Sleep Debt Mediates the Relationship between Work-Related Social Factors, Presenteeism, and Well-Being in Japanese Workers.

Sleep debt is associated with presenteeism and mental health; however, the association of sleep debt with presenteeism and well-being in the context of work-related social factors (commuting time, workdays, and working hours) has not been fully elucidated. This study aimed to examine whether work-related social factors are associated with presenteeism and well-being via sleep debt. The participant group comprised 872 full-time and 526 part-time workers (mean age: 44.65 ± 12.37 and 48.47 ± 12.93 years, respectively). For both the full-time and part-time workers, increased sleep debt was significantly associated with presenteeism (ß = -0.171; ß = -0.160) and low well-being (ß = -0.135; ß = -0.153). Notably, commuting time was significantly associated with increased sleep debt in full-time workers (ß = 0.09). In contrast, the number of workdays was significantly associated with increased sleep debt in part-time workers (ß = -0.102). Working hours were not significantly associated with sleep debt for both full- and part-time workers. These results reveal that sleep debt might lead to various risks among workers, elucidating the work-related social factors related to sleep debt. They also highlight the importance of considering work-related social factors when addressing sleep debt.

Objective discrimination of fur type based on electrophoresis optimized for fur-hair proteins.

The accurate identification of animal species used for fur is important for conserving endangered animals, stopping illegal fur distribution, and addressing consumer concerns. Animal species used for fur are currently differentiated by observing species-specific morphological fur-hair features through a microscope. Although this method is simple, the results may differ among inspectors owing to its subjective nature. To develop an objective approach for differentiating animal species based on fur, we utilized the electrophoretic patterns of fur-hair proteins. First, we optimized protein extraction methods to produce clear electrophoretic patterns from fur-hair proteins. Then, we obtained 324 electrophoretic patterns from 54 fur samples belonging to 24 different animals; 216 of the 324 patterns were used for the construction of a discrimination model using two-way orthogonal partial least squares discriminant analysis. The model correctly discriminated between all the remaining 108 patterns without any false negatives or positives. Moreover, this model could discriminate between fur samples from closely related species that are difficult to distinguish using conventional microscopic identification because of the visual similarity of the fur hairs.

Necrotizing fasciitis of the extremities in high and low Charlson Comorbidity Index: A multi-center retrospective cohort study.

BACKGROUND: Necrotizing fasciitis (NF) is a life-threatening and acute progressive soft tissue infection and needs early surgical intervention, that is, debridement or amputation. Surgical strategy or prognosis is influenced by the speed of progression and patients' general condition, which can be calculated by the Charlson Comorbidity Index (CCI). The purpose of this study was to investigate the association between the CCI scores and prognosis of patients with NF of the upper/lower extremities. METHODS: In the retrospective cohort study, we analyzed patients with NF of the upper/lower extremities who were determined to undergo surgery by orthopedic surgeons at four tertiary hospitals between August 2003 and April 2016. We divided the patients into two groups, Group L (low CCI scores of 0-2) and Group H (high CCI scores of ≥3). The primary event of this study was defined as death or amputation. Mortality cases were included when amputation was informed with documented certification but patients died while waiting for surgery. We compared the patients' background, laboratory data on admission, the laboratory risk indicator for necrotizing fasciitis (LRINEC) score, and primary outcome between the two groups. RESULTS: Of the 56 patients, 28 patients were classified into Group L and the other 28 patients into Group H. The data in this study showed that patients in Group H had lower white blood cell counts and hemoglobin and higher creatinine than Group L, but there was no difference in LRINEC scores between the two groups. Streptococcus pyogenes was the most common infectious agent in Group L (54%) but not in Group H (11%). Poorer outcome was observed in Group H compared with Group L (4 mortality and 16 amputation vs. no mortality and 9 amputation, P = 0.007). CONCLUSIONS: Laboratory data and causative microorganisms were different between high CCI and low CCI patients with NF. High CCI scores were associated with limb amputation or death caused by NF of the upper/lower extremities; whereas, low CCI scores were more likely associated with S. pyogenes monoinfection.

Non-replicating adenovirus based Mayaro virus vaccine elicits protective immune responses and cross protects against other alphaviruses.

Mayaro virus (MAYV) is an alphavirus endemic to South and Central America associated with sporadic outbreaks in humans. MAYV infection causes severe joint and muscle pain that can persist for weeks to months. Currently, there are no approved vaccines or therapeutics to prevent MAYV infection or treat the debilitating musculoskeletal inflammatory disease. In the current study, a prophylactic MAYV vaccine expressing the complete viral structural polyprotein was developed based on a non-replicating human adenovirus V (AdV) platform. Vaccination with AdV-MAYV elicited potent neutralizing antibodies that protected WT mice against MAYV challenge by preventing viremia, reducing viral dissemination to tissues and mitigating viral disease. The vaccine also prevented viral-mediated demise in IFN⍺R1-/- mice. Passive transfer of immune serum from vaccinated animals similarly prevented infection and disease in WT mice as well as virus-induced demise of IFN⍺R1-/- mice, indicating that antiviral antibodies are protective. Immunization with AdV-MAYV also generated cross-neutralizing antibodies against two related arthritogenic alphaviruses-chikungunya and Una viruses. These cross-neutralizing antibodies were protective against lethal infection in IFN⍺R1-/- mice following challenge with these heterotypic alphaviruses. These results indicate AdV-MAYV elicits protective immune responses with substantial cross-reactivity and protective efficacy against other arthritogenic alphaviruses. Our findings also highlight the potential for development of a multi-virus targeting vaccine against alphaviruses with endemic and epidemic potential in the Americas.

Skipping Pedicle Screw Insertion Into Infected Vertebra is a Risk Factor for Revision Surgery for Pyogenic Spondylitis in the Lower Thoracic and Lumbar Spine.

BACKGROUND: Surgical intervention for pyogenic spondylitis is indicated when conservative treatment fails and biomechanical instability persists. Whether to insert pedicle screws into all vertebrae, including the most erosive vertebrae, or whether to skip 1 vertebra in pedicle screw insertion remains controversial. METHODS: A single-institution retrospective cohort study was conducted in consecutive patients with pyogenic spondylitis in the lower thoracic and lumbar spine (T9-S1) between January 2008 and December 2016. The patients were treated with interbody fusion plus posterior stabilization using pedicle screws and were divided into 2 groups as follows: (1) patients in whom 1 vertebra, usually the most erosive, was skipped in pedicle screw insertion (Group Skipping) and (2) pedicle screw insertion into all vertebrae (Group All). Patients' operation data were evaluated, and clinical outcomes were compared between the 2 groups. There were no significant differences between the 2 groups in terms of age, sex, past histories, blood loss, operation time, the presence of abscesses, or operative approach. RESULTS: The length of fixation was greater by 1 vertebral level in the Group Skipping than in the Group All, and the rate of revision surgery for pseudarthrosis was higher in the Group Skipping than in the Group All (P = .02). There was no statistically significant difference between the 2 groups in terms of the mean segmental lordotic angle or Barthel Index. CONCLUSIONS: Skipping pedicle screw insertion for pyogenic spondylitis in posterior fixation led to an increased number of fixed vertebrae and may be a risk factor for revision surgery for pseudarthrosis. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: The insertion of short pedicle screws at the infected vertebra can prevent early treatment failure and increase the biomechanical stability of construct.

Vaccine-Induced Skewing of T Cell Responses Protects Against Chikungunya Virus Disease.

Chikungunya virus (CHIKV) infections can cause severe and debilitating joint and muscular pain that can be long lasting. Current CHIKV vaccines under development rely on the generation of neutralizing antibodies for protection; however, the role of T cells in controlling CHIKV infection and disease is still unclear. Using an overlapping peptide library, we identified the CHIKV-specific T cell receptor epitopes recognized in C57BL/6 infected mice at 7 and 14 days post-infection. A fusion protein containing peptides 451, 416, a small region of nsP4, peptide 47, and an HA tag (CHKVf5) was expressed using adenovirus and cytomegalovirus-vectored vaccines. Mice vaccinated with CHKVf5 elicited robust T cell responses to higher levels than normally observed following CHIKV infection, but the vaccine vectors did not elicit neutralizing antibodies. CHKVf5-vaccinated mice had significantly reduced infectious viral load when challenged by intramuscular CHIKV injection. Depletion of both CD4+ and CD8+ T cells in vaccinated mice rendered them fully susceptible to intramuscular CHIKV challenge. Depletion of CD8+ T cells alone reduced vaccine efficacy, albeit to a lesser extent, but depletion of only CD4+ T cells did not reverse the protective phenotype. These data demonstrated a protective role for CD8+ T cells in CHIKV infection. However, CHKVf5-vaccinated mice that were challenged by footpad inoculation demonstrated equal viral loads and increased footpad swelling at 3 dpi, which we attributed to the presence of CD4 T cell receptor epitopes present in the vaccine. Indeed, vaccination of mice with vectors expressing only CHIKV-specific CD8+ T cell epitopes followed by CHIKV challenge in the footpad prevented footpad swelling and reduced proinflammatory cytokine and chemokines associated with disease, indicating that CHIKV-specific CD8+ T cells prevent CHIKV disease. These results also indicate that a T cell-biased prophylactic vaccination approach is effective against CHIKV challenge and reduces CHIKV-induced disease in mice.

Adaptation and limitation of anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine.

BACKGROUND: Surgical strategy for pyogenic spondylitis is controversial when vertebral body erosion is severe. Radical debridement and anterior column reconstruction is indicated for the purpose of early ambulatory to prevent secondary complication for long bed rest. However, such aggressive debridement and risk of perioperative complications are trade-off. The purpose of this study was to evaluate the risk factor of poor prognosis after anterior column debridement and reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine. METHODS: We performed a retrospective review of 40 patients diagnosed with pyogenic spondylitis in lower thoracic and lumbar spine who were introduced to our institution due to losing ambulatory ability and underwent anterior column debridement and reconstruction between January 2008 and May 2016. After the patient population was split into a regaining ambulatory group (Group A; n = 23) and a poor prognosis group (Group P; n = 17), we used Fisher exact tests and t-tests as appropriate for univariate analyses to compare patient characteristics and outcomes between the 2 groups. RESULTS: Univariate analysis showed that the significant variables were massive bleeding (>2000 ml) (P < 0.01), Charlson Comorbidity Index ≥3 (P = 0.01), and two-stage surgery needed (P = 0.04). Logistic regression analysis showed that the factors associated with poor prognosis were massive bleeding (Odds Ratio 11.9; 95% confidence interval 1.8 to 119.7; P = 0.04). CONCLUSIONS: Massive bleeding was associated with poor prognosis after debridement followed by anterior column reconstruction for pyogenic spondylitis in lower thoracic and lumbar spine.

Consecutive images of conservatively treated cervical spontaneous spinal epidural hematoma.

Spontaneous spinal epidural hematoma (SSEH) in the cervical spine is rare, and it remains unclear how this condition resolves. We aimed to elucidate the underlying pathology of SSEH conservatively treated using magnetic resonance imaging (MRI) analysis. We reviewed the clinical records of patients with SSEH treated conservatively between January 2011 and November 2016 and analyzed the patients' medical history, medication, spinal cord compression on MRI, and neurological status. Patients underwent the first MRI on admission and the second MRI at average 10.8 days (range, 3-24 days) after the first MRI. Ten patients were enrolled (five men and five women), and the average age on admission was 73 years. In all patients, the neurological status improved within 24 h and the spinal cord area had increased on the second MRI. Four patients were diagnosed with hematoma regression and six with hematoma persistence by 14 orthopedic surgeons, who were blinded to the patients' data. Hematoma regression was associated with the difference of MRI interval (hematoma regression four patients 16.3 days vs. hematoma persistence six patients 7.2 days, p = 0.01). In conclusion, our report is the largest case series of SSEH with consecutive MRI; we found that SSEH in the cervical spine required approximately 10 days for absorption on the spot, without spreading longitudinally. This information could be useful for deciding when to alter the rehabilitation program.

Nighttime behavioral study of flying foxes on the southern coast of West Java, Indonesia.

Flying foxes are important in the maintenance of forests and diversity. However, knowledge of their behavioral ecology, especially of movement and foraging patterns, which are essential for conservation and management of their populations, are not well known. Therefore, movement behavior of two individuals of Pteropus vampyrus were examined using an Argos telemetry system, and foraging pattern of Pteropus spp. was directly observed, at West Java province, Indonesia in October 2017. The maximum distance between the location at which bats were released and their furthest roost, recorded via satellite telemetry, was approximately 100 km. This reflects the long-distance flight ability of P. vampyrus. Daytime roosting sites and nighttime foraging places consisted of several types of habitats, such as intact forests, agricultural lands, and residential areas. This evidence indicated that there was habitat overlap between humans and bats in West Java province. According to direct observation of the behaviors of flying foxes at two locations within residential areas, various activities such as wing spreading, excretion, fighting, aggressive calls, movement, hanging relax, and hanging alert were found. The number of bat-visits to the trees varied among night hours, and had a positive correlation with the number of fruit dropping. The data obtained in this study have improved our understanding of nighttime behavior and habitat utilization of P. vampyrus, that can be used to support landscape management, species conservation, and disease prevention in regions of Southeast Asia.

Successful management of prolonged venovenous extracorporeal membrane oxygenation in an octogenarian.

Venovenous extracorporeal membrane oxygenation is now an established treatment for acute respiratory distress syndrome. However, this treatment remains rare in octogenarians and is associated with poor outcomes. An 81-year-old man with a history of chronic obstructive pulmonary disease and heavy smoking underwent mitral and tricuspid valve repair and the Maze procedure for mitral and tricuspid regurgitation and paroxysmal atrial fibrillation. Although he was extubated the following day, his postoperative course was complicated with pneumonia followed by acute respiratory distress syndrome. He was reintubated on day 7. Ratio of partial pressure of arterial oxygen to fraction of inspired oxygen continuously dropped to less than 100 mmHg, and venovenous extracorporeal membrane oxygenation support was induced on day 18. His lung condition showed slow and steady recovery, and he was successfully weaned from mechanical support on day 44 (total support, 27 days). Bleeding complication from tracheotomy (day 31) due to disseminated intravascular coagulation was successfully managed using recombinant human soluble thrombomodulin. He was ambulatory and discharged to a nursing facility without tracheotomy on day 172. Proper extracorporeal membrane oxygenation management, while challenging to keep the elderly patient away from further complications, saved an 81-year-old patient.

Daytime behavior of Pteropus vampyrus in a natural habitat: the driver of viral transmission.

Flying foxes, the genus Pteropus, are considered viral reservoirs. Their colonial nature and long flight capability enhance their ability to spread viruses quickly. To understand how the viral transmission occurs between flying foxes and other animals, we investigated daytime behavior of the large flying fox (Pteropus vampyrus) in the Leuweung Sancang conservation area, Indonesia, by using instantaneous scan sampling and all-occurrence focal sampling. The data were obtained from 0700 to 1700 hr, during May 11-25, 2016. Almost half of the flying foxes (46.9 ± 10.6% of all recorded bats) were awake and showed various levels of activity during daytime. The potential behaviors driving disease transmission, such as self-grooming, mating/courtship and aggression, peaked in the early morning. Males were more active and spent more time on sexual activities than females. There was no significant difference in time spent for negative social behaviors between sexes. Positive social behaviors, especially maternal cares, were performed only by females. Sexual activities and negative/positive social behaviors enable fluid exchange between bats and thus facilitate intraspecies transmission. Conflicts for living space between the flying foxes and the ebony leaf monkey (Trachypithecus auratus) were observed, and this caused daily roosting shifts of flying foxes. The ecological interactions between bats and other wildlife increase the risk of interspecies infection. This study provides the details of the flying fox's behavior and its interaction with other wildlife in South-East Asia that may help explain how pathogen spillover occurs in the wild.

Successful Repair of Regurgitant Pentacuspid Pulmonary Valve Combined With Pulmonary Artery Aneurysm.

Pentacuspid pulmonary valve is an extremely rare congenital anomaly. A 71-year-old woman presented with dyspnea on exertion. The preoperative examination showed a large pulmonary artery aneurysm with severe pulmonary regurgitation. The pentacuspid pulmonary valve was an intraoperative finding with four equivalent leaflets and one hypoplastic leaflet. The valve was successfully repaired by use of a bicuspidization technique combined with annuloplasty, and pulmonary artery reduction was performed. Postoperatively, the patient remained asymptomatic with trivial pulmonary regurgitation 1 year later. To our knowledge, this is the first report of a pentacuspid pulmonary valve repair.

Long-term maintenance of human induced pluripotent stem cells by automated cell culture system.

Pluripotent stem cells, such as embryonic stem cells and induced pluripotent stem (iPS) cells, are regarded as new sources for cell replacement therapy. These cells can unlimitedly expand under undifferentiated conditions and be differentiated into multiple cell types. Automated culture systems enable the large-scale production of cells. In addition to reducing the time and effort of researchers, an automated culture system improves the reproducibility of cell cultures. In the present study, we newly designed a fully automated cell culture system for human iPS maintenance. Using an automated culture system, hiPS cells maintained their undifferentiated state for 60 days. Automatically prepared hiPS cells had a potency of differentiation into three germ layer cells including dopaminergic neurons and pancreatic cells.

[A Clinical Comparison of Continuous Sciatic Nerve Block and Epidural Anesthesia for Postoperative Pain Control in Patients with Fracture of the Foot].

BACKGROUND: Epidural analgesia provides good pain relief for patients with fracture of the foot Ultrasound-guided peripheral nerve block offers safety and efficacy without affecting the leg. METHODS: We compared the continuous sciatic nerve block with the continuous epidural anesthesia regarding postoperative pain after the open reduction and internal fixation (ORIF) of the ankle fracture or calcaneal bone fracture. RESULTS: Fifteen patients were included in the epidural group (group E), and 17 patients in the sciatic nerve block group (group S). The postoperative pain scores were significantly lower in group S 3 hours and 12 hours after the procedure, and tended to be lower in other periods. Perioperative periods were uneventful in both groups. CONCLUSIONS: Continuous sciatic nerve block developed good postoperative analgesia in ORIF of ankle fracture or calcaneal bone fracture compared with continuous epidural anesthesia.

Predictive factors of myasthenic crisis after extended thymectomy for patients with myasthenia gravis.

OBJECTIVES: Postoperative myasthenic crisis (POMC) is one of the serious complications after extended thymectomy for patients with myasthenia gravis (MG). This study aims to clarify the risk factors of POMC occurrence. METHODS: The clinical data of 55 MG patients (25 male, 30 female; median age, 51 years) who underwent extended thymectomy at Kyoto University from 2000 to 2013 were retrospectively reviewed. Surgical outcomes and pre- and perioperative predictive factors of POMC were analysed. RESULTS: The preoperative Myasthenia Gravis Foundation of America stage was I, II, III and IV in 24, 22, 8 and 1 patients, respectively. Ten patients (18.2%) developed POMC; 6 required prolonged intubation over 24 h and 4 required reventilatory support. All patients were weaned after 5.6 (2-26) days of ventilator support, and were discharged. Univariate analysis revealed a correlation with a high preoperative anti-acetylcholine receptor antibody titre (P = 0.009), history of myasthenic crisis (MC) (P = 0.0004) and unstable MG after preoperative medical therapy (P = 0.003). Multivariate logistic regression analysis showed history of MC (odds ratio, 11.84; 95% confidential interval, 1.05-372; P = 0.045) and unstable MG (odds ratio, 29.45; 95% confidential interval, 2.00-1063; P = 0.013) independently predicted POMC. The surgical response rate was not significantly different between the two groups (66.7% with POMC, 85.4% without POMC; P = 0.334). CONCLUSIONS: POMC occurred more frequently in unstable MG before surgery or in patients with a history of MC. Adequate preoperative medical therapy and perioperative care should be provided to these patients.

Effect of the thickness and nonlinear elasticity of tissue on the success of surgical stapling for laparoscopic liver resection.

Recently, the range of applications of surgical staplers has been extended to include laparoscopic liver resection because manipulation of a surgical stapler is very simple. Revealing the causes of stapling failure and suggesting a method to solve stapling failure are important for safe laparoscopic liver resection. Surgeons say that tissues make stapling more likely to fail if they are thick and brittle. However, the combinatorial effect of the thickness and stiffness of tissues on the success of surgical stapling for laparoscopic liver resection has not been investigated. Therefore, the objective of the present study was to investigate the effect of tissue thickness and tissue stiffness on the success rate (SR) of surgical stapling. From ex vivo stapling experimental results using pig livers, it is suggested that the effect of tissue thickness is greater than the effect of tissue stiffness on the SR of stapling. If tissue thickness is 5 mm, the SR of stapling is high regardless of the magnitude of the tissue-stiffness parameter. However, if tissue thickness is >10 mm, the SR of stapling has a relationship with nonlinear viscoelastic parameters. Therefore, the SR of stapling could be predicted from tissue thickness and nonlinear elastic parameters.

[Succesful management of esophageal banding and gastrostomy for esophageal atresia in a trisomy 18 child with complex cardiac malformation].

Trisomy 18 is one of the congenital disorders caused by a chromosomal abnormality. Ninety percent of fetuses with trisomy 18 have various other malformations. The present patient had heart failure due to a complex cardiac malformation and a Gross C type esophageal atresia. Before the esophageal banding, ventilation of the lungs was impossible and respiratory condition was unstable. Considering that direction of the shunt can easily change by hyperventilation and high oxygen concentration, we employed the lowest oxygen concentration and ventilation as possible. In the present case, it was necessary to provide respiratory care for both esophageal atresia and complex cardiac malformation.

Biosignal-based relaxation evaluation of head-care robot.

Such popular head care procedures as shampooing and scalp massages provide physical and mental relaxation. However, they place a big burden such as chapped hands on beauticians and other practitioners. Based on our robot hand technology, we have been developing a head care robot. In this paper, we quantitatively evaluated its relaxation effect using the following biosignals: accelerated plethymography (SDNN, HF/TP, LF/HF), heart rate (HR), blood pressure, salivary amylase (sAA) and peripheral skin temperature (PST). We compared the relaxation of our developed head care robot with the head care provided by nurses. In our experimental result with 54 subjects, the activity of the autonomic nerve system changed before and after head care procedures performed by both a human nurse and our proposed robot. Especially, in the proposed robot, we confirmed significant differences with the procedure performed by our proposed head care robot in five indexes: HF/TP, LF/HF, HR, sAA, and PST. The activity of the sympathetic nerve system decreased, because the values of its indexes significantly decreased: LF/HF, HR, and sAA. On the other hand, the activity of the parasympathetic nerve system increased, because of the increase of its indexes value: HF/TP and PST. Our developed head care robot provided satisfactory relaxation in just five minutes of use.

[A case of ilioinguinal hernia with Möbius syndrome].

We gave general anesthesia for an infant with ilioinguinal hernia and Möbius syndrome. Anesthesia was performed with sevoflurane inhalation and intravenous infusion of remifentanil. Intraoperative anesthetic course was uneventful. Möbius syndrome is a syndrome of rhombencephalic maldevelopment involving predominantly motor nuclei and axons, as well as traversing long tracts. Airway management is a great challenge in these patients. Micrognathia, retrognathia, mandibular hypoplasia, and palatine cleft are some of the manifestations seen in these patients.

Development of new measurement system of thoracic excursion with biofeedback: reliability and validity.

BACKGROUND: Respiratory rehabilitation reduces breathlessness from patient with respiratory dysfunction. Chest expansion score, which represents the circumference magnitude of the thoracic cage, is used for a target when treating patients with respiratory disease. However, it is often difficult for patients to understand the changes in the respiratory status and be motivated for therapy continuously. We developed a new measurement system with biofeedback named BREATH which shows chest expansion scores in real time. The purpose of this study was to determine the reliability and validity of the novel system in advance of clinical application. METHODS: Three evaluators measured chest expansion in 33 healthy individuals using tape measure, which is used for the measurement traditionally, and BREATH. The wire for BREATH system was threaded over the thoracic continuously and the data was recorded automatically; whereas the tape was winded and measured each maximal expiration and inspiration timing by evaluator. All participants were performed both measurement simultaneously for three times during deep breath. In this study, we studied chest expansion score without using biofeedback data of BREATH to check the validity of the result. To confirm intra- and inter-evaluator reliability, we computed intra-class correlations (ICCs). We used Pearson's correlation coefficient to evaluate the validity of measurement result by BREATH with reference to the tape measure results. RESULTS: The average (standard deviation) chest expansion scores for all, men and women by the tape measure were 5.53 (1.88), 6.40 (1.69) and 5.22 (1.39) cm, respectively, and those by BREATH were 3.89 (2.04), 4.36 (1.83) and 2.89 (1.66) cm, respectively. ICC within and among the three evaluators for BREATH and the tape measure were 0.90-0.94 and 0.85-0.94 and 0.85 and 0.82, respectively. The correlation coefficient between the two methods was 0.76-0.87. CONCLUSION: The novel measurement system, BREATH, has high intra- and inter-evaluator reliabilities and validity; therefore it can lead us more effective respiratory exercise. Using its biofeedback data, this system may help patients with respiratory disease to do exercises more efficiently and clinicians to assess the respiratory exercise more accurately.