Mycoplasma pneumoniae (MP) infection. A retrospective analysis of 62 children with MP pneumonia during a recent epidemic (2019–2020) was conducted. The MAA and ELISA immunoglobulin M (IgM) and IgG measurements were conducted twice at admission and around discharge, and MP PCR once at presentation. Diagnostic rates in each test were calculated at presentation and at discharge. The seroconverters were 39% (24/62) of patients tested by MAA and 29% (18/62) by ELISA. At presentation, the diagnostic positive rates of MAA, ELISA, and PCR tests were 61%, 71%, and 52%, respectively. After the second examination, the rates were 100% in both serologic tests. There were positive correlations between the titers of MAA and the IgM values of ELISA. The single serologic IgM or PCR tests had limitations to select patients infected with MP in the early stage. The short-term, paired IgM serologic tests during hospitalization can reduce patient-selection bias in MP infection studies.The aim of the present study is to re-evaluate the clinical application of two-times serologic immunoglobulin M (IgM) tests using microparticle agglutination assay (MAA), an enzyme-linked immunosorbent assay (ELISA), and polymerase chain reaction (PCR) assay in diagnosing  Mycoplasma pneumoniae (MP) is one of the major respiratory pathogens that cause community-acquired pneumonia in children and young adults [g adults . MP pneug adults ,3. MP png adults ,5,6,7,8.The rapid diagnosis of MP pneumonia is crucial for determining treatment options for severe cases. Although polymerase chain reaction (PCR) assays are a rapid and effective test for early diagnosis, the sensitivity and specificity of PCR assays are influenced by many confounding factors such as different detection rates regardless of the disease severity and disease stage, age of the patients, sampling sites, causative strain subtypes, and the technical errors ,10,11. FSerology tests are commonly used as diagnostic tools for infectious disease, including MP infections, and antibody testing methods include indirect microparticle agglutination assay (MAA) and enzyme-linked immunosorbent assay (ELISA) ,15. MAA The purpose of this study was to compare the two serologic testing methods—MAA and ELISA titers—by investigating the correlation between MAA and the ELISA titers and understanding clinical implications of the results of subsequent IgM titers followed up in short interval durations.This was a retrospective cohort study of patients below 15 years old who were admitted at The Catholic University of Korea Daejeon St. Mary’s Hospital for MP pneumonia during the recent 2019 nationwide epidemic. Patients with pneumonia admitted from May 2019 to February 2020 were included in this study. The inclusion criteria of this study were as follows: (1) underwent at least two MP serology tests including IgM and IgG using the MAA  and ELISA  methods in intervals of at least 48 h between the two tests, (2) additionally received bacterial PCR assay at admission, and (3) cases were satisfied with criteria in MAA method above fit the definition for MP pneumonia. Patients that fit all of the criteria above were included in this study. The exclusion criteria were as follows: (1) patients that only had initial serology test results, (2) patients that only had one type of MP serology testing methods (MAA or ELISA), (3) patients that did not undergo bacterial PCR assay upon admission, and (4) patients that had chronic underlying diseases that predisposed them to have recurrent pulmonary infections.The diagnostic criteria for acute MP pneumonia differed for each of the testing methods. In serology testing using the MAA method, MP pneumonia was defined using the following criteria: (1) negative to positive IgM seroconversion (≥1:40), (2) two-fold or greater increase in IgM titers tested in intervals of at least 48 h or more, or (3) initial and continuous high titers ≥1:640 at follow up. Patients whose serology did not show increasing IgM titers or those that showed decreased titers at follow-up were regarded as false positives, following previous studies at our center ,19,20,21Streptococcus pneumoniae, Haemophilus influenzae, Legionella pneumoniae, Chlamydia pneumoniae, Bordetella pertussis via CFX96 Touch TM Real-Time PCR detection system . The respiratory specimen used for bacterial PCR assay were obtained via nasopharyngeal swab.After applying the inclusion and exclusion criteria, the final study participants were determined, and their electronic medical records were reviewed for the following data: demographics, clinical and image findings, and laboratory results. Upon admission, all patients received bacterial PCR assay detecting MP, The positive rates of the two serology testing methods and PCR assay at presentation and at discharge were investigated. Using the paired serology results  from each of the patients, IgM and IgG titers of MAA and ELISA were compared.p-values were two-tailed, and p values of <0.05 were considered statistically significant.All calculations were performed using SPSS ver. 14.0 . The data are expressed as mean ± standard deviation (SD) for continuous variables or as the number of cases (percentage) of a specific group for categorical variables. Comparisons of titers between MAA and ELISA were performed by Pearson’s correlation. All A total of 62 patients who had two paired serology results  for both the MAA and ELISA methods and results for bacterial PCR assay were included in the study . The mean = 62) were as follows: negative to positive seroconversion was observed in 24 (38.7%) patients, increased ≥two-fold titers were observed in 27 (43.5%) patients, and high titers ≥1:640 in both initial and follow-up serology testing were observed in 11 (17.7%) patients. The results of their IgM serology using the ELISA method were as follows: A total of 44 (71.0%) patients were seropositive at the initial examination, 12 (19.3%) were seronegative, and 6 (9.7%) were equivocal. At follow-up, all 62 patients became seropositive for IgM; increased IgM values were observed in 54 (87.1%) of the patients, 5 (8.1%) showed decreased IgM values, and 3 (4.8%) showed no change in IgM values  for MAA, 71% (44/62) for ELISA, and 52% (32/62) for PCR assay. At short-term follow-up serology testing, both MAA and ELISA methods showed 100% seropositive and met the diagnostic criteria for MP pneumonia  of the patients were positive for MP in the bacterial PCR assay. Among them, 40.6% (13/32) of the cases showed co-detection with other bacterial species such as neumonia .The patients were divided into three groups according to the MAA criteria for the diagnosis of acute MP pneumonia, and in each of the groups, the serology results of the ELISA tests were compared. Group 1 included 24 patients that showed negative to positive seroconversion (from negative to ≥1:40~ ≥1:1280). Group 2 included 27 patients that showed increased IgM titers (19 patients increased ≥four-fold), and group 3 included 11 patients that had high IgM titers (≥1:640) at initial and follow-up tests. In group 1, 50% (12/24) were initially IgM seronegative, 16.7% (4/24) initially equivocal, and 33.3% (8/24) initially seropositive according to the ELISA testing method. At follow-up, all patients became IgM seropositive, however, one case showed slightly decreasing positive titers. In group 2, 92.6% (25/27) and 7.4% (2/25) were initially IgM seropositive and equivocal by the ELISA, and at follow-up, all patients showed IgM seropositive, but one patient’s IgM value did not increase. In group 3, all were initially seropositive; 45.5% (5/11) patients showed increasing IgM values, 36.4% (4/11) showed positive but decreasing values, and 18.2% (2/11) showed the same positive IgM values .p < 0.001, R2 = 0.347)   A. Moreov= 0.138) B. HoweveMP is one of the major pathogens causing respiratory tract infections in childhood, with other pathogens including influenza virus and coronavirus. In these infections, pathogen-specific IgM antibodies are produced first, and then specific IgG and IgA antibodies follow during systemic immune responses to the insults of the pathogen ,23. AccoThe positive rates in detecting IgM can vary across serologic methods because the antigens used in serologic kits and assays differ. Thus, the sensitivity and specificity of IgM/IgG are somewhat different according to the used kits. Although we used MAA as the “gold standard” in this study, we found that ELISA IgM/IgG kit used in this study may have a higher sensitivity than MAA because of lower negativity in the early stage of disease presentation. In the present study, at admission, the positive rates of MAA, ELISA, and PCR assay were 61%, 71%, and 52%, respectively. In contrast, the positive rates of paired IgM tests were 100% in both serologic methods. However, little change or decreased IgM values obtained from a short-term follow-up of ELISA IgM, especially lower values, may depict recent past infection. However, paired IgG values could in part help differentiating acute infection from the recent past infection because some patients reach the peak levels of IgM at presentation, and IgG seroconversion began to occur in the early stages and IgG values continuously elevated during the early convalescent stage of MP infection.The IgM titers in MAA were positively correlated with the numerical values in ELISA. We previously reported that there was a positive correlation between titers in MAA and titers of cold agglutinins, which are nonspecific IgM and are used for the diagnosis of MP infection in the era of the absence of MP-specific serologic assays . We haveMany study groups have reported the sensitivity and specificity of serologic methods through comparison with PCR assay as the “gold standard” ,28. IndeThe immunopathogenesis of MP infection and other pathogen infections, including COVID-19, remains unknown. It is proposed that the etiological substances in infectious diseases may be produced from certain pathogen-infected cells, including MP infection ,32,33. IThe limitations of this study include the retrospective design and small sample size.Because there is no standardized serologic test available, we used MAA as the “gold standard”. However, this study provides novel insight on serological diagnostic methods through a comparison of two serologic tests.In conclusion, a PCR test and/or single IgM test have limitations for confirmative diagnosis and patient selection on MP infection; there are PCR negative patients, especially those that were examined at late disease course  and MP colonized patients (carriers) with pneumonia caused by other pathogens during MP epidemics . In addition, early presented patients and/or severe MP pneumonia show IgM seronegative during the early stages of infection , and other pneumonia patients with prolonged seropositivity caused by prior MP infection show IgM seropositive . Thus, short-term, follow-up, or repeated IgM (and IgG) serologic tests during hospitalization are helpful for reducing patient-selection bias in MP infection studies.


By using earthquake catalogs, previous studies have reported evidence that some changes in the spatial and temporal organization of earthquake activity are observed before and after of a main shock. These previous studies have used different approaches for detecting clustering behavior and distance-events density in order to point out the asymmetric behavior of foreshocks and aftershocks. Here, we present a statistical analysis of the seismic activity related to the  Diverse methods from complexity studies have been applied to evaluate spatio-temporal organization of seismic activity from different regions of the world. An important aspect of some of these studies is that they intend to identify potential anomalous patterns prior to the occurrence of a mainshock. Although there is some debate about the universality of these features, there are efforts to elucidate the dominance of some peculiar spatio-temporal organizational patterns in specific regions with high seismic activity. The occurrence of earthquakes is a complex phenomenon which results from interactions covering a wide range of spatio-temporal scales, with some statistical properties frequently expressed as power-law functions with fractal behavior. In many cases, the use of a single scaling exponent is not sufficient to fully characterize the variety of dynamical behaviors displayed by earthquake activity, and the use of multifractality is necessary, where a broad distribution of fractal scaling exponents is associated with the richness of the dynamics. For instance, a multifractal structure of inter-event time series has been reported for various earthquake sequences ,4,5,6,7.In a related way, the identification of a seismic quiescence, defined as a temporal window where a function associated with the rate of seismic process attains an abnormal value, represents a potential source of information to characterize anomalous seismic activity . Probabliescence ,14. As wly large . Howeverly large ,17. Motif Ohtake . The papServicio Sismológico Nacional (SSN), Universidad Nacional Autónoma de México (www.ssn.unam.mx). Our dataset contains events for the period January 1998 until 12 June 2018. The geographical region under study is defined by a circle of radius The information of seismic activity was directly obtained from the 03 W see . We notiWe define the pseudo-velocity of a “walker” between two consecutive events as N. First, an integration is performed,s  was intruduced by Kantelhardt et al.  as an exIf the original time series exhibits multifractal properties, The exponent  τ=qhq−1 ,21. Finaormation ,21:(5)αqsingularity strength or Hölder exponent and Here, zed by α . The chaSSN catalog is reliable and complete for the application of the Schreider algorithm [n-th earthquake inside the cylindrical volume, with magnitude s is the smoothness parameter [k-th seismic event is related to the convolutionWe assume that the lgorithm . A magnifunction ,(7)f behavior with a notorious reduction of the left-hand width of the spectrum for a period that comprises the beginning of 2013 until the end of 2015. The monofractality (narrow spectrum) indicates that the pseudo-velocity sequence exhibits less nonlinear features compared to a broad multifractal spectrum. Moreover, the Schreider algorithm was used for the identification of the pattern of significant seismic quietude within a cylindrical volume of a 200 km radius, located between 30 and 90 km depth and centered at the epicenter of the earthquake of magnitude orted by  for eart


Recent advances in genetic analysis have led to the discovery of novel genetic subtypes of precursor B‐cell acute lymphoblastic leukemia (B‐ALL) with prognostic relevance. In this study, we studied a cohort of pediatric B‐ALL patients to retrospectively determine the incidence of patients harboring novel genetic subtypes, as well as their outcome.CRLF2 expression was analyzed by quantitative RT‐PCR. Anchored multiplex PCR‐based enrichment was used to detect fusions and point mutations in 81 ALL‐related genes.B‐ALL patients (N = 190) diagnosed in a single Korean hospital were included in the study. Patients' medical records were reviewed for data on established genetic abnormalities and outcome. ETV6‐RUNX1 (21.6%), BCR‐ABL1 (7.9%), KMT2A rearrangement (7.4%) TCF3‐PBX1/TCF3‐HLF (7.4%), and hypodiploidy (1.1%). Incidence of new genetic subtypes was as follows: BCR‐ABL1‐like (13.2%), ETV6‐RUNX1‐like (2.1%), EWSR1‐ZNF384 (1.1%), and iAMP21 (1.1%). Median age at diagnosis of BCR‐ABL1‐like ALL was 6.8 years. According to type of genetic abnormality, BCR‐ABL1‐like ALL was divided into ABL class (12%), CRLF2 class (8%), JAK‐STAT class (12%), and RAS class (68%). The 5‐year event‐free survival (EFS) of BCR‐ABL1‐like patients was significantly inferior to non‐BCR‐ABL1‐like low‐ and standard‐risk patients  and comparable to non‐BCR‐ABL1‐like high (75.2 ± 6.2%) and very high‐risk patients (56.8 ± 7.4%). All four ETV6‐RUNX1‐like patients survived event‐free.Incidence of established recurrent genetic subtypes was as follows: high hyperdiploidy (21.6%), BCR‐ABL1‐like ALL in our cohort was 13.2% with outcome comparable to high and very high‐risk patients. A significantly high number of RAS class mutations was a distinct feature of our BCR‐ABL1‐like ALL group.Analogous to previous studies, incidence of  BCR‐ABL1‐like ALL in a Korean pediatric cohort was 13.2% with outcome comparable to high and very high‐risk patients. A significantly high number of RAS class mutations was a feature that uniquely identified our BCR‐ABL1‐like ALL group.Incidence of  Initial studies defined this subtype as having a gene expression profile similar to BCR‐ABL1 (+) ALL, a high incidence of IKZF1 deletions, and overall poor prognosis.BCR‐ABL1‐like ALL patients harbor kinase‐activating abnormalities, including ABL‐class fusions, CRLF2 rearrangements, JAK2 fusions, other mutations activating the JAK‐STAT pathway, and mutations of the RAS pathway.DUX4, MEF2D, and ZNF384.Recurrent genetic abnormalities in precursor B‐cell acute lymphoblastic leukemia (B‐ALL) are used to define disease subtype and predict patient prognosis. Studies aiming to identify genetic lesions in B‐ALL patients without established genetic abnormalities led to the discovery of Identification of these newly proposed subtypes is important not only because the subtypes correlate with clinical parameters including outcomes, but also because they reveal therapeutic targets that may allow a reduction in morbidity and mortality related to conventional chemotherapy. However, optimum diagnostic strategy of these new genetic subtypes in the clinic lacks consensus, and several practical considerations remain.In this study, we determined the genetic characteristics, including the incidence of patients harboring new genetic subtypes, as well as outcome in a cohort of pediatric B‐ALL treated at a single Korean hospital. In addition, we tried to outline the optimum laboratory methodology required for accurate identification of new genetic subtypes.22.1ETV6‐RUNX1, BCR‐ABL1, E2A‐PBX1, KMT2A rearrangements, high hyperdiploidy, hypodiploidy) in the patients was diagnosed using reverse transcription polymerase chain reaction (RT‐PCR), fluorescence in situ hybridization (FISH) and Giemsa band karyotyping, using methods reported previously.Patients diagnosed with B‐ALL and treated at the Department of Pediatrics in Seoul St. Mary's Hospital from March 2009 to September 2015 were included in the study ). The study received institutional review board approval from Seoul St. Mary's Hospital, The Catholic University of Korea (IRB No. KC17SESI0717). Diagnosis of ALL was done according to the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues based on bone marrow (BM) pathology, immunophenotyping, cytogenetics, and molecular genetics.2.2ETV6‐RUNX1 were most common, with both detected in 41 patients (21.6%). BCR‐ABL1 was detected in 15 patients (7.9%), followed by KMT2A rearrangement , TCF3‐PBX1/TCF3‐HLF , and hypodiploidy . Among 63 patients without recurrent genetic abnormalities, 49 patients with remaining samples underwent further genetic analysis including anchored multiplex PCR (AMP)  as described in a previous report.−ΔΔCt method. Then, AMP was performed to determine gene expression, fusions, exon‐skipping and point mutations associated with the BCR‐ABL1‐like subtype using the Archer FusionPlex ALL kit (ArcherDX). Briefly, reverse transcription using random primers was performed for synthesis of cDNA, followed by end repair and adenylation steps. The cleanup of cDNA using Agencourt® AMPure® XP beads and ligation of molecular barcode (MBC) adapters and universal primer sites were performed. The MBC adapter‐attached cDNA was amplified by the GSP1 primer pool and primer complementary to universal primer site, and the second PCR using GSP2 primer pool was performed. The libraries were quantitated using a KAPA Universal Library Quantification Kit (Kapa Biosystems), then normalized and loaded to NextSeq (Illumina). Data were analyzed by Archer® Analysis version 5.1.7 (ArcherDX).From the overall study group, 127 patients were classified as B‐ALL with the six recurrent genetic abnormalities (Table ) Figure . First, 2.3http://bioinfo.ut.ee/primer3‐0.4.0/).RT‐PCR and FISH were performed to confirm the fusion genes detected by AMP NGS. RT‐PCR was carried out using primers that were previously described in other studies and designed by Primer3 (ABL1 break‐apart probe (Cytocell Ltd), JAK2 break‐apart probe (Cytocell Ltd), IGH break‐apart probe (Cytocell Ltd) and P2RY8 deletion probe (Cytocell Ltd).In addition, we underwent FISH as an alternative method to identify gene fusions, using 2.4® Genomic DNA Purification kit (Promega). We used a clinically targeted panel  and the Ion Torrent Sequencer, S5XL. Base calling and alignment of the sequences to reference genome hg19 were performed on the Ion Torrent Suite Software (Version 5.8.0). Variant calling was done using Ion Reporter software (Version 5.6). Elaborated sequence data in FASTQ format were adjusted and annotated according to the hg19 human reference genome.We validated genetic mutations identified from AMP NGS with those from massive parallel sequencing. DNA was extracted from patients’ BM aspirates using Wizard2.5BCR‐ABL1‐like ALL in our study group. The subsequent objective was to analyze clinical parameters at diagnosis and EFS of patients with novel genetic subtypes.The initial objective of the study was to retrospectively determine the incidence of established genetic abnormalities, as well as novel genetic subtypes such as 2.6BCR‐ABL1‐like ALL patients. Clinical and treatment response‐based parameters predicting the presence of RAS class mutation were analyzed by logistic regression. EFS and OS were determined by Kaplan‐Meier method, with comparisons of EFS done with log‐rank test. EFS was defined as the time from diagnosis to last follow‐up in CR, or first event . OS was defined as the time from diagnosis to last follow‐up or death from any cause. The date of last follow‐up was 31 September 2019. P value < .05 was considered significant.Comparisons of median age and WBC count at diagnosis, and ALL risk group classification between genetic subgroups was done with the Mann‐Whitney test and Pearson's chi‐square test, respectively. Patients with RAS class mutations comprised a significant subgroup of 33.1RANBP2‐ABL1 (n = 1), EBF1‐PDGFRB (n = 2), IGH‐CRLF2 (n = 2), other IGH rearrangement (n = 2), EWSR1‐ZNF384 (n = 2), PAX5 rearrangement (n = 6), TCF3 rearrangement (n = 1), PICALM‐ME3 (n = 1), and ETV6‐EP400 (n = 1)  by FISH. Gene fusion was detected in 18 patients; ® ALL. Mutations activating JAK‐STAT pathways were identified in three patients including IL7R (n = 1) and FLT3 (n = 2). Interestingly, RAS pathway mutations were most commonly identified (n = 17); NRAS (n = 8), KRAS (n = 3), KRAS and NRAS (n = 1), NRAS and NF1 (n = 1), PTPN11 (n = 3), and NF1 (n = 1)  did not significantly predict the presence of RAS mutations (data not shown). Exon skipping was also detected in ETV6 (n = 6), RUNX1 (n = 7), EBF1 (n = 3), and IKZF1 (n = 7).We also detected single nucleotide variations and small insertion/deletions by FusionPlex1) Table . For theBCR‐ABL1‐like ALL including ABL‐class fusions, CRLF2 rearrangements, JAK‐STAT pathway mutations and RAS pathway mutations, and classified them as BCR‐ABL1‐like ALL  . The remaining 16 patients (8.4%) were grouped as B‐other ALL , and did not differ significantly from that of the non‐BCR‐ABL1‐like ALL subgroup. The median WBC count of the BCR‐ABL1‐like ALL subgroup was 18.98 × 109/L (range: 0.89‐161.61 × 109/L), and again did not show any clear difference from that of the non‐BCR‐ABL1‐like ALL subgroup. A significantly higher proportion of BCR‐ABL1‐like ALL patients were classified as NCI high risk than non‐BCR‐ABL1‐like ALL patients. Also, a greater proportion of patients was classified as either high or very high‐risk according to institutional classification criteria among BCR‐ABL1‐like ALL patients than among non‐BCR‐ABL1‐like ALL patients (Table The median age at diagnosis of the ts Table .BCR‐ABL1‐like ALL subgroup was 71.5 ± 9.1% (18/25). There was no significant difference in EFS and OS for BCR‐ABL1‐like ALL patients with or without RAS pathway mutations .The 5‐year EFS of the s Figure . Events BCR‐ABL1‐like ALL patients who relapsed were standard risk according to institutional criteria, with the remainder being high or very high‐risk. Hence, for the standard‐risk group as a whole (N = 29), all of the 24 non‐BCR‐ABL1‐like ALL standard‐risk patients survive event‐free, while two of the five BCR‐ABL1‐like ALL patients experienced an event .Two of the six BCR‐ABL1‐like ALL subgroup was significantly lower than that of the non‐BCR‐ABL1‐like ALL low‐ and standard‐risk patients , and was similar to the 5‐year EFS of 75.2 ± 6.2% found for non‐BCR‐ABL1‐like ALL high‐risk patients .The 5‐year EFS of the ETV6‐RUNX1‐like patients did not show significant difference in clinical characteristics including age and WBC count compared with other B‐ALL patients (data not shown). All 6 ETV6‐RUNX1‐like patients survived event‐free.4BCR‐ABL1‐like ALL category by detecting gene fusions and mutations. BCR‐ABL1‐like ALL comprised 13.2% of pediatric B‐ALL in our cohort, an incidence similar to that reported by previous studies.BCR‐ABL1‐like ALL is aberrant signaling through cytokine and tyrosine kinase receptors.CRLF2, ABL‐class tyrosine kinase genes, and JAK2, as well as mutations activating JAK‐STAT and RAS signaling.Recent advances in genetic analysis have led to the identification of novel genetic subtypes of B‐ALL with prognostic relevance. In this study, we studied a cohort of pediatric B‐ALL patients to retrospectively determine the incidence of patients harboring new genetic subtypes, as well as their outcome. We successfully identified patients in the BCR‐ABL1‐like ALL patients (N = 17). Previous studies showed that patients with RAS mutations do not comprise a significant proportion of BCR‐ABL1‐like ALL patients, with incidence ranging from 3.6% to 6%.BCR‐ABL1‐like ALL is one of the subtypes of ALL in which RAS mutations are more prevalent, with an incidence of clonal RAS mutations reported in approximately 30% of BCR‐ABL1‐like ALL patients.BCR‐ABL1‐like ALL. Recent studies based on Asian patients focused on the identification of kinase fusions, IKZF1 deletions, and JAK mutations associated with BCR‐ABL1‐like ALL.BCR‐ABL1‐like ALL.RAS pathway mutations had the highest frequency in our BCR‐ABL1‐like ALL are likely to be older and have a high WBC count at diagnosis, resulting in a greater proportion of NCI high‐risk patients in the BCR‐ABL1‐like ALL category.BCR‐ABL1‐like ALL patients. In our study, a significantly higher proportion of BCR‐ABL1‐like ALL patients were classified as high risk according to both NCI and institutional classification criteria compared with non‐BCR‐ABL1‐like ALL patients.In terms of clinical parameters, pediatric patients with BCR‐ABL1‐like ALL subgroup was significantly lower than that of the non‐BCR‐ABL1‐like ALL low‐ and standard‐risk patients, and was similar to that of non‐BCR‐ABL1‐like ALL high‐risk patients. Inferior outcome of BCR‐ABL1‐like ALL patients compared with low‐ and standard‐risk patients is consistent with the majority of BCR‐ABL1‐like ALL patients being high risk according to both NCI and institutional criteria. However, two of the five standard‐risk BCR‐ABL1‐like ALL patients relapsed, while all of the 24 non‐BCR‐ABL1‐like ALL standard‐risk patients survive event‐free. One extensive study showed that standard‐risk BCR‐ABL1‐like ALL patients had significantly worse EFS than other standard‐risk patients,BCR‐ABL1‐like ALL genotype may influence the role of well‐established prognostic factors in pediatric ALL.The 5‐year EFS of the BCR‐ABL1‐like ALL. However, it is not widely available in routine clinical practice. Several studies using an 8‐ or 15‐gene quantitative assay using TaqMan‐based low‐density array showed high correlation with gene expression profiling,BCR‐ABL1‐like ALL using AMP NGS. This method utilizes specific and universal primers, allowing for diagnosis of a translocation without the identification of both fusion partners.BCR‐ABL1‐like ALL were confirmed by RT‐PCR, FISH or sequencing. Through this strategy, we identified sentinel gene fusions that may be used as therapeutic targets. A substantial number of clinical reports have shown that patients with kinase‐activating lesions associated with BCR‐ABL1‐like ALL are amenable to targeted therapy, with tyrosine kinase inhibitors for patients with ABL‐class fusions, and JAK inhibitors for those with JAK2 fusions or mutations.BCR‐ABL1‐like ALL may allow for novel and effective targeted therapy. Other recurrent genetic abnormalities including ETV6‐RUNX1‐like ALL and ZNF384 rearrangements were identified in this study. Although past studies have tried to characterize their incidence and clinical significance,Gene expression profiling is the main method for diagnosis of BCR‐ABL1‐like ALL patients comprised 13% of B‐ALL, had inferior outcome compared with low‐ and standard‐risk patients, and had a high incidence of RAS class mutations. This is the first report to demonstrate the characteristics of BCR‐ABL1‐like ALL in Korean pediatric patients. Further analysis based on a greater number of BCR‐ABL1‐like ALL patients is necessary to confirm the key findings of our study.In summary, our cohort of The authors declare that they have no competing interests.Conceptualization and design: YK, N‐GC, and MK. Patient data and samples: JWL, BC, SK, and P‐SJ. Experiments, collection and assembly of data: JL, HC, and GDL. Data analysis and interpretation: JWL, YK, HC, and MK. Manuscript writing and editing: JWL, N‐GC, YK, and MK.SupinfoClick here for additional data file.


The 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs.Using the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program.Beyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose.The successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other.NCT04147169, retrospectively registered with clinicaltrials.gov on October 31, 2019. The 3 Wishes Project (3WP) is an end-of-life program designed to attenuate human suffering by cultivating connections and deepening relationships among patients, family members, and clinicians in the intensive care unit (ICU) –3. TheseAs 3WP continues to expand, the original 3WP site receives numerous requests for advice about initiation in new centers. Many requests relate to how new sites might implement 3WP with limited resources, and how the program might operate without the research elements and the associated infrastructure of an academic tertiary care hospital. With the goal of assisting new centers considering local implementation of 3WP, the objective of this study is to describe various designs of the 3WP across 9 ICUs in North America, to identify essential elements for success, and to describe local adaptations.We conducted a qualitative descriptive  study ofThe expansion of the 3WP was guided by implementation support from the original center in the form of a Start-Up Guide , publicaParticipating centers were sampled from amongst centers where 3WP was successfully implemented and data was shared back to the original center. We allowed each center to self-define “successful implementation”, because we wanted a sample of centers with different levels of experience with the program, from different sizes of hospitals so imposing a definition of success related to the number of patients enrolled or longevity at the center would not be helpful. We sampled participating centers to represent diversity in the model of 3WP implemented, duration of implementation, and organizational and geographical context. All centers collected data describing patient characteristics and wishes implemented. At some centers, quantitative data were supplemented with qualitative data about the experiences of family members and clinicians. Ethics approval for this study was obtained from the Hamilton Integrated Research Ethics Board and from each institutional review board.From 2016 to 2019, we conducted interviews and focus groups with individuals active in the initiation or day-to-day leadership of 3WP at each of the 7 hospitals. Focus groups were composed of individuals from multiple centers to facilitate conversations about local variations. Interviews included one or two key personnel from each center to generate an in-depth description of the program at their site. Interview and focus group guides were designed and piloted with members from the original center and further refined as the project progressed. All interviews and focus groups were conducted by trained qualitative researchers who do not have clinical roles (MV and MES) or bedside implementation experience, but who have long standing familiarity with the program. Interviews and focus groups were audio-recorded and transcribed verbatim; all participants provided written informed consent.Interview and focus group data were supplemented with process documents produced by the original center. After preliminary analysis, we returned to center leads at each hospital, asking for additional input on several key concepts identified during analysis where data were incomplete. Review of findings and provision of supplemental information where necessary served as a form of member checking to ensure resonance and credibility ; and alsData were analyzed using an iterative, step-wise approach adapted from Grounded Theory . PrelimiFigure All centers identified a common goal for project initiation: a desire to improve end-of-life care. In addition to identifying essential elements related to this goal, we also describe variations across sites, mainly related to organizational context and resources. Finally, we describe a consistent pattern of program evolution, wherein local adaptations and refinements were facilitated through cross-pollination of ideas fostered by a network of like-minded individuals with shared purpose.The best part of it is talking with people. It’s not the actual doing of the wish, it’s the conversation with the family that I find the most meaningful” (RC). These connections are strengthened by active demonstrations of compassion: “I often talk about [3WP] as crowd-sourcing compassion. … We share a common desire to be compassionate towards patients and families” (RN). The grassroots, clinician-led nature of the program with wide participation from all members of the clinical team is consistent across centers: “This project, specifically, has connected us in a way that’s very different from day to day” (RN). This embeddedness ensures the program is part of usual care, rather than compartmentalized as something “extra”: “I didn’t even know it was a program, I thought it was ingrained into clinical practice in the ICU.” (Resident).We identified several essential elements of 3WP that were present across all centers. The program is founded upon the importance of authentic connections among individuals in the ICU: “The main points of variation across centers related to the organizational context and resources with which the program was implemented. These differences created diverse foundations upon which local versions of 3WP were built.We’re so short-staffed, so I don’t know how often those kinds of things occur cause, like if eight people are working that means only three people can go sit down and have a [3WP] meeting.” (MD).Differences across participating sites provoked discussion of practical and logistical issues. For example, smaller centers with fewer staff members found it challenging to mobilize individuals to implement wishes due to competing clinical demands: “Honestly, we’re talking several hundred people that we’re trying to talk to.” (RN) This site also described needing to do a periodic “educational blitz” (RN) to reach new staff and keep awareness of the program at the top of everyone’s mind.Larger centers also faced communication and mobilization challenges, but for different reasons. While it was easy to identify 3WP champions from a large pool of individuals, communicating about the program to the full staff complement was more difficult. “Any university that is accustomed to having lots of research studies … it’s easier to start than having to prove the benefits beforehand.” (MD). For other sites, it was an institutional mission statement that focused on high quality end-of-life care or the importance of a positive patient experience. Others identified particular strengths or resources of team members, such as having “a very young staff” (RN) enthusiastic about initiating new projects, or having a culture that emphasized the importance of palliative care “end-of-life is not something that most of our group shy away from” (MD).Each center identified different features of their ICU that facilitated the start and spread of the program. For some academic centers, it was a research tradition and the accompanying infrastructure “When this came up he [Manager] threw his support behind it 150 percent” (RN), while others emphasized the initial challenge posed by management before they understood the nature and value of the program. Describing an early attempt to implement a patient’s wish of seeing his pet one last time, one clinical leader recalled asking for permission to bring the animal into the ICU. The person he asked “emailed his boss and then it turned into… ‘you need to get the CEO, every single leader and also the whole [University] to sign off, this is a universal policy’” (MD). More commonly, the initiation of 3WP was described as outside of the attention of administrators: “I’m sure they don’t know what 3 Wishes is, I don’t think anyone knows or cares what we’re doing” (MD). Typically, as the program continued, administrators became more aware of it, and were described as supportive - either passively or actively.Level of administrative support varied, with some centers emphasizing the key roles that clinical managers played in creating space and time to initiate 3WP, “Our social workers, our spiritual care providers, our nurses do the asking part whereas the research team would collect the data. The research team often did the running if something required running” (RC). All sites noted that their program was initiated and run by front-line clinicians, and the team composition evolved over time: “One of the things that was intentional but looked organic was that it started out as an intensive care, palliative care, spiritual care collaboration with nursing, respiratory therapy, so it was very interprofessional from inception” (MD). Nursing staff were commonly described as key to the 3WP, especially in smaller centers: “Because we’re a community ICU, the bulk of our staff that are involved with patients are physicians and nurses just based on who’s available, because our interdisciplinary team is stretched thinner across the hospital than perhaps in the bigger sites, and so they’re not getting to know the patients as intensely as the nurses and physicians are.” (RN).Each center had a core team of clinicians with different backgrounds and of different sizes who started the 3WP: “During various times we actually have a lot of [volunteer] people there, so they helped us a lot. These are students from the university … we actually utilize them a lot to help us gather supplies or to help us.” (RN). Other resources had to be creatively sourced. Organizing financial resources required ingenuity, with teams securing funds from research grants, awards, fundraising among staff and the hospital community, and small corporate grants for supplies, as outlined in Table The [school] board said ‘yup, we love it, it’s a great idea, but we in turn would like someone from the hospital to come and talk about death and dying and why the program is important’” (MD). Provision of supplies and services from local coffee shops and other stores was facilitated by forming relationships with local businesses. At one site, the hospital provided support from their operating budget: “a 3 Wishes Project Manager was hired by administration after a little over a year of 3WP implementation when they saw the value of the project.” (MD).All sites were required to creatively identify and secure resources to support the 3WP, but strategies and successes differed. Some resources were readily available: staff enthusiasm, community contributions, and volunteer energy. “In each center, the program has evolved over time, adapting to changing needs, transitions in the clinician leadership team, and new resources. These changes have been supported by cross-pollination of ideas in a network of like-minded individuals both within and across hospitals.Each site shared many local adaptations relating to the way they identified program assets, communicated about the program, involved trainees, and interacted with units outside of the ICU. Many centers developed their own “signature wish”, or a popular wish that was frequently offered by the staff to families. Signature wishes such as word clouds, plaster casts of clasped hands, and thumbprint keychains or jewelry were often developed and popularized at one site and then shared with other centers through the 3WP network.There are definitely clear phases. An implementation phase that involved fundraising, networking, problem solving and demonstrating that 3WP was safe, effective, beneficial, and feasible. We are now in a maintenance phase where we provide ongoing reinforcement of existing knowledge and look for ways to grow the program.” (RN). Between the implementation and maintenance phase exists a time wherein the program transitions “into part of the unit culture and [is] incorporated into the standard of care for our end-of-life patients” (RN). Others described expansion as part of the latter phase of the project, with several sites mentioning that they have expanded the clinical program to other units within their hospital, or affiliated institutional sites: “We have now expanded to 6 other units in a two-hospital health system.” (MD).Experienced sites noted different stages as the 3WP evolved: “People feel awkward to initiate the conversation and to get from the family what’s most important for that person” (RN). This initial hesitancy dissipated with experience supported by creating local resources : “We developed these resources that people leaned on very heavily when they first started out” (MD). As the program became more established, there was less reliance on the core team as “the skills and capacity increase amongst the staff” (RN). The final stage occurs when 3WP is framed as an explicit approach to caring through acts of compassion rather than a program. This was marked by a different approach when speaking with families: “I just say ‘Would it be ok if we provide a blanket for your mom’?” (RC) “It’s like a gentle approach. ‘What did they like and what did they not like?’ or ‘Do you have a pet?’ and you start getting the ideas going” (RN). Instead of inviting a patient to participate in the 3WP, one site opens with the question, “Is there anything else that we can do for you right now?” (RN).We also identified a shift in thinking about the program, from a defined clinical and/or research project with specific initiation and enrollment criteria to an organic, engrained approach to end-of-life care. Determining the eligibility of a specific patient and increasing staff comfort with introducing the program was a common initial focus: “It could just be one story that affects hundreds of providers, so whatever allows you to have these meaningful patient interactions that people see and want to share” (MD). Storytelling helps to sustain enthusiasm for the program and encourages participation: “Word of mouth is the most powerful way to communicate” (Organ Donation Coordinator). This communication is typically direct and one-to-one. Coordination and logistics are shared within the ICU through staff huddles, meetings, email, protocol binders, research newsletters and bulletin boards, core team group meetings, and group chats (e.g. WhatsApp Messenger). Encrypted group text chains are often used to coordinate wishes, offering the opportunity to ask a large group for help when items outside the hospital are needed: “They [program champions] have a really good network and then if sometimes their work gets tied up they may text someone else who is coming in: ‘Can you stop by and pick up flowers or a treat from [local store]?’” (RN).Each site discussed the importance of sharing stories and coordinating efforts within their own ICU: “It [the nurse-for-a-day fundraiser] inspired some really good little competition and, and it was just funny. We got other units involved to come make donations, because I mean all our docs usually work at other places … We were trolling down in Emerg to make donations … it was so fun” (RN). As word of 3WP spread within each center, other units are often interested in implementing elements of the program: “We have no formal partnerships outside of the ICU but are actively communicating with other units who are interested in starting a similar program.” (RN). This intra-institutional communication has led to establishing the 3WP in several other wards in multiple centers .Communicating about 3WP to others outside of the ICU but within the institution was considered important, often with the intent of both sharing stories and soliciting supportive resources: “We’ve partnered with a local artisan jeweler and a charity knitting group” (RN). Many hospitals received local news media coverage about their program which not only disseminated information about the mission of the project, but also inspired volunteer interest, donations, and new project initiation.Participants from each center reported making connections within their communities outside of the hospital. Sometimes these connections yielded additional resources or assistance in implementing wishes: “In consultation with social work, spiritual care, nursing, respiratory therapy, and leadership teams we developed the 3W Guide for Staff to clarify wishes that are possible, share visual examples of implemented wishes, provide advice and examples of how to initiate the conversation, elicit wishes, implement wishes, and encourage creativity and engagement amongst staff.” (RN). New hospitals interested in developing 3WP now connect with a number of existing sites, capitalizing on the overall professional network: “We’ve had numerous discussions with other ICUs in our area and elsewhere [lists sites]. Many of these sites have gone on to implement successful clinical programs.” (RN).Finally, interaction among centers has been an important way to share ideas and solutions to common logistical challenges. Interactions that were initially coordinated by the original center created a multicenter network that continues to share central resources, engage in reverse site-visits, host retreats with program leaders, and communicate through social media. Ideas were further pollinated across centers once they were established; thus, individuals involved in the 3WP no longer relied solely on the original center as a hub, as other sites took the lead in actively developing resources such as instructional staff videos and guides: “In this paper we describe the implementation of 3WP in 9 ICUs located in 7 hospital systems, detailing variations in the program across sites, identifying essential elements, and reporting potential adaptations that new centers may find helpful when considering whether or how to implement 3WP. Examining the factors facilitating multicenter implementation reveals the importance of program flexibility and the empowerment of frontline staff. These related elements are both fundamental to successful expansion of 3WP.Each environment in which the 3WP is implemented is unique, with different organizational features, core team composition, administrative support, academic affiliation, and available resources. The semi-structured nature of the program allows for adaptations that consider the culture and context of each setting , 19 and Another key consequence of frontline clinician ownership of the program is the team approach to end-of-life care. This may supplement the typical patient-physician dyad by explicitly empowering other healthcare staff to recognize and respond to the needs of both the dying patients and their family members. Although an interprofessional approach is generally acknowledged as an important component of high quality end-of-life care in ICU , 23, othThis analysis of a palliative care program draws on data from 9 ICUs in 7 hospitals with different populations, institutional contexts, and geographical settings. We collected qualitative data from clinicians occupying diverse roles. Analysis was conducted by investigators with varied clinical and professional backgrounds. The longitudinal involvement of the research team ensured familiarity with the program to better identify unique features in each setting. While not planned a priori, this analysis describes how the 3WP was initiated and eventually integrated organically into practice without a rigid protocol in 9 ICUs with their own culture in Canada and the United States. Family perspectives, though previously obtained about different aspects of this program , 7, 9–11In this report, we describe the adaptations and refinements to the 3 Wishes Project that enabled successful implementation and fostered viability in variable ICU settings despite different contexts, needs, and resources. Commitment to high quality end-of-life care was an essential motivator, inspiring frontline clinicians to initiate the program, creatively resource it, and maintain enthusiasm. As the program became more established, it transitioned from an “add on” to existing end-of-life programs to become “embedded into” the unit’s approach to end-of-life care. This evolution was initially facilitated and later fueled by the alliance of like-minded individuals within each site, among several communities, and across the 3WP network.Additional file 1: Supplemental Figure A. 3 Wishes Project Implementation Models. Description: There are multiple ways in which an institution can adopt the 3 Wishes Project. This figure illustrates some implementation models for the clinical program and possible variations for an associated research component. Reproduced from Vanstone et al., 2020.


Based on social cognitive theory (SCT), an educational program was developed to prevent rural elderly residents from respiratory infections in South Korea. The effectiveness of the program was investigated in terms of knowledge, attitudes, and practices about respiratory infection prevention, as well as social capital. A pretest–posttest nonequivalent control group quasi-experimental design was used to test the short-term effect of this program. In addition, 1- and 6-month follow-up surveys were administered to evaluate the long-term effects. A total of 69 subjects  participated in the experiment. The results showed that knowledge about respiratory infection prevention, respiratory infection prevention practices, and social capital were enhanced among the elderly residents who participated in the educational program. The educational effects differed significantly across time periods  in all the above variables. In particular, the program remained effective 1 month after the intervention, but a reinforcement session extended the program’s effects up to 6 months later. This educational program would be used as an effective intervention to help rural elderly residents prevent respiratory infections. As a country whose aging population is growing faster than anywhere else in the world, South Korea is estimated to become a super-aged society—where 20 percent or more of the population is 65 or older—in 2025 and to have the largest elderly population worldwide by 2045 ,2. SinceAging has been shown to increase the prevalence and severity of diseases, as well as the risk of mortality. According to Korean cause of death statistics, in 2018, the mortality rate from pneumonia was only 0.1 per 100,000 for 10–19 year olds, but increased rapidly with aging to 24.9 per 100,000 for 60–69 year olds, 144.0 per 100,000 for 70–79 year olds, and 978.3 per 100,000 for 80 years or older . MedicalThe World Health Organization (WHO) has recommended both pharmacological interventions and non-drug treatments for the prevention of infectious diseases . HoweverSince 1981, South Korea has established public health facilities and assigned dedicated healthcare workers, not only to improve access to healthcare services, but also to provide comprehensive primary healthcare services for medically vulnerable rural residents. Rural healthcare providers are generally local government officials who have nursing or midwifery licenses. These officials are assigned to public health facilities to conduct medical activities and health promotion among rural residents . TherefoBased on Bandura’s social cognitive theory (SCT) , which cIn light of this, we aimed to develop a theory-driven health education program for the prevention of respiratory infections among elderly residents of rural areas. In addition, we aimed to evaluate the effectiveness of the program among the rural elderly residents. Guided by the knowledge–attitude–practice (KAP) model, the effects of the program were investigated with knowledge, attitudes, and practices concerning respiratory infection prevention , togetheResearch Question 1. Are there any differences in knowledge about respiratory infection prevention, attitudes toward respiratory infection prevention, respiratory infection prevention practices, and social capital between experimental and control groups?Research Question 2. Are there any differences in knowledge about respiratory infection prevention, attitudes toward respiratory infection prevention, respiratory infection prevention practices, and social capital across pretest, posttest, 1-month, and 6-month follow-ups?Research Question 3. Do the experimental-control group differences vary across pretest, posttest, 1-month, and 6-month follow-ups?Based on Bandura’s SCT , a healtThe subjects of this study were rural elderly individuals (over 60 years of age) with no visual, auditory, cognitive, and/or speech impairments. Before the experiment began, all subjects were explained in detail the purpose and procedure of the study and the potential risks and benefits of participation afterward. A one-to-one explanation of the study was also provided to each subject and then the subjects were asked to sign a written consent form if they agreed to participate in the study. They understood the purpose of this study and consented to participation in the experiment. In order to select the public health facilities for research participation, the researcher contacted 13 public health facilities located outside the city, two of which showed an intention to participate in this study. Of those who were under the care of the two public health facilities, the elderly who indicated their intention to participate in this study were recruited as the subjects through the health facilities. One of the two public health facilities was selected for the experiment since this facility expressed interest in participating in the educational program. Therefore, elderly individuals under the care of this facility comprised the experimental group. The control group, on the other hand, comprised elderly individuals who were under the care of the other public health facility. Both public health facilities were in the same administrative district so that the elderly residents lived in similar rural settings. However, the two facilities were geographically far apart from each other; that is, one of the facilities was located on the south side of a river and the other on the north side.The sample size required for this study was calculated using G*power 3.1 , in which the values of significance level, effect size, and power were 0.05, 0.30, and 0.80, respectively, for repeated-measures analysis of variance (repeated ANOVA). The result showed that this study would require at least 58 subjects; thus, a total of 72 individuals were recruited to account for potential dropout. In fact, three people in the experimental group were excluded: two for missing one of the four training sessions, and one due to a health issue. Thus, the final analytical sample comprised 69 subjects, 37 in the experimental group and 32 in the control group . The RIPEP-SCT was developed after reviewing a number of studies that addressed the prevention of respiratory infections ,17, as wThe RIPEP-SCT comprised four training sessions held over the course of four weeks, with one session per week, each 50 min in duration. A reinforcement session was also held about one to six months after the initial training . The eduDuring each training session, one topic was covered, such as symptoms of respiratory infections, proper cough etiquette, correct hand washing and dental hygiene, and healthy walking. The content of the sessions reflected the four observational learning processes. First, to reflect the stage of attention, the trainees were asked to discuss what they already knew about respiratory infections, and they were shown some visual stimuli depicting respiratory infections to enhance their awareness of the severity of these infections. The attentional level of each trainee was also determined by asking them about their experiences with the topics to be covered in the following session. From the memory stage to the motivation stage, lessons learned from the previous sessions were created as a song to make them easy to remember, and the trainees were asked to share their experiences with prevention practices. Reflecting the memory stage, the educational material was designed to stimulate the five primary senses. For example, visual stimuli  were presented using PowerPoint to stimulate hearing and sight, and a dental model was provided to the trainees to stimulate sight and touch. The dental model was an actual model of teeth, and it was used to teach correct brushing techniques because oral hygiene is an important part of preventing respiratory infections. Looking at the model and touching it was intended to increase the educational effect of the elderly who experience a decline in cognitive function. Also, the trainees were asked to sing a song reflecting the melody of a happy birthday song, which allowed them to more easily remember the core educational content. They were also asked to recite the pledge of practice promoted in the sessions. For the retention stage, the program was constructed in the form of demonstration and experience. More specifically, the instructor showed the trainees how to properly wear a mask in the first training session. In the second training session, a demonstration was provided to the trainees to educate them about the six steps of correct hand washing. Next, the trainees were asked to wash their hands with soap and water. Their hands were checked through a hand hygiene training view box, which is designed to instantly highlight any germs on hands under UV light. In the third session, the instructor showed the trainees how to correctly brush their teeth, and they were given toothpaste and toothbrushes to use for practice. In addition, the trainees were asked to conduct an oral routine in front of a mirror after a demonstration was given by the instructor. Although physical activity is important for enhancing immunity, only 37.3% of the elderly in Korea meets the recommended physical activity guideline for more than 30 minutes a day and 5 times a week . TherefoAfter the completion of all the sessions, a ceremony was held to celebrate their graduation from the program, and they were asked to complete the posttest questionnaire. During the ceremony, the trainees watched videos that had been recorded during the training sessions, and a certificate and prize were given to each of them. The trainees reflected on what they had learned during the training sessions by singing songs about each subject and reciting the pledge of practices. Lastly, time was allocated for a group discussion and evaluation of the program.About one to six months after the program ended, a reinforcement session was provided to the trainees. In the reinforcement session, the trainees were asked to summarize the focal point of the four sessions and to remember the songs and the pledge of practice. A game format was employed to enhance their interest and motivation. Rewards were again used to motivate the participants to remember what they had learned .Knowledge about respiratory infection prevention includes the awareness and understanding of how to prevent these infections . In thisAttitudes toward respiratory infection prevention entail a mindset geared for preventing respiratory infections . In thisRespiratory infection prevention practices encompass behaviors directly aimed at respiratory infection prevention . In thisSocial capital was measured using the scale deployed by Shin and Ko . A totalAll measures of this study were subjective, indicating that the term ‘knowledge’, ‘attitudes’, ‘practices’, and ‘social capital’ actually refers to perceived knowledge, perceived attitudes, perceived practices, and perceived social capital.The experiment was conducted in two public health facilities in rural areas. The experimental group comprised residents from four rural towns who were under the care of one public health facility; the control group comprised residents who were under the care of the other public health facility. The researchers explained the details  of the research study and the rights of the participants. Before participation, each participant had to sign a consent form. Data were collected from December 4, 2018 to June 25, 2019 through a one-by-one, face-to-face survey. The participants were fully informed of their right to leave or withdraw from the study at any time for any reason. All participants were compensated with five-dollar gifts  for their participation.The educational program was conducted by community health experts who were certified as home and health nurses and had over 20 years of experience. They participated in the development of the program and worked as program instructors. In addition to the nurse instructors, four nursing students (three undergraduate students and one graduate student) were employed as research assistants for the experiment. Before the program began, a training session was provided to the nurses and research assistants to ensure that they fully understood the program procedures. After conducting a preliminary test, two researchers were asked to share the difficulties and problems they encountered and to provide feedback aimed at reducing research bias.For the experiment, the participants were asked to complete a consent form after the researchers explained the purpose of the study. Subsequently, a face-to-face survey was conducted for the pretest. The experimental group received five training sessions of the educational program in the town hall, whereas the program was not applied to the control group. To evaluate the program, both experimental and control groups completed pretest, posttest, and one- and six-month follow-up surveys. A total of 72 subjects  were initially recruited for the study, but three from the experimental group were ultimately excluded, as explained above. Thus, the final analytical sample comprised 69 individuals . The training sessions were provided by nurse instructors, with assistance from six to seven researchers. The ages of the instructors were approximate to the ages of the trainees to promote instructor–trainee familiarity. The posttest was conducted immediately after the training sessions had ended for the experimental group. The control group completed posttest with no training. Both experimental and control groups completed two follow-up surveys 1 and 6 months after the program. In the meantime, a reinforcement session was provided to the trainees. In the reinforcement session, the trainees were asked to recall not only what they had learned during the four training sessions but also the songs they had sung as well as the pledge of practice. A game format was adopted to enhance the trainees’ interest in the program and increase their motivation to remember the focal point of the training sessions. t-test were performed to determine intergroup homogeneity. A mixed analysis of variance (mixed ANOVA) was used to test the effectiveness of the educational program, since this type of analysis is likely to be more robust than other statistical methods when the assumption of homogeneity of variances is violated. To test the hypotheses, the mixed ANOVA was performed separately with four dependent variables  to investigate whether any significant differences existed between control and experimental group members concerning their knowledge, attitudes, and practices regarding respiratory infection prevention, as well as social capital across the pretest, post-test, one-month, and six-month follow-up assessments. Toward this end, one within-subjects factor  and one between-subjects factor  were included in the data analysis. The questionnaire included questions about participants’ demographic characteristics, health-related attributes, and social capital, as well as their knowledge, attitudes, and practices concerning respiratory infection prevention. A chi-square test, Fisher’s exact test, and independent sample t = 0.90, p = 0.373), practices , and social capital , whereas a significant difference was found in attitudes   .With regard to RQ1, four separate mixed ANOVAs were conducted to determine whether group differences existed in: (1) knowledge about respiratory infection prevention; (2) attitudes toward respiratory infection prevention; (3) respiratory infection prevention practices; and (4) social capital. F = 7.34, p = 0.009, M = 0.96, SE = 0.01) of respiratory infection prevention was better than that of the control group . There was also a statistically significant main effect of group for respiratory infection prevention practices, F = 20.56, p < 0.001, M = 4.26, SE = 0.05) undertook more respiratory infection prevention practices than the control groups . In terms of social capital, a statistically significant main effect of group was found in this study, F = 17.95, p < 0.001, M = 4.16, SE = 0.05) was higher than that of the control group . For attitudes toward respiratory infection prevention, however, there was no statistically significant main effect of group, F = 0.12, p = 0.734, For knowledge about respiratory infection prevention, the mixed ANOVA results indicated a statistically significant main effect of group, 2 = 0.10 . Specifi2 = 0.24 . The exp2 = 0.21 . The sco2 = 0.00 .Regarding RQ2, four mixed ANOVAs were performed separately to test whether differences would be found across time periods for: (1) knowledge about respiratory infection prevention; (2) attitudes toward respiratory infection prevention; (3) respiratory infection prevention practices; and (4) social capital. F = 9.50, p < 0.001, F = 5.88, p = 0.018, F = 10.99, p = 0.001, F = 2.94, p = 0.091, M = 0.97, SE = 0.01), 6-month follow-up , posttest , and pretest . For knowledge about respiratory infection prevention, the Huynh–Feldt correction was applied for non-sphericity. The mixed ANOVA results indicated a statistically significant main effect of time, Wilks’ lambda = 0.66, 2 = 0.12 . PairwisF = 10.03, p < 0.001, F = 5.90, p = 0.018, F = 21.65, p < 0.001, F = 3.42, p = 0.069, M = 4.85, SE = 0.03), posttest , 1-month follow-up , and pretest . Furthermore, a significant main effect of time was found for attitudes toward respiratory infection prevention, Wilks’ lambda = 0.65, 2 = 0.13 . PairwisF = 18.85, p < 0.001, F = 35.11, p < 0.001, F = 10.61, p = 0.002, F = 10.52, p = 0.002, M = 4.28, SE = 0.04), posttest , 1-month follow-up , and pretest .In terms of respiratory infection prevention practices, there was a statistically significant main effect of time, Wilks’ lambda = 0.59, 2 = 0.22 . The degF = 3.17, p = 0.032, F = 6.08, p = 0.016, F = 1.66, p = 0.202, F = 0.64, p = 0.427, M = 4.09, SE = 0.06), 6-month follow-up , 1-month follow-up , and pretest .In addition, the mixed ANOVA results showed that there was a statistically significant main effect of time for social capital, Wilks’ lambda = 0.91, 2 = 0.05 . The degWith regard to RQ3, four 2 F = 3.09, p = 0.038, F = 8.03, p < 0.001, F = 14.10, p < 0.001, F = 10.81, p < 0.001, The mixed ANOVA revealed a significant interaction between group and time on the knowledge, Wilks’ lambda = 0.85, 2 = 0.14 .The means and standard deviations by group and time for the above four variables are shown in In this study, an educational program was developed to prevent respiratory infections among rural elderly people (over 60 years of age), and the effectiveness of the program was investigated. With the purpose of enhancing awareness among the elderly about respiratory infections, the educational program was designed on the basis of psychological, physical, and mental characteristics associated with old age . The eldOne of the four observational learning processes, attention, was incorporated in the program in such a way as to enhance trainees’ interests and motivation: the trainees were asked to think about why the topic of each training session was important. They were also asked to reflect on what they had learned by singing a song or taking a pledge of practice. The memory process, which involves the cognitive storage of information learned from observation, was promoted in the program through video materials, which were used to stimulate both vision and hearing among the trainees. To enhance their concentration, a variety of instruments were used, such as a dental model, a view box, masks, and a walking mat. These instruments helped to demonstrate actions like correct hand washing, correct walking, and so on. Next, the retention process, which involves determining the level of consistency between what one learns and how one subsequently behaves through internal feedback, was invoked among trainees through self-observation and self-correction, i.e., the trainees were guided to adapt their behavior to the model’s behavior. After demonstrations by the instructor, the trainees were instructed to use the program instruments to practice various activities, such as correct hand washing and correct toothbrushing, and they were also given opportunities for self-correction via feedback from the instructor or from their peers. As the final step, the motivation process was stimulated by encouraging desire among trainees to engage in program practices. The trainees sang a song that included keywords and key concepts from each training session. In addition, the trainees were also asked to take a pledge of practice to review what they had learned.Rewards were used to increase participation among the trainees across all sessions. At the beginning of each session, rewards were given to the trainees who shared what they had learnt from the previous session with their peers. Some trainees were also rewarded with items for respiratory infection prevention such as a handkerchief, hand sanitizer, and toothbrush/toothpaste for completing tasks, memorizing the songs and pledge of practice, or correctly answering questions on the quiz. In the final session, certificates and prizes were awarded to the trainees for participating in the program.For the program, instructors were selected based on whether their ages approximated those of the trainees, for the purpose of enhancing rapport and familiarity between them. Such an approach has previously been applied as an effective method for increasing compliance with respiratory infection prevention practices .Similar to this study, many studies have used SCT to develop health education programs, such as a food safety education program for the elderly , a web-bUnlike the research of Lee and Park  or Choi By combining the strengths of the existing programs, we developed a theory-driven intervention program aimed at educating rural residents about respiratory infection prevention. It was designed to facilitate behavioral changes among trainees, allowing them to more easily understand what they have learned from the program . The effWith the purpose of evaluating the effectiveness of the respiratory infection prevention program, this study examined the knowledge, attitudes, and practices concerning respiratory infection prevention among rural elderly residents, as well as their social capital, before and after the intervention. A reinforcement session was also provided about one to six months after the educational program ended. In this study, knowledge, attitude, and practice (KAP) of trainees were assessed because many studies have empirically examined these variables to evaluate the effectiveness of educational intervention ,32. In aIn this study, all the research questions were supported, except for a group difference in attitudes. In the experimental group, knowledge about respiratory infection was enhanced by the educational program, peaking six months after the program ended. In contrast, knowledge among control group members increased by the 1-month follow-up, but then decreased. This may be because the participants in the control group were given the same questionnaire on three separate occasions, which may have consequently improved their knowledge, albeit slightly. In addition to knowledge differences, significant differences were found in attitudes across time periods. This effect was qualified by a significant interaction with the group. In terms of respiratory infection prevention practices, significant differences were observed between groups and across time periods. The experimental group was consistently high in practice at all three time points of the investigation , whereas practices among control group members were reduced one month after the program ended. The findings of this study were similar to those of previous studies on the issue of respiratory infection prevention ,32,36. IThe strength of this study is that a reinforcement session was provided to the trainees and the effects of such reinforcement session was also evaluated with follow-up surveys. For the surveys, knowledge, attitudes, practices, and social capital were all assessed with respect to the extent to which they had been increased after the reinforcement. Although decreases were found in the trainees’ attitudes, practices, and social capital between posttest and 1-month follow-up, increases in their knowledge, attitudes, practices, and social capital during the intervention period were even more increased between 1- and 6-month follow-ups. It would appear that the reinforcement was effective. The finding is similar to the study conducted by Nahm et al.  in whichA limitation of this study is that the sample only included elderly residents from rural areas near a small city. Consequently, the findings might not be generalizable outside this population, and thus studies on elderly populations living in remote areas or living in isolation, as well as elderly populations in other countries, are needed. Additionally, longitudinal research occurring over a period of at least one year is required to confirm the long-term effects of the respiratory infection prevention program. It would also be useful to perform research on other topics, such as nutrition and environmental management, within the context of respiratory infection prevention programs. Nonetheless, this study was meaningful given that the same group participated in the program for six months, and the short-term and long-term effects of the program were evaluated through repeated measures over this period of time.Based on social cognitive theory (SCT), we developed an educational program for respiratory infection prevention for rural elderly residents in South Korea. The effectiveness of the program was investigated in terms of knowledge, attitudes, and practices about respiratory infection prevention, as well as social capital. The results showed that knowledge, attitudes, and practices for preventing respiratory infections were improved among the elderly residents who participated in the educational program. Social capital in the experimental group increased over time, whereas it decreased in the control group. In particular, differences between experimental and control groups over time periods were greater in practices than in knowledge and attitudes, which indicates that the educational program is a highly practical program. In addition, the program remained effective one month after the intervention, but a reinforcement session extended the program’s effects up to six months later. However, the six-month follow-up after the intervention may not be enough to conclude that this intervention has long-term effectiveness. Therefore, additional follow-ups, such as at one and two years after the intervention, are required in future studies. The effectiveness of the educational program also needs to be evaluated not only through subjective measures but also through objective measures . Built on these academic efforts, it is expected that our educational program can be used as an effective intervention, one which can help rural elderly residents prevent respiratory infections.