Exertional heat stroke-related rhabdomyolysis recurring twice in a 12-year-old boy athlete

Exertional heat stroke (EHS) is a life-threatening entity characterized by elevated core temperature with potential for multiorgan dysfunction. EHS-related rhabdomyolysis usually occurs in the early phase. We report a boy athlete with EHS-related rhabdomyolysis, which recurred 15 and 79 days after the initial event. This case indicates that EHS can cause recurrences of rhabdomyolysis along with persistent symptoms, which could hamper the return to daily activity. Children with EHS, particularly athletes, may be at risk for recurrent rhabdomyolysis.

Primary malignant mucosal melanoma of the maxillofacial area

Objectives@#We aimed to collect and report data from all patients who have been diagnosed with mucosal malignant melanoma to obtain the epidemiology and principles of current treatments. @*Materials and Methods@#Between January 2008 and December 2018, 20 patients underwent surgery or follow-up observations at Yonsei University Dental Hospital. The patients’ clinical information was reviewed retrospectively. @*Results@#Seventeen of 20 patients had undergone definitive surgery, while only 6 patients received adjuvant radiotherapy or systemic therapy. Eight of 20 patients, including those that had recurrent lesions, were provided immunotherapy. The 3-year survival for all stages was 50%, with a local recurrence rate of 75% and a metastasis rate of 65%. @*Conclusion@#The overall survival of patients receiving surgical treatment was longer than that of patients who did not undergo surgical resection.Eight of 20 patients received immunotherapy as the first-line regimen at our clinic, and those patients exhibited longer overall survival compared to patients in reported keynote studies.

Comparative analysis of distance measurement on the rendering screen between dental CAD programs / 대한치과보철학회지

This study was to find out whether the rendering screen difference affect to measuring distance in a CAD program according to three types of CAD programs. Materials and methods: The model presented in ISO 12836 for dental scanner evaluation was reduced by 70%. This model was repeatedly scanned 15times using Trios II (3Shape, Denmark). Using the output STL file, 3Shape CAD, inLab 15, and ExoCAD programs were used to measure the horizontal distance (H) and vertical distance (V) between adjacent point angle, and for each experiment, three groups were set according to the CAD program type. Statistical analysis was performed using One-way ANOVA test and post hoc was performed using Dunnett T3 test. Results: In the horizontal and vertical distance measurement, there was no difference in the average of the measured values between the three groups according to the CAD program (P>.05). Conclusion: There were no effect of the difference in the rendering screen in the horizontal and vertical linear distance measurements of the inlay model on the dental CAD program.

Long Term Follow-Up of Metabolic Syndrome in Patients with Severe Mental Illness among Korean Population : A 10-Year Follow-Up Study (2011-2020) / 생물치료정신의학

Objectives@#：This study was aimed to investigate the changes in metabolic syndrome (MetS) status and long-term impact of its components over a 10-year period in severe mental illness (SMI) patients in a national mental hospital. @*Methods@#：A total of 93 patients (schizophrenia=88, bipolar disorder=5) who met the diagnosis of Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) and participated in the MetS study in 2011 were included. MetS was defined by revised National Cholesterol Education Program-Adult Treatment Panel III (revised NCEP-ATP-III) guidelines. @*Results@#：The prevalence of MetS was significantly increased from 40.9% in 2011 to 60.2% in 2020. There were significant differences in admission status and hospitalization months, compared to the groups with and without MetS. Upon reviewing the changes over a decade, systolic blood pressure (SBP) was a significant factor in the group without MetS. In the group with MetS, SBP, waist circumference, and BMI (body mass index) were significant factors. Multiple logistic regression analysis revealed that hospitalization during follow-up periods [odds ratio (OR)=0.969, 95% confidence interval (CI): 0.948-0.991] and BMI (OR=1.426, 95% CI: 1.196-1.701) were significantly associated with MetS in subjects. @*Conclusion@#：The prevalence of MetS in patients with SMI significantly increased over time. The admission status and hospitalization were also confirmed to be the significant values of MetS.

Appropriate follow-up period for odontogenic keratocyst: a retrospective study / 대한악안면성형재건외과학회지

Purpose@#The aim of this study was to conduct epidemiologic investigations on the pattern of the lesion and differences between treatment modalities in terms of recurrence by reviewing follow-up records to form a basis for planning patient follow-up visits. @*Materials and methods@#In this retrospective, single-center cohort study, 266 patients diagnosed with odontogenic keratocyst between 1993 and 2013 were included. Medical records and radiographic images were analyzed for age distribution, occurrence site and size, treatment modalities, and recurrence. @*Results@#The average age at first diagnosis was 33.1 years, and the male to female ratio was 1.33:1.00. The highest rate of incidence was in the third decade followed by the fourth, second, and fifth decades. The incidence in the maxilla was 34%, and 66% in the mandible. Mandibular ramus was most commonly involved. Lesions between 3 and 6 crowns were the most common, and the rate of recurrence increased with size. Enucleation after decompression had higher rate of recurrence (35.8%) than enucleation (27.1%), but there was no statistical significance. @*Conclusion@#The recurrence of odontogenic kerotocyst (OKC) was significantly associated with large size, multilocular form, and surgical procedure. A 10-year follow-up period is recommended to determine any recurrence of OKC.

Primary malignant mucosal melanoma of the maxillofacial area

Objectives@#We aimed to collect and report data from all patients who have been diagnosed with mucosal malignant melanoma to obtain the epidemiology and principles of current treatments. @*Materials and Methods@#Between January 2008 and December 2018, 20 patients underwent surgery or follow-up observations at Yonsei University Dental Hospital. The patients’ clinical information was reviewed retrospectively. @*Results@#Seventeen of 20 patients had undergone definitive surgery, while only 6 patients received adjuvant radiotherapy or systemic therapy. Eight of 20 patients, including those that had recurrent lesions, were provided immunotherapy. The 3-year survival for all stages was 50%, with a local recurrence rate of 75% and a metastasis rate of 65%. @*Conclusion@#The overall survival of patients receiving surgical treatment was longer than that of patients who did not undergo surgical resection.Eight of 20 patients received immunotherapy as the first-line regimen at our clinic, and those patients exhibited longer overall survival compared to patients in reported keynote studies.

The Role of PI3K/AKT Pathway and NADPH Oxidase 4 in Host ROS Manipulation by Toxoplasma gondii

Dendritic cell is one of the first innate immune cell to encounter T. gondii after the parasite crosses the host intestinal epithelium. T. gondii requires intact DC as a carrier to infiltrate into host central nervous system (CNS) without being detected or eliminated by host defense system. The mechanism by which T. gondii avoids innate immune defense of host cell, especially in the dendritic cell is unknown. Therefore, we examined the role of host PI3K/AKT signaling pathway activation by T. gondii in dendritic cell. T. gondii infection or T. gondii excretory/secretory antigen (TgESA) treatment to the murine dendritic cell line DC2.4 induced AKT phosphorylation, and treatment of PI3K inhibitors effectively suppressed the T. gondii proliferation but had no effect on infection rate or invasion rate. Furthermore, it is found that T. gondii or TgESA can reduce H2O2-induced intracellular reactive oxygen species (ROS) as well as host endogenous ROS via PI3K/AKT pathway activation. While searching for the main source of the ROS, we found that NADPH oxidase 4 (NOX4) expression was controlled by T. gondii infection or TgESA treatment, which is in correlation with previous observation of the ROS reduction by identical treatments. These findings suggest that the manipulation of the host PI3K/AKT signaling pathway and NOX4 expression is an essential mechanism for the down-regulation of ROS, and therefore, for the survival and the proliferation of T. gondii.

Role of Intestinal Microbiota in Metabolism of Voglibose In Vitro and In Vivo

BackgroundVoglibose, an α-glucosidase inhibitor, inhibits breakdown of complex carbohydrates into simple sugar units in intestine. Studies showed that voglibose metabolism in the liver might be negligible due to its poor intestinal absorption. Numerous microorganisms live in intestine and have several roles in metabolism and detoxification of various xenobiotics. Due to the limited information, the possible metabolism of voglibose by intestinal microbiota was investigated in vitro and in vivo.MethodsFor the in vitro study, different concentrations of voglibose were incubated with intestinal contents, prepared from both vehicle- and antibiotics-treated mice, to determine the decreased amount of voglibose over time by using liquid chromatography-mass spectrometry. Similarly, in vivo pharmacodynamic effect of voglibose was determined following the administration of voglibose and starch in vehicle- and antibiotic-pretreated non-diabetic and diabetic mice, by measuring the modulatory effects of voglibose on blood glucose levels.ResultsThe in vitro results indicated that the remaining voglibose could be significantly decreased when incubated with the intestinal contents from normal mice compared to those from antibiotic-treated mice, which had less enzyme activities. The in vivo results showed that the antibiotic pretreatment resulted in reduced metabolism of voglibose. This significantly lowered blood glucose levels in antibiotic-pretreated mice compared to the control animals.ConclusionThe present results indicate that voglibose would be metabolized by the intestinal microbiota, and that this metabolism might be pharmacodynamically critical in lowering blood glucose levels in mice.

Spatiotemporal expression of RCAN1 and its isoform RCAN1-4 in the mouse hippocampus after pilocarpine-induced status epilepticus

Regulator of calcineurin 1 (RCAN1) can be induced by an intracellular calcium increase and oxidative stress, which are characteristic features of temporal lobe epilepsy. Thus, we investigated the spatiotemporal expression and cellular localization of RCAN1 protein and mRNA in the mouse hippocampus after pilocarpine-induced status epilepticus (SE). Male C57BL/6 mice were given pilocarpine hydrochloride (280 mg/kg, i.p.) and allowed to develop 2 h of SE. Then the animals were given diazepam (10 mg/kg, i.p.) to stop the seizures and sacrificed at 1, 3, 7, 14, or 28 day after SE. Cresyl violet staining showed that pilocarpine-induced SE resulted in cell death in the CA1 and CA3 subfields of the hippocampus from 3 day after SE. RCAN1 immunoreactivity showed that RCAN1 was mainly expressed in neurons in the shammanipulated hippocampi. At 1 day after SE, RCAN1 expression became detected in hippocampal neuropils. However, RCAN1 signals were markedly enhanced in cells with stellate morphology at 3 and 7 day after SE, which were confirmed to be reactive astrocytes, but not microglia by double immunofluorescence. In addition, real-time reverse transcriptase–polymerase chain reaction showed a significant upregulation of RCAN1 isoform 4 (RCAN1-4) mRNA in the SE-induced hippocampi. Finally, in situ hybridization with immunohistochemistry revealed astrocytic expression of RCAN1-4 after SE. These results demonstrate astrocytic upregulation of RCAN1 and RCAN1-4 in the mouse hippocampus in the acute and subacute phases of epileptogenesis, providing foundational information for the potential role of RCAN1 in reactive astrocytes during epileptogenesis.

Developmental Outcome of Very-Low-Birth-Weight Infants without Major Brain Injuries Based on Data from the Korean Neonatal Network: A Nationwide Cohort Study

Purpose@#As preterm infants have shown advances in survival rate, many very-lowbirth-weight (VLBW) infants have shown developmental delay even without a major brain injury. Thus, the incidence of and risk factors associated with poor neurodevelopmental outcome should be evaluated. @*Methods@#A multicenter nationwide prospective longitudinal cohort study of VLBW infants born in South Korea between 2013 and 2015 was conducted. Poor neurodevelopmental outcome was diagnosed if the Bayley Scales of Infant and Toddler Development (BSID)-III composite score was ≤85 (cognition, language, motor). We analyzed the associations of baseline neonatal characteristics, environmental characteristics and neonatal morbidities with poor neurodevelopmental outcome. @*Results@#The study included 285 infants, of whom 34 (11.9%) exhibited cognition delay; 59 (20.7%), showed language delay and 32 (11.2%) showed motor delay. The mean gestational age and birth weight were 29 weeks and 1,130 g, respectively. Moderate and severe bronchopulmonary dysplasia (P=0.056) and intraventricular hemorrhage grade I (P=0.079) were marginally associated with cognition delay. Higher paternal educational level (P<0.05) was significantly associated with the language outcome. Birth weight (P<0.05) and head circumference at discharge (P<0.05) were the major predictors of motor delay. @*Conclusion@#The population-based nationwide cohort study shows that approximately 20% of VLBW infants without major brain injury have developmental delay. Several factors that are not directly associated with major brain injury were significantly associated with poor neurodevelopmental outcome.

Factors Associated with Resilience in School-Aged Adolescents / 생물치료정신의학

Objectives@#：The aim of this study was to examine socio-demographic variables and the correlation of their factors and mental health with resilience in adolescents. @*Methods@#：Participants were 4,325 middle and high school students living in Jeollanam-do, South Korea. Participants completed self-report questionnaires examining socio-demographic characteristics and including the following self-rating scales: the resilience test, the adolescent mental health and problem behavior screening questionnaire-II (AMPQ-II). @*Results@#：The resilience test scores were positively correlated with the adolescent mental health and problem behavior screening questionnaire-II scores (p<0.001). In multiple regression analysis, below average academic achievement (OR 4.05, 95%CI 2.62-6.27, p<0.001), perceived poor relationship with parents (OR 2.91, 95%CI 2.28-3.71, p<0.001), body dissatisfaction (OR 2.09, 95%CI 1.57-2.79, p<0.001), middle school students (OR 2.02, 95%CI 1.59-2.56, p<0.001), male (OR 1.95, 95%CI 1.55-2.46, p<0.001), low socioeconomic status (OR 1.68, 95%CI 1.11-2.52, p=0.014), low maternal education level (OR 1.64, 95%CI 1.09-2.48, p=0.018) showed significant negative correlation with resilience. @*Conclusion@#：Resilience needs to be considered to promote mental health of adolescents. Specifically, interventions providing psychological support should target adolescents with factors correlated low resilience

Actigraphic Measurement of Sleep Quality and Physical Activity of Schizophrenic Inpatients with Metabolic Syndrome / 생물치료정신의학

Objectives@#：The authors examined the association of sleep quality and metabolic syndrome (MetS) in schizophrenic patients using actigraphy. @*Methods@#：A total of 101 schizophrenic patients were included in this study. Fifty-four (53.4%) patients met the criteria of MetS. Self-assessment of subjective sleep quality, daytime sleepiness, physical activities were measured using Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and International Physical Activity Questionnaire (IPAQ), respectively. Objective sleep quality and physical activity were measured by Actigraph (ActiGraph wGT3X-BT). @*Results@#：Total time in bed (TIB) (p=0.032), sleep latency (SL) (p=0.001), wake after sleep onset (WASO) (p<0.001) and average awakening (p=0.015) were significantly longer in patients with MetS than those of non-MetS. Results of multiple logistic regression showed that long sleep latency (OR 7.876, 95% CI 1.519, p=0.014) and low sleep efficiency (OR 9.902, 95% CI 1.111, p=0.040) were high risk factors for MetS. @*Conclusion@#：This was the first study to find the correlations of sleep quality and MetS in schizophrenic patients by objective sleep measurements. Although long sleep latency and low sleep efficiency were associated with MetS in patients with schizophrenia, more extensive and complicated designed studies may be needed to the association of MetS and sleep problems in schizophrenic patients.

Developmental Outcome of Very-Low-Birth-Weight Infants without Major Brain Injuries Based on Data from the Korean Neonatal Network: A Nationwide Cohort Study

Purpose@#As preterm infants have shown advances in survival rate, many very-lowbirth-weight (VLBW) infants have shown developmental delay even without a major brain injury. Thus, the incidence of and risk factors associated with poor neurodevelopmental outcome should be evaluated. @*Methods@#A multicenter nationwide prospective longitudinal cohort study of VLBW infants born in South Korea between 2013 and 2015 was conducted. Poor neurodevelopmental outcome was diagnosed if the Bayley Scales of Infant and Toddler Development (BSID)-III composite score was ≤85 (cognition, language, motor). We analyzed the associations of baseline neonatal characteristics, environmental characteristics and neonatal morbidities with poor neurodevelopmental outcome. @*Results@#The study included 285 infants, of whom 34 (11.9%) exhibited cognition delay; 59 (20.7%), showed language delay and 32 (11.2%) showed motor delay. The mean gestational age and birth weight were 29 weeks and 1,130 g, respectively. Moderate and severe bronchopulmonary dysplasia (P=0.056) and intraventricular hemorrhage grade I (P=0.079) were marginally associated with cognition delay. Higher paternal educational level (P<0.05) was significantly associated with the language outcome. Birth weight (P<0.05) and head circumference at discharge (P<0.05) were the major predictors of motor delay. @*Conclusion@#The population-based nationwide cohort study shows that approximately 20% of VLBW infants without major brain injury have developmental delay. Several factors that are not directly associated with major brain injury were significantly associated with poor neurodevelopmental outcome.

Factors Associated with Resilience in School-Aged Adolescents / 생물치료정신의학

Objectives@#：The aim of this study was to examine socio-demographic variables and the correlation of their factors and mental health with resilience in adolescents. @*Methods@#：Participants were 4,325 middle and high school students living in Jeollanam-do, South Korea. Participants completed self-report questionnaires examining socio-demographic characteristics and including the following self-rating scales: the resilience test, the adolescent mental health and problem behavior screening questionnaire-II (AMPQ-II). @*Results@#：The resilience test scores were positively correlated with the adolescent mental health and problem behavior screening questionnaire-II scores (p<0.001). In multiple regression analysis, below average academic achievement (OR 4.05, 95%CI 2.62-6.27, p<0.001), perceived poor relationship with parents (OR 2.91, 95%CI 2.28-3.71, p<0.001), body dissatisfaction (OR 2.09, 95%CI 1.57-2.79, p<0.001), middle school students (OR 2.02, 95%CI 1.59-2.56, p<0.001), male (OR 1.95, 95%CI 1.55-2.46, p<0.001), low socioeconomic status (OR 1.68, 95%CI 1.11-2.52, p=0.014), low maternal education level (OR 1.64, 95%CI 1.09-2.48, p=0.018) showed significant negative correlation with resilience. @*Conclusion@#：Resilience needs to be considered to promote mental health of adolescents. Specifically, interventions providing psychological support should target adolescents with factors correlated low resilience

Actigraphic Measurement of Sleep Quality and Physical Activity of Schizophrenic Inpatients with Metabolic Syndrome / 생물치료정신의학

Objectives@#：The authors examined the association of sleep quality and metabolic syndrome (MetS) in schizophrenic patients using actigraphy. @*Methods@#：A total of 101 schizophrenic patients were included in this study. Fifty-four (53.4%) patients met the criteria of MetS. Self-assessment of subjective sleep quality, daytime sleepiness, physical activities were measured using Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and International Physical Activity Questionnaire (IPAQ), respectively. Objective sleep quality and physical activity were measured by Actigraph (ActiGraph wGT3X-BT). @*Results@#：Total time in bed (TIB) (p=0.032), sleep latency (SL) (p=0.001), wake after sleep onset (WASO) (p<0.001) and average awakening (p=0.015) were significantly longer in patients with MetS than those of non-MetS. Results of multiple logistic regression showed that long sleep latency (OR 7.876, 95% CI 1.519, p=0.014) and low sleep efficiency (OR 9.902, 95% CI 1.111, p=0.040) were high risk factors for MetS. @*Conclusion@#：This was the first study to find the correlations of sleep quality and MetS in schizophrenic patients by objective sleep measurements. Although long sleep latency and low sleep efficiency were associated with MetS in patients with schizophrenia, more extensive and complicated designed studies may be needed to the association of MetS and sleep problems in schizophrenic patients.

Role of Intestinal Microbiota in Metabolism of Voglibose In Vitro and In Vivo

BackgroundVoglibose, an α-glucosidase inhibitor, inhibits breakdown of complex carbohydrates into simple sugar units in intestine. Studies showed that voglibose metabolism in the liver might be negligible due to its poor intestinal absorption. Numerous microorganisms live in intestine and have several roles in metabolism and detoxification of various xenobiotics. Due to the limited information, the possible metabolism of voglibose by intestinal microbiota was investigated in vitro and in vivo.MethodsFor the in vitro study, different concentrations of voglibose were incubated with intestinal contents, prepared from both vehicle- and antibiotics-treated mice, to determine the decreased amount of voglibose over time by using liquid chromatography-mass spectrometry. Similarly, in vivo pharmacodynamic effect of voglibose was determined following the administration of voglibose and starch in vehicle- and antibiotic-pretreated non-diabetic and diabetic mice, by measuring the modulatory effects of voglibose on blood glucose levels.ResultsThe in vitro results indicated that the remaining voglibose could be significantly decreased when incubated with the intestinal contents from normal mice compared to those from antibiotic-treated mice, which had less enzyme activities. The in vivo results showed that the antibiotic pretreatment resulted in reduced metabolism of voglibose. This significantly lowered blood glucose levels in antibiotic-pretreated mice compared to the control animals.ConclusionThe present results indicate that voglibose would be metabolized by the intestinal microbiota, and that this metabolism might be pharmacodynamically critical in lowering blood glucose levels in mice.

A rare case of ovarian vein thrombosis in a gestational trophoblastic neoplasia patient

Ovarian vein thrombosis (OVT) is a rare disease with complications that can be life-threatening. An ovarian vein thrombus in a gestational trophoblastic neoplasia (GTN) is an extremely rare condition that has not been previously reported in the literature. We report the case of a 23-year-old woman who presented with symptoms of amenorrhea for 15 weeks and 6 days along with intermittent lower abdominal pain. She was diagnosed with a hydatidiform mole, and a metastatic workup was scheduled. Abdominal computed tomography showed a right ovarian vein thrombus. She received methotrexate chemotherapy combined with oral anticoagulants. Complete radiological remission was obtained. During the 12-month follow-up period, no disease progression or recurrence was noted. Early recognition and detection of the condition are of the utmost importance. The differential diagnosis of OVT must be considered when there is unexplained abdominal pain, fever, and leukocytosis during the diagnosis and treatment of GTN. A high level of suspicion is required for prompt diagnosis of OVT.

Erratum: Addition of a Co-Author: Etiology of Invasive Bacterial Infections in Immunocompetent Children in Korea (2006–2010): a Retrospective Multicenter Study

The authors regret that one co-author (Kyung-Hyo Kim) was missing in the article.

High antistreptolysin O titer is associated with coronary artery lesions in patients with Kawasaki disease / 소아과

PURPOSE: In Kawasaki disease (KD) patients, coronary artery complications, incomplete and refractory types occur more frequently in patients with streptococcal or other bacterial/viral infections. Recently, we observed a higher incidence of coronary lesions in KD patients with high anti-streptolysin O (ASO) titer. Therefore, we hypothesized that KD patients diagnosed with concurrent streptococcal infection have poor prognoses, with respect to treatment response and development of coronary artery lesions. METHODS: A retrospective review was performed in 723 patients with KD who were admitted to 2 major hospitals between June 2010 and September 2017. RESULTS: Among 723 patients with KD, 11 initially showed an elevated ASO titer (>320 IU/mL) or elevated follow-up ASO titer after treatment. Of these patients, 5 showed no response to the first intravenous immunoglobulin treatment, 3 had abnormalities of the coronary arteries. This is a significantly higher proportion of patients with a high ASO titer (n=3, 27.3%) than those with a normal ASO titer (n=53 [7.4%], P=0.047). A severe clinical course was seen in 81.8% of patients in the high ASO group versus 14.5% of patients in the normal ASO group. CONCLUSION: It is not certain whether acute streptococcal infection may cause KD, but this study revealed that KD with high ASO titers showed higher rates of severe clinical course. It may be helpful to analyze concurrent streptococcal infection in patients with a severe clinical course.

Connected in cinema: educational effects of filmmaking classes on medical students / 한국의학교육

PURPOSE: The purpose of this study is to explore what the students experienced in short filmmaking class performed to 1st grade premedical students of a medical school, and to trace educational effects of the class. METHODS: Taking a qualitative approach, the authors used semi-structured interviews to collect the data. This study employed the quota sampling method to purposefully select students to interview. Data coding and analysis were performed based on the grounded theory. The filmmaking experiences consistently described by the interviewees were labeled and reorganized into categories through the open, axial, and selective coding. RESULTS: The students experience the group filmmaking class as a participatory class. Learners also experienced the procedure of performing complicated group tasks according to detailed and scheduled processes. Participation leads to collaboration. Collaboration here is through communication and participation, not through mechanical cooperation. Students also experience various dimensions of communication. The students learned that successful performance of the group filmmaking process is enabled through consideration towards others, and experience a sense of connectedness resulting in a type of community spirit. Having fun and interest, finally, the students experience the sense of accomplishment and sharing through joint screening. CONCLUSION: Students' shared experiences and their education effects of the filmmaking class can be explained in terms of the above mentioned seven closely intertwined categories. In this class, the students were able to express emotions they would not normally express. Through this, the students were able to find the true character and new aspects of their fellow students, forming intimacy, which led to a sense of belonging and connectedness.