A whole-body bone scan (WBBS) may aid the detection of missed skeletal injuries, but the current level of research in this regard is insufficient. Thus, this study aimed to investigate whether a WBBS is useful for the detection of missed skeletal injuries in patients with multiple traumas. (2) Methods: This retrospective, single-region, trauma center study was conducted at a tertiary referral center from January 2015 to May 2019. The rate of missed skeletal injuries detected via WBBSs was evaluated, and factors that could influence the outcome were analyzed and divided into missed and not-missed groups. (3) Results: A total of 1658 patients with multiple traumas who underwent WBBSs were reviewed. In the missed group, the percentage of cases with an Injury Severity Score (ISS) ≥ 16 was higher than the not-missed group (74.66% vs. 45.50%). The rate of admission route through surgery and embolization was high in the missed group. Moreover, the proportion of patients that experienced shock in the missed group was higher than that in the not-missed group (19.86% vs. 3.51%). In univariate analysis, ISS ≥ 16, admission route through surgery and embolization, orthopedic surgery involvement, and shock were related to missed skeletal injuries. ISS ≥ 16 was determined to be statistically significant in multivariate analysis. Additionally, a nomogram was constructed based on multivariable analysis. (4) Conclusions: Missed skeletal injuries were significantly associated with several statistical factors, and a WBBS can be used as a screening method to detect missed skeletal injuries in patients with multiple blunt traumas. Skeletal injuries may be missed in patients presenting with multiple traumas during an initial assessment. To avoid missing injuries, the Advanced Trauma in Life Support course proposes the implementation of a head-to-toe secondary survey after the primary survey for life-threatening injuries . MoreoveA whole-body bone scan (WBBS), a functional imaging modality used to detect metastatic bone tumors, metabolic bone disease, traumatic injuries, and inflammation, might aid the detection of skeletal injuries that may be missed in multiple-trauma patients during an initial evaluation . HoweverIn this study, by reviewing data of patients who had undergone WBBSs at a regional trauma center in a tertiary referral center, we aimed to investigate the usefulness of WBBSs for the detection of missed skeletal injuries and evaluate the factors related to these injuries. The hypothesis of the study was that a WBBS might help detect missed skeletal injuries in multiple-trauma patients.This study was a retrospective, single-region, trauma center study conducted at a tertiary referral center in South Korea from January 2015 to May 2019. This study was approved by the Institutional Review Board (CR319105) and registered in a Clinical Research Information System that is affiliated with the World Health Organization’s International Clinical Trials Registry Platform (KCT0004371).During the study period, we reviewed data of patients with multiple traumas who underwent WBBS and divided them into two groups (missed injury group and non-missed injury group) based on the presence or absence of missed diagnoses. The initial diagnoses were made using plain radiography, ultrasonography, and computed tomography (CT) to examine the regions of interest based on patients’ symptoms and physical examinations. If a patient complained of pain or had confirmed injuries in two or more areas of the body, including their internal organs, they were classified as a multiple-trauma patient. The following factors were collected and reviewed: patient’s basic clinical information; Injury Severity Score (ISS); Glasgow Coma Scale (GCS) score; the admission department in which the patient was received, and the duration from admission to evaluation of WBBS; admission route; intensive care unit (ICU); ward; surgery; and embolization. Moreover, deployment of the trauma team (yes or no), involvement of the department of orthopedic surgery (OS) (yes or no), shock state, mechanism of injury, and WBBS results were also reviewed. In addition, we compared and analyzed the incidence of missed skeletal injuries by trauma site and vector and identified additional treatments for missed injuries. Damaged areas were categorized into the face, chest, upper extremity, lower extremity, and spine. Trauma vectors were classified as passenger traffic accident (TA), motorcycle TA, pedestrian TA, workplace accident, fall, and others. Additional types of treatment were classified as surgery, pain control, and immobilization.A trauma team is a group of medical staff that remains at a regional trauma center for 24 h, mimicking the US level 1 trauma center. In this study, the trauma team was composed of experts in general surgery, thoracic surgery, and emergency medicine. Depending on the condition of the severe trauma patients, the mechanism of injury, and emergency ultrasonography results, the trauma team was deployed, and the trauma team’s staff began to treat the patient promptly.After the trauma team has been deployed and the initial assessment of trauma patients has been completed, the process proceeds to the next step, acting as a definite management plan. The patients were hospitalized for nonoperative or surgical treatment or angiographic embolization. Cases of nonoperative treatment were divided into ICU and ward. We referred to these “treatments as the next step” as the admission route.As part of the follow-up plan for multiple-trauma patients, the WBBS did not have an institution-specific protocol; instead, a protocol was conducted at the discretion of the attending physician. The WBBS was performed using Tc-99m methylene diphosphonate (20 mCi) at an average of 10 days (3–21 days) after admission. Images of the regions of interest on WBBS were read by an experienced nuclear medicine physician. Hot-uptake areas in the WBBS were regarded as injured sites and finally diagnosed after additional examinations (such as X-ray or CT scans). During this process, non-active skeletal damage, such as arthritis or old fracture lesions, were classified into the non-missed injury group.t-test was used for continuous variables, which was based on the normality assumptions derived from the Shapiro–Wilk test. Additionally, chi-square test or Fisher’s exact test were used to compare categorical variables. Univariate and multivariable logistic regression analyses were used to test the association between missed injuries and sex, age, admission department, ISS, GCS, duration from admission to evaluation of the WBBS, admission route, trauma team deployment, OS involvement, shock, and mechanism of injury. The Hosmer and Lemeshow goodness-of-fit test was used to assess the suitability of the models. The discrimination of the model was measured using the concordance index. Analyses were performed using the SAS program  and the R Statistical Package .To compare the characteristics of multiple-trauma patients who had missed skeletal injuries and those who did not, the two-sample p < 0.001). The rate of admission through surgery and embolization was high in the missed injury group, and a significant difference was found between the two groups (p < 0.001). In addition, the proportion of patients with shock was 19.86%, which was higher in the missed injury group than in the not-missed injury group (p < 0.001). A significant difference in OS involvement was also noted between the two groups (p = 0.004)  .The most common injury sites in the missed injury group were the chest  followed by the upper and lower extremities. Analysis of the treatment pattern in the missed injury group revealed pain control in 104 (71.23%), immobilization in 23 (15.75%), and surgery in 19 (13.01%) patients. As a result of the analysis of the treatment method according to the identified fracture sites, it was determined that pain control was performed for the chest of all patients, surgery was performed most frequently in the upper extremities, and immobilization was performed for the lower extremities .As determined through the analysis of the risk of missing a skeletal injury according to clinical characteristics, the odds ratio (OR) was 3.53 times higher , 2.40–5.19) in patients with an ISS ≥ 16 than in patients with an ISS < 16. In addition, compared to hospitalization through the intensive care unit, the OR of missed injuries was 1.95 times higher  in surgery cases and 4.54 times higher  in embolization cases. Moreover, the OR of missed skeletal injuries for patients without OS involvement was 1.66 times higher  than it was for those with OS involvement, while the OR of shock patients was 6.82 times higher  than those that did not experience shock. The OR for missed skeletal injuries in patients with an ISS ≥ 16, even after adjustment for sex, age, admission route, OS involvement, shock, and mechanism of injury, was 3.98 times higher  than that in patients with ISS < 16 .p-values of the Hosmer–Lemeshow Goodness-of-Fit test were >0.05 for the model, indicating that it was suitable. The discrimination ability of the model, measured using the concordance index, was equal to the area under the receiver operating characteristic curve , and the corresponding treatment was different depending on the lesion. In particular, surgery was performed on 13.01% of patients in the missed skeletal injury group. Third, the OR of missed skeletal injuries detected via a WBBS was high in patients with moderate to severe multiple trauma (ISS ≥ 16).In multiple-trauma patients, the reported incidence of missed injuries varies. Tammelin et al. reported an incidence of 2.7% , while LThe present study was conducted to determine the usefulness of a WBBS as a screening test for missed skeletal injuries in multiple-trauma patients. A bone scan is more sensitive than radiography with respect to detecting bone lesions as it uses physiologic bone changes for imaging . Our resIn previous studies, rib fractures were identified in up to 56% of cases of multiple trauma ,13,14,15Many previous studies have demonstrated that a higher ISS has a significant relationship with missed injuries in trauma patients ,18,19,20Understanding the mechanism of trauma is necessary to obtain valuable clues for the diagnosis of missed injuries in trauma patients. Fitschen-Oestern et al. reported that missed foot injuries were common among patients who were involved in car accidents or patients who fell from a great height . FurnivaHensgens et al. have reported the missed injury rate after the inter-hospital transfer of severely injured trauma patients . They meThe nomogram derived from our study was verified through its calibration plot . Among tAnother method of minimizing missed injuries is the use of a trauma tertiary survey . AccordiThis study has several limitations. First, this study potentially suffered from selection bias because it is not a randomized retrospective analysis performed by a single institution. Second, our study population was not large enough to generalize the results. Third, since this study was conducted using the Korean single-region trauma center’s trauma team deployment criteria, WBBS protocol, and insurance criteria, the results of this study may have limited ability to be generalized to other institutions or countries. Fourth, we exclusively focused on skeletal injuries and did not consider missed injuries other than bone damage, which can lead to different results and misinterpretations that might not be present in other studies that address missed injuries. Therefore, our findings should not be generalized to other trauma patients, and systemic multicenter randomized prospective trials are needed to validate our findings. However, despite these limitations, this study could be the impetus for further research in the field of trauma and may help cast the use of a WBBS in a more positive light.In conclusion, missed skeletal injuries were significantly associated with several statistical factors, and a WBBS is a screening method that can detect missed skeletal injuries in patients with multiple traumas. Furthermore, systemic multicenter prospective studies are needed to confirm the efficiency and validity of WBBSs.


This study aimed to elucidate the impact of media trust on epidemic prevention motivation and behaviors based on the Protection Motivation Theory (PMT) and to evaluate the moderation effect of personal epidemic experience, which focused on the differences in two groups with or without epidemic experience.The exogenous constructs and PMT model and scale were constructed through literature analysis, and a web-based questionnaire survey was conducted among 428 individuals aged above 18 years in China. Statistical analysis and hypothesis testing were performed in SPSS 26 and SmartPLS 3.p-value < 0.001), followed by social media , and interpersonal communication . Media trust was positively and significantly related to both threat appraisal  and coping appraisal . Threat appraisal  and coping appraisal  were positively and significantly related to epidemic prevention motivation, which positively and significantly related to epidemic prevention behaviors . The R2 values of epidemic prevention motivation and behavior are 0.350 and 0.240, respectively, indicating an acceptable explanation. Multiple-group analysis revealed five significant differences in paths between the two groups, indicating personal epidemic experience acting as a slight moderator on these paths.Traditional media trust accounted for the largest weight in media trust (w = 0.492, Traditional media trust and social media trust were the important elements in COVID-19 prevention and control, and public health departments and governments should ensure the accuracy and reliability of information from traditional and social media. Simultaneously, the media should balance threat information and efficacy information in order to generate the public’s prevention motivation and behaviors. To limiIn the past 3 years, there have been several studies on health behaviors related to COVID-19. Some researchers only discussed the intention or motivation of health behaviors without discussing the specific health behaviors , 31, wheAlthough many researchers have proposed different exogenous variables, such as trust in the government , knowledQ1: What is the relationship between public media trust, PMT constructs, and health prevention behaviors in a public health emergency?Q2: During the COVID-19 crisis, do people with different personal epidemic experiences have differences in forming health protective behaviors?2.2.1.2.2.According to the model of behavior formation, the theoretical framework of PMT is divided into three parts: information source, cognitive mediation process, and response mode. As a result, the source of information is the starting point for protection motivation . IndividTherefore, media trust (MT) is one of the essential factors affecting health behavior, thus acting as the exogenous variable of PMT. Media trust can be divided into traditional media trust (TMT), social media trust (SMT), and interpersonal communication trust (ICT) , which aThus, this study proposed the following hypotheses.H1: Media trust (MT) is positively related to threat appraisal (TA).H2: Media trust (MT) is positively related to coping appraisal (CA).The PMT contains threat appraisal and coping appraisal, which form the core of the cognitive process and contribute to the individual’s motivation or intention to adopt protective behaviors . Threat Coping appraisal is an individual’s assessment of the recommended measures, and it contains sub-constructs such as response efficacy, self-efficacy, and response cost. Response efficacy refers to beliefs about whether the recommended measures are effective in reducing the threat. Self-efficacy refers to individuals’ beliefs about whether they have the capacity to implement the recommended measures. Response costs refer to beliefs about how costly it will be for an individual to implement the recommendations, and the higher the response costs of adopting the response, the less likely the individual will adopt it. Since the response costs are negatively related to coping appraisal, while response efficacy and self-efficacy are positively related to it, we can define coping appraisal as a second-order construct and response efficacy and self-efficacy as sub-constructs to it, except for the response costs. Therefore, the greater an individual’s response efficacy and self-efficacy to countermeasures, the greater the coping appraisal, the lesser the response costs of countermeasures, the more motivated individuals are to protect themselves, and the more likely they are to adopt protective behaviors .Some scholars believe that there is a certain sequence in individuals’ cognitive assessment processes. When a health threat event occurs, individuals first assess the severity and vulnerability of the event through acquired knowledge, thus forming a threat appraisal, then assess the countermeasures they can take  through past experiences, subsequently forming a coping appraisal. Finally, through the interaction of threat appraisal and coping appraisal, a definite protective motivation will be generated, which will lead to protective behavior .Previous research used health behavior theory to explain various types of health protective behaviors during the COVID-19 pandemic, such as hand washing, limiting social contact, disinfection of articles, wearing a mask, physical activity, and injection of the COVID-19 vaccine. Previous research measured health protective behaviors as a single behavior or as a simple list of protective behaviors. In fact, we can classify the health behaviors adopted during COVID-19, thus creating some new sub-constructs. According to the classification of health behaviors, we can categorize the health behaviors under four constructs: epidemics as avoidance behavior of environmental hazards (ABEH), anti-epidemic measures (AEM), rational use of health services (RUHS), and basic health behaviors (BHB). Thus, this study proposed the following hypotheses.H3: Rewards (RW) are negatively related to threat appraisal (TA).H4: Response costs (RC) are negatively related to coping appraisal (CA).H5: Threat appraisal (TA) is positively related to epidemic prevention motivation (EPM).H6: Coping appraisal (CA) is positively related to epidemic prevention motivation (EPM).H7: Threat appraisal (TA) is positively related to coping appraisal (CA).H8: Epidemic prevention motivation (EPM) is positively related to epidemic prevention behaviors (EPB).As the epidemic continues and recurrences occur in China, some areas have experienced one or more rounds of the COVID-19 outbreak, while other areas have not, which has led to some people having direct experience with COVID-19, whereas others do not. Previous studies have shown that just like “ripple,” people who are closer to the disaster have higher levels of emotion and perceived risk , as wellH9: The TPB model has a significant difference between the personal epidemic experience group and the no epidemic experience group.3.3.1.The current research is a cross-sectional study that aims to explore and validate the model. It takes the protection motivation theory (PMT) as the theoretical framework and the public’s media trust as a second-order formative external variable to explore the relationship between media trust and PMT variables, thus constructing a second-order structural equation model. It also explores whether having a personal experience with an epidemic has an effect on the model-that is, whether the model paths are significantly different.The research design of the current study was based on variance-based structural equation modeling. Structural equation modeling (SEM) is prevalent in social sciences and has two main techniques, namely covariance-based SEM and variance-based SEM. The former is a traditional structural equation model, which is a multivariate statistical technique combining regression analysis, factor analysis, and ANOVA. The latter uses the Partial Least Squares Method (PLS), a mathematical optimization technique combining multiple linear regression analysis, typical correlation analysis, principal component analysis, and causal modeling. PLS, according to Ringle et al., has a number of advantages, including the ability to accept small samples and non-normally distributed data, as well as analyze formative constructs and handle complex models for exploratory studies and theory development . The sta3.2.Considering the risk of COVID-19 transmission, this study conducted an online survey for the public on the Tencent questionnaire platform from 1 March 2022, until 7 March 2022, when China implemented zero-COVID policy and strategies. The link to the survey was sent to different WeChat groups. Participation was open to anyone residing in China with a self-reported age of over 18 years old. The introduction of the questionnaire provided an informed consent form that explained the purpose of the study, the potential risks and benefits of participating in the study, the confidentiality measures for personal privacy, and the voluntary nature of participation in the survey. Participants first read the informed consent form and then began to fill out the questionnaire if they agreed. Participants could stop filling out the questionnaire at any time during the process. The complete completion of the questionnaire was considered consent to participate in this survey. Otherwise, it was considered unwilling to participate in the research. Finally, a total of 450 questionnaires were collected, excluding those with too many inconsistent options, and 428 valid questionnaires were retained, with an effective response rate of 95.1%. The 3.3.To ensure content validity, the measurement items were modified from relevant existing literature and translated into Chinese. Several scholars discussed and revised it several times. Then, a pretest was conducted to modify the instruments. The complete questionnaire consisted of 48 items for 14 first-order constructs and 4 s-order constructs with reflective–formative type and reflective–reflective type questions , as showPersonal epidemic experience was identified by a multiple-choice question that asked respondents, “Since the outbreak of COVID-19, which of the following situations have you now or ever experienced?” The response options were as follows: (1) My health code is yellow; (2) My health code is red; (3) My neighborhood has been blocked; (4) The area where I live used to be a medium or high-risk area; (5) Someone I know around me has been diagnosed with COVID-19; (6) I have been diagnosed with COVID-19; (7) I was quarantined in the hotel; (8) I was asked to be home-based quarantined; and (9) none of the above. The respondents who chose option nine were classified as the no epidemic experience group. The others who selected one or more options from 1 to 8 were classified as being in the epidemic experience group.3.4.3.4.1.The data collected on the Tencent questionnaire platform were imported into SPSS 26.0 for data cleaning, and 428 samples were finally retained. SPSS 26.0 was also used for descriptive statistics analysis by obtaining the frequency of socio-demographic variables, such as gender, age, education, and epidemic experience.3.4.2.This study applied PLS to analyze the outer model and the inner model, and most of the examinations in this study followed the two-step approach put forward by Anderson and Gerbing with the software of SmartPLS 3.0. The first step is outer model analysis, including reliability and validity testing, while the second step is inner model analysis, including estimating and validating the structural model’s path coefficients and explanatory power. The preceding two steps are intended to confirm whether the constructs are reliable and valid, thereby validating the relationships between constructs , 55.In the first step, the validity test includes a convergent validity test and a discriminant validity test. The convergent validity test was used to determine the degree of similarity of different measures in measuring the same concept. In this study, standardized factor loading of each indicator, reliability of each construct, and average variance extracted (AVE) of each construct were used to test convergent validity. Specifically, reliability was assessed using the composite reliability (CR), Cronbach’s alpha coefficients, or Dijkstra-Henseler’s rho. If any of the three values is greater than 0.6 or 0.7, the reliability is deemed desirable . AccordiIn the second step, path coefficients were used to represent the intensity and direction of the variable relationships to show the cause and effect between latent variables. Bootstrapping was used to estimate the significance (α = 0.05) of each path coefficient. Additionally, explanatory power was estimated by the R square value, which refers to the percentage to which the dependent variable can be explained, representing the predictive ability of the model . The valp-values of both steps 2 and 3 are not significant, then full measurement invariance exists in the model. However, if only the permutation p-values in step 2 are not significant, the model has partial measurement invariance, and MGA should be used to compare the groups  was used to test the moderation effect of personal epidemic experience in order to determine if there were differences in all hypotheses between the epidemic experience group and the no epidemic experience group , 63. To e groups .4.4.1.Among the respondents, 182 (42.5%) were male and 246 (57.5%) were female; 26 (6.1%) were aged between 18 and 24 years old, 144 (33.6%) were aged between 25 and 30 years old, 153 (35.7%) were aged between 31 and 40 years old, 47 (11%) were aged between 41 and 50 years old, and 58 (13.6%) were over 50 years old; 34 (7.9%) were in junior high school and below, 67 (15.7%) in high school or technical secondary school, 268 (62.6%) were undergraduates or in college, and 59 (13.8%) were postgraduate students and above. Moreover, 198 (46.3%) had personal epidemic experience, while 230 (53.7%) had no personal epidemic experience.4.2.A formative model was assessed by examining variance inflation factor (VIF) scores and the significance of the weights . In our In the first step of PLS, the standardized factor loading and T-value of each item, the composite reliability, Cronbach’s alpha, Dijkstra-Henseler’s rho, and AVE of each construct were tested for convergent validity. As is shown in 4.3.2) for the inner model are shown in p-value < 0.001; H2: β = 0.260, p-value < 0.001), rewards negatively but not significantly affect threat appraisal , response costs negatively and significantly affect coping appraisal , threat appraisal and coping appraisal both positively and significantly affect epidemic prevention motivation , threat appraisal positively and significantly affects coping appraisal , and epidemic prevention motivation positively and significantly affects epidemic prevention behaviors . The analysis indicated that RW had no significant direct effect on TA, and thus H3 was not supported, while the remaining seven path hypotheses were significant and supported.In the second step of PLS, the standardized path coefficients, significance, and explanatory power , a permutation algorithm is necessary to examine MICOM. In this study, permutation e exists .p-value > 0.1) and from TA to EPM  were not significant, but other path coefficients were. In the epidemic experience group, all the path coefficients were significant. Regarding the comparative study, significant differences were found between the two groups in five paths, including TA to PV , MT to CA , CA to RE , CA to SE , and TA to EPM . The personal epidemic experience played a moderating role in these paths. In particular, we found that TA positively and significantly predicted EPM in the epidemic experience group, whereas this path was not significant in the no epidemic experience group, and the difference between the two groups was significant. On the other hand, RW negatively and significantly predicted TA in the epidemic experience group, but this path was not significant in the no epidemic experience group, and the difference between the two groups was not significant either.5.The overall purpose of this study was to explore the influence factors and formation mechanisms of epidemic preventive behaviors implemented by the public. This study conducted empirical research that elucidated the impact of media trust on COVID-19 prevention motivation and behaviors based on the PMT, and evaluated the moderation effect of personal epidemic experience, which focused on the differences in two groups with and without epidemic experience. There are three main findings, as follows.First, the present study introduced media trust as the information source primarily influencing COVID-19 prevention motivation and behaviors. More specifically, the public acquired information about COVID-19 through various channels, including traditional media, social media, and interpersonal communication. Trust in different information channels was the exogenous variable that produced motivation and behaviors. According to the path coefficients, media trust was positively and significantly related to both threat appraisal and coping appraisal, with a nearly equal degree of correlation to both. Traditional media trust has the strongest relationship with media trust and, further, with protection motivation and behaviors through threat appraisal and coping appraisal. Therefore, in accordance with findings reported by Li et al. , traditiSecond, several results of association between PMT constructs in this model are worth discussing. There was a negative but not significant association between rewards and threat appraisal, which was different from the conclusion made by Malak Al-Rasheed . The reaThird, the individuals with and without personal epidemic experience were adopted as different samples to examine the moderation effect of personal epidemic experience on the model by MGA of PLS. In sum, despite the minor variations, the study successfully replicated the PMT model on epidemic prevention behaviors among both the epidemic experience group and the no epidemic experience group, thereby verifying the generalization ability of the model. However, there were also several significant differences between the two groups. The coefficient path from threat appraisal to perceived vulnerability was significant and positive for both groups, but the correlation of the no epidemic experience group was stronger than that of the epidemic experience group. This finding agrees with the perspective of Frewer et al., who hold the view that perceived vulnerability is the subjective cognition of the individual, and that some media provide one-sided information that greatly stimulates the individual’s risk perception and amplifies perceived susceptibility . This fiThere are both theoretical and practical implications of the findings in the present study. Theoretically, this study made five main contributions. First, it used the PMT to show the entire path of the association from media trust to epidemic prevention behaviors, which had significant implications for understanding how information source and trust influenced behavior. Second, it built four second-order constructs, including media trust, threat appraisal, coping appraisal, and epidemic prevention behaviors. High-order constructs contribute to model simplicity by reducing the number of path model relationships . Third, In practice, these findings indicated that traditional media and social media play an important role in risk management. Public health departments and governments should consider traditional and social media comprehensively to disseminate risk information about public health events. Another important practical implication is that the effect of coping appraisal on motivation formation for COVID-19 prevention could be applied during the COVID-19 pandemic, as most studies have demonstrated that coping appraisal is an effective factor in motivation formation and behavior engagement . There iThis study still has several limitations. First, due to the epidemic prevention and control policy at the time after the spring festival of 2022 in China, when the epidemic had spread to many places, we chose convenient sampling through the Tencent questionnaire platform. As a result, the study may have suffered from selection bias because it did not include the rural poor or people with low educational levels, and the study’s representativeness was limited. Second, media trust, as the one exogenous variable, has insufficient explanatory power for threat appraisal. The result shows that only 4.4% of the variance of threat appraisal is explained by media trust. It indicated that except for media trust, there may be other variables to explain the threat appraisal.2 value of threat appraisal and strengthen the explanatory power of the model.We encourage future research to consider more personal factors such as underlying disease, smoking status, health literacy, and so on that may influence PMT variables and epidemic prevention motivation and behaviors. Furthermore, many other variables influencing threat appraisal should be contained in the model in future studies in order to increase the R6.This study expanded the connotation and extension of PMT and enriched the current literature about the public’s prevention behaviors about COVID-19. Different from past studies, it validated the relationship between public media trust, PMT constructs, and four types of health behaviors in a public health emergency. Three types of media trust, especially traditional media trust and social media trust, were positively and significantly related to both threat appraisal and coping appraisal, which both positively and significantly affect epidemic prevention motivation and behaviors. Moreover, it validated the slightly moderating role of personal epidemic experience in the model for in-depth research. Our findings suggested that traditional and social media were the main channels to disseminate risk information, and public health departments and governments should ensure the accuracy and reliability of their information. Simultaneously, the media should balance threat information and efficacy information in order to generate the public’s prevention motivation and behaviors.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Dianchi College of Yunnan University. The participants provided their written informed consent to participate in this study.DZ and ZZ: conceptualization. DZ: methodology, software, and formal analysis. ZZ and XM: validation. FS and XM: investigation. FS: resources and data curation. DZ and XM: writing—original draft preparation and funding acquisition. ZZ: writing—review and editing and supervision. XM: visualization. FS: project administration. All authors contributed to the article and approved the submitted version.This research was funded by the Humanities and Social Sciences Research Project of the Education Department of Guizhou Province (2021QN017) and the Science and Technology Program of the Science and Technology Department of Guizhou Province .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There was a negative correlation between the overall quality of life and mental health domains. Sport was negatively correlated with mental illness symptoms and positively correlated (p < 0.05) with Pediatric Quality of Life. The regression models revealed that stress was a significant predictor for the quality of life of male and female adolescents  to (−0.02), p < 0.05)] and , respectively). The analysis revealed a moderate level of physical activity among the schools’ students when they returned to school following COVID-19 lockdown. Children’s involvement in physical activity was associated with improved quality of life and mental health. The results call for the need to develop appropriate intervention programs to increase school students’ physical activity levels.Increasing evidence suggests that physical activity (PA) can reduce depression and anxiety in adolescents. At the same time, quality of life (QoL) is sensitive to both mental health and PA, but little is known about the mechanism between these three variables among adolescents. This study aimed to assess the physical activity, mental health, and quality of life of school students when they returned to school after two years of distance learning in the Jazan region. This current investigation represented an observational cross-sectional survey conducted in January 2022 among a random sample of 601 students from intermediate and high schools in the Jazan region, Saudi Arabia. Three standardized questionnaires were used for data collection; the Arabic version of the Pediatric Quality of Life Inventory (PedsQL), Depression Anxiety Stress Scales (DASS21), and the Fels PAQ for children. The analysis revealed a moderate level of physical activity, decreased HRQoL, and symptoms of mental health problems  among the schools’ students when they returned to school following COVID-19 lockdown. The overall Pediatric Quality of Life mean score was (81.4 ± 16.4), which differed significantly according to gender, age groups, and grade levels ( The COVID-19 pandemic has significantly altered people’s daily lives, compelling countries to implement school closures and replacements with virtual classes, lockdowns, isolation, and social distancing to contain the virus’s spread and mitigate its adverse health consequences . AdditioPhysical activity refers to any body movement generated by skeletal muscles that require energy expenditure . How to Recent research ,8 suggesThe COVID-19 pandemic also poses a significant mental health threat among children, adolescents, and all students generally . It has A prior study of parents in Italy and Spain discovered that more than 85% of their children decreased their physical activity, increased their screen times, and increased maladaptive emotional and behavioral indicators . AccordiMany studies have documented that PA is positively associated with mental health, while an inverse association has been reported between psychiatric distress  and quality of life among adolescents ,15. Addi2, including some 5000 villages and towns, with a population of 1.5 million. The intermediate educational stage in Saudi Arabia lasts three years, while secondary education lasts for the same period. During the COVID-19 pandemic, around 22,000 schools were closed from 9 March 2020. Classrooms opened again for students in intermediate and high schools on 29 April 2021. Inclusion criteria involved school-age children (intermediate and secondary schools) who registered for the academic year 2021/2022, lived in the Jazan region, and were aged between 12 to 18 years old. This research was conducted in January 2022.A cross-sectional survey was conducted among students of intermediate and high schools in the Jazan region. School-aged children and adolescents (intermediate and secondary schools) are an important segment of the population, and additional information was needed to determine their mental health, QoL, and PA statuses post COVID-19 period. The Jazan region is one of the KSA’s thirteen regions. It is located on the tropical Red Sea Coast in southwestern KSA. The region covers an area of 11,671 km2 * p * q)]/d2, where p is the (estimated) proportion of the population, which has the attribute in question; q = (1 − p); d is the desired level of precision; and Z is the critical value of the normal distribution at the required confidence level; usually, Z = 1.96 for 95% C.I. This research utilized the following indicators: p = prevalence of the required, studied phenomenon, which was set at 50% (as no information related to the main research outcome was available); Z = 1.96 confidence interval; and d = error not more than 4%, with a 10% non-response rate. Due to the pandemic situations of COVID-19, the research combined both the random and non-random sampling designs to recruit the students for this study. In the first stage, eight schools (two intermediate and two high schools for both genders) were selected randomly from each educational sector. The Jazan region, administratively, is divided into two educational sectors. Second, a convenience sample was utilized to select the pupils from each selected school to participate in this study. The survey link was sent to the child’s parent/guardian, and the parents/guardians were asked to assent to their child’s participation in the survey before the child could participate.A sample size of 640 students was determined for conducting this survey. The sample size estimation was based on Cochran’s formula  for crosThe study was conducted using a self-administered questionnaire prepared in Arabic and distributed via an anonymous online survey instrument. The first part of the questionnaire covered the socio-demographic information of the study participants, such as age, gender, nationality, residence, and parent’s education level. The second part of the questionnaire involved the validated Arabic version of the Fels PAQ for children 7–19 years). The instrument was a self-administered questionnaire assessing habitual physical activity in an eight-item questionnaire containing three “open” questions for which some activities required listing by the study participants. The frequency of participation for each activity was also obtained . The thi years. TThe research was conducted according to the ethics guidelines of Saudi Arabia. Ethical clearance was obtained from the Standing Committee for Scientific Research Ethics-Jazan University (HAPO-10-Z-001) (REF# REC-43/05/088). All study participants read and signed the consent form following a short introduction about the study objectives. Participants were told that they had the right to withdraw at any time and that there would not be any harm or loss of benefits if they continued or withdrew from participating. Finally, we strictly ensured that each participant’s personal information was preserved and confidentiality was maintained.p-value less than 0.05 was considered significant.The IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp program was used for data analysis. The analysis involved descriptive as well as inferential statistics according to the essential purpose of each relationship. Categorical variables were described as frequencies and percentages. The normality of the continuous variables was assessed using the Kolmogorov–Smirnov test. To assess the differences in the demographic characteristics in the FELS PAQ and PedsQL, we compared the means of continuous variables using the Student’s t-test and one-way ANOVA, respectively. The effect size, based on Cohen’s d and omega squared, was calculated. Cohen’s d was interpreted as follows: <20 as very small; 0.20–0.49 as small; 0.51–0.80 as intermediate; and >0.8 as a large effect. An omega-squared effect size of 0.01–0.06 was considered small, 0.06–0.14 was considered medium, and >0.14 was considered large. A multiple linear regression model was used to assess predictors of the overall score of quality of life among the pupils. The final model was assessed for multicollinearity and assumptions of the ordinary least squares (OLS) technique. The Pearson correlation coefficient was computed to assess the correlation between the overall quality of life, sport index, and the DASS21 domains among the adolescents. The correlation coefficient was defined as weak (0–0.29), moderate (0.30–0.50), and strong (>0.50). A p < 0.05 for all).p < 0.001). According to the Pediatric Quality of Life (PedsQL), the table showed that boys had significantly higher scores in all PedsQL domains (p < 0.05), with a small effect size ranging between 0.169–0.450.p < 0.05)  and ).The present study aimed to assess the mental health, physical activity, and quality of life of school students when they returned to school after two years of distance learning in the Jazan region, southwest Saudi Arabia. Children and adolescents were at higher risk of mental problems due to restrictions during the pandemic. For that, families were greatly challenged to adapt to these restrictions and to create a healthy environment, particularly during online classes.During the pandemic, the government established quarantine measures to control the spread of the disease; this led to restrictions on freedom and significantly increased stress among the population. These restrictions also led to violence, in some instances, among families and may have had an impact on the mental health of children and adolescents ,21, evenRegular physical activity and exercise are related to an improved sense of well-being, physical health , life saA significant finding of our study was that depression, stress, and anxiety levels all had negative effects on the overall quality of life and physical activity; these findings were consistent with a study in Italy and Spain that reported that 85.7% observed a change in the behaviors and emotions of their children during the pandemic, based on parents’ reports . AnotherThe results suggested that 43.3% of participants were depressed, and overall quality of life correlated with depression. These outcomes were also found in a study conducted in China among adolescents, which reported that 39.5% of the participants experienced depression, which was linked with less physical activity as a factor of depression during the COVID-19 pandemic .In this study, quality of life involved the physiological integrity of individuals, as well as mental health and social comfort. The analysis revealed that parameters of quality of life were affected negatively by psychological issues. Additionally, males and females with higher physical activity levels had considerably higher quality of life scores. Regular physical activity was established in literature to considerably improve the quality of life of healthy individuals and chronic disease patients. In line with this approach, the results of our study’s multiple linear regression analysis revealed that students’ mental health had a negative effect on their quality of life, particularly depression, which is a major predictor of both male and female teenage quality of life. These findings highlighted the critical significance of including physical exercise and mental health programs in community-based rehabilitation programs to safeguard and maintain patients’ quality of life during the ongoing pandemic . This stThe present study had some limitations. This was a cross-sectional-based study. Therefore, the temporal correlation between explanatory variables and outcomes could not be assessed. As this was an online survey-based study, response and selection biases are possible. Finally, the results of our study cannot be generalized to the whole population in the Jazan Region.The analysis revealed a moderate level of physical activity among the schools’ students when they returned to school following COVID-19 lockdown. Children’s physical activity involvement is linked to the improvement in quality of life and mental health. The results call for the need to develop appropriate intervention programs to increase school students’ physical activity levels. Future research focusing on the inter-variable associations between PA, mental health, and quality of life, using higher study designs, such as a cohort study, is highly needed.


Drosophila is used as a model organism in addiction research. A well-described behavioral response examined in flies is the induced increase in locomotor activity after a single dose of volatilized cocaine (vCOC) and volatilized methamphetamine (vMETH), the sensitivity, and the escalation of the locomotor response after the repeated dose, the locomotor sensitization. However, knowledge about how vCOC and vMETH affect different neurotransmitter systems over time is scarce. We used LC-MS/MS to systematically examine changes in the concentration of neurotransmitters, metabolites and non-metabolized COC and METH in the whole head homogenates of male flies one to seven hours after single and double vCOC or vMETH administrations. vMETH leads to complex changes in the levels of examined substances over time, while vCOC strongly and briefly increases concentrations of dopamine, tyramine and octopamine followed by a delayed degradation into N-acetyl dopamine and N-acetyl tyramine. The first exposure to psychostimulants leads to significant and dynamic changes in the concentrations relative to the second administration when they are more stable over several hours. Further investigations are needed to understand neurochemical and molecular changes post-psychostimulant administration.Due to similarities in genetics, cellular response, and behavior,  Drosophila, the ease of genetic manipulations provides a means for describing changes in the neuronal functioning that are induced by psychostimulants [The administration of psychostimulants leads to changes in the concentration, the localization, and the chemical form of neurotransmitters crucial for their behavioral effects ,2. By biimulants ,10. Therimulants , preventDrosophila uses neurotransmitters such as dopamine (DA), serotonin (5-HT), glutamate (GLU), acetylcholine (ACh) and γ-aminobutyric acid (GABA), regulated by plasma membrane and vesicular transporters that are homologous to mammals [Drosophila, tyramine (TA) and octopamine (OA) have a homologous function to epinephrine and norepinephrine in the brain of mammals. TA and OA are present in mammals only as trace amines [N-acetyl dopamine and N-acetyl tyramine has been shown and measured [Drosophila, arylalkylamine N-acetyltransferase (AANAT) and arylalkylamine N-acyltransferase-like 2 (AANATL2) are major enzymes involved in N-acylation and inactivation of biogenic amines. The two enzymes have similar affinity for the acylation of DA, TA and OA. mammals . In Drose amines . Neurotrmeasured . Furthermeasured . In DrosDrosophila has been extensively used in the study of substance abuse and treatment [Drosophila, locomotor sensitization (LS), or progressive and persistent augmentation of behavioral or locomotor response to the repeated dose of the same concentration, has been described only after volatilized exposure [Based on similarities of the genetic regulation and behavioral responses, reatment ,16,17,18reatment ,20. Thisreatment ,22,23. Iexposure ,24. In rexposure . Althougexposure ,27. Mostexposure , which aexposure . Since tDrosophila. Since these two psychostimulants have a distinct mechanism of action and initiate a cascade of molecular and biochemical events, it seems reasonable that this leads to a different minimal time interval needed to induce the development of LS to repeated administrations of vCOC and vMETH [Currently, there are no published reports about temporal changes in neurotransmitter concentration following administration of vCOC or vMETH in nd vMETH ,24. A deN-acetyl dopamine (NaD) and TA metabolite, N-acetyl tyramine (NaT). We applied the LC-MS/MS analysis to whole heads homogenates following one and two administrations of vCOC or vMETH, and analyzed the extracts one, three, five and seven hours post-administration.To this end we examined the temporal profile of changes that occur at the level of the whole brain. We quantified the concentration of neurotransmitters dopamine (DA), octopamine (OA), and tyramine (TA). We also semi-quantified glutamate (GLU), acetylcholine (ACh) and γ-aminobutyric acid (GABA), as well as non-metabolized cocaine (COC) and methamphetamine (METH), and DA metabolite D. melanogaster leads to an increase in locomotor activity, or the sensitivity (SENS). Flies develop locomotor sensitization (LS) to the second exposure when it is given at least six hours later for vCOC, and ten hours later for vMETH [The administration of a single dose of vCOC or vMETH to or vMETH ,24. ThisDrosophila. There was a pronounced peak in DA concentration three hours after the administration of a single dose of vCOC, which returned to the pre-peak levels at five and seven hours , and the TA metabolite, N-acetyl tyramine (NaT), after vCOC or vMETH exposures. NaD concentrations gradually increased after the first vCOC and vMETH administrations, reaching the highest levels at seven hours  and acetylcholine (ACh) regulate rticular , we quanSimilar to the monoamines, concentrations of GLU and ACh were higher after the first administration of vCOC and vMETH than after the second A–D. HoweThe temporal profile of GABA had two unique differences relative to all other neurotransmitters. First, it had a sharp increase at seven hours after the first vCOC administration E, while Drosophila and their mechanism of action. Neurotransmitter systems in the brain are highly complex, with specific neuronal populations exhibiting distinct functional roles in behavioral regulation. The difference in the vCOC and vMETH dosing intervals that lead to the development of LS is likely related to the difference in the pharmacokinetics of those psychostimulants in the specific brain areas. However, reports about the temporal regulation of the neurotransmitter concentration, even in the whole brain of flies, are still lacking. To systematically examine changes in the concentration of several excitatory and inhibitory neurotransmitters in the whole head homogenates of male flies, we used the LC-MS/MS method with two important metabolites and non-metabolized COC and METH across the span of one to seven hours after the administration of single and double volatilized COC (vCOC) or METH (vMETH). We show that DA, TA, and OA show sharp and brief concentration spikes after the first vCOC administration, but they are lacking after vMETH administration. The common element between vCOC and vMETH is that there is a greater variation in the concentration of monoamines after the first than after the second administration. Peak concentrations of DA and TA metabolites, NaD and NaT, show a time delay relative to peak DA and TA concentrations, but only after the first vCOC administration where the peaks are brief and pronounced. In all other experiments, the level of metabolites mostly overlaps with the amount of DA and TA. These findings provide valuable insights into the neurochemical dynamics associated with COC and METH exposure in Drosophila [After a single dose of vCOC, there is a significant increase in DA concentration, limited to three hours post-administration. This agrees with reports that show an increase in DA concentration outside the cell after COC exposure , and witosophila ,22,32. Cosophila . Becauseosophila ,33, our Flies and other insects do not appear to further process dopamine to noradrenalin or adrenalin, but rather use the structurally similar neurotransmitters TA and OA , both clAlthough flies show similar sensitivity to the motor-activating effect of vMETH and develop LS , the minRelative to the surge in TA and OA following the first vCOC administration, the changes following the first vMETH administration are relatively modest. There is a small but significant increase in OA concentration at five hours after the first vMETH administration and at seven hours after the second. The observed changes in OA are interesting in the context of a potential interaction between dopaminergic and octopaminergic regulation. In mammals, trace amine associated receptor 1 (TAAR1) serves as a direct intracellular target for amphetamines in DA neurons . The actN-acetyltransferase (AANAT) [N-acyltransferase-like 2 (AANATL2) [N-acetyl dopamine (DaT) and N-acetyl tyramine (NaT). After the first vCOC administration, there is a gradual increase in the concentration of NaD over seven hours, with a significant increase two hour after the DA spike, suggesting that the acetylases are metabolizing DA to control the vCOC-induced DA increase. Similarly, a sharp increase in NaT occurs with a two-hour delay relative to the TA peak, indicating that most of the TA has been metabolized to NaT. However, in both cases, there is a time lag of two hours present between the DA and TA peak and the metabolite peak. There are two potential explanations for this dynamic. First, new AANAT and AANATL2 must be synthesized to metabolize the excessive amounts of DA and TA. Second, the existing amount of the enzymes requires a longer time to metabolize the substrate. We favor the first explanation, particularly in the case of the TA to NaT conversion after the first vCOC administration, because if the second explanation is correct, we should be able to detect a more gradual increase in NaT. Since in all other measurements we do not observe any time lag, we suspect that the enzymes that are present are sufficiently active to metabolize DA and TA. However, in all those instances, the levels of DA and TA are not excessively high, further supporting the potential dual mechanism of N-acetylases action to maintain the physiological levels of DA and TA, one that involves new synthesis and another that involves rapid turnover   and arylAANATL2)  into N-aturnover . Drosophila, it is not known what role GLU, ACh and GABA have in the regulation of psychostimulant-induced behaviors. The temporal dynamics of GLU and ACh after the first or second administration of vCOC and vMETH are lacking abrupt or extensive changes in concentration, as we have described for the monoamines. However, considering that GLU transmission is a primary contributor in the majority of neuroplastic processes related to abused substances in mammals [In  mammals , minor, In mammals, the function of the inhibitory neurotransmitter GABA is intricately linked with the release of DA in the striatum where it modulates behaviors such as motivation and reinforcement learning  and inhiD. melanogaster wild-type (wt) strain Canton S, grown on a standard nutrient medium based on cornmeal and agar at 25 °C with 70% humidity in a 12-h light/12-h dark cycle. Using CO2 anesthesia and a microscope, adult males were collected and transferred to plastic vials with corn food until complete recovery, after which they were transferred to the FlyBong apparatus. The corn food contains sugar (7.9%), inactivated yeast (5.0%), agar (0.8%), corn flour (7.2%), 15 mL 10% antifungal methyl parahydroxybenzoate  dissolved in 96% ethanol  and 8 mL of propionic acid .We used 3–5 days old male The FlyBong enables the delivery of a precise dose of volatilized COC (vCOC) and volatilized METH (vMETH) to individual flies housed in the polycarbonate tubes placed in a monitor that holds 32 tubes (Drosophila Activity Monitoring System (DAMS), TriKinetics, Waltham, MA, USA) ,24,32. TDrosophila head homogenates [After drug administration using the FlyBong, the flies remained in the monitors and 15 flies were randomly collected one, three, five and seven hours after one and two vCOC and vMETH administrations, and the same for the controls exposed to heated air . Flies wogenates ,52. FiftN-acetyl dopamine (NaD) and TA metabolite N-acetyl tyramine (NaT). A Purospher STAR RP-18 Hibar HR column  was used for chromatographic separation. The mobile phase was composed of (A) 1% formic acid in miliQ water and (B) acetonitrile. The gradient elution was as follows: 0–0.9 min linear gradient from 1% to 10% B, 0.9–3 min from 10% to 20% B, 3–4.5 min from 20% to 25% B, 4.5–6 min from 25% to 30% B, 6–6.1 min from 30% B to 99% B, 6.1–6.2 min from 99% B to 1% B and 6.2 to 10 min 1% B. Post time was set to two min. The flow rate was 0.33 mL/min. The column oven was maintained at 25 °C. The sample injection volume was 2.5 µL. All samples were injected in triplicate. For AJS-ESI-QQQ, the parameters were set as follows: capillary voltage was 3.5 kV in both positive and negative modes, nozzle voltage was 0.5 kV, ion source temperature was set to 300 °C, gas flow was 5 L/min, nebulizer pressure was 45 psi, drying gas temperature was 250 °C, and sheath gas flow was 11 L/min. Nitrogen was used as the collision gas. The MSMS optimization parameters are listed in An Agilent 1260 series HPLC chromatograph equipped with a degasser, binary pump, autosampler, and column oven was coupled to an Agilent 6460 triple quadrupole mass spectrometer (QQQ) with an AJS ESI source to perform quantitative analyses of the monoamines DA, OA, and TA as well as semi-quantitative analyses of GLU, ACh, GABA, COC, METH, DA metabolite p < 0.05.All the data from MassHunter Qualitative Analysis software v. B.07.00  were processed by MS Excel to calculate the concentration ratio between experimental groups exposed to the volatilized compound and the control group exposed to hot air. Statistical analyses and visualizations were performed using Prism 10.0.2 . Differences between treatments at different time points were analyzed using two-way ANOVA, followed by Tukey’s multiple comparisons test, depending on the data set. All data were tested for normality using Bartlett’s test or Brown–Forsythe’s test. Differences were considered significant if Drosophila, temporal profiles of GLU, ACh and GABA, which all show a more moderate and delayed increase in their concentration. Although the measurements were performed on whole head homogenates, which are not representative of localized changes at the level of the specific neuronal groups that are important in the control of different behaviors, our study generated several important findings that require further work to gain a better understanding of the neurochemical and molecular changes that occur after psychostimulant administration.The major findings of this study include a depiction of the distinct and dynamic changes in the concentration of several major neurotransmitters and their metabolites in the fly brain following cocaine or methamphetamine administration. The complex changes in the profile of neurotransmitters following vMETH administration are in line with multiple cellular targets of vMETH relative to vCOC. We confirmed the importance of DA and TA in response to vCOC, and a delay in the appearance of their metabolites. Such a delay is not present in cases where neurotransmitters do not show a high increase in their concentration, such as with second exposures to vCOC or vMETH. In general, concentrations after second exposures are more stable than after the first, suggesting potential adaptations at the level of synthesis, release, and degradation of the neurotransmitters. We have shown, for the first time in


There was a difference between SH, THD, CHD, MSTH, and MRH on the operated and non-operative sides (p < 0.05). There was no difference between Y balance scores on the operated and non-operative sides, and there were no differences between LSI scores resulting from SLHTs (p > 0.05). There were no significant relationships between YBT (composite scores) and SH, TH, CH, MSTH, and MRH distances in the healthy leg (p > 0.05), but a significant correlation with only CH in the ACL leg (p < 0.05). Conclusions: Our research shows that sixth-month post-operative SLHT findings were lower on the ACL side compared to the healthy side in patients tested with the MAI ACLR technique. However, when these scores are evaluated in terms of balance, it can be seen that both sides reveal similar findings. The similarity of LSIs in SLHTs applied in different directions, and balance scores of ACL and healthy sides revealed that the MAI technique is also an ACLR technique that can be used in athletes from a functional point of view.Background and Objectives: Anterior cruciate ligament (ACL) ruptures are common injuries, and ACL reconstruction (ACLR) is among the most common surgical procedures in sports surgery. Our research aims to compare the 6-month post-operative results of the modified all-inside (MAI) ACLR technique, single leg hop tests (SLHT), and Y balance tests applied in different directions on the operated and non-operated sides. Materials and Methods: A retrospective cohort of 22 male recreational athletes who underwent MAI ACLR techniques performed by the same surgeon were evaluated. The functional knee strengths of the participants on the operated and non-operated sides were evaluated with five different tests of SLHTs: single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) with hop for distance (MRH). Their dynamic balance was evaluated with the Y balance Test. Results: Compared to pre-operative levels, there was a significant improvement in the mean Lysholm, Tegner, and IKDC scores during the post-operative period ( The anterior cruciate ligament (ACL) is one of the most common orthopedic injury sites, and the mechanisms of injury have been associated with rotational movements, including sudden acceleration and deceleration, sudden changes in direction when the foot is in a fixed position, and external blows to the knee during sports ,2. ACL rAfter ACLR, patients experience problems such as pain, impaired knee function, and especially quadriceps muscle weakness and atrophy ,11. It iSLHTs are widely used to evaluate athletes’ functional status after ACLR, reveal limb asymmetries between the operated and non-operated sides, and follow the limb’s developments ,32,33. TBased on all this information, our study evaluates the results of SLHT applied both in the forward direction and in the medial and rotational directions, the resulting limb asymmetries and SCT results in patients with a 6-month post-operative ACLR history who underwent the MAI ACLR technique and compared them with the healthy sides. It was hypothesized that similar SLHT and SCT results would be obtained between the ACLR and non-operated sides of the research subjects.This study used a retrospective institutional registry of patients treated for ACL tears at an academic medical center. We identified 22 active  male patients aged between 18 and 35 from a sequential case series from January 2020 to December 2021 with a diagnosis of isolated ACL tear who were treated with MAI (hamstring autograft) anterior cruciate ligament reconstruction (ACLR). Before diagnosing ACL rupture, patients presented with weakness, atrophy, pain, swelling, and slipping in the knee at the examination. Diagnosis of ACL tear was made primarily by the Lachman test and MR imaging. The number of subjects was determined by G*Power 3.1. According to the results, it would be sufficient to work with 19 patients . However, our study was completed with 22 subjects to examine the research findings. None of them was a professional sports patient, and participants consisted of those who participated in recreational activities only. Inclusion criteria were undergoing MAI (hamstring autograft) anterior cruciate ligament reconstruction (ACLR) and having no history of any other neuromuscular or musculoskeletal injury and contralateral knee surgery or injury. Exclusion criteria were non-compliance with the rehabilitation calendar, failure to complete patient-reported outcomes (PROs), SLHT, and YBTs, or exposure to various complications at the follow-up . The avePROs ) (pre- and post-operative), single-leg hop test (SLHT) distances, and YBT scores obtained 6–7 months after ACLR were taken from routine clinical procedures. All reported evaluations were routinely part of the ongoing clinical procedure. The MAI ACLR technique was performed by a single surgeon specializing in soft tissue knee injuries, and data were collected from a single center. Post-surgical treatment was provided with a mandatory rehabilitation protocol as a routine clinical procedure. The rehabilitation program was the same for all patients and was followed in a controlled manner. All patients underwent anatomical single-bundle ACL reconstruction using adjustable suspension fixation with a quadruple semitendinosus tendon autograft. The retrieved semitendinosus tendon (24–28 cm long) was quadrupled with adjustable loop cortical suspension fixation  on the tibial end and fixed loop button system  on the femoral side. The Lift Loop Outer fastening system consists of a 20 mm wide titanium button and two loops controlled by a knotless locking mechanism. The femobutton comprises a 10 mm wide titanium button and a continuous loop available in 6 lengths (15–40 mm). The anatomical femoral tunnel was carved from the anteromedial portal. First, a full bone tunnel was drilled over the guide pin using a 4.5 mm drill. The tunnel length was then measured, and a socket was opened using a router the same size as the graft, considering the 6 to 8 mm EndoButton ‘flip’ movement distance. A complete outside-in tibial tunnel was created at the anatomical footprint’s central location. The graft was passed from the intra-articular space to the tibial and femoral tunnels, and the graft knee was stretched at 20° of flexion and flexed and extended 30 times. Graft tightness was then examined with a probe. Finally, the entire structure was re-tensioned on the tibial side, and an additional ligation was made on the adjustable suspension fixation device using a non-slip knot [All patients refrained from performing the high-intensity exercise the day before measurements to avoid the effects of cumulative muscle fatigue. The patients completed the YBT and SLHT functional tests consisting of anterior (ANT), posterolateral (PL), and posteromedial (PM) directions for balance and the single hop for distance (SH), triple hop for distance (TH), crossover triple hop for distance (CH), medial side triple hop for distance (MSTH), and medial rotation (90°) hop for distance (MRH) assessments. Trials were performed prior to measurements to familiarize patients with the tests fully. There were 10-min intervals between the YBT and SLHT, and all patients performed a 5-min warm-up before the tests. Anthropometric information, such as height, weight, body mass index (BMI), thigh length, and lower limb length was collected. Thigh length was measured from the anterior superior iliac spine to the superolateral border of the patella. The lower limb length was measured bilaterally in supine position from the anterior superior iliac spine to the most distal aspect of the medial malleolus to the nearest half-centimeter .The YBT measures dynamic balance in the ANT, PL, and PM directions. The ground was marked in 3 different directions (⅄-shape) with a 15 cm wide tape; the angles between the anterior stripe and both posterior  stripes were 135 degrees, with 90 degrees between the two posterior stripes. Participants were instructed to place the stance foot in the marked position (zero-mark position) of the anterior, reach as far as possible in the reaching direction determined with the standing foot at the starting line, and then return the reaching foot to the starting position. ANT reach distance was measured from the toe of the stance foot in the starting position to the point reached, and PL and PM were measured from the heel of the stance foot to the point reached. The supervisor visually checked positions. Trials were canceled and repeated if the patient: 1) could not maintain his balance, and 2) failed to return the reach leg to the side of the stance leg after achieving maximal reach distance. Patients performed three trials for each direction  on both legs with bare feet, and the best of the trials was recorded. Reach distances were normalized to anatomical leg length and expressed as a percentage (reach distance/limb length × 100). Composite normalized reach distance was computed for each leg as (ANT + PM + PL)/(3 × limb length) × 100 ,27.The SLHT included SH, TH, CH, MSTH, and MRH over a single line with maximum effort ,43. KivlThe ground was marked with a 6 m long, 15 cm wide tape running perpendicular to the start and finish lines. Before starting the tests, an examiner explained and demonstrated the hop test procedures. Patients performed one practice trial (familiarizing practice) per limb, followed by three trials measured and recorded. Both limbs were tested, and subjects were not restricted in their arm movements. A 30-s rest interval was used after each attempt of the same hop tests. To minimize fatigue, a rest period of up to two minutes was given between different types of hop tests. Patients began each trial behind a marked starting line. The best-recorded performance was the distance between the starting line and the heel of the foot where it landed at the end of the task. All hop tests were considered successful if the landings were stable. The post-jump landing was approved when it was under the participant’s full control and on the tested limb. The test was repeated if the participant lost balance, touched the wall, or had additional bounces after landing . The exat-test or Wilcoxon test. The ANOVA was also used to evaluate the limb symmetry index (LSI) differences. The Spearman’s rank correlation test was used to calculate correlations between YBT (Composite score) and SLHT scores. Effect sizes were determined using the Cohen d, which defines 0.10, 0.30, and 0.50 as small, moderate, and large, respectively [p < 0.05, with associated 95% confidence intervals. All statistical analyses were conducted using SPSS for Windows version 21 . Descriptive data were presented as the mean, standard deviation (SD), median (Med), minimum (Min), or maximum (Max). The data were checked for normality using the Shapiro–Wilk test and were examined for kurtosis and skewness. Differences between PROs , YBT , and SLHT  distances were compared with paired samples ectively . Signifip > 0.05), and pre- and post-operative Lysholm, IKDC, and Tegner scores are presented in p < 0.001; IKDC, p < 0.001; Tegner, p = 0.002).p > 0.05).p = 0.006), TH , CH , MSTH , and MRH , respectively   .p > 0.05), but significant correlation with only CH in the ACL leg  (There were no significant relationships between YBT (composite scores) and SH, TH, CH, MSTH, and MRH distances in the healthy leg (=−0.520) .When the major findings of our study were evaluated, the results were as follows; The MAI ACL reconstruction technique revealed an improvement between the pre-operative and post-operative findings in terms of Tegner, Lysholm, and IKDC scores, and the sixth-month post-operative findings of the patients’ SH, TH, CH, MSTH, and MRH performances were lower in the ACLR sides compared to the healthy sides. When evaluated in terms of LSIs, it was determined that the resulting rates were within the normal norm ranges. Finally, when the patients were evaluated in balance scores, sixth-month post-operative findings were similar between ACLR and healthy knee.Due to the damage to the proprioceptive receptors after ACL tears, the stimuli from the mechanoreceptors to the nervous system disappear, which may lead to a loss of balance ,15,16,17Functionally, SLHTs used to determine the knee functions and RTS duration of the subjects after ACLR are tests that can be easily used to reveal the differences between the operated and non-operated sides. Researchers have reported that LSI rates calculated from SLHTs are 10%–15% in healthy limbs . When thRegarding ACL surgery and graft types, the “all-inside” technique has many advantages, such as using a single tendon and creating a socket instead of a tunnel on the tibial side. The disadvantages are evaluated as the need to use special burs on the tibial side, the creation of the socket, the limited margin of error in the adjustment of the socket depth, the need to place the graft from the portal and the higher cost. Considering the abovementioned disadvantages, the “MAI” technique was developed for ACLR. This technique has the advantages of the all-inside technique but does not have the disadvantages mentioned above.Our research is the first study to evaluate the MAI technique’s post-operative SLHT and balance results. In this respect, it is important to evaluate knee proprioception, stabilization, and strength together after an ACL injury. However, our study has a limitation in that it does not include tests involving fast turns and running, where ACL injuries often occur. In addition, the lack of other graft types and the absence of a control group are the main limitations of our study. In addition, one of the important limitations of our study is that the subjects did not feel any fatigue in the study. ACL injuries may occur due to voluntary or involuntary sudden movements at certain fatigue levels. It is important to plan studies by considering these limitations in future studies.As a result, balance scores of patients who underwent MAI ACLR technique were similar on the operated and non-operated sides. In addition, although there were differences between both parties in SLHTs, this rate was not negatively reflected in LSIs. The fact that the CS scores were below 80% in the Y balance test and that the LSI scores were within the normal norm ranges reveals the outcome of the surgical technique and rehabilitation program applied, and that the non-operated sides were the least capable of the operated sides. Moreover, when supported by the literature, these findings are expected results for recreational athletes. In the future, prospective design studies on athletes, sedentary individuals, and recreational athletes, and the MAI technique’s short-, medium-, and long-term findings will be evaluated. This will contribute to the literature investigating whether this technique is viable in subject groups. At the same time, clinical and biomechanical tests and functional tests will provide clear information about whether this technique harms the movement structure in patients to whom the MAI technique is applied.


The protocol was registered in the PROSPERO International Register of Systematic Reviews (CRD42022338038). We included six articles in the systematic review, of which the sample size ranged from 716 to 141,740, and the median length of follow-up was 5 years. The pooled RR was 1.21 (95% CI = 1.12–1.29) with an I2 of 71%. Our findings suggest that antidepressant use was associated with an increased risk of dementia in older adults with depression, yet moderate to high heterogeneity existed across studies. Future work accounting for the depression progression is needed to differentiate the effect of depression and antidepressants on dementia risk.Depression, commonly treated with antidepressants, is associated with an increased risk of dementia, especially in older adults. However, the association between antidepressant use and dementia risk is unclear. We searched for randomized controlled trials and observational studies from PubMed, Embase, and Cochrane on 1 February 2022, restricting to full texts in English. Since dementia is a chronic disease requiring a long induction time, we restricted studies with ≥1 year follow-up. We extracted the relative risk (RR) adjusted for the most variables from each study and evaluated the heterogeneity using I square (I Dementia, a neurodegenerative disorder affecting 14% of adults aged 70 years or older . PatientPharmacological therapies are primary interventions for depression . AntidepRandomized controlled trials (RCTs) have reported cognitive improvement as a therapeutic benefit of SSRIs ,23,24,252 = 99%) and thus limiting the reliability of the findings. Thus, we aimed to conduct a systematic review and meta-analysis including the most up-to-date evidence to examine the association between antidepressant use and risk of dementia over a follow-up period of ≥1 year in older adults with depression. Different classes of antidepressants may also affect the association with cognitive function due to their mechanism of action. Thus, we also investigated the effect by grouping patients’ class of antidepressants .To our knowledge, existing reviews examining the effect of antidepressants on cognitive function only included studies conducted prior to 2018, which may not cover the most recent evidence. Additionally, most did not consider the length of follow-up to account for a long induction time since dementia takes a long time to develop. A meta-analysis of observational studies following patients for 3 to 11 years (median: 6 years) suggested that antidepressant use was associated with an increased risk of dementia compared with no use in elderly patients  AND  AND { OR [“monoamine oxidase inhibitor”/exp OR “noradrenalin uptake inhibitor”/exp OR “serotonin uptake inhibitor”/exp OR “tetracyclic antidepressant agent”/exp OR “tricyclic antidepressant agent”/exp]} AND { OR [“Cognitive defect”/exp OR “Dementia”/exp]}. The search details for the other databases are listed in Three reviewers were involved in the article selection process , and the results were tracked using an Excel spreadsheet. First, two reviewers independently screened the titles and abstracts of all potential articles. We included reviews, RCTs, and observational studies, such as cohort studies and case-control studies that evaluated the association between antidepressant use and the risk of dementia in older adults, with a follow-up period of ≥1 year. Letters to the editor, editorials, case reports, and case series were excluded. Then, we retrieved the full texts of the included articles, and two reviewers independently reviewed them based on the selection criteria. From reviews, we extracted individual studies relevant to our research question and included them in the full-text assessment; however, reviews were not included in the meta-analysis. Any disagreement throughout the study selection process was resolved by the third reviewer.From the included studies, we collected the name of the first author, year of publication, study design , study location, population , details of antidepressant use , dementia outcome measures, length of the follow-up period, and main findings of the study with crude and adjusted odds ratio (OR), risk ratios (RRs), and hazard ratios (HRs) as well as 95% confidence intervals (CIs). If multiple classes of antidepressants were discussed in an article, we identified the result for each specific class during categorization. All the above items were documented in an Excel spreadsheet.We used the latest version of the Cochrane risk-of-bias tool (RoB2) to evaluate the methodological quality of the included RCTs . RoB2 as2) to assess the extent of heterogeneity [2 were 25%, 50%, and 75%, indicating low, moderate, and high heterogeneity, respectively. We considered I2 of 75% or above as an a priori indication of considerable heterogeneity [Our outcome of interest was dementia, and the exposure of interest included all types of antidepressants. From the identified studies, we restricted the analysis to articles including the information of OR/RR/HR with 95% CI and using non-antidepressant users as the comparator. HR is broadly equivalent to RR , and OR ogeneity ,35, consogeneity ,35. We an = 1546, n = PubMed 748, n = Cochrane 305) using the search strategies. After excluding 798 duplicates, 1801 studies were screened for the title and abstract. We excluded 1738 articles that were not related to our research question and 15 articles with a follow-up period of less than 1 year. In the full-text assessment, 48 studies were evaluated, and six eligible studies were added from the reviews. We then excluded nine reviews, one study with irrelevant content, 12 articles with a follow-up period of less than 1 year, five duplicates of included studies, 14 articles without full text, three articles without RR/OR/HR or 95% CI reported, and four articles not using non-users as the comparator. Eventually, this systematic review and meta-analysis included six studies. A flowchart showing the study selection process is shown in We identified 2599 articles from the three databases (Embase n = 2) and excellent (n = 3) with an average STROBE-M of 0.86 . Half of the included studies were conducted in the US, two were conducted in Taiwan, and one was conducted in the UK. The majority of the studies included both sexes, except one study  that coThe included studies were summarized and organized by their publication year and ordered alphabetically by the first author’s last name.Goveas et al., 2012  was an RChatterjee et al., 2015  was a neLee et al., 2016  was a caHan et al., 2020  was a rePeakman et al., 2020  was a reSu et al., 2020  was a re2 = 71%). The pooled RR was 1.59 (95% CI = 0.82–3.09) for SSRI and 0.64 (95% CI = 0.09–4.47) for TCA (2 = 98% for both SSRI and TCA). We pooled the adjusted RR to quantify the effect of antidepressant use compared to no use on the risk of dementia among older adults with depression. The funnel plot was symmetrical around RR = 1, which did not show significant publication bias . The poo for TCA  comparedThis meta-analysis found that overall antidepressant use was associated with a higher long-term (≥1-year follow-up) risk of dementia among older adults with depression. This may be explained by the anticholinergic side effect of antidepressants, especially TCAs ,17. For While anticholinergic antidepressants can worsen cognitive functions, some antidepressants might ameliorate cognitive function in depressed patients. For example, Keefe et al. conducted a systematic review of 43 RCTs to examine the effects of SSRIs, SNRIs, TCAs, and other psychotropic agents on cognitive function with a median follow-up duration of 8 weeks . The aut2 = 71%), probably due to different study locations, study populations, antidepressants included, length of follow-up, and the confounding factors adjusted in each study. We were unable to conduct further stratification or subgroup analysis due to an insufficient number of studies (n = 6). Future studies are needed to comprehensively adjust for the severity of depression using the duration or clinical scales  to thoroughly account for confounding by indication. However, we restricted the study population to older adults with depression to reduce the selection bias, and the heterogeneity largely decreased compared with a previous meta-analysis that pooled observational studies following older antidepressant users for 3 to 11 years (I2 = 99%) [n = 5) studies adjusted for demographic characteristics , comorbidities , and comedications , while four even adjusted for baseline depressive symptoms and cognitive function. Third, we did not report the differential risks of dementia across all classes of antidepressants due to the lack of information from existing studies. We examined the most commonly used antidepressants in elderly patients, i.e., SSRIs and TCAs, and identified no significantly increased risk of dementia of these therapeutic classes. However, the heterogeneity was very high for both SSRI and TCA (I2 = 98%), probably due to the limited number of studies . Fourth, the cumulative exposure of antidepressants  was not evaluated due to insufficient details in the included studies. Fifth, the progress of depression  may explain the long-term risk of dementia among antidepressant users, but we were not able to obtain such information to control for in the current analyses. Sixth, it is possible that a lack of response to antidepressant therapy leads to a decline in performance and cognitive function. However, patients not receiving antidepressants can also suffer from depression progression and cognitive decline. Seventh, patients  may receive social and psychological support or behavioral treatments including counseling, but the treatments’ effects on risk of dementia were unknown. Eighth, few studies have focused on the association between antidepressant use and specific types of dementia other than Alzheimer’s disease . Despite the limitations, our meta-analysis included the most updated evidence with a follow-up period of at least one year when evaluating the association between antidepressant use and cognitive function. In addition, we focused on patients with depression to increase the homogeneity across the studies. Future studies are needed to account for the severity of depression and to differentiate the effect of depression from that of antidepressants on dementia risk.Our study is subject to several limitations. First, the heterogeneity in the main analysis was moderate to high (IOur results suggest that antidepressant use is associated with an increased risk of dementia in older adults with depression. Future studies are needed to account for the severity of depression and differentiate the effect of depression and antidepressants on dementia risk.