy, Department of Rehabilitation Therapy

Graduate School of Medicine, Nagoya University[Introduction]
Gait initiation is a complex motor task that gene-rates
transitioning from a static standing position to a dynamic
state characterized by gait cycle. This process demands ahigher degree of control and complexity compared tosteady-state gait (SSG) and presents potential fall risks
associated with postural control during gait initiation [1,2].
To address this critical issue, numerous studies have been
conducted, focusing on the stability of gait initiation fromthe perspective of postural control.
One fundamental aspect of postural control during gait
initiation is the control of the center of mass (COM)within a base of support (BOS), which is the area ofcontact with the supporting surface. This control isessential to maintain stability throughout the transition
from standing to walking. Additionally, the center of footpressure (COP) plays a pivotal role in controlling the floor
reaction force, ensuring that the COM remains within theboundaries of the BOS [3]. An important concept used toassess postural control ability is COP-COM coordination
which provides insights into the coordination between
COP and COM during this critical phase of movement.
The process requires when the trajectory of COM
alternately passes between COP, which is controlled byeach supporting leg. This concept is crucial inunderstanding the mechanisms behind successful gait
initiation [4].
In recent years, there has been a lot of research on the useof wearable devices to acquire biometric information andtake up gait analysis, with small accelerometers inparticular being a representative tool. The information
obtained from acceleration data is trunk sway, and trunk
acceleration measured with an accelerometer attached to
the lumbar spine (L3-4) as an indicator of gait stability has
established reliability and validity [5]. Therefore, it isexpected to be a tool for sensitivity and convenience ingait analysis. In addition, the information represented bytrunk acceleration includes a gait strategy and propulsive

process of the stance phase [6,7] in the anterior-posterior
direction, the forefoot rocker timing and propulsive
preparation [8] in the vertical direction, and the symmetryof the entire gait cycle and trunk stability [8] in the lateral
direction, thus visualizing various postural adjustment
processes from the three axes.
Building upon this foundation of knowledge, the aim of
the present study is to investigate the involvement of
COP-COM coordination in the process of acceleration
control during gait initiation among community-dwellingelderly people.
[Methods]
11 young people (22.2±1.4 years) and 23 communitydwelling elderly people (71.9±4.3 years) walked 5 timesof 12m gait as self-selected speed. COM were detectedfrom 15 markers on subject’s body by using motion
capture system. COP was traced by 2.4m foot pressure
distribution sensor. “COP-COM separation” wascalculated as root mean square of a period from starting
motion to 3rd step in the anteroposterior (AP) andmediolateral (ML) direction. Acceleration in tri axis wasmeasured by a gyro combined accelerometer (MVP-RF8,
MicroStone), which placed at the torso (height of L3
spinous process [5]. Both acceleration and angularvelocity components were used to detect trunk
acceleration, with correction for gravitational acceleration
based on the Euler angle principle. The measured data
were processed with Butterworth low-pass filter (4th order,
cutoff frequency 12.5Hz [9]). After post process,acceleration data was calculated as root mean square of aperiod from starting motion to 3rd step (RMS ML, RMS
V RMS AP, respectively). To compare sensitive
difference of balance ability, we divided elderly people
into two groups; elder(H) and elder(L), based on Timed
Up and Go Test (TUG) time (Table1). We compared eachoutcome with applying one-way ANOVA and Bonferroni
Method as post-hoc test. Multiple regression analysis was
executed for elderly group as explanatory variables were“COP-COM separation” in each direction and age andresponse variable was acceleration RMS in each direction.
Significant level was set as p<0.05 (included adjustment).
Table1 Subjects’ characteristics
Young (n = 11)

Elder(H) (n = 12)

Elder(L) (n =11)

P-value(All)**Age(year)22.2±1.4**70.9±3.973.0±4.6<0.01

Height(cm)167.8±8.6163.1±6.9162.3±7.2

n.s

Weight(kg)57.3±10.2

61.3±9.2

60.2±14.4

n.s

TUG COM(s)―**8.14±0.48

9.97±0.70

Mean±SD* < 0.05<0.01** < 0.01[Results]“COP-COM separation” in the AP direction of elder
group with low performance of TUG was significantly
lower than the others(p<0.001, Fig.1). RMS V, younggroup was significantly larger than the other two groups(p<0.05, p<0.001, respectively Table2); RMS AP, young,elder (H), and elder (L) groups were significantly larger,
in that order (p<0.01, p<0.05, .respectively Table2).

Table2 Acceleration RMS in 3-axis direction[Discussion]
In terms of COP-COM coordination, a previous researchfor healthy elderly people who were tasked to cross overan obstacle reported as a similar result as our results [4].
Besides, young people had greater value than elderly
people in the AP direction and elderly people with highrisk of fall were lower than those with low one in the ML
direction when they did continuous voluntary movement
in standing [10]. Interestingly, “COP-COM separation” in
the ML direction for subjects who are lower fall risk isestimated to be around 60% [4]. We suspect that the
Author address(E-Mail)difference was not seen in the ML direction, where the riskof falling is more easily detected for patients or those whohave a severe balance disfunction, but only in the AP
direction.
Lower COP-COM coordination was found to limit COM
acceleration for COM transfer on gait initiation [11]. One
factor is likely to be a decrease in functional BOS due toage-related decline in postural control [12]. It may
suppose that an interaction between COP and COM on
gait initiation could not be successfully activated to theforward shift of COG and was not linked to effective
kinematic control during walking. We propose that a maininterpretation of this study is elderly people with reduced
balance ability adjusted their walking speed related toacceleration drive by compensatory reduction of distance
between COP and COM to maintain stability, and may besupported as an indicator to estimate dynamic posturalcontrol ability on gait initiation.
In summary, COP-COM coordination of healthy older
adults on gait initiation is likely to be sensitive in the AP
direction, suggesting that it contributes to acceleration
control leading up to SSG. This fact provides a valid
quantification of dynamic postural control ability on gait
initiation.
[References]
1.van Andel S., Cole MH., Pepping. GJ. Influence of age and falls incidence on tau
guidance of centre of pressure movement during gait initiation. GAIT&POSTURE,
70, 104-108, 2019
2.Callisaya ML. Blizzard L., Martin K., et al. Gait initiation time is associated withthe risk of multiple falls. GAIT&POSTURE, 49, 19-24, 2016
3.Lugade, V., Lin, V., Chou, L.S. Center of mass and base of support interaction
during gait. Gait Posture, 33, 406–411, 2011
4.Michael EH., Li-Shan C. Age-related reduction in sagittal plane center of mass
motion during obstacle crossing, Journal of Biomechanics, 37, pp837–844, 2004
5 Moe-Nilssen R. Test-Retest Reliability of Trunk Accelerometry During
Standing and Walking. Archives of Physical Medicine and Rehabilitation, 79(11),pp1377-85, 1998
6 Zijlstra W., Hof LA. Assessment of spatio-temporal gait parameters from trunk
accelerations during human walking. Gait and Posture, 18, pp1-10, 2003
7 Menz BH., Lord SR., Fitzpatrick CR. Acceleration patterns of the head andpelvis when walking on level and irregular surfaces. Gait and Posture, 18, pp3546, 2003
8 Karimpour R., Krupenevich LR., Miller HR., et al. EVALUATION OF GAIT
ASYMMETRY USING FORCE PLATES VERSUS ACCELEROMETER.
Journal of Mechanics in Medicine and Biology, 18(2), 1850015, 2018
9 Howcroft, J., Kofman, J., Lemaire, ED., et al. Analysis of dual-task elderly gaitin fallers and non-fallers using wearable sensors. JOURNAL OF
BIOMECHANICS, J Biomech, 49(7), pp992-1001, 2016
10.Murray GT., Justin JK., Steven M., et al. Voluntary sway and rapid orthogonaltransitions of voluntary sway in young adults, and low and high fall-risk older
adults, 24, 597-605, 2009
11. Masani, K., Vette, A. H., Kouzaki, M., et al. Larger center of pressure minus
center of gravity in the elderly induces larger body acceleration during quiet
standing. Neuroscience Letters, 422, 202–206, 2007
12.KING, MB., JUDGE, JO., WOLFSON, L. FUNCTIONAL BASE OFSUPPORT DECREASES WITH AGE, JOURNALS OF GERONTOLOGY, 49(6),258-263, 19

nishimura.masahiro.r8@s.mail.nagoya-u.ac.jp

Effects of auditory stimulation on gait orientation
Akira OMI, Yasushi UHIYAMADivision of Medicine, Department of Health Science
graduate School of Health Science, Nagoya University

Introduction

Minimum hearing thresholds were measured at four

Postural control is based on the use of spatial positionalfrequency bands of 500 Hz, 1000 Hz, 2000 Hz, and 4000

information from visual, vestibular, and proprioceptive

Hz in both ears using an audiometer MT JIS T1201-1 (Assystems.[1] The central nervous system (CNS) receivesOne.)

feedback from these sensory systems regarding body

The main experiment was a 10-meter walk experiment.

orientation and selectively activates muscles.[2] Recently,

Subjects were asked to walk in the direction of a soundit has been reported that in addition to these senses,

coming from any of three locations with their eyes

hearing also has an important influence on postural

covered with an eye mask. The sound locations were left

control.[3][4] Hearing helps us to know where we are inforward, forward, right forward (forward, plug direction,

our environment and it allows us to track our changing

no plug direction). First, subjects walked 3-meters without

position dynamically over space and time and auditory

sound, and, when they reached the 3-meter mark, we

stimulation can provide the effect similar to the benefits

started playing sound that is white noise. The experimentassociated with visual fixations or light touch.[4] Somewas performed three times for each subject in eachstudies show that hearing loss increases anxiety when

direction in a random order. We played an intermittent

walking and decreases walking speed and stride length

sound of 65dB. We allowed the subjects to walk towardand people with hearing loss have three times the risk ofthe target sound and then measured differences in distancefalling compared to those without hearing loss. [5][6]from the target arrival point, and compared this distanceSome studies show the interaction between standing

between with earplugs and without ear plugs.

balance and auditory stimulation and auditory stimulation
can be used by human subjects to decrease posturalsway.[7][8]However, the relationship between auditory stimulationand gait orientation has not been clarifiedThus, this study aim is to clarify the effects of auditory
stimulation on gait orientation.

Methods
The study group consisted of 19 young, healthy
subjects: (11men, 8women, age: 21.7±0.7 years, height:
165.8±7.8cm, weight: 55.0±7.5kg).

Figure1: experimental environment

Results

References

Without earplug, the average hearing threshold was[1] Horak FB. Postural orientation and equilibrium: what

13.3±4.2dB and with earplugs, the average hearing

do we need to know about neural control of balance tothreshold was 34.4±6.1dB (Table1). The difference fromprevent falls? Age Ageing. Suppl 2:ii7-ii11. 2006.

the target arrival point was greater with earplugs than[2] Peterka RJ. Sensorimotor integration in human

without earplugs (Table2).

postural control. J Neurophysiol 88: 1097–1118, 2002.
[3] Carpenter MG, Campos JL. The Effects of Hearing

Loss on Balance: A Critical Review. Ear Hear. 41 Suppl

Table1: hearing thresholds

hearing

1:107S-119S.2020.

without ear

with earplug

plug (n=19)(n=19)[4] Campos J, Ramkhalawansingh R, Pichora-Fuller MK.

13.3±4.2

34.4±6.1

Hearing, self-motion perception, mobility, and aging.
Hear Res. 369:42-55. 2018.

thresholds (dB)[5] Assi S, Twardzik E, Deal JA, Hearing loss and physicalactivity among older adults in the US. J Gerontol A Biol

Table2:gap from the target(cm)
without ear
plug (n=19)

forwardno plugplug

direction

direction

29.3±34.2

28.5±29.2[6] Lin FR. Hearing loss and cognition among older adults
in the United States. J Gerontol A Biol Sci Med Sci.

22.8±20.6

66(10):1131-6. 2011[7] Gandemer L, Parseihian G, Kronland MR, et al: Thewithearplug

Sci Med Sci. 186. 2023

42.2±40.9

59.0±60.5

54.0±47.3(n=19)

influence of horizontally rotating sound on standingbalance. Exp Brain Res. 232:3813-20, 2014.
[8] Gandemer L, Parseihian G, Kronland MR, et al:

Discussion
The difference from the target arrival point was greater

Spatial cues provided by sound improve postural
stabilization: evidence of a spatial auditory map?. Front

with earplugs than without earplugs (p<0.05). Vause

Neurosci. 11:357, 2017.

reported 25% increase in error in sound localization when

[9] Vause NL, Grantham DW: Effects of earplugs andusing earplugs compared to not using earplugs in a test ofprotective headgear on auditory localization ability in thesound localization.[9] In addition, Wanrooij showed thehorizontal plane. Hum Factors. 41(2):282-294, 1999

error of sound localization was 10˚ to 20˚ larger with

[10]. Wanrooij MMV, Opstal JV: Sound Localization

earplugs than without earplugs.[10] Furthermore, it has

Under Perturbed Binaural Hearing. J Neurophysiol.

also been reported that wearing earplug increase postural

97(1):715-726, 2007.

sway.[11] These results show that hearing loss decrease[11] Zarei H, Norasteh AA, Lieberman LJ. Balancesound localization and increase gap from the target

Control in Individuals with Hearing Impairment: A
Systematic Review and Meta-Analysis. Audiol Neurootol.
9:1-19. 2023.

Analysis of the molecular mechanisms underlying the cell surface localization of
M-cadherin during skeletal muscle regeneration
Y. Suzuki1), S. Kametaka1)
1) Department of Physical Therapy, Graduate School of Medicine, Nagoya University, Nagoya, Japan
Introduction
Skeletal muscle has various physiological functions
in vivo. It has also self-regeneration ability from injury,
which is often the subject of physical therapy. Thus, inmy view, understanding the molecular mechanisms ofmusculoskeletal regeneration leads to a better
comprehension of muscular disorders.
The process of the muscle regeneration fromdamage is composed of multiple steps. When skeletal
muscle is injured, first, muscular stem cells, ‘satellite
cells’, localizing around the damaged muscle fibers areactivated to become myoblasts to start cell growth.
Second, myoblasts migrate into the damaged area andfuse to each other to form multi-nucleated myotubes
that are precursors for myofibers. By repeating theseprocesses, huge, functionally intact myofibers areregenerated. (fig.1) [1].
myonucleus

basal lamina

muscle fiber(muscle cell)satellite cell

damageactivation, proliferation
myoblast
migration, recognition,
cell-cell adhesion and fusion
myotubefusion and maturation

Fig.1 The process of muscle regeneration
In the complex regeneration processes, it is thought
to be necessary for myoblasts to recognize and adhere
to the similar type of cells as fusion partners. The cellrecognition and adhesion process should be strictly
regulated, and I thought that promotion of this step by
medical interventions could improve the rate ofmyoblast fusion and further skeletal muscle repair.
M-cadherin (Mcad) is one of the adhesion
molecules expressing specifically in muscle cells andits expression level is transiently up-regulated during
muscle regeneration [2]. Because cell surface
localization of Mcad should be required for its
recognition of neighboring cells and its function as anintercellular tethering machinery, intracellular
localization could be controlled under induction of
myogenesis. Few studies, however, have quantified thefunctional Mcad on the plasma membrane, and themechanisms of intracellular transport and plasma
membrane localization of endogenous Mcad remain
unclear.

In order to investigate the regulatory mechanisms of
Mcad intracellular transport, I tried to develop a newtool to quantify the amount of Mcad localized on thecell surface of myoblast using Nano-Glo® HiBiTsystem (Promega Corporation) (fig.2).
Reconstituted
luciferase

NanoLuc® luciferase
HiBiT
LgBiT

high affinity (Kd=0.7nM)

Self reconstruction→Reacquire enzymatic activity

Split into two fragment→No enzymatic activity

Fig.2 Nano-Glo® HiBiT system
First, I inserted the HiBiT tag of 11 amino acidresidues into the extracellular domain of Mcad toconstruct an ‘Mcad-HiBiT’ artificial gene, and McadHiBiT was transfected into C2C12 cultured myoblast
cells. Then, LgBiT protein was added to the C2C12
cells expressing Mcad-HiBiT gene. LgBiT bound to the
HiBiT region of cell-surface Mcad-HiBiT became
active luciferase enzyme and was detected bymeasuring its activity. The luminescence intensity
reflects the number of Mcad localized on the cellsurface (fig.3).
Using the newly established tool to monitor theamount of cell-surface Mcad, chemical compounds
library was screened to search for compounds that
could affect the Mcad surface expression.
A) Schematic diagram of Mcad-HiBiT
HiBiTIntracellular domain
Transmembrane domain

Extracellular domainB) Detection of Mcad-HiBiT localized on the cell surface
Mcad-HiBiT localized on the cell surface
C2C12 cell
LgBiTextracellular

intracellular

Fig.3 Concept of the new tool established in thisstudy.
Methods
Cell culture: C2C12 cells were cultured in the growth
medium (GM) containing DMEM (Wako) with 12%
Fetal Bovine Serum (FBS, biowest), 1% penicillinStreptomycin (Wako) at 37˚C under 5% CO2. Muscle
differentiation of C2C12 cells were induced byreplacing the medium with differentiation medium(DM): DMEM supplemented with 2% horse-serum(Sigma-Aldrich) and 1% penicillin-streptomycin.

Chemical compound screening: Drug screening was
performed using SCAD inhibitor kits (kit I, ver.4; kit II,ver. 2.1; kit III, ver.1.7; kit IV, ver2.4) obtained from
the Molecular Profiling Committee, Grant-in-Aid for
Scientific Research on Innovative Areas “Platform of
Advanced Animal Model Support (AdAMS)” from the
Ministry of Education, Culture, Sports, Science andTechnology, Japan (JSPS KAKENHI Grant Number JP
16H06276).
C2C12 cells stably expressing Mcad-HiBiT gene
were plated at 2×104 cells/well in a 96well plate withwhite opaque walls and transparent bottoms(PerkinElmer). After incubation in GM for 24 h,
myogenic differentiation was initiated by switching the
medium to DM for more 24 h. Then a total of 364 drugs
were added to each well at a final concentration of 2
µM. The compounds were dissolved in DMSO at a final
concentration 0.1% and same amount of DMSO wasadded to the control well. After 24 h incubation, cells
were fixed in 4% paraformaldehyde, washed with PBS,
and 2µg LgBiT were added each well. After incubation
excessive amount of LgBiT was washed out and theamount of the LgBiT-Mcad-HiBiT complex localized
at the cell surface was detected using the Nano-Glo®
Luciferase assay system (Promega Corporation),
following the manufacturer’s instructions. The
luminescence intensity was measured using aluminometer ARVO MX1420 (PerkinElmer). After the
luminescence measurements, nuclei were stained with
Hoechst33342 to count the cell number automaticallyusing BZ-X800 (KEYENCE).
Results
To explore chemical compounds that affect the
intracellular localization of Mcad, the 364 inhibitors tovarious kinds of cellular enzymes were screened.
Relative luminescence intensity divided by the numberof the cells was shown with a negetive control (DMSO)(fig.4). Any chemical compounds that vary the cellnumber by more than 20% compared to control, were
excluded. The result showed 9 compounds greately
affect the amount of Mcad localized on the cell surface(Table.1).
2.5

2.0

1.5

Negative Control(DMSO)

1.0

0.5

0.0

Luminescence

0.156
0.297
0.376
0.384
0.410
0.459
1.000
1.939
2.122
2.855

inhibitor

Target enzyme/cellular effectThapsigargin
anisomycin
brefeldin A
Nigericin
Bafilomycin A1
Cdk2/9 inhibitor
DMSO
Y27632
Scriptaid
MG-132

Ca2+ATPase
p38 MAPK activator
golgi inhibitor
K+ ionophore
V-ATPase
CDK2/9(negative control)
ROCK
HDAC
proteasome

Discussion
In this study, new assay tool that can selectively
detect Mcad localized on the cell surface wasestablished. And some chemical compounds were
found to affect the intracellular localization of Mcadduring muscle regeneration.
Scriptaid, an inhibitor of HDAC (histone
deacetylase), was reported to decrease dexamethasoneinduced muscle atrophy, and HDAC itself involves
induction of muscle atrophy due to muscle disuse [3,4].
So, it is interesting if HDAC is also involved in thefunction of Mcad during muscle regeneration in vivo.
In the future, further screening of molecules andgenes using the newly established screening tool will
provide us important information concerning themolecular regulatory mechanisms on the myogenic
differentiation. Moreover, accumulation of suchknowledge is supposed to contribute the developmentof effective clinical interventions for patients who need
physical therapy.
References[1] Abmayr SM, Pavlath GK. Myoblast fusion: lessons
from flies and mice. Development 2012;139(4):641656.
[2] Zeschnigk M, Kozian D, Kuch C, et al. Involvementof M-cadherin in terminal differentiation of skeletal
muscle cells. Journal of Cell Science 1995; 108: 297381.
[3] Habibian J.S., Bolino M, Qian A, et al. ClassI
HDAC inhibitors attenuate dexamethasone-induced
muscle atrophy via increased protein kinase C(PKC)delta phosphorylation. Cellular Signaling 2023;
110: 110815[4] Beharry A.W., Sandesara P.B., Roberts B.M. et al.
HDAC activates FoxO and is both sufficient andrequired for skeletal muscle atrophy. Journal of Cell
Science 2014; 127: 1441-53

1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
64
67
70
73
76
79
82
85
88
91
94
97
100
103
106
109
112
115
118
121
124
127
130
133
136
139
142
145
148
151
154
157
160
163
166
169
172
175
178
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184
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190
193
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202
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211
214
217
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226
229
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256
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265
268
271
274
277
280
283
286
289
292
295
298
301
304
307
310
313
316
319
322
325
328

Luminescence(Surface expression)

3.0

Table.1 The list of chemical compounds with large
variation

chemical compoundFig.4 The amount of the Mcad localized on the cellsurface.

Author e-mail address
E-Mail: suzuki.yumika.r8@s.mail.nagoya-u.ac.jp

Ankle Strategies for Step-Aside Movement during
Straight Walking
Lingchao Xie and Sanghyun Cho
Department of Physical Therapy, Yonsei University
Introduction
Step-aside movement (dodging step) during walking is
a common maneuver to avoid obstacles; however, it isassociated with fall risk owing to differences in neuralcontrol mechanisms and ankle strategies compared tostraight walking. In our previous study, themechanisms of ankle muscle contraction, foot centerof pressure (CoP) displacement, and ground reaction
force (GRF) generation in step-aside movements
during standing were explored, excluding theinfluence of walking [1]. The current study aimed toextend previous findings by studying thesemechanisms during straight walking, offering
potential avenues for understanding obstacle
avoidance.
Methods
Twenty healthy young male participants wererecruited, experimental trials were conducted in a 36
m straight corridor, and the participants walked in two
conditions at normal walking speed (1.15 ± 0.13 m/s)
between three parallel lines of yellow pinstripe tape on
the corridor floor at shoulder-width distances as per
walking guidelines [16,17]. The participants walked
straight between the left and middle guidelines; ten
steps were statistically analyzed.
Afterward, the participants walked straight within
the left and middle guidelines again, but this time,they were instructed to step aside to the right to walk
between the middle and right pinstripe tapes at aself-selected time. Since a change in direction must beplanned in the previous step [18], participants dictatedverbal cues of “1, 2, 3” to themselves while they madestep-aside movements. The specific foot placement of
the step-aside movement and timing of the self-verbal
cues are shown in Figure 1.

The participants performed three sessions for both
walking conditions, and only ten step-aside
movements in the third session were recorded andanalyzed. The data from the first and last steps of eachcondition were not included in the statistical analysis.
The present study tested the differences between
the conditions in EMG muscle activity, CoP
displacement, and GRF by statistically examining theentire time series using one-dimensional statisticalparametric mapping (SPM1d) in Python 3.8(www.python.org), using the open-source software
package SPM1d 0.4.8)
Result
The two-tailed paired t-test revealed significant
increases in EMG activation of all three ankle muscles
during the left push and right loading phases of thestep-aside movement compared to straight walking.

Figure 2. (a,c,e) Grand mean patterns for normalized TA, PL,
and SOL EMG amplitudes of the step-aside to right movement (red)and the straight walking (black) in the left push phase. The grey

Figure 1. The sequence of “step-aside to the right” during straightbars indicate the region of interest (ROI). (b,d,f) SPM{t} results

walking. The numbers indicate the self-verbal cue.

depict the differences in muscle activities between the two
conditions. The critical threshold t* (wide dashes) exceeded during(b) 37.2–51.4%, 56.2–59.9%, and 61.7–63.8%, (d) 34.7–51.8%, and
58.2–59.9%, (f) 38.9–50.0% of the gait cycle. p values < 0.05 (*),
<0.01 (**), and <0.001 (***) indicate significant differences
between step-aside movement (SA) and straight walking (SW).

In the left push phase, the two-tailed paired t-test
indicated a significant decrease in foot CoPx
displacement at 19.0–26.5%, and a significant increaseat 37.0–58.9% of the gait cycle (Figure 5b).
Furthermore, foot CoPy displacement significantly
increased from 19.0–28.9% and 36.3–53.9%, with asignificant decrease at 60.3–61.8% of the gait cycle.
However, the right-foot CoPx displacement
significantly decreased only during 7–22.0% of the
gait cycle compared to straight walking (Figure 5f).

Figure 3. (a,c,e) Grand mean patterns for normalized TA, PL, andSOL EMG amplitudes of the step-aside to right movement (red) andstraight walking (black) in the right loading phase.

The SPM{t} trajectory of the left-foot forefoot GRF(F-GRF) and heel GRF (H-GRF) crossed the criticalthreshold downward, representing a significant
decrease compared to straight walking (Figure 4b,d).
Additionally, the SPM analysis revealed that during
the right loading phase of the step-aside movement, amajor region of the SPM{t} trajectory of the right-footFigure 4. (a,c,e,g) Grand mean patterns for CoP displacement of thestep-aside to the right movement (red) and the straight walking(black) in the left push and right loading phase.

Figure 5. (a,c,e,g) Grand mean patterns for F-GRF and H-GRF of
the step-aside to the right movement (red) and straight walking(black) in the left push and right loading phase.

H-GRF exceeded the critical threshold, signallinga remarkable and significant increase in step-aside
movement (Figure 4h).
Discussions
The study's findings indicate that during step-aside
movements, there is significantly higher bilateralankle muscle activation, particularly in the left PL
muscle during the left push phase. This contrasts withstraight walking. The analysis also supports the
hypothesis that the CoP trajectories significantly differ
during the left push phase. These differences areobserved in both CoPx and CoPy trajectories.
During the right loading phase of step-aside
movements, the muscle activation patterns supported
the hypothesis of increased ankle stability duringinitial foot contact. Additionally showed decreased
CoPx displacement but minimally changed in CoPy
displacement.
During the pre-swing period of step-aside movements,
greater muscle contractions are observed in the TA
and PL muscles compared to straight walking,contributing to toe clearance. Participants shift theirbody weight earlier to the left during step-aside
movements, similar to anticipatory posturaladjustments (APA), which generate forward
propulsive force. This shift involves moving theleft-foot CoP in the opposite direction, benefiting PL
muscle contractions for right-side propulsive force.
Additionally, the left-foot CoP moves further andends the displacement sooner than in straight walking,facilitating longer strides.
Author address: stanforia09@gmail.com

Who are the Best Candidates for Robotic Gait Training Rehabilitationin Hemiparetic Stroke?
Wonjun Oh
Division of Health Science, Department of Physical Therapy

Postgraduate School of Physical Therapy, Yonsei University- Statistical Analysis: Descriptive statistics, power
analysis, and ANCOVA were used to analyze the data.
Introduction
The significance level was set at 0.05, and data were
RAGT (Robot-Assisted Gait Training) has gained
adjusted for outliers and missing values.
popularity for improving gait function in hemiparetic
Results
stroke patients, but the ideal timing and patient
ANCOVA test found a significant difference in FMA
characteristics for its effectiveness remain unclear [1].
scores between the LFAC and HFAC groups, with
There's a need to determine the best initial ambulation
higher sensorimotor recovery in the HFAC group.
level (FAC) for RAGT in stroke patients [2]. SomeANCOVA analysis showed no significant difference
suggest that exoskeletal RAGT, like Lokomat andin MAS scores between groups and time effect.
Walkbot, may be more effective for patients with FAC
ANCOVA demonstrated that RAGT intervention< 2 (weight supporting group), while overgroundsignificantly changed the balance (BBS scores) in both
walking training is recommended for FAC ≥ 2groups, with greater balance improvement in the(non-weight supporting group) [3]. Studies on
HFAC group. TIS results indicated that RAGT
Lokomat and Walkbot RAGT have shown varying
intervention significantly improved trunk stability
results in stroke patients [4-10]. To address this
(TIS scores) in both groups, with greater improvement
variability and accommodate patients with FAC levelsin the HFAC group. Number of Steps showed aranging from 0 to 4, we developed a Walkbot RAGT
significant time effect in both groups, but no groupoffering interactive guidance and progressive
differences were observed. Walking Distance also
resistance modes, along with real-time feedback on
showed a significant time effect in both groups, withjoint kinetics and kinematics [4]. This study aims to
no group differences.
evaluate the effects of Walkbot RAGT on
sensorimotor recovery in subacute stroke patients with
FAC <2 (low initial functional ambulation category
Table 1. Clinical outcome data difference between LFAC
[LFAC]) and FAC ≥ 2 (high initial functionaland HFAC groups.
ambulation category [HFAC]) using FMA, MAS,
LFAC
HFAC
P-Value
BBS, TIS scores, as well as the number of steps and
Pre
Post
Pre
Post
Time
Betwee Time×walking distance. We hypothesize that RAGT will
Test
Test
Test
Test
EffectnGrouplead to similar improvements in both groups.
Groups
MethodF 12.7
15.5
32.5
36.3
We included 57 subacute stroke patients who
M 3 ± ±
9 ± 7 ±
0.000
0.404
0.303
participated in RAGT at Cheong Dam Hospital, Seoul,
A 16.1
17.1
24.2
24.9
**
South Korea, between June 2017 and September 2019.
55
5
4
Inclusion criteria covered age, stroke type, andM 1.57
1.47
1.37
1.37
physical parameters, while exclusion criteria involved
A ±
±
±
±
0.805
0.363
0.000
various medical and physical conditions.
S 0.82
0.73
0.74
0.74
- Clinical Outcome Measures
B
15.4
27.1
1. FAC: A 6-point scale assessing ambulation ability.
B 3.2 ± 7.23
8 ±
0.000
0.000
0.000
9 ±
2. FMA Scale: Evaluating sensorimotor impairment in
S 3.46
± 4.6
10.3
**
**
**
6.25
hemiparetic stroke patients.
3
3. MAS: Assessing spasticity in various neurological
T 3.97
4.87
9.11
12.9
0.026
0.000
conditions.
I ±
±
±
6 ±
0.167
**
**
4. BBS: Evaluates balance during specific tasks.
S 5.33
5.59
5.41
5.26
5. TIS: Assesses trunk motor impairment after a stroke.
S 646.
654.
1125
1043
6. Number of Walking Steps and Walking Distance:
T 4 ±15 ± .07 ± 0.000
.83 ±
0.482
0.000
Measured using the Walkbot system.
E 347.
340.
311.
**
346
- Intervention: Both groups received RAGT three
P 67
79
58
times/week for six weeks using the Walkbot-G system.
D 350.
564
364.
590.
The system provides real-time feedback and adjusts
I 43 ± ±74 ± 22 ± 0.000
0.593
0.000
support as needed. Conventional physical therapy was
S 185.
183.
223.
216.
**
also administered twice daily.
58
85
96
55

Data

are

presented

as

the

mean

±

standard

deviation.

Abbreviations:; FMA, Fugl–Meyer assessment; MAS, Modified
Ashworth scale; BBS, Berg Balance Scale; TIS, Trunk Impairment
Scale; STEP, number of steps; DIS, walking distance. ANOVA,
analysis of variance ANCOVA, analysis of covariance * P < 0.05.
** P < 0.01.

Figure 1.
Walkbot exoskeletal
system.
(a) hip joint actuator
including servomotor;(b) knee joint actuator
including servomotor;and (c) ankle joint
actuator including
servomotor.

Discussions
This study investigated the effect of RAGT on
sensorimotor recovery function using the FMA scale,spasticity based on the MAS, balance based on the
BBS, and trunk stability based on the TIS, as well as
number of walking steps and walking distance insubacute stroke patients with low or high initial FAC.
As anticipated, regardless of the baseline FAC, bothgroups demonstrated significant improvements insensorimotor, spatiotemporal, loss of balance, andtrunk stability function following Walkbot RAGTintervention. Most importantly, the current findings
dispute the notion that exoskeletal RAGT using
Walkbot can provide clinically meaningful changes inbalance and gait function in subacute hem-iparetic
stroke patients with low or high initial FAC. To ourbest knowledge, there is no previous study on this in
the literature, which makes it difficult to compare ouroutcome measure data in subacute stroke patients withlow or high initial FAC.

Figure 2. New robotic-assisted gait training schematic
guideline based on baseline functional ambulatory category
level.
References[1] Kim, H.Y.; You, J.S.H. A Review of Robot-Assisted
Gait Training in Stroke Patients. Brain Neurorehabilit 2017,10, e9 , doi:10.12786/bn.2017.10.e9 .

[2] Mehrholz, J.; Thomas S.; Werner C.; Kugler J.; Pohl
M.; Elsner B. Electromechanical-assisted training forwalking after stroke: A major update of the evidence. Stroke
2017, 48, e188–e189. doi:10.1161/strokeaha.117.018018.
[3] Morone, G.; Paolucci, S.; Cherubini, A.; De Angelis, D.;
Venturiero, V.; Coiro, P.; Iosa, M. Robot-assisted gait
training for stroke patients: Current state of the art andperspectives of robotics. Neuropsychiatr. Dis. Treat. 2017,13, 1303–1311, doi:10.2147/ndt.s114102.
[4] Kim, S.-Y.; Yang, L.; Park, I.J.; Kim, E.J.; Park, M.S.;
You, S. H.; Kim, Y.-H.; Ko,H.-Y.; Shin, Y.-I. Effects of
Innovative WALKBOT Robotic-Assisted Locomotor
Training on Balance and Gait Recovery in Hemiparetic
Stroke: A Prospective, Randomized, Experimenter Blinded
Case Control Study With a Four-Week Follow-Up. IEEE
Trans. Neural Syst. Rehabil. Eng. 2015, 23(4), 636–642,
doi:10.1109/tnsre.2015.2404936.
[5] Park, I.J.; Park, J.-H.; Seong, H.Y.; You, S.H.; Kim, S.J.;
Min, J.H.; Ko, H.Y.; Shin, Y.-I. Comparative effects ofdifferent assistance force during robot-assisted gait training
on locomotor functions in patients with subacute stroke: An
assessor-blind, ran-domized controlled trial. Am. J. Phys.
Med. Rehabil. 2019, 98, 58–64,
doi:10.1097/phm.0000000000001027.
[6] Seo, H.G.; Lee, W.H.; Lee, S.H.; Yi, Y.; Kim, K.D.; Oh,
B.-M. Robotic-assisted gait training combined withtranscranial direct current stimulation in chronic stroke
patients: A pilot double-blind, randomized controlled trial.
Restor. Neurol. Neurosci. 2017, 35, 527–536.
doi:10.3233/rnn-170745.
[7] Duncan, P.W.; Sullivan, K.J.; Behrman, A.L.; Azen,
S.P.; Wu, S.S.; Nadeau, S.E.; Dobkin, B.H.; Rose, D.K.;
Tilson, J.K.; Cen, S.; et al. Body-Weight–Supported
Treadmill Rehabilitation after Stroke. New Engl. J. Med.
2011, 364, 2026–2036, doi:10.1056/nejmoa1010790.
[8] Schwartz, I.; Meiner, Z. The influence of locomotor
treatment using robotic body-weight-supported treadmill
training on rehabilitation outcome of patients suffering fromneurological disorders. Harefuah 2013, 152, 166–71,
pmid:23713378.
[9] Park, J.-H.; Shin, Y.-I.; You, J.H.; Park, M.S.
Comparative effects of robotic-assisted gait training
combined with conventional physical therapy on paretic hip
joint stiffness and kinematics between subacute and chronic
hemiparetic stroke. NeuroRehabilitation 2018, 42, 181–190,
doi:10.3233/nre-172234.
[10] Kim, H.; Park, G.; Shin, J.-H.; You, J.H. Neuroplastic
effects of end-effector robotic gait training for hemiparetic
stroke: A randomised controlled trial. Sci. Rep. 2020, 10, 1–
9, doi:10.1038/s41598-020-69367-3.
Author address
E-Mail: sdc01047@naver.com

Long-term Effects of Deep Learning Digital Therapeutics on Sustainable Pain andMovement in Low Back Pain Management
Yunhwan Kim
Department of Physical Therapy
Postgraduate School of Software and Digital Healthcare Convergence, Yonsei University
Introduction
Low back pain (LBP) involves multifactorial
sources of pain including faulty posture, and movement,
sleep disturbance, and depression and other factors. In
particular, essential movement including bending,standing, lifting, twisting (rotation) and walking arecommonly impaired during ecological activities ofdaily living (ADL) and social participation,
compromising quality of life in people with LBP.
Derangement syndrome may involve mechanicalobstruction of the affected joint structure thatcompresses the intervertebral disc and nerve root,
resulting in either centralized or peripheralized pain
during repetitive abnormal lumbar movement [1]. To
mitigate the spinal movement impairments, a variety ofmanual therapeutic approaches including massage,
electrotherapy, manipulation, mobilization, mechanicaltraction and therapeutic exercise have been used [2].
However, to fight the prolonged coronavirus disease2019 (COVID-19) pandemic, a recent healthcare model
has adaptively reformed from the conventional contact(hands-on) approach to the untacked approach toprevent the collapse of national health care systems
worldwide [3]. Hence, the clear need exists to develop
the untacted therapy system for effective andsustainable monitoring, diagnosis, and treatment inpeople with LBP. The purpose of the present study was
to compare the effects of the deep learning-based
digital application (Dr.AI) with digital application
physical therapy (DPT) on back pain intensity, limited
functional disability, radicular symptoms, and qualityof life as well as post-questionnaire for satisfaction
questionnaire when compared to conventional physicaltherapy (CPT) in 100 patients with low back pain.
Methods
A convenience sample of 100 participants (meanage 35.5±8.8; 20 females) was recruited and underwent
either DPT or CPT for 30-min sessions, 3 times a week
over a 4-week period. Outcome measures included the(1) Oswestry disability index (ODI), (2) Quebec Back
Pain Disability Scale (QUE), (3) Roland–Morris
disability questionnaire (RMDQ), (4) numeric pain
rating scale (NPRS), (5) short-form 12 (SF-12), and (6)post-intervention satisfaction questionnaire.
The DPT using Dr. AI provided an individualizedintervention video, which followed the exercise as
outlined in the mechanical diagnosis and therapy(MDT) exercise theory and dynamic neuromuscularstabilization (DNS) along with a video, such asanterior/posterior derangement syndrome, dysfunction
syndrome, postural syndrome, and prone hip extension.
Participants observed the centralization vs.
peripheralization and better/worse response to theexerciseafter
theexercise.
However,ifperipheralization or pain worsened, the AI
recommended other exercises.
Fig 1. Dr.AI smartphone application

The CPT intervention comprised the therapeuticmodalities (heat, ultrasound, and TENS), mobilization,
manipulation, and therapeutic exercises (stretching,sling exercise, and core stability training), and wasconsistently delivered by the two licensed, experienced
physical therapists (6-12 years) according to thestandardized intervention protocols.
Statistical analysis included analysis of variance(ANOVA) to determine the intervention-relatedchanges in the outcome variables: (1) ODI, (2) QUE,
(3) RMDQ, (4) NPRS, (5) FMS (6) SF-12. Independentt-tests were used to compare post-questionnaire resultsfor post-intervention satisfaction between the DPT and
CPT groups.
Results
Fig 2. Clinical outcome measurements

The ANOVA revealed a positive effect on clinicaloutcome measures following 8 weeks of both DPT and
CPT. Especially, the DPT group demonstrated
significantly greater enhancements in the postintervention satisfaction compared to the CPT group(Figure 2 and Table 2).
Table. 2: Post-intervention satisfaction questionnaire.

DPT

CPT

pvalueAccessibility
Effectiveness
Cost
Sustainability
Real-time
feedback

4.67±0.48
4.09±0.72
4.91±0.29
4.06±0.75
3.58±0.75

3.27±0.84
4.39±0.75
2.76±0.97
3.97±0.88
2.42±1.39

0.02*
0.1
0.01*
0.68
0.01*

Discussion
Pain and associated disability analysis showed thatenhancement was significantly different in ODI, NPRS,
and RMDQ between the DPT and CPT intervention,
respectively. It is possible that the pain and associateddisability were improved in both groups because CPT(passive manual reduction) and DPT (patient selfreduction) may have improved pain and associateddisability in both groups due to maligned soft tissue andlumbar disc prolapse [4].
ADL analysis showed that both DPT and CPT leadto significant improvements in QUE. Mechanism for
ADL improvement is that CPT and DPT interventions
both provide knowledge of results (KR) and KP
feedback, where audiovisual motor learning strategy(motor and clinical) improvements are related to bettermovement, flexibility, and ADL abilities. Presumably,
these ADL processes are more involved in making useof critical information about moving and adapting
motor behavior to improve efficiency [5]. The resultsof this research suggest that providing incremental realtime feedback during progress toward a goal, alongwith the use of activity monitors, helps patients adjust
their behavior in time to make better progress and thus
may be more helpful compared to traditional feedback[6].
The QOL analysis demonstrated that bothinterventions were equally effective in enhancing SF12. DPT and CPT would increase patient motivationand life-activity in the intervention, making it more
effective in the short and medium terms. Providing
incremental real-time feedback during progress toward
a goal, along with the use of activity monitors, helps
patients adjust their behavior in time to make better
progress. Use of such activity monitors has been shown

to improve level of physical activity, thus enhancing
improvement in function and decrease in pain inpatients with LBP [7]. Mobile devices are personal andconstantly accessible to patients, the use of DPT,
specifically smartphone applications, is considered apotentially useful way for patients to monitor theircondition, as it enhances patients’ ability and their
willingness to engage in self-management, thus
improving treatment compliance [6, 7].
The post satisfaction questionnaire analysis showed
more significant differences in accessibility, cost andreal-time feedback in the DPT group compared to the
CPT group. The findings of this study seem to beconsistent with the opinion that telerehabilitation is a
viable link that may help remedy the challenges ofbarriers of distance, time, and travel to receive care [7].
In conclusion, DPT was a successful intervention
for clinical outcome measures (ODI, RMDQ, and
NPRS), lower extremities muscle force, trunk mobility,
activities of daily living (QUE), FMS, and quality oflife (SF-12). Most importantly, DPT demonstrated
more positive effects on cost-effectiveness,
accessibility, and real-time feedback compared to CPT.
References[1] Mckenzie A., and May S. Mechanical diagnosis andtherapy: the lumbar spine. Waikanae, New Zealand: Spinal
Publications, 2003.
[2] Buchbinder R., Jolley D., and Wyatt. M. Population based
intervention to change back pain beliefs and disability: threepart evaluation. Bmj, 2001, 322.7301: 1516-1520.
[3] Turolla A. Rossettini, G., Viceconti, A., Palese, A., andGeri, T. Musculoskeletal physical therapy during the
COVID-19 pandemic: is telerehabilitation the answer?.
Physical therapy, 2020, 100.8: 1260-1264.
[4] Kent, P., and Keating, J. L. Classification in nonspecific
low back pain: what methods do primary care clinicians
currently use?. Spine, 2005, 30.12: 1433-1440.
[5] Gordon, R., and Bloxham, S. A systematic review of theeffects of exercise and physical activity on non-specificchronic low back pain. In: Healthcare. MDPI, 2016. p. 22.
[6] Yang, J., Wei, Q., Ge, Y., Meng, L., and Zhao, M.
Smartphone-based remote self-management of chronic low
back pain: a preliminary study. Journal of healthcare
engineering, 2019, 2019.
[7] Almhdawi, K. A., Obeidat, D. S., Kanaan, S. F., Oteir, A.
O., Mansour, Z. M., and Alrabbaei, H. Efficacy of an
innovative smartphone application for office workers withchronic non-specific low back pain: a pilot randomized
controlled trial. Clinical Rehabilitation, 2020, 34.10: 12821291.
Author address
E-Mail: aidenkim@yonsei. ac.kr

Department sessions
Occupational Therapy
13:30

Opening Remark

Prof. Minoru Hoshiyama

NagoyaSession Ⅰ
13:35～14:43

Presentation: 12 minutes Question & Answer: 5 minutes
Prof. Ickpyo Hong

Yonsei

13:35～13:52

Suyeong Bae

Yonsei13:52～14:09

Yuga Takeda

Nagoya

14:09～14:26

Yeonju Jin

Yonsei

14:26～14:43

Masato Sasaki

Nagoya14:43～15:00

Chair

Neural activity related to task shift/switching
Relationship between visual function of distance acuity, near acuity and contrast
sensitivity and activities of daily living

Change of Brain Activity in Sensory Motor Cortex by Somatosensory
Discrimination Task -A Preliminary Study

Presentation: 12 minutes Question & Answer: 5 minutes
Prof. Minoru Hoshiyama

Nagoya

15:00～15:14

Prof. Yuko Nishiura

Nagoya15:14～15:31

Jung-Min Han

Yonsei

15:31～15:48

Soo Yeon Yoo

Yonsei

15:48～16:05

Hyunseo An

YonseiProf. Ickpyo Hong

Yonsei

16:05～

disabilities

Intermission

Session Ⅱ
15:00～16:05

Social participation and life satisfaction among adults with physical

Chair

Closing Remark

Development of automatic calendar App “yottey” for older persons withneurocognitive disorders
Health improving programs for older adults living alone: A systematic review
Social Isolation Program for Older Adults Living Alone: A Systematic Literature
Review
Association Between Social Networks and Health Promoting Behaviors in
Community Dwelling Older Adults

Social participation and life satisfaction among adults with physical disabilities
Suyeong Baea, Ickpyo Hongba

Department of Occupational Therapy, Graduate School, Yonsei University; bDepartment of Occupational Therapy,
College of Software and Digital Healthcare Convergence, Yonsei University
Introduction
The number of adults having disabilities is rising in
the Korea [1]. In Korea, 2.64 million people havedisabilities, and 2.11 million are 50 years and older withdiagnosed disabilities, with 49.4% having physicaldisabilities [1].
Older adults with disabilities experience moredecline in physical and mental abilities than those
without disabilities [2-3]. Physical disabilities often
lead to limited social participation and impact their
quality of life and life satisfaction [4-5].
Social participation can positively impact the life
satisfaction of middle-aged individuals. Studies haveshown that active social engagement reduces theanxiety and depression-related symptoms in middleaged adults with no disabilities [6-7]. However,research on the connection between social participationand life satisfaction in middle-aged adults withdisabilities remains unclear. Therefore, we aimed toinvestigate the association between social participationand the life satisfaction of middle-aged adults withdisabilities.
Methods
This study utilized the 2016-2021 Korea Panel
Survey of Employment for the Disabled (PSED)
databases and conducted a retrospective cohort study.
The dataset included demographic and clinicalinformation of 4,577 Korean participants withdisabilities. The final sample consisted of 558 middleaged adults with physical disabilities.
Social participation was measured using a 4-point
Likert scale (1 = “I can’t partiwcipate at all,” 2 = “I
can’t participate,” 3 = “I tend to participate,” 4 = “Iparticipate a lot”) and it was considered as the timevarying independent variable. The dependent variable
was overall life satisfaction, assessed on a 5-point
Likert scale (1 = strongly dissatisfied, 2 =dissatisfaction, 3 = neutral, 4 = satisfaction, 5 = strongly
satisfied). Time-invariant covariates included age,gender, marital status, and educational attainment.
Latent growth models (LGMs) were employed to
explore the relationship between life satisfaction andsocial participation over time (Figure 1) [8]. Model fit
was assessed using five model fit indices.
The analysis revealed the association between timevarying social participation and life satisfaction, while
controlling for time-invariant covariates. Data cleaning
was performed in SAS (version 9.4), and LGM analysis
was conducted using Mplus (version 8.8).

Results
Table 1 shows the demographic characteristics ofadults with physical disabilities. Those who weresatisfied with their lives numbered 1,411 (45.34%). The
majority of the samples are females (n = 1,136,
80.51%).
Table. 1: The demographics of the participants (N = 558)
Variables
Age, mean (SD)
Sex
Male
FemaleEducational attainment
Below middle school
High school
Above college

N (%)
57.39 ± 4.40
322 (57.71)
236 (42.29)
306 (54.84)
201 (36.02)
51 (9.14)

Figure. 1: The conceptual conditional piecewise growth
analysis model
Table. 2: Association between social participation andlife satisfaction from the conditional piecewise
growth analysis model
Variable
Time-varying covariates
Social participation 2016
Social participation 2017
Social participation 2018
Social participation 2019Social participation 2020
Social participation 2021
Note. *p<0.05; **p<0.01Standardized
coefficients
0.082*
0.131**
0.190**
0.268**
0.194**
0.137**The LGM model shows good model fit results, as
indicated by a chi-square χ2 value of 126.241 with a pvalue of 0.000, an RMSEA (Root Mean Square Errorof Approximation) of 0.049, a CFI (Comparative Fit
Index) of 0.947, a TLI (Tucker-Lewis Index) of 0.927,

and an SRMR (Standardized Root Mean Square
Residual) of 0.093 (Figure 1).
This LGM model revealed that social participationconsistently had a positive association with life
satisfaction across multiple time points, withstandardized coefficients ranging from 0.082 to 0.268,
all of which were statistically significant (all p-values< .05) (Table 2).
Discussions
This study investigated the association betweensocial participation and life satisfaction in adults aged
50 to 64 with physical disabilities. The findings showedthat a consistent and significant association betweensocial participation and life satisfaction over time.
Social participation, which includes activities like
cultural and religious leisure pursuits and interpersonal
relationships, has been a focal point in prior research,
particularly concerning individuals with disabilities [9].
Studies have emphasized their interest in participating
both in the workforce and leisure activities, as it proves
beneficial [10]. Nevertheless, individuals withdisabilities have often been observed engaging inpassive leisure activities like watching TV and listening
to the radio [11-13]. These findings highlight the strong
desire of individuals with disabilities to partake insocial activities, both in terms of leisure and work,
which can enhance their life satisfaction.
In a 2020 survey by the Korea Institute for Healthand Social Affairs, disabled individuals cited economic
challenges, poor health, and limited mobility as themain reasons for not participating in leisure activities[1, 14]. As middle-aged adults age, they have more time
for leisure, but older adults with disabilities face
increased limitations [15, 16]. Health policymakers
should recognize these findings and create moreaccessible opportunities for disabled individuals toengage in leisure and social activities.
References[1] Korea Institute for Health and Social Affairs. 2021.
2020 Survey of the disabled. Available at
http://www.mohw.go.kr/react/al/sal0301vw.jsp?PAR_MENU_ID=04&MENU_ID=0403&CONT_SEQ=365
357&page=1[2] Havercamp SM, Scott HM. National healthsurveillance of adults with disabilities, adults withintellectual and developmental disabilities, and adults
with no disabilities. Disability and Health Journal. 8(2):165-172. 2015
[3] Kim G, Lee J. The influence of the double
discrimination on Successful aging of elderly people
with disability: A mediating effect of role performance.
Journal of Welfare for the Aged. 59: 257-280. 2013[4] Rajati F, Ashtarian H, Salari N, et al. Quality of life
predictors in physically disabled people. Journal of
Education and Health Promotion, 7. 2018.
[5] Song KY. A study on factors influencing on
successful aging of elderly with disability: Comparisonof elderly without disability. Korean Journal of CareManagement. 22: 137-160. 2017.
[6] Ma X, Piao X, Oshio T. Impact of social
participation on health among middle-aged and elderly
adults: Evidence from longitudinal survey data in
China. BMC Public Health, 20(1): 1-8. 2020.
[7] Chiao C, Weng LJ, Botticello AL. Social
participation reduces depressive symptoms amongolder adults: An 18-year longitudinal analysis in
Taiwan. BMC Public Health. 11(1): 292. 2011.
[8] Muthén B. Second-generation structural equation
modeling with a combination of categorical andcontinuous latent variables: New opportunities forlatent class–latent growth modeling. 2001.
[9] Levasseur M, Richard L, Gauvin L et al. Inventory
and analysis of definitions of social participation foundin the aging literature: Proposed taxonomy of social
activities. Social Science & Medicine. 71: 2141-2149.
2010.
[10] Hästbacka E, Nygård M, Nyqvist F. Barriers andfacilitators to societal participation of people withdisabilities: A scoping review of studies concerning
European countries. Alter. 10(3): 201-220. 2016.
[11] Han SY, Lee M. Literature review on the leisureof people with physical disabilities in the Korean
research journals. Korean Journal of Physical, Multiple& Health Disabilities. 62(2): 85-109. 2019.
[12] Pagán-Rodríguez R. How do disabled individuals
spend their leisure time? Disability and Health Journal.
7(2): 196-205. 2014.
[13] Yi MG. Social, cultural and leisure activities ofpeople with disabilities: Current state and policy
implications. Health and Welfare Policy Forum. 263:
73-88. 2018.
[14] Kwon HJ, Jang JS, Lee NR. Comparative analysis
study of leisure activities between disabled person andnon-disabled person: Based on 2019 National Leisure
Activity Survey. Journal of Korean Society of Assistive
Technology. 14(1): 11-22. 2022.
[15] Kobayashi T, Tani Y, Kino S, et al. Prospective
study of engagement in leisure activities and all-cause
mortality among older Japanese Adults. Journal of
Epidemiology. 32(6): 245-253. 2022
[16] Yu HW, Chiang Tl, Chen DR, et al. Trajectories
of leisure activity and disability in older adults over 11
years in Taiwan. Journal of Applied Gerontology. 37(6):706-727. 2018.
Author address
E-mail: sbae1@yonsei.ac.kr

Neural activity related to task shift/switching
Nagoya University Department of Rehabilitation Sciences
Graduates School of Medicine
Yuga Takeda

BACKGROUND: One of the therapeutic targets of

METHODS: In the present study, I detected changes in

occupational therapy is intervention for executive

brain activity that occurred during the time of task

dysfunction. Patients with executive dysfunction show

switching by continuously performing task switching withdifficulty in starting, transitioning and switching

only a few instructions under the same stimulus

consecutive tasks. When the human brain performs

environment. Subjects were asked to perform six active

cognitive tasks, several brain regions are considered totasks in sequence every 30 seconds in response toform neural networks that functionally interrelate.

information presented in an altruistic and continuous

Although some neural networks have been reported asmanner to visual, auditory, and somatosensory sensory

large-scale networks that are constructed throughout the

information. The subjects were 12 healthy young adults.

brain, the number of such networks, including large, small,Brain

and multiple overlapping networks, has not been clear.

magnetoencephalography (MEG), and cortical current

The activities of these neural networks are thought todensity and estimated currents in the alpha frequency bandinteract with each other, and to alter from one networkof the brain region of interest (ROI) based on the current

pattern to the next. However, the details of how thissource were compared before and after the task

transition of network activity occurs are not clear. In theconversion was taught cue. Brain activity during the taskpresent study, I used magnetoencephalography and its

transformation was averaged and compared regardless ofanalytical methods to clarify the shift/switching of task-

the task type.

activitywasrecordedusingarelated network mechanisms that are essential forcontinuity and change in behaviors.

RESULTS: Valid brain activity was obtained from 10 of
the 12 subjects. The mean cortical current density before
and after the task conversion cue was calculated, and six
ROIs were defined based on the distribution of corticalcurrent density before and after the cue (p<0.05, after FDR
correction). The time course of activity in the alphafrequency band before and after the task conversion cue
showed that the right insular cortex was more active
before and after the cue, but the change over time in theright orbitofrontal cortex was not constant.

(Heine et al., 2012）

regardless of whether the task was switched before or after
the conversion. The brain regions that showed significant
differences in task switching-related activity were theright insular cortex and the right lateral orbitofrontal
cortex in terms of alpha frequency bandwidth. Bothregions have been reported as brain regions related to task
switching, but the insular cortex showed a clear timecourse of brain activity before and after task switching,suggesting that it was one of the brain regions that was
DISCUSSION: Brain activity during task switching was

prompted by external stimuli (cue) to task switching.

evaluated in the present study. By comparing the brain
activity before and after the task switching, brain activity

Author addresscomponents related to the task switching was evaluated,

E-mail: takeda.yuga.k3@s.mail.nagoya-u.ac.jp

Relationship between visual function of distance acuity, near acuity and contrast sensitivity
and activities of daily living
Yeonju Jina, Ickpyo Hongba

Department of Occupational Therapy, Graduate School, Yonsei University; bDepartment of Occupational Therapy,
College of Software and Digital Healthcare Convergence, Yonsei University
Introduction
Vision is an important sensory function for
individuals to perform their daily activities
independently [1]. Visual function is defined as how theeye functions, and it provides information about target
locations and body movement as well as gives us thedetails that we need to see clearly [1]. This critical
function declines with age which could lead to vision
loss. As visual function decreases, older adults havemore difficulties in activities of daily living. Olderadults with impaired visual function experience a
twofold increase in the risk of falls, along with anelevated risk of cognitive impairment, dementia, and ahigher rate of comorbidity with other medical
conditions [2]. Additionally, they exhibit a greater
likelihood of concurrent physical and mental healthconditions or complex comorbidities compared to thesame age group [3]. Consequently, the decline in visualfunction among older adults is associated withincreased difficulties in performing activities of dailyliving and participating in social engagements,
contributing to negative health status.
Therefore, this study aimed to examine therelationship between visual function and independent
activities of daily living in community-dwelling older
adults.
Methods
We used a retrospective cross-sectional design. Outof the 3,817 participants in the 2021 National Healthand Aging Trends Study (NHATS), 2,824 individuals
were selected for the evaluation of visual function,
excluding any missing data. We utilized a series ofmultivariate regression models and estimated therelationship between visual function and independent
activities of daily living. We used the total scores ofthree visual function variables (distance acuity, near
acuity, contrast sensitivity) as the independent variable
and eight activities of daily living tasks (e.g., dressing,
shopping) and total scores as the dependent variables.
All statistical analyses and data management wereconducted using SAS statistical software version 9.4[4].

Results
The majority of the study sample was 75-79 years
old (n = 867, 30.7%), and male (n = 1,137, 35.7%).
Near acuity was statistically related to the total scoresof the four basic activities of daily living (BADLs) (β =0.32, standard error [SE] = 0.10; p = 0.0018), bathing(β = 0.13, SE = 0.05; p = 0.0056), eating (β = 0.07, SE= 0.03; p = 0.0066). However, distance acuity showedno significant relation to any of the BADLs activities.
Contrast sensitivity was only negatively related to theeating item (β = -0.06, SE = 0.02; p = 0.0048) (Table
1). Near acuity was statistically related to four
instrumental activities of daily living (IADLs) total
scores (β = 1.18, SE = 0.27; p = <.0001), shopping (β =0.52, SE = 0.10; p = <.0001), making hot meals (β =0.21, SE = 0.10; p = 0.0258), and baking (β = 0.32, SE= 0.10; p = 0.0020). However, distance acuity showedno significant relation to any of the IADLs activities.
Contrast sensitivity was only negatively related to thebanking item (β = -0.22, SE = 0.08; p = 0.0064) (Table
2).
Table1. Multivariable linear regression models withvision function and BADLs in the older adults
Variable

Total
score

Distance
acuity0.32(0.10)
0.04(0.11)

Contrast
sensitivity-0.12(0.08)

Near acuity

p
<.00*
0.73
0.12

Dress
ing
0.08
(0.05)
0.01(0.05)-0.03(0.04)

Toile
ting

p
0.08
0.76

0.03
(0.03)
0.01(0.04)

0.40-0.02(0.03)

p
0.30
0.84
0.53

Note. *Significant at <.05.
Table1. Multivariable linear regression models withvision function and BADLs in the older adults (cont.)
Variable

BathingpEatingp

Near acuity

0.13 (0.05)<.00*

0.07 (0.03)<.00*-0.02 (0.05)

0.65

0.04 (0.03)

0.18-0.02 (0.04)

0.63-0.06 (0.02)<.00*

Distance
acuityContrast
sensitivity

Note. *Significant at <.05.

Table2. Multivariable linear regression models withvision function and IADLs in the older adults
Variable

Total
score

Distance
acuity1.18(0.27)
0.31(0.29)

Contrast
sensitivity-0.14(0.21)

Near acuity

p
<.00*
0.28
0.48

Laun
dry
0.13
(0.10)
0.09(0.11)
0.02(0.08)

p
0.17
0.40
0.80

Shop
ping
0.52
(0.10)-0.02(0.11)-0.02(0.08)

p
<.00*
0.84
0.78

Note. *Significant at <.05.
Table2. Multivariable linear regression models withvision function and IADLs in the older adults (cont.)
Variable

Makinghot mealspBankingp

Near acuity

0.21 (0.10)<.02*

0.32 (0.10)<.00*

Distance
acuity0.05 (0.10)

0.64

0.19 (0.11)

0.07

Contrast
sensitivity

0.07 (0.07)

0.31-0.22 (0.08)<.00*

Note. *Significant at <.05.
Discussion
This study examined the relationship between
visual function and independent activities of dailyliving and in community-dwelling older adults.
Our findings are consistent with previous studies,
which suggest that good near acuity is related to older
adults being independent in activities of daily living [57]. However, contrast sensitivity showed a negative
relationship with eating and banking tasks. Older adults
need longer stimulation durations due to delays invisual processing speed due to problems such as decline
in cognitive function [1]. These results are limited
because we do not know if strategies such as lighting
was used when individuals were participating in
activities of daily living. Distance vision was not
significant in all activities of daily living. This isconsistent with other studies showing nonsignificant
associations between distance vision and activities ofdaily living tasks [8]. This means that distance vision
may be less important or utilized less frequently thanother visual function in performing activities of dailyliving. Near vision was the more frequently used visualfunction in various activities of daily living [5].

A limitation of this study was that it was difficult todetermine the cause of visual function decline.
Specifically, we were unable to ascertain whether the
study subjects had any degenerative conditions related
to vision (e.g., glaucoma, optic neuropathy, etc.). In thisdataset, visual function was assessed in a large sample,
potentially introducing measurement errors in theevaluation due to variances among evaluators(interviewers) and variations in the home environment.
References[1] Owsley C. Aging and vision. Vision Research.
51(13): 1610-1622. 2011.
[2] Cao GY, Chen ZS, Yao SS, et al. The association
between vision impairment and cognitive outcomes inolder adults: A systematic review and meta-analysis.
Aging & Mental Health. 27(2): 350-356. 2023.
[3] Crews JE, Jones GC, Kim JH. Double jeopardy: The
effects of comorbid conditions among older people
with vision loss. Visual Impairment & Blindness.
100(1_suppl): 824-848. 2006.
[4] SAS Institute Inc. SAS/STAT® 9.4 user’s guide.
2008.
[5] Burmedi D, Becker S, Heyl V, et al. Behavioral
consequences of age-related low vision. Visual
Impairment Research. 4(1): 15-45. 2002.
[6] Guo X, Arsiwala LT, Dong Y., et al. Visual function,
physical function, and activities of daily living in two
aging communities. Translational Vision Science &Technology. 10(14): 15-15. 2021.
[7] Kempen GI, Ballemans J, Ranchor AV, et al. The
impact of low vision on activities of daily living,
symptoms of depression, feelings of anxiety and social
support in community-living older adults seeking
vision rehabilitation services. Quality of Life
Research. 21: 1405-1411. 2012.
[8] Sloan FA, Ostermann J, Brown DS, et al. Effects ofchanges in self-reported vision on cognitive, affective,
and functional status and living arrangements among
the elderly. American Journal of Ophthalmology.
140(4): 618.e1-e12. 2005.
Author address
E-mail: yjin1@yonsei.ac.kr

Change of Brain Activity in Sensory-Motor Cortex
by Somatosensory Discrimination Task
- A Preliminary Study –Masato Sasaki 1),Mao Ichikawa2), Jun-ichi Uemura3)1)Division of Occupational Therapy, Department of Health Sciences
Graduate School of Medicine, NAGOYA University2) Department of Rehabilitation, Aichi Medical University hospital
3) Prevention & Rehabilitation Sciences Course, Department of Integrated Health Sciences,
Graduate School of Medicine, Nagoya University
Introduction
Somatosensory loss is observed in approximately
half of all stroke survivors [1]. Somatosensory loss instroke survivors have a negative impact on their qualityof life and personal safety, including impaired ability toperform daily tasks such as object recognition, grasping,and manipulation; balance during upright posture andwalking; and risk of burns and injuries due to impaired
warmth and pain perception [2].
Somatosensory discrimination training (SENSe
assess) has been proposed for somatosensory loss after
stroke, with the main goal of restoring somatosensory
discrimination ability [2]. This training was developed
by Carey et al. (2011) and is believed to provide higher
functional recovery than conventional treatment
methods [2].
Regarding to brain function, it has been reported
that the human brain is constantly changing in a plastic
manner in response to internal and external stimuli [2].
Focusing on this brain plasticity, training methods that
aim to induce neuroplastic changes in brain regions
related to somatosensory function are believed toprovide higher functional recovery than conventional
treatment methods [2]. However, the effects of the wrist
position sense task on brain activity have not beenstudied neurophysiologically. Therefore, the purpose ofthis study was to clarify the changes in brain activity inthe sensorimotor cortex induced by the Wrist Position
Sense Test (WPST) included in SENSe using themagnetoencephalography (MEG). We think thatclarifying these changes will provide basic insight into
the effects of sensory functional-training on brain
function.
MethodThirteen healthy adult volunteers (10 males,
average age: 22.8±1.6) participated in the experiment.
All participants were right-handed and had no historyof neurodegenerative diseases or organic brain
disorders presenting as visual, auditory, or
somatosensory impairments. Before the experiment, allparticipants were informed about the study and consent

was obtained in writing. People with metal insertions in
the body were excluded. This study was approved by
ethical committee of Nagoya University, school of
health science (approve number: 21-605).
The experiment task was the WPST [2]. First, theexaminer fixed the participant's right wrist and forearmto hand splint in a position not visible to the participant,with the wrist in its natural position and the elbow bent
at 90 degrees. Second, the examiner moved thepatient`s wrist sequentially to several pre-determined
angles. Participants answered the angle of their wrist by
moving the pointer or verbally. After each trial, tester
provided feedback to the participant on the correct
angle.
The control task only consisted of the examiner tomove the participant's right wrist, similar withexperimental task, while the participant watched asilent film. Participants did not respond without being
aware of the angle.
The experimental and control tasks were randomly
administered to the same participants with at least a
one-week interval between two tasks. The duration of
two tasks was 20 minutes, respectively.
We recorded the resting-state brain activity before
and after the task. Participant lay down on a bed in amagnetically shielded room and looked at cross markprojected on the monitor 30 cm ahead of participants
during the recording. We used a whole-head MEG
system (PQ1160C. RICHO) with 160 channels. The
bandpass filter was between 0.3 to 200 Hz, at asampling rate of 1000 Hz. We recorded the resting-state
brain activity for 4 minutes in a dark room before andafter the task. Before the MEG measurement of eachparticipant, the shape of the scalp was measured using
a 3D digitizer. Electrooculogram (EOG) andElectrocardiogram (ECG) were simultaneously
recorded for artefact rejection. Participants were
informed to keep their eyes open and not to sleep.
The MEG data were analyzed by 'Brainstorm'
software (https://neuroimage.usc.edu/brainstorm). The
EOG and ECG data were used to reject the artefacts
caused by heart rate and eye movement.

Source data were generated for each of theexperimental and control tasks. The power spectral
density (PSD) was then calculated from the source data.
MEG data were analyzed in the alpha band (8~12Hz).
The difference in pre- and post-task brain activity(Δpost-pre) was then calculated by subtracting the pretask PSD from the post-task PSD. The Δpost-pre wasthen compared between experimental and control tasks
by permutation t-test. The significance level was set at
5%. In this study, we focused on the primary andsecondary somatosensory area.

increasing memory load in a working memory task [3].
In this studies, an increase in the alpha band source near
the sensorimotor cortex was observed. This study also
raised the hypothesis that the increase in alpha power
may represent a neuronal mechanism for the
maintenance of working memory. We thought thatworking memory was required during responding to thetask based on the feedback from previous execution.
The increase in alpha power during the task might
continue to occur in the sensorimotor cortex after thetask.

Results
Comparing the experimental and control tasks forsensory and motor cortex, the experimental taskenhanced brain activity in the alpha frequency bands.
For the alpha band in the right hemisphere, theexperimental task enhanced brain activity of theprefrontal, precentral, postcentral and superiorparietal
compared to the control task (Fig.1). Additionally, inthe left hemisphere alpha band, the experimental taskenhanced brain activity in the prefrontal, precentral,and postcentral (Fig.1).

References[1] Susan M Hunter, Linda Hammett, Sue Ball, Nina
Smith, Cheryl Anderson, Allan Clark, Raymond
Tallis, Anthony Rudd, Valerie M Pomeroy. Doseresponse study of mobilisation and tactile stimulation
therapy for the upper extremity early after stroke: aphase I trial. Neurorehabil Neural Repair. 25(4):31422, 2011
[2] Leeanne Carey, Richard Macdonell, Thomas A
Matyas. SENSe: Study of the Effectiveness of
Neurorehabilitation on Sensation: a randomized
controlled trial. Neurorehabil Neural Repair,25(4):304-13,
2011[3] Ole Jensen, Jack Gelfand, John Kounios, John E
Lisman. Oscillations in the alpha band (9-12 Hz)
increase with memory load during retention in a shortterm memory task. Cereb Cortex, 12(8):877-82, 2002
Author address
E-Mail: sasaki.masato.k4@s.mail.nagoya-u.ac.jp

Fig.1 Significant differences in brain changes between
experimental and control groups. The warm colors
represent greater change in the experimental comparedto the control taskgroup.

Discussion
In the alpha band, significant differences were
found in the pre- and post-central. In the areas, powerincreased in the experimental task and slightly
decreased in the control task. Previous studies showedthat alpha power values increased linearly with

Health improving programs for older adults living alone: A systematic review
Jung-Min Hana, Young-Myoung Limb, Ji-Hyuk Parkca

Department of Occupational Therapy, Graduate School, Yonsei University; bSuper-Aged Society New Normal
Lifestyle Research Institute, Yonsei University; cDepartment of Occupational Therapy, College of Software andDigital Healthcare Convergence, Yonsei University
Introduction
As of 2022, the proportion of older adult living alone
among 65 years or older population is 20.8% and it isreported that this will gradually increase. Compared toolder adults who live with others, living alone have lesssocial interaction, having lower awareness of healthrelated services, and show reduced levels of physicalhealth, mental health, and social health as causes of highlevels of depression, anxiety and loneliness [1].
It has been reported that all health factors are according to
the reduced health level of older adults living alone
because physical, mental, and social health have beenreported to be interrelated [2]. Compared to older adults
living with others, living alone have been reported to havea negative impact on not only their social health but also
their physical and mental health due to the problem ofsocial isolation [3]. Therefore, interest and necessity arebeing emphasized in terms of physical, mental, and social
health of older adults living alone [4].
Therefore, health improving intervention for older adults
living alone are necessary for their health and quality oflife. This study aims to find the program method whichbrings most positive effects for physical, mental, andsocial health.
Methods
The database for this study was searched using PubMed,
Embase, Riss, and DBpia. The search period was set fromJanuary 2013 to January 2023. Ant the main search termsare (‘elderly’ or ‘older’ or “old adult” or ‘age’) and(“health improve” or “health promotion”) and (“living
alone” or “live alone”) and ‘intervention’.
Eligible criteria for this research was 1) participation ages
more than 65 who lives alone, 2) A study which relatedwith health improving program, 3) Experimental groupand control group design study, 4) Article available towatch full text, and 5) article which language’s written in
Korean or English. And exclude criteria for this research
was 1) Dissertations, books, and protocol studies, 2)
Conference presentation materials and posters.
A final 1,045 papers were searched. After reading titles,
abstract, and full text, irrelevant literature was removed,
and total 6 papers were selected.
Results
A total of 6 analysed studies were assigned andexperimental and control group. All of the experimentalgroups were treated with a health promotion intervention,and the control group was provided with a previously
applied nutritional intervention 1studies [5]. In the other 5
studies, no interventions were applied to the control group.
As a result of confirming the intervention methods used inthis study, the study conducted in Korean nursing
conducted the most diverse program [3, 5, 6]. Theintervention method was carried out in three ways: healthcare education, exercise program, and cognitive program
for the experimental group. 2 Studies progressed home
visit intervention [5, 6], and 1 study used agency visit
intervention [3]. Looking at the remaining intervention
methods, a study conducted only an exercise program
though a home visit intervention [7], a study in which a
medical alert device was worn through a tele intervention[8], nutrition education and eating habits management
intervention was conducted through a combination ofhome visit intervention and tele intervention [9].
In the studies effects which had both tele and home visit
intervention, experiment groups had improved their
physical health, but didn’t saw significant differencecompare with control groups. Experiment groups mental
health had improved but didn’t saw significant difference[7]. And result about social health was not reported. In thestudies effects which had used home visit intervention,
physical health and mental health has showed
improvement and significant difference. And in one study
which showed social health results showed improvement
and significant difference too.
Discussion
The purpose of this study was to conduct a systematic
review focusing on the methods and effects of healthpromotion interventions for older adults living alone. The
effectiveness of health promotion interventions showedsignificant difference according to two studies that
conducted various health management education, exercise
programs, and cognitive programs in nursing throughhome visit interventions [5, 6]. Additionally, one study
reporting the effect on social health showed a significant
difference [5]. Additionally, existing research reports thatintervention methods that carry out the most diverse
intervention activities show the most positive effects [10].

Table. 1: Intervention Type and Method
Intervention
type[reference]

Intervention method

Visit/ tele

Recommend Exercise from WHO (eg, Take a[7]

Walk for 30 Minute, Chair Stand Exercise,
Stair Climbing, Sit-Ups)

Tele

Using Medical Alert Device/Service and[8]Receive Small Call Button

Visit/tele

Visit Group: Home Visit to Check Eating[9]

Habits /Recommend Meals
Tele Group: Telephone to Check Eating Habits

Visit

Health Education (eg, Management of Chronic[6]

Disease, Fall-Prevention, Preparing for theHeat Wave, Food Positioning Prevention)
Exercise Program (eg, Floor-Seated Exercise)
Cognitive Function Stimulation Practice (eg,Drawing, Puzzle Matching, Hand-Knitting)

AgencyMetabolic Syndrome Education (eg,[3]

Understanding Metabolic Syndrome,
Preventing Metabolic Syndrome)
Exercise Program (eg, Warm-up Exercise,
Main Exercise, Cooling Down Exercise)Self-Esteem Promotion Strategy (eg, Caring
Back Massage, Blessing Each Other,
Accepting Each Other)

Visit

Health Education: (Nutrition Education by[5]

Cooking Classes Focused on Healthy Foods
and Convenient Recipes)
Exercise Program: (eg, TheraBands Exercise,
Aerobic Movements, Rhythmic Movement)
Cognitive Program: (Calendar Making with
Various Material, Cup Nanta by Rhythm)

References[1] Mouodi S, Bijani A, Hosseini S R, et al. Genderdifferences in the health status of elderly living alonecompared to those who are not alone: Evidence of the
AHAP study, North of Iran. Caspian Journal of Internal
Medicine. 7(2): 126-132. 2016[2] Ni MY, Yao XI, Cheung F, et al. Determinants ofphysical, mental and social well-being: A longitudinal
environment-wide association study. International Journalof Epidemiology. 49(2): 380-389. 2020.

[3] Kim JI, Kim SA, Park KM, et al. Effects of BeHaS
program on health behavior, physiologic index and selfesteem of the elderly living alone with metabolic
syndrome based on community based participatory
research. Journal of Korean Academy of Nursing. 50(4):571-582. 2020.
[4] Lim YM, Baek JH, Lee SM, et al. Association between
loneliness and depression among community-dwellingolder women living alone in south Korea: The mediating
effects of subjective physical health, resilience, and social
support. International Journal of Environmental Researchand Public Health. 19(15): 9246-9258. 2022
[5] Song MS, Boo SJ. Effects of a nurse-led
multicomponent intervention for frail older adults living
alone in a community: A quasi-experimental study.
BioMed Central Nursing. 21(1): 20-28. 2020.
[6] Park YRJ, Sohng KY. Effects of a customized healthpromotion program on depression, cognitive functioning,and physical health of elderly women living alone incommunity: A cluster randomized controlled trial. Journalof Korean Academy of Nursing, 49(5): 515-525. 2019.
[7] Cederbom S, Rydwik E, Söderlund A, et al. A
behaviour medicine intervention for older women living
alone with chronic pain - A feasibility study. ClinicalIntervention in Aging. 9: 1383-1397. 2014.
[8] Morgenstern LB, Adelman EE, Hughes R, et al. The
Women Independently Living Alone with a Medical Alert
Device (WILMA) trial. Translational Stroke Research.
6(5): 355-360. 2015.
[9] Pedersen JL, Pedersen PU, Damsgaard EM. Early
nutritional follow-up after discharge prevents
deterioration of ADL functions in malnourished,independent, geriatric patients who live alone - A
randomized clinical trial. Journal of Nutrition, Health &Aging. 20(8): 845-853. 2016.
[10] Höhl W, Moll S, Pfeiffer A. Occupational therapy
interventions in the treatment of people with severe
mental illness. Current Opinion in Psychiatry. 30(4): 300305. 2017.

Author address
E-Mail: jungmin1998@gmail.com

Social Isolation Program for Older Adults Living Alone: A Systematic Literature Review

Soo Yeon Yooa, Ah-Ram Kimb, Ji-Hyuk Parkc
aDepartment of Occupational Therapy, Graduate School, Yonsei University; bYonsei New-normal Lifestyle ResearchCenter; cDepartment of Occupational Therapy, College of Software and Digital Healthcare Convergence, Yonsei
University

Introduction
With the development of the economy and medical
technology, human lifespan has gradually increased, andKorean society has also entered an aging era. Looking at
the proportion of single-person households by age group,
those in their 60s were 16.4% and those in their 70s orolder were 18.1% [1]. For men in their 60s, 14.5% and18.3% for women were single-person households, and formen over 70, 8.8% and 27.3% of women were singleperson households [1].
Old age is a time when social isolation is at high-risk,
and one of the various causes of social isolation in old age
is the increase in the number of elderly people living alone[2]. Social isolation has a negative impact on older people,
leading them to a fractured form of life, causing
deterioration in health, and even leading to suicide orlonely death [3].
Seniors living alone who complain of social isolationneed appropriate intervention, and domestic research on
this topic is lacking. Therefore, the purpose of this study
is to confirm the need for intervention for seniors living
alone who feel socially isolated through systematic review,and to summarize and consider the effectiveness ofinterventions for social isolation of seniors living alone.
Methods
The databases used in this study are RISS, CINAHL,
SCOPUS, and Web of Science. We searched for papers
published from January 1, 2012 to January 31, 2023. And
the main search terms were “social isolation” AND (older
OR elder OR aged OR geriatric) AND (“living alone” OR“live alone”) AND intervention.
The selection criteria were 1) literature targeting seniors
aged 60 or older living alone, 2) literature on intervention
for social isolation, and 3) literature published fromJanuary 1, 2012 to January 31, 2023. And the exclusion
criteria were 1) duplicate literature, 2) literature for which
the full text could not be obtained, 3) literature written inlanguages other than Korean and English, and 4)
systematic review literature.

A total of 2,962 papers were searched. After excluding
duplicate literature and reading the abstract and full text,
5 papers were finally selected.
Results
In five studies, the subjects were all elderly people whocomplained of social isolation. As a result of analyzing thesearch results, the study subjects were classified into
senior citizens living alone and senior citizens who did notlive alone. Of the five studies, two (40%) only targetedelderly people living alone. The remaining three articles(60%) targeted elderly people living alone and non-alone
elderly people.
To evaluate social isolation, the UCLA Loneliness
Scale, Friendship Scale, LSNS-6, and DUFSS were used,
and loneliness, depression, cognition, and quality of life
were also evaluated.
Among the 5 studies, 4 studies compared groups thatreceived intervention related to social isolation withgroups that did not, and the remaining study conductedpre- and post-surveys on 21 subjects and compared theresults [4- 8]. The period during which the intervention
was provided varied from 8 weeks to 1 year and 9 months,
and the number of interventions varied depending on the
study, with a minimum of 5 times and a maximum of 70
times per week. There were four main types ofinterventions: discretionary activity interventions in thecommunity, group activities and counseling interventions,interventions to learn how to use tablets and the Internet,
and interventions related to social interaction such as
telephone and in-person interventions [4-8].
The interventions provided in all five studies showedsignificant effects in reducing social isolation andloneliness. In addition, the effects of increased life
satisfaction, increased social support, improved
environmental quality of life, improved technicalknowledge, well-being, and improved trust in people andpublic social security were also observed. Among these,
environmental quality of life, trust in people and publicsocial security, and technical literacy improved, but nosignificant effects were observed.

Table. 1: Details of the Intervention
Intervention
Authors (year)

EG

CON

Czaja et al.
(2018) [4]

PRISM software
applications

A notebook
with printed
content similar
to that within
PRISM

Gadbois et al.
(2022) [5]

Learn how to
use tablets,
access theInternet, andparticipate inphone andInternet-based
virtual seniorcenter programs-

Hernández-Ascanio et al.
(2023) [6]Intervention of
six home-facing
sessions and fivephone calls
sessions

Only a followup of thesituation

Ristolainen
et al.
(2020) [7]

Consultation andactivities
including visits,
outdoorgatherings,
group exercises,
and recreation-

Winstead et al.
(2014) [8]Discretionary
activities-

Discussion
The purpose of this study was to analyze theeffectiveness of interventions provided to elderly people
living alone who are experiencing social isolation. First,
the interventions provided in 4 of the 5 studies wereinterventions related to social relationships or interactions.
In addition, there were computer-based arbitrations, butthey only accounted for 1 out of 5 cases. Second, among
the 5 studies, 3 evaluated quality of life. This means that
there is a close relationship between social isolation andquality of life. Lastly, 3 of the 5 studies commonly
evaluated social isolation and loneliness. This means thatsocial isolation and loneliness are closely related and are
an interactive relationship [9].
References[1] Statistics Korea. 2022. 2022 Statistics of One-person
Households.
Availableathttps://kostat.go.kr/board.es?mid=a10301060500&bid=1
0820&act=view&list_no=422143[2] Park MJ. Predictors of social isolation for the elderly
living in community. Journal of Regional Studies. 21(3):91-110. 2013
[3] Cacioppo JT, Hughes ME, Waite LJ, et al. Lonelinessas a specific risk factor for depressive symptoms: Crosssectional and longitudinal analyses. Psychology andAging. 21(1): 140-151. 2006
[4] Czaja SJ, Boot WR, Charness N, et al. Improvingsocial support for older adults through technology:
Findings from the PRISM randomized controlled trial.
Gerontologist. 58(3): 467–477. 2018
[5] Gadbois EA, Jimenez F, Brazier JF, et al. Findings
from talking tech: A technology training pilot intervention
to reduce loneliness and social isolation among
homebound older adults. Innovation in Aging. 6(5): 1-12.
2022[6] Hernández‐Ascanio J, Torres LÁP, Rich‐Ruiz M, et al.
Effectiveness of a multicomponent intervention to reducesocial isolation and loneliness in community‐dwellingelders: A randomized clinical trial. Nursing Open. 10(1):48-60. 2023
[7] Ristolainen H, Kannasoja S, Tiilikainen E, et al.
Effects of ‘participatory group-based care management’on wellbeing of older people living alone: A randomized
controlled trial. Archives of Gerontology and Geriatrics,
89: 1-10. 2020
[8] Winstead V, Yost EA, Cotten SR, et al. The impact ofactivity interventions on the well-being of older adults incontinuing care communities. Journal of applied
gerontology. 33(7): 888–911. 2014[9] Tong F, Yu C, Wang L, et al. Systematic review of
efficacy of interventions for social isolation of older adults.
Frontiers in Psychology. 12: 1-14. 2021
Author address
E-Mail: yeon6v6@yonsei.ac.kr

Association Between Social Networks and Health Promoting Behaviors in
Community-Dwelling Older Adults

Hyunseo Ana, Inhye Kima, Sohyeon Yuna, Hae Yean Parkba

Department of Occupational Therapy, Graduate School, Yonsei University; bDepartment of Occupational
Therapy, College of Software and Digital Healthcare Convergence, Yonsei University

Introduction

As the period of old age extends, it becomes vital to live
healthily and actively. The World Health Organization
highlights the importance of health-promoting behaviors
such as good eating habits and regular exercise [1].
Health-promoting behaviors are everyday actions thatenhance overall well-being, particularly in older adults,
and are influenced by personal and societal factors [2, 3].
Social networks refer to a specific set of connections
between a limited number of people [4]. Social networks,
which encompass relationships with family, friends, andothers, play a crucial role in the health behaviors of older
adults. Social networks have both structural (size, contact
frequency) and functional (quality, support) aspects, each
impacting health in different ways [5].
Current research on how these network aspects
influence health-promoting behaviors in older adults islimited. This study aims to bridge this gap by analyzing
the relationship between older adults' social networks andtheir health behaviors, especially in health management.

Methods

This research aimed to study the influence of social
networks on the health behaviors of community-dwellingelderly individuals aged 65 and up. Conducted on April
18-19, 2023, the online survey had 226 participants. Data
collection proceeded after the approval of the Yonsei
University Institutional Review Board (IRB).
This study used the Korean version of the Lubben
Social Network Scale (LSNS-18) to survey older adults'social networks [6]. LSNS-18 measures the social
network size, contact frequency, and perceived social
support in the family (relatives), neighbors, and friend
networks. This research differentiated between noncohabiting family and close relatives, thus investigating
four networks: non-cohabiting family, relatives, neighbors,and friends. The scale used had 28 items, with seven items
for each network.
The Korean version of the Health Enhancement

Lifestyle Profile (K-HELP) was used to assess healthpromoting behaviors, covering seven health-related areas[7]. A higher score on this tool reflected better healthbehaviors. The reliability of the tool in this study was
Cronbach's α = .85.
Data was analyzed with SAS 9.4, examining
participants' demographics, social networks, and healthbehaviors using descriptive statistics. Health behavior
differences were assessed via t-test, ANOVA, and Scheffe
test. The correlation between social networks and healthbehaviors was determined using the Pearson correlation
coefficient, and their relationship was further exploredthrough hierarchical regression analysis.

Results

The study involved participants averaging 67.86 years
old, with a majority being male. Most had a university
degree or higher. Participants typically rated theireconomic and health statuses as average. Fewer reported
depression, with an average PHQ-9 score of 3.67. Over
half had chronic diseases, averaging 1.49 diseases each.
Women with better economic or health statuses and nondepressed participants showed significantly higher healthpromoting behaviors.
For the structural characteristics of social networks, theorder of network size was friends, non-cohabiting family,
relatives, and neighbors. Contact frequency was highestwith non-cohabiting family, followed by friends, relatives,and neighbors. For functional characteristics, perceived
social support was highest with non-cohabiting family,
friends, relatives, and neighbors. The total healthpromoting behavior score was 109.80±23.58. Among theseven sub-areas, scores were highest for activities of dailyliving, followed by diet, other health promotion and risk
behaviors, stress management and spiritual participation,
exercise, leisure, and productive/social activities.
Analysis between social networks and healthpromoting behaviors showed significant positive
correlations with all social network variables used in thisstudy, as shown in Table 1.

Table. 1: Correlation between social networks and healthpromoting behaviors
Variable
Networksize

Non-cohabiting family
Relatives
FriendNeighbor
Contact
Non-cohabiting familyfrequency Relatives
FriendNeighbor
SocialNon-cohabiting family
supportRelatives
FriendNeighbor*
p<.05, **p<.01, ***p<.001.

r (p)Health-promoting behaviors
0.299***
0.323***
0.256***
0.345***
0.249***
0.308***
0.257***
0.356***
0.440***
0.454***
0.435***
0.478***In the study, hierarchical regression analysis was
conducted to evaluate the impact of social networks onhealth-promoting behaviors (HPB), as shown in Table 2.
Three models were developed: Model 1 utilized
demographics as control variables, Model 2 added
structural aspects of social networks, and Model 3
incorporated functional aspects. In Model 1, gender,
subjective economic status, and depression statisticallysignificantly correlated with HPB. In Model 2, gender,
subjective economic status, depression, relative network
size, and neighbor contact frequency correlated
significantly with HPB. In Model 3, gender, depression,and social support from neighbors showed significant
correlations with HPB. The changes in explanatory power
between each model were significant.
Table. 2: Influencing factors on health-promoting
behaviors
Variable
Gender (ref=female)
Subjective economic status
Subjective health status
Depression
Network
Non-cohabiting family
size
Relatives
FriendNeighbor
Contact
Non- cohabiting familyfrequency Relatives
FriendNeighbor
SocialNon- cohabiting family
supportRelatives
FriendNeighbor
R2(Adjusted R2)

Model
1
β
0.19**
0.17**
0.12-0.26***

Model
2
β
0.15*
0.14*
0.09
-0.21**
0.03
0.17*
0.06
0.01
0.02
0.07
-0.04
0.21*

.217
.348
(.202)(.311)
F
15.28***
9.45****
p<.05, **p<.01, ***p<.001. ref = Reference group.

Model
3
β
0.12*
0.09
0.10
-0.19**
-0.04
0.06
0.01
-0.08
-0.01
0.05
-0.09
0.07
0.09
0.10
0.12
0.27**.415(.370)
9.26**

Discussions

This study examined the influence of social networks'
structural and functional aspects on the health-promoting
behaviors of elderly residents in a community. Social
networks showed significant positive correlations withhealth-promoting behaviors, and the primary influencing
factor of health-promoting behaviors was social support
from neighbors. Establishing and activating satisfyingsocial networks among older adults in the community isdeemed essential to promote health-promoting behaviors.
Encouraging mutual support for health-promoting actions
and active participation in healthcare tasks is also
considered crucial. When implementing lifestyleintervention programs for older adults, leveraging social
support through these social networks is expected to
produce synergistic effects.

References[1] World Health Organization. Health and well-being andhe 2030 agenda for sustainable development in the WHO
European region: An analysis of policy development andimplementation. 2021.
[2] Walker S, Sechrist K, Pender N. The health-promoting
lifestyle profile: Development and psychometriccharacteristics. Nursing Research. 36: 76-81. 1987.
[3] Srof B, Velsor-Friedrich B. Health promotion inadolescents: A review of Pender’s health promotion model.
Nursing Science Quarterly. 19: 366-373. 2006.
[4] Mitchell J. Social networks in urban situations:
Analyses of personal relationships in Central African
towns. Manchester University Press. 1969.
[5] Chang S. Structural and functional aspects of social
network in old age, and the subjective quality of life:
Focusing on the comparison according to age and gender.
Social Science Research. 26: 75-100. 2010.
[6] Kim Y. A validation of the Korean version of the
Lubben Social Network Scale among the elderly. Healthand Social Welfare Review. 40: 331-360. 2020.
[7] Jung H, Jung MY, Yoo EY, et al. Development of the
Korean version of health enhancement lifestyle profile (KHELP) and its reliability. Korean Journal of Occupational
Therapy. 23: 31-43. 2015.
Author address
E-Mail: gustj102700@yonsei.ac.kr