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Abstract
This study measured intracranial volume (ICV) and normalized cerebral, cerebellar, and ventricu-lar volumes of Korean people in their 20s and 40s, to identify differences in brain volume according to gender and age group and also the relationship between each brain volume and the physical indi-ces. We recorded magnetic resonance brain images for 80 people in their 20s and 82 in their 40s. To investigate the effects of gender and age on ICV and normalized cerebral, cerebellar, and ventricu-lar volumes, we employed a two-way analysis of variance. We analyzed the relationship between each brain volume and physical index using the Pearson correlation method. ICV, cerebral and ce-rebellar volumes of males and the 20s group were significantly greater than those of females and the 40s group. Ventricular volumes for males and the 40s group were significantly greater than those of females and the 20s group. For all subjects the-re was a positive the-relationship between ICV, cethe-re- cere-bral and cerebellar volume and weight and height. There was a brain volume difference correlated with both gender and age; however, there was a close correlation between brain volume and hei-ght, as well as weight. ICV and cerebral and cere-bellar volumes of Korean people were similar to, or slightly smaller than, those of Western people. Differences in brain volume due to gender and age group were similar to previously published re-sults. There was a brain volume difference corre-lated with both gender and age; however, there was a close correlation between brain volume and height, as well as weight.
Key words: MRI, Intracranial volume and ce-rebral, cerebellar, and ventricular volume, Gender, Age, Physical index
Introduction
Each region of the human brain has different functions and structures. Currently, analyses of the brain's structure and volume mainly utilize Magnetic Resonance Imaging (MRI), and these results aid researchers in understanding the brain's structure and function and in diagnosing its disea-ses. There have been numerous studies on changes in brain volume due to aging, examining people from youth through old age (1, 2, 3, 4, 5, 6, 7). Li-kewise, researchers have studied changes in brain volume in connection with gender (4, 6, 7, 8, 9, 10, 11). With regard to Korean people, researchers have examined differences in cerebellar and ven-tricular volume that are correlated with gender, age, and also physical indices (12, 13).
Chung et al. (2005, 2006) reported a relati-onship between cerebellar and ventricular raw volumes and age, gender, and physical indices. Since the raw brain-volume data might vary gre-atly among participants, the raw data needs to be normalized, to reduce this variance (7, 14). There have not been any previously published reports on the relationship between normalized brain volume and gender, age, and physical indices for Korean people. Daniel et al. (2008) and Free et al. (1995), who examined Western people, used several approaches to study the relationship between the volumes of several brain regions and both gen-der and age, as follows. First, they used correla-tion analysis to examine the relacorrela-tionship between (non-normalized) brain volume and the indepen-dent variables of age and gender. Second, after setting Intracranial Volume (ICV) as the covariant, they analyzed the relationships between the inde-pendent variables (age and gender) and normali-zed brain volume, using regression equations (i.e.,
Measurement of intracranial, cerebral,
cerebellar, and ventricular volumes of Korean
people in their 20s and 40s
Beob-Yi Lee1, Mi-Hyun Choi2, Jin-Seung Choi2, Soon-Cheol Chung2
1 Department of Anatomy, School of Medicine, Konkuk University, Seoul, South Korea,
2 Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Biomedical
analysis of covariance or ANCOVA). Third, they analyzed the relationships after obtaining the rati-os between ICV and several brain volumes (ratio analysis). They reported that ANCOVA was the optimal method for reducing variances. Therefore, to do an accurate brain volume study on Korean people, we also needed to use ANCOVA.
Studies have reported that males and younger people have larger brain volumes than do females and the elderly (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). This study's first objective was to measure ICV and ce-rebral, cerebellar, and ventricular volumes in Ko-rean people (males and females, in their 20s and in their 40s). Furthermore, after normalization of the raw data, we aimed to identify the differences in brain volume that correlated with gender and age and to compare the results with the published data based on Western people.
Most previous studies reported a relationship between brain volume and height (15, 16, 17) but no relationship between brain volume and weight (15). However, our studies using raw data showed a relationship between ventricular volume and hei-ght and between cerebellar volume and weihei-ght (12, 13). Therefore the study's second objective was to accurately determine whether there is a relation-ship between brain volume and height or weight, by using normalized data regarding gender and age.
This study measured intracranial volume (ICV) and normalized cerebral, cerebellar, and ventricular volumes of Korean people in either their 20s or their 40s. Also, after normalizing the cerebral, cerebellar, and ventricular volumes based on ICV and using covariance analysis, the study aimed to identify di-fferences in brain volume correlated with gender and age and the precise relationship between each brain volume and the physical indices of height and weight.
Materials and methods Subjects
We selected for this study 162 normal Korean participants (in either their 20s or their 40s) who had no previous brain damage or head injuries and did not have any medical problems, as confirmed by neurologists. Table 1 shows the basic informa-tion on the participants. For the individual groups of males, females, and participants in their twen-ties or in their fortwen-ties, independent t-tests on age, weight, and height showed that there was a signi-ficant difference between males and females with regard to both weight and height and a significant difference between the 2 age groups with regard to both age (as would be expected) and height.
Image acquisition
We conducted MRIs using a 3.0-T FORTE ma-chine (ISOL Technology, Korea), equipped with whole-body gradients and a quadrature head coil, and obtained T1-weighted brain images with a three-dimensional, magnetization-prepared, ra-pid-gradient echo sequence (TR/TE/TI=10/4/100 ms; slice thickness, 1.5 mm; field of view, 220mm×192mm×192 mm; number of slices, 128; slice gap, 0; matrix size, 256×224×128; and num-ber of excitations, 2).
Volumetry
Using Brain Voyager 2000 (Brain Innovation BV, Germany) software, we separated the regions of the cerebrum, cerebellum, and ventricle and me-asured their volumes. After MRI acquisition, we reconstructed each image and performed the post-processing using a Brain Voyager 2000. Note that if there are any irregularities in image brightness along each slice, errors may occur during the au-tomatic segmentation procedure based on image brightness. To prevent this problem, we carried out inhomogeneity corrections, based on the brightness of the white matter, for all axial, sagittal, and
coro-Table 1. Basic information on participants
Male Female Sig. 20s 40s Sig.
Number 70 92 80 82
Age (year) 34.29±13.46 35.02±13.28 .729 21.60±2.36 47.49±3.50 .000
Body Weight (kg) 70.07±9.95 55.64±6.35 .000 60.99±11.45 62.74±10.12 .302
nal planes. We used sigma filtering, which is similar to the standard Gaussian smoothing filter and can remove impulse noise, to increase image contrast. After these two pre-processing routines, we perfor-med a region-growing algorithm, based on image brightness, for automatic segmentation. Finally, one of the authors, who has sufficient neuroanatomical knowledge to process boundary and detailed regi-ons properly, performed manual segmentation. Af-ter measuring the regions of inAf-terest, we calculated the total volume of each region by multiplying the area by the slice thickness to get the volume of each slice and then summing each region's slice volumes.
Finally, we calculated Intracranial Volume (ICV) based on the Talairach Atlas and using Eq. 1 below and the length, width, and height of the cerebrum (10, 18).
ICV(cc)=4/3*π*length/2*width/2*height/2 ... (1) We measured the cerebrum by excluding the cerebellum and brainstem. It was easy to divide the left and right parts of cerebellum in the axial image, and we extracted the cerebellum by exclu-ding the cerebellar peduncles, brainstem, and me-dullary vela regions (12). The ventricular volume was the total volume contained in the lateral ven-tricle, 3rd ventricle, and 4th ventricle (13).
Data analysis
To apply the ANCOVA, which is the data nor-malization method, it is necessary to analyze the relationships among the brain region volumes. When there is a significant relationship among ICV, cerebral, cerebellar, and ventricular raw vo-lumes, ANCOVA can be used. Since there was a significant relationship between the ICV and the other brain volumes, as shown in the results, we could carry out the normalization based on the ICV. In this study, we divided each brain volume into 4 groups (20s age group males, 20s females, 40s males, and 40s females), calculated each gra-dient based on ICV, and used Eq. 2 to normalize the data (14, 19).
Normalized volume = original volume
- grad(ICV - ICV mean) ... (2)
(grad: the gradient of the regression line between the original volume and the intracranial volume)
To investigate the effect of gender and age on ICV and normalized cerebral, cerebellar, and ven-tricular volumes, we employed a two-way analysis of variance (ANOVA), which used gender (2 levels) and age (2 levels) as independent variables, using SPSS software (ver. 12.0). We analyzed the relati-onship between each brain volume and the physical indices using the Pearson correlation method.
Results
The mean ICV for 20s males was 1489.81 ±
107.99cm3; for 20s females, 1337.74 ± 93.49cm3;
for 40s males, 1435.39 ± 83.69cm3; and for 40s
females, 1319.44 ± 76.89cm3 (Table 2). The
rela-tionships between ICV and cerebral, cerebellar, and ventricular volumes were .665, .488, and .206, respectively, which are all positive (Table 3). Since there was a relationship between ICV and these vo-lumes, we give the results, which were normalized by covariance methods, in Table 2. The normali-zed cerebral volume for 20s males was 1362.44 ±
69.54cm3; for 20s females, 1220.74 ± 73.46cm3; for
40s males, 1233.32 ± 73.85cm3; and for 40s
fema-les, 1103.14 ± 75.86cm3. The normalized
cerebe-llar volume for 20s males was 140.42 ± 15.06cm3;
for 20s females, 125.80 ± 10.88cm3; for 40s males,
127.15 ± 9.25cm3; and for 40s females, 116.71 ±
18.42cm3. The normalized ventricular volume for
20s males was 18.35 ± 9.42cm3; for 20s females,
18.75 ± 12.79cm3; for 40s males, 30.57 ± 12.60cm3;
and 40s females, 21.10 ± 6.62cm3.
Males' ICV, cerebral, and cerebellar volumes were significantly greater than those of females, and those of the 20s group was significantly gre-ater than those of the 40s group (Table 4). Howe-ver, there was no interactive effect between age and gender (Fig.1 (a, b, and c)). Males' ventricular volumes were significantly greater than those of females, those of the 40s group were significantly greater than those of the 20s group, and there was an interactive effect between age and gender (Ta-ble 4). There was a siza(Ta-ble increase in ventricular volume as males became older, as compared to fe-males (Fig.1 (d)).
Table 2. The means, the minima, and the maxima of the intracranial and normalized cerebral, cerebe-llar, and ventricular volumes (unit: cm3), by gender and age.
Age Male Female Male + Female
Mean ± S.D. Min. Max. Mean ± S.D. Min. Max. Mean ± S.D. Min. Max.
Intracranial Volume 20s 1489.81±107.99 1277.5 1737.3 1337.74±93.49 1178.1 1627.4 1406.26±125.42 1178.1 1737.3 40s 1435.39±83.69 1262.7 1590.3 1319.44±76.89 1110.1 1487.1 1364.60±97.46 1110.1 1590.3 Total 1463.99±100.41 1262.7 1737.3 1327.91±85.06 1110.1 1627.4 1384.98±113.64 1110.1 1737.3 Cerebral Volume 20s 1362.44±69.54 1235.61 1552.74 1220.74±73.46 1050.19 1413.52 1283.72±100.51 1050.19 1552.74 40s 1233.32±73.85 1100.78 1390.54 1103.14±75.86 914.55 1283.35 1153.68±98.21 1283.35 1390.54 Total 1304.07±96.07 1100.78 1552.74 1160.79±94.94 914.55 1413.52 1220.56±118.63 1050.19 1552.74 Cerebellar Volume 20s 140.42±15.06 105.10 172.15 125.80±10.88 96.12 148.39 132.39±14.79 96.12 172.15 40s 127.15±9.25 103.72 153.35 116.71±18.42 97.37 153.08 120.82±16.24 97.37 153.35 Total 134.12±14.22 103.72 172.15 120.96±15.9 96.12 153.08 126.51±16.55 96.12 172.15 Ventricular Volume 20s 18.35±9.42 10.98 35.92 18.75±12.79 9.32 45.56 18.56±11.27 9.32 45.56 40s 30.57±12.60 7.75 61.93 21.10±6.62 7.74 39.30 24.82±10.46 7.74 61.93 Total 24.13±12.56 7.75 61.93 20.04±9.89 7.74 45.56 21.80±11.27 7.74 61.93
Table 3. The relationships among ICV and cerebral, cerebellar, and ventricular volumes.
Intracranial Volume Cerebral Volume Cerebellar Volume Ventricular Volume
Intracranial Volume 1 .665 (**) .488 (**) .206 (**)
Cerebral Volume 1 .649 (**) -.052
Cerebellar Volume 1 -.056
Ventricular Volume 1
Table 4. Results of intracranial, cerebral, cerebellar, and ventricular volumes from two-way ANOVA using age and gender as independent variables.
Source Type III Sum of Squares df Mean Square F Sig.
Intracranial Volume
Corrected Model 905348.826(a) 3 301782.942 37.014 .000
Age 59661.183 1 59661.183 7.318 .007 Gender 810267.056 1 810267.056 99.381 .000 Age´Gender 14712.767 1 14712.767 1.805 .181 Cerebral Volume Corrected Model 1527508.523(b) 3 509169.508 94.536 .000 Age 643864.025 1 643864.025 119.544 .000 Gender 781957.480 1 781957.480 145.184 .000 Age´Gender 1402.085 1 1402.085 .260 .611 Cerebellar Volume Corrected Model 13445.757(c) 3 4481.919 21.955 .000 Age 5619.876 1 5619.876 27.529 .000 Gender 7057.687 1 7057.687 34.572 .000 Age´Gender 196.703 1 196.703 .964 .328 Ventricular Volume Corrected Model 3596.279(d) 3 1198.760 11.116 .000 Age 2224.988 1 2224.988 20.632 .000 Gender 863.659 1 863.659 8.009 .005 Age´Gender 1022.512 1 1022.512 9.482 .002
- R Squared = .379 (Adjusted R Squared = .369) - R Squared = .624 (Adjusted R Squared = .617) - R Squared = .267 (Adjusted R Squared = .255) - R Squared = .359 (Adjusted R Squared = .213)
Figure 1. Interactive effects between age and gender on (a) ICV (b) cerebral volume (c) cere-bellar volume (d) ventricular volume
Table 5 shows the relationship between the physical indices (weight and height) and ICV and normalized cerebral, cerebellar, and ventricu-lar volumes. For all subjects there was a positi-ve relationship between both the physical indices and ICV and cerebral and cerebellar volume. For males, there was a positive relationship between height and both ICV and cerebral volume. For fe-males, there was a positive relationship between height and cerebral volume. For the 20s group, there was a positive relationship between both the physical indices and ICV and cerebral and cerebe-llar volumes. For the 40s group, there was a posi-tive relationship between both the physical indices and ICV and cerebral and cerebellar volume, as well as a positive relationship between height and ventricular volume.
Table 5. The relationship between the physical indices (weight and height), ICV, and normalized cere-bral, cerebellar, and ventricular volumes and age and gender
All Male Female 20s 40s
Intracranial Volume WeightHeight .421(**).546(**) .309(**) .121 -.079 -.004 .540(**) .547(**) .337(**) .484(**) Cerebral Volume WeightHeight .432(**) .661(**) .426(**) .125 .338(**) -.042 .650(**) .634(**) .498(**) .593(**) Cerebellar Volume WeightHeight .244(**) .406(**) .119 .189 -.175 .158 .380(**) .433(**) .223(*) .234(*) Ventricular Volume WeightHeight .061 .074 -.067 -.205 -.075 -.012 -.106 -.031 .420(**) .201
** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed).
Table 6. Typical published results of the measurements of intracranial, cerebral, cerebellar, and ventri-cular volumes
Age Gender (number) : Volume (cm3)
Intracranial Volume
Duane et al., 1995 16-65 years female (105) : 1335.49~1400.33 male (89) : 1548.91~1594.10
Wilkinson et al., 1997 30s female (19) : 1388±103 male (32) : 1596±136
Nopoulos et al., 2000 20s female (42) : 1351.5±112.8 male (42) : 1490.4±116.7
Edith et al., 2001 40s female (41) : 1234.8 male (51) : 1449
Wolf et al., 2003 70s female (42) : 1408±131male (42) : 1555±110
Kruggel 2006 20s female (145) : 1494.9±96.3 male (145) : 1616.3±91.1
Cerebral Volume
Ruben et al., 1991 18~80 years Female (35) : 1045.79±109.86 male (34) : 1137.36±100.51 Duane et al., 1995 16-65 years female (105) : 1357.84~1508.29 male (89) : 1188.14~1310.99
Wilkinson et al., 1997 30s female (19) : 1228±97 male (32) : 1403±117
Nopoulos et al., 2000 20s female : 1130.3±93.0 male : 1254.1±98.0
Goldstein et al., 2001 30s female (21) : 1021.8±89.5 male (27) : 1113.1±92.5
Eileen et al., 2002 20s female (50) : 1320±0.1 male (50) : 1510±0.4
Kovalev et al., 2003 18-70 years female (76) : 1161±87 male (76) : 1282±93
Kruggel 2006 18-70 years female (145) : R 575.5±40.8 / L 575.4±38.9male (145) : R 625.8±39.3 / L 627.3±39.0
Cerebellar Volume
Nopoulos et al., 2000 20s female (42) : 139.3±14.4 male (42) : 148.9±19.6 Hutchinson et al., 2003 20s female (30) : 137.15±11.28 male (30) : 143.28±12.70
MacLullich et al., 2004 65-70 years male + female (50) : 144.1±15.3
Kruggel 2006 18-70 years female (145) : R 64.7±8.7 / L 66.7±7.4male (145) : R 69.9±9.9 / L 74.2±8.2
Ventricular Volume
Nicholas et al.., 1997 4–20 years (lateral ven-tricular) female (105) : 9.3 male (89) : 10.7 Nopoulos et al., 2000 20s (internal CSF ) female (105) : 34.6 male (89) : 35.3
Good et al., 2001 cluding ventricular and 17-79 years (CSF in-surface sulci)
male (265) : 397 female (200) : 401 Steven et al., 2003 70 s (lateral ventricular) female (42) : 34.6±12.2 male (42) : 35.3±10.5
Discussion
This study measured ICV and normalized ce-rebral, cerebellar, and ventricular volumes for Ko-rean males and females in their 20s and 40s and analyzed the differences in brain volume accor-ding to age, gender, and the physical indices of height and weight.
Table 6 shows typical results of ICV and cere-bral, cerebellar, and ventricular volumes for Western people (1, 2, 4, 5, 6, 8, 10, 16, 17, 20, 21, 22, 23, 24, 25). For younger subjects (20s-30s), ICV for males
ranged between 1490cm3 and 1616cm3, for females,
between 1351cm3 and 1494cm3. Cerebral volume
for males ranged between 1113cm3 and 1510cm3,
for females, between 1021cm3 and 1657cm3.
Ce-rebellar volume for males ranged between 143 cm3
and 148cm3, for females, between 137 cm3 and 139
cm3. Internal CSF volume for males was 35cm3, for
females, 34cm3. For older subjects (40s-70s), ICV
for males ranged between 1449cm3 and 1555cm3,
for females, between 1234cm3 and 1408cm3.
Ce-rebral volume for males ranged between 1137cm3
and 1282cm3, for females, between 1045cm3 and
1161cm3. Cerebellar volume for males was 143cm3,
for females, 130cm3. Lateral ventricular volume for
males was 35cm3, for females, 34cm3. The
norma-lized volumes for this study are shown in Table 2. By comparing published results with the result of this study, based on age and gender (i.e., for people in their 20s and 40s and for males and females), we found our participants' ICV and cerebral and cerebe-llar volumes were similar to or smaller than those of Western people. However, the comparison of ventri-cular volumes was difficult, since ventriventri-cular volu-me showed lots of variation due to volu-measured range. We believe that further study is necessary to analyze differences in brain volume with regard to race.
Published results show that ICV and cerebral, cerebellar, and ventricular volumes are greater for males than for females and that ICV and ce-rebral and cerebellar volumes decrease and ven-tricular volume increases with age (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 20, 21, 22, 23, 24, 25, 26, 27). The corresponding results of this study on Korean people were identical to the published results of age and gender effects for Western people. In this study, there was no interactive age and gender ef-fect on ICV or on cerebral and cerebellar volumes,
but there was an interactive age and gender effect on ventricular volume. This means that, for ma-les, ventricular volume increased with aging more than it did for females. This result agrees with the results of Coffey et al. (1998) and Ruben et al. (1991) but disagrees with the results of Good et al. (2008) and Guttmann et al. (1998). The reason for these gender differences with regard to aging is still unclear and may be due to internal factors (such as sex hormones) and/or external factors (fa-mily circumstances, education, and habits such as smoking and drinking) (13, 28). This issue needs to be explored further.
Studies have reported that age and gender, as well as physical indices such as height, correlate with differences in brain volume (15, 16, 17, 29). Koh et al. (2005) reported that, for males, there was a positive relationship between height and cerebral volume and, for females, there was a po-sitive relationship between height and cerebellar volume. After analyzing the relationship between height and cerebral and cerebellar volumes among 120 males and females in their 20s, Hutchinson et al. (2003) reported a positive relationship between cerebellar volume alone and height. Egan et al. (1995) reported a positive relationship between height and brain volume but not between weight and brain volume. Nopoulos et al. (2000) reported that, for females, there was a positive relationship between cerebral volume and height. As shown here, most of the previous results reported that, even though there was a difference between the genders, there was a significant relationship ove-rall between height and brain volume. Published results by our team showed that, for males, the-re was a positive the-relationship between ventricu-lar volume and height and a positive relationship between cerebellar volume and weight (12, 13). However, such previous results determined the-se relationships using un-normalized brain vo-lumes, since the studies used raw data (12, 13). After normalizing the previous data, we found that, for males, there was a significant relation-ship between both ICV and cerebral volume and height, while, for females, there was a significant relationship between just cerebral volume and he-ight. This study analyzed the relationship between brain volumes and physical indices by separating out gender as well as the age groups. For both the
20s group and the 40s group, there was a positive relationship between ICV and cerebral and cere-bellar volumes and both weight and height. For the 40s group, there was a positive relationship between height and ventricular volume. There was no significant difference between the two age gro-ups with regard to the relationship between brain volume and the physical indices. To find the rela-tionship between brain volumes and the physical indices of height and weight, we used the stepwi-se approach in regression analysis. This showed that, for males, there was a significant relationship between height and ICV; for females, between weight and cerebral volume; and for the 20s gro-up, between weight and cerebral volume. We can conclude there is a close relationship between bra-in volume and height, as well as weight. These fbra-in- fin-dings suggest that overall body weight and height are closely related to, or regulated by, the factors that determine brain volume (30, 31).
Conclusively, this study found ICV and ce-rebral and cerebellar volumes of Korean people were similar to, or smaller than, those of Western people. Differences in brain volume due to age and gender were similar to published results. Even though there was a difference due to age and gen-der, there was a close relationship between brain volume and height, as well as weight. This study provides exact brain volume information for Ko-rean males and females in their 20s and 40s and might give basic information on how age, gender, and physical indices influence on brain volume in Korean people.
Acknowledgements
This work was supported by Konkuk Univer-sity in 2011.
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Corresponding Author Soon-Cheol Chung,
Department of Biomedical Engineering, Research Institute of Biomedical Engineering, College of Biomedical & Health Science, Konkuk University,
Chungju, Chungbuk, South Korea,
Abstract
The primary purpose of this study was to deter-mine differences of patients’ satisfaction after HA-CCP/ISO 22000 implementation in hospital food service. The subjects were 466 patients consisting of 191 males, 275 females from different clinics in one of university hospital. The questionnaire of food and food service satisfaction of patients were filled by intern dietician.Before HACCP/ISO 22000 implementation overall score of patients’ satisfaction was 74.7, after HACCP/ISO 22000 implementation it was increase to 81.3 p=0.000. As like as this result approximately all of indivi-dual scores (organoleptic, menu and service) were increase after HACCP/ISO 22000 implementation p<0.05. HACCP and ISO 22000 implementation is not only for food quality but also improves or-ganoleptic, menu and service specifications and increase overall satisfaction scores of patients.
Key words: HACCP, ISO 22000, patient satis-faction, Food Service
Introduction
The hazard analysis and critical control points (HACCP) is a food safety system which is accep-ted worldwide and developed by Codex Alimenta-rus Commission. HACCP is a preventive approa-ch and it also has some standards and procedures for food services[1]. After all International Orga-nization for Standardization (ISO) was bridging a gap between ISO 9001:2000 and HACCP. This called ISO 22000 and it integrates all procedures of HACCP, good manufacturing practices (GMP) and good hygiene practices (GHP). This standard can be applied with or without independent
certi-fication of conformity. There are lots of benefits for users. Some of them are better using of resour-ces, more effective hazard analyses and at the end better satisfaction of customers [2].
Patient satisfaction is become a critical point in past two decades by which the quality of health care service is evaluated [3-5]. In overall patient satisfaction food service satisfaction sometimes looks like negligible. But many researchers stre-ssed that food service satisfaction has very im-portant role in overall score of patient satisfaction [6-9]. Food-quality components that patients are most concerned with are freshness, taste, tempera-ture, variety, and aroma [10-13].
The studies on satisfaction with food and food service stressed that quality of food service is a co-mmon problem around the world. In general pati-ents say food is not acceptable or they don’t like food service [11, 14]. In this case patients are un-dernourished and maybe recovery duration of them increased. For this reason food service should be seen as an inseparable part of treatment[15]. Main purpose of study is to determine the factors affec-ting satisfaction level of food and food service.
Material Methods
The study is carried in a university hospital which has HACCP and ISO 22000 certificate for food service department. The main criteria for the sample selection are the ability of the patients on evaluating food service quality. For this reason we choose patients from different clinics in hos-pital. After choosing patients we inform them about study and questionnaire filled by last class students of Department of Nutrition and
Dieteti-Patients Satisfaction Level Before and After
HACCP/ISO 22000 Implementations to Food
and Food service in University Hospital, Ankara,
Turkey
Uyar M.F1, Dikmen D1, Kizil M1, Tengilimoglu M1, Bilici S2, Tavaslı A1, Sağlam F1
1 Hacettepe University, Faculty of Health Sciences, Department of Nutriton and Dietetics, Sıhhıye, Ankara,Turkey, 2 Gazi University, Faculty of Health Sciences, Department of Nutriton and Dietetics, Sıhhıye, Ankara,Turkey.
cs at same university. This study was held in two stages. First of all there were 226 participants (78 male, 148 female) before HACCP and ISO 22000 implementation, and there were 240 participants (113 male, 127 female), after implementation who were voluntarily for study.
The questionnaire: consists of 3 parts. In the first section the general characteristics of individuals, the second part the satisfaction state of the service, the third section, the satisfaction state of food were investigated. The second and the third section, on the status of satisfaction of patients to the service and food were asked to score between 1 and 5 po-ints. 1 point very bad, 2 bad points, 3 points, mode-rate, good 4 points, 5 points were assessed as very good. Bulk Nutrition Services component of 3 po-ints or more in question was interpreted as satisfied. The data were analyzed by using Statistical Package for Social Science (SPSS for Windows, version 15.0). The descriptive statistics were used to summarize socio-demographic characteristics of the patients, satisfaction levels, and quality of food services. Bivariate analyses (primarily chi-square test) were used to determine the relation-ship between each satisfaction scores before and after HACCP/ISO 22000 implementation.
Results
Table 1 represents the socio-demographic cha-racteristics of the patients. According to table % 34.5 and % 47.1 patients were male before and after HACCP/ISO 22000 implementation tively. Females were % 65.5 and % 52.9 respec-tively for before and after HACCP/ISO 22000 implementation. Most of total patients (%77) were have high school or less educational level. More than % 60 patients were stay in hospital 1 to 7 days in both genders.
Table 2 shows the patients’ views on hospital food and service before and after HACCP/ISO 22000 implementation. Except viscosity, hygiene, cleanness of fork, spoon, dishes and attitude and behaviors of the serving staff scores there is stati-cally significant differences between other scores.
Table 3 indicate that overall score of pati-ents satisfaction. Although before HACCP/ISO 22000 implementation it is % 74.7, after HACCP/ ISO 22000 implementation increase to % 81.3 p=0.000. Also minimum score of patients satisfac-tion is also increase % 10 to % 20.
Table 1. The socio-demographic characteristics of the patients in the sample of study Before HACCP (n=226) After HACCP (n=240)
Total n % n % Gender Male 78 34.5 113 47.1 191 Female 148 65.5 127 52.9 275 Age <18 39 17.3 13 5.4 52 18-30 43 19.0 30 12.5 73 31-50 72 31.9 77 32.1 149 >51 72 31.9 120 50.0 192 Marriage Status Married 139 61.5 161 67.1 300 Single 87 38.5 79 32.9 166 Education Level
High school or less 176 77.9 183 76.2 359
Higher education 50 22.1 57 23.8 107
Length of Stay
1-7 153 67.7 146 60.8 299
8-14 42 18.6 46 19.2 88
Discussion
In this study we evaluate patients’ satisfaction before and after HACCP/ISO 22000 implemen-tation in hospital food service. According to this study before and after HACCP/ISO 22000 imple-mentation % 49.1 patients were satisfied with taste of food like as Sahin’s study [11]. In contrast more than 60 percent patients satisfied with taste of food according to Simmons research [16]. Approxima-tely % 80 of patients were satisfied with appearan-ce of food before HACCP/ISO 22000 implemen-tation in contrast only % 60 of patients satisfied in Sahin’s study [11]. According to this study more than three quarter patients were satisfied with va-riety of food, in contrast approximately % 60 of patients satisfied in some researches [11, 16].
Some results of this study show that there was a negative relationship with between length of stay and satisfaction score of food and food service. This supported by others [7, 11]. According to this study mean of overall score of patients satisfac-tion is approximately 78 and there is statistically differences between before and after implementa-tion of HACCP/ISO 22000 p<0.01. These results supported by others [13, 17, 18]. In contrast Sahin [11], Aytar [19] and Akoijam [20] found the ove-rall score only 48.7, 50.2 and 24.
Before and after HACCP/ISO 22000 imple-mentation all of satisfaction scores are increased and most of them is statistically significant p<0.05. Maybe the reason for this, these systems makes food service in same standards. Starting from
pur-Table 2. The patients’ views on hospital foods and food services
Before HACCP/ISO 22000 After HACCP/ISO 22000
p
Yes No Uncertain Yes No Uncertain
Aspects n % n % n % n % n % n % Organoleptic Specifications Appearance of food* 179 79.2 33 14.6 14 6.2 220 91.7 7 2.9 13 5.4 0.000 Taste of food* 111 49.1 90 39.8 25 11.1 178 74.2 21 8.8 66 14.2 0.000 Viscosity of food 189 83.6 15 6.6 22 9.7 198 82.5 13 5.4 29 12.1 0.640 Warmth of food 183 81.0 23 10.2 20 8.8 195 81.3 13 5.4 32 13.3 0.064 Hygiene of food 219 96.9 3 1.3 4 1.8 236 98.3 2 0.8 2 0.8 0.582 Freshness of Salads* 161 71.2 59 26.1 6 2.7 187 77.9 18 7.5 35 14.6 0.000 Freshness of Fruit* 217 96.0 6 2.7 3 1.3 217 90.4 9 3.8 14 5.8 0.026 Menu Specifications Amount of food* 162 71.7 51 22.6 13 5.8 219 91.3 14 5.8 7 2.9 0.000 Variability of food* 196 86.7 24 10.6 6 2.7 412 88.4 33 7.1 21 4.5 0.040 Frequency of food* 156 69.0 41 18.1 29 12.8 216 90.0 8 3.3 16 6.7 0.000 Service Specifications Service Shape* 217 96.0 9 4.0 0 0.0 232 96.7 3 1.3 5 2.1 0.018
Cleanness of fork, spoon, and dishes 214 94.7 1 0.4 11 4.9 229 95.4 6 2.5 5 2.1 0.052
Cleanness of staff 226 100.0 0 0.0 0 0.0 240 100.0 0 0.0 0 0.0
Cleanness of wear of staff 226 100.0 0 0.0 0 0.0 240 100.0 0 0.0 0 0.0
Attitude and behaviors of the
serving staff* 210 92.9 6 2.7 10 4.4 233 97.1 1 0.4 6 2.5 0.069
*p<0.05
Table 3. Overall score of patient’s satisfaction before and after HACCP/ISO 22000 implementation Overall score of satisfaction
Mean Std. Dev. Min Max n
Before HACCP/ISO 22000 74.7 21.73 10 100 156
After HACCP/ISO 22000 81.3 14.87 20 100 236
chasing raw materials to the end of service all of stages for food service is being standard quality. Healthy and adequate nutrition is very important in treatment of patients and decreases the length of stay in hospitals. For this reason hospital food and food service must be satisfied patients. According to this research HACCP and ISO 22000 implemen-tation is not only for food quality but also improves organoleptic, menu and service specifications and increase overall satisfaction scores of patients.
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Corresponding Author Fatih M. Uyar, Hacettepe University, Faculty of Health Sciences,
Department of Nutriton and Dietetics, Sıhhıye, Ankara,
Turkey,
Abstract
Having in mind often neglecting and insuffi-cient paying attention to organizational measures concerning providing of proper lighting in work environment, i.e. at workplaces, and in order to understand how and in which way the measures for providing proper lighting in the work envi-ronment can be carried out, this paper deals with assessment of working conditions in relation to the parameter- level of lighting based on the rese-arch in an industrial environment , i.e. the places where the workers were during their work. Level of lighting was measured by an instrument- “Lux” at three work places: cutting-pressing works sec-tion, carpentry works section and the boiler room. Key words: lighting, work environment, in-strument-“Lux”
1. Introduction
Day light is the best lighting for all conditions of one’s life and work due to its diffusion. When the artificial light is being used it should be scree-ned, not glared and as diffused as possible. Light is a part of energy from electromagnetic spectrum
radiation which one can register through eyesight.2
Since our eyesight is very important in all wor-king activities, lighting is a significant factor of working environment as well as a necessary con-dition for conducting work. But from eyesight, inadequate lighting influences also the psycholo-gical state, work productivity and injuries at work. Day light is the best condition for working, but since it is not always achievable it is essential to use an adequate artificial light.
While organizing working places, space posi-tioning in a room it is important to consider the penetrating of direct sunlight into the rooms or work space, preventing the shading of work field by objects or workers as well as preventing the glaring of light and smooth surfaces, prevent the setting of glared shiny surface under the working space except in the case when the working place demands it.3
All working positions must have the greate-st amount of day light as possible and should be equipped with artificial light which must provide adequate lighting in order to accomplish safe and
healthy working conditions.9
2. Lighting
All professional activities involve eyesight. The majority of industrial jobs are done in facto-ries where the use of artificial light is necessary to be used due to limited duration and intensity of day light. According to the definition of the Engi-neering Lighting Society (ELS) the light is “the energy of radiation which is able to awaken the retina and enable the sense of sight“.
On the picture No. 1is presented the relation of color spectrum (and the colors within it) and other spectrums. The picture shows that the wave length of the light spectrum is from 380 to 760
nanome-ters, while the frequency is (3, 5 - 8) 1014 Hz.
The recommendations and standards regarding the necessary lighting level differ among each ot-her on the group of experts who gave the reco-mmendation or the country where the standard is applied.
The Research of Lighting’s Influence on the
Psychological State of Employees in Working
Environment
Zvonko Sajfert1, Carisa Besic2, Aleksandar Damnjanovic3, Stevan Musicki4, Popovic Borko5
1 Technical University “Mihajlo Pupin“, Zrenjanin, University in Novi Sad, Serbia, 2 University in Kragujevac, Technical faculty Cacak, Serbia,
3 The Higher Education School for Business Economy and Entrepreneurship, Belgrade, Serbia, 4 Martial Academy, Belgrade, Serbia,
Picture 1. Electromagnetic spectrum (McCormick) Table 1. The compared model of two standards which are used for determination of the necessary illumination level8
Type German DIN (lx) ELS (lx)
Accurate prefabricated work 1000 3000
Highly accurate work on tool
machines 1000 7500
General office work 500 750
While determining the necessary illumination level the following issues are taken into conside-ration:
1. Employee’s work activity; 2. Employee’s age;
3. Demands regarding the speed and accuracy in conducting tasks; and
4. The reflection of the surface.
When the details which need to be differed are smaller, the higher level of lightening is needed as well as when it comes to older workers whose eyesight ability is reduced. More light is needed also when high speed and accuracy are needed and in case of reduced reflection as well.
2.1. The Quality of Light
A good quality light implies the light sources which contribute to one’s eyesight performances, providing the easiness of watching and work se-curity. In order to fully understand the need for good quality illumination of the work space it is necessary to know that inadequate illumination affects not only the eyesight but also the psycho-logical state of a person which can be manifested through injuries at work and productivity. If it is
possible the work should be conducted under day light, but since it is not always possible to enable these conditions the need for the uses of artificial light arouses.
The constant and equaled light contributes to good quality lighting. The brightness of light de-pends on the activity and work action which is be-ing realized at work places. It also depends on the number of “lux” (the “lux” corresponds the illu-mination of a certain field that the light falls on –a candle strong and a meter distant). The illuminati-on (the size which is the relatiilluminati-on between the light flux and the illuminated surface) of the work place should vary between 40 and 500 “lux” (lx) and up to 2000 lx for conducting a very precise jobs.
The recommended light color is yellow (pro-duced by sodium light bulbs-the middle wave len-gth) because the absorption of yellow is smaller
than of the blue or purple.1
The influence of the light color on the recogni-tion speed, sharpness and precision of eyesight and its influence on work quality are determined by the conducted experiments and the following
arrangement has been done: 4
1. Yellow; 2. Yellow-green; 3. Orange; 4. Green; 5. Red; 6. Blue-green; and 7. Blue.
When choosing the light color it is necessary to do the following:
1. To avoid the use (monochromatic light) at
ordinary work places;1
2. To use white or mixed light for illumination;4
3. To be aware that fluorescent light bulbs are convenient for illumination, since they provide the light which is similar to day light.4
While making the technical documentation in order to provide the necessary level, quality and characteristics of illumination based on domestic regulations and international HASAP standards as well, the technical documentation should contain:
1. Light calculation;
2. The choice of light bulbs which satisfies the demands for illumination and standards for industrial drive ( depending on the production process which is being conducted);
3. The positions of light bulbs ( i.e. joinery work department) and appropriate switches and single pole scheme form connecting selected light bulbs and cabinets;
