Following stroke, changes in neuronal connectivity in tissue surrounding the infarct play an important role in both spontaneous recovery of neurological function and in treatment-induced improvements in function. Microglia and astrocytes influence this process through direct interactions with the neurons and as major determinants of the local tissue environment. Subpopulations of peri-infarct glia proliferate early after stroke providing a possible target to modify recovery. Treatment with cell cycle inhibitors can reduce infarct volume and improve functional recovery. However, it is not known whether these inhibitors can influence neurological function or alter the responses of peri-infarct glia without reducing infarction. The present study aimed to address these issues by testing the effects of the cell cycle inhibitor, olomoucine, on recovery and peri-infarct changes following photothrombotic stroke.Stroke was induced by photothrombosis in the forelimb sensorimotor cortex in Sprague-Dawley rats. Olomoucine was administered at 1 h and 24 h after stroke induction. Forelimb function was monitored up to 29 days. The effects of olomoucine on glial cell responses in peri-infarct tissue were evaluated using immunohistochemistry and Western blotting.Olomoucine treatment did not significantly affect maximal infarct volume. Recovery of the affected forelimb on a placing test was impaired in olomoucine-treated rats, whereas recovery in a skilled reaching test was substantially improved. Olomoucine treatment produced small changes in aspects of Iba1 immunolabelling and in the number of CD68-positive cells in cerebral cortex but did not selectively modify responses in peri-infarct tissue. The content of the astrocytic protein, vimentin, was reduced by 30% in the region of the lesion in olomoucine-treated rats.Olomoucine treatment modified functional recovery in the absence of significant changes in infarct volume. The effects on recovery were markedly test dependent, adding to evidence that skilled tasks requiring specific training and general measures of motor function can be differentially modified by some interventions. The altered recovery was not associated with specific changes in key responses of peri-infarct microglia, even though these cells were considered a likely target for early olomoucine treatment. Changes detected in peri-infarct reactive astrogliosis could contribute to the altered patterns of functional recovery.The online version contains supplementary material available at 10.1186/s12974-021-02208-w. Stroke is a leading cause of adult disability . IschemiMany of those affected by stroke show improvements in neurological function within the first few weeks to months after disease onset . ChangesThe focal ischemic insult and infarct formation trigger a complex chain of cellular responses in surrounding tissue. Microglia respond rapidly with prominent morphological changes that include retraction of the cellular processes and enlargement of the soma –11. MicrResponses of astrocytes in peri-infarct tissue are initiated within the first day or two of stroke onset, at least in part as a response to signals from the microglia –18. The Astrocytes in tissue extending well beyond the developing glial scar also exhibit features of reactive astrogliosis that persist for many weeks –18. ThesThe proliferation of microglia and astrocytes within the first hours to days after stroke are key elements of tissue changes that influence adaptive responses in peri-infarct tissue and functional recovery. The manipulation of these glial cell changes has the potential to improve outcomes. Treatment with the cell cycle inhibitors, olomoucine and roscovitine, initiated shortly before or immediately after temporary middle cerebral artery occlusion can result in smaller infarct volumes –26, reduIn the present study, we tested whether olomoucine can affect key responses of peri-infarct microglia and astrocytes and improve recovery in a photothrombotic model of stroke  in whichThe effect of olomoucine on forelimb function was assessed using a placing test and two components of a single-pellet skilled reaching test. The forelimb placing test examines a motor response to stimulation of the vibrissae that provides a sensitive measure of general limb function following photothrombotic stroke . The skiTwo aspects of Iba1 immunolabelling were used as the primary indicator of the responses of microglia in peri-infarct tissue at 3 days after stroke, a time when changes in these properties are near maximal . The useIncreases in expression of GFAP and vimentin, indicative of astrogliosis, develop more slowly and continue for longer than changes in Iba1 immunolabelling in the peri-infarct tissue . PossiblMale Sprague-Dawley rats were obtained from Laboratory Animal Services . The animals were kept in a temperature-controlled and humidity-controlled room with a 12 h/12 h light/dark cycle.A total of 50 rats were used in these investigations. One of these rats died during induction of anesthesia and a second at the conclusion of the period of light exposure. The other 48 rats successfully completed the process for stroke induction and met an inclusion criterion for the study based on performance in a forelimb placing test (see below). Of these rats, 20 were used for assessment of forepaw function up to 29 days after stroke; 12 for studies of Iba1, CD68 and Ki67 immunolabelling and infarct volume at 3 days; and 16 for Western blot analysis at 7 days. Sections of brains removed at 29 days from 12 rats were used for studies of GFAP and collagen IV immunolabelling. Figure Rats weighed between 270 and 340 g at the time of stroke induction. There was no significant difference between the two treatment groups in the weights of the rats for any of the investigations: forepaw function – olomoucine-treated: 293 ± 9 g (mean ± S.D.), vehicle-treated: 300 ± 16 g; immunohistochemistry and infarct volume – olomoucine-treated: 301 ± 14 g, vehicle-treated: 290 ± 9 g; Western blot analysis: – olomoucine-treated: 288 ± 7 g, vehicle-treated: 286 ± 11 g.Rats were randomly pre-assigned to treatment with either olomoucine or vehicle. All assessments of forepaw function as well as the imaging and analysis of brain sections and Western blots were performed by investigators who were blinded to the treatment.An infarct was produced in the forelimb motor cortex using minor modifications  of previA 150 W light source  equipped with a green filter (532.5–587.5 nm pass band) and attached fibre-optic cable (6 mm diameter) was used to illuminate the skull. Before each use, the intensity of the light source was measured at the point of emission from the fibre-optic cable and ranged between 155,000 and 172,000 lx. There was no significant difference in the mean light intensity between the two treatment groups for the three main elements of the investigations. The fibre-optic cable was positioned directly over the window of the stencil and as close as possible to the skull without contacting it. Rose bengal  was injected at 200 μl/min via the femoral vein cannula. The light source was then immediately activated and remained illuminated for 15 min.Rats were treated with olomoucine using a minor modification of the protocol of Wang et al. . A stockThe forelimb function of rats was assessed up to 29 days after stroke induction using a forelimb placing test and two components of a single pellet skilled reaching test.A minor modification  of the fThree variants of the test were used , 34. TheA baseline value for this study was obtained within four days of stroke induction. Rats were tested again at 3 h and then at 1, 7, 14, 21 and 28 days after stroke. A score of 5 or less for the limb contralateral to the infarct at 3 h after stroke was used as an inclusion criterion for the study. This criterion was met by all 48 rats that survived the procedure for stroke induction.Rats were trained to retrieve a pellet through a narrow slit in a single pellet reaching box and tested at baseline and up to 29 days after stroke for total success and first attempt success in retrievals using the forelimb contralateral to the infarct as described previously , 36. To In a previous study, recovery on this task was highly variable when rats were only tested at weekly intervals after stroke . To imprBrain tissue from 12 rats was fixed for immunohistochemistry and analysis of infarct volume at 3 days after stroke. The brains of the 20 rats that were used to test recovery of forelimb function were fixed for additional immunohistochemical analysis on day 29. Rats were anesthetized with 100 mg/kg ketamine and 10 mg/kg xylazine injected intraperitoneally. The brains were perfusion fixed and prepared for sectioning as described previously . CoronalInfarct volume was determined at 3 days after stroke induction using cresyl-violet stained sections at 0.5 mm intervals through the infarct, as described previously .Antibodies for immunohistochemistry to detect Iba1 , Ki67 , CD68  and collagen IV  were from Abcam . The antibody for detecting GFAP  was from Sigma-Aldrich  and for NeuN  was from Millipore-Chemicon . Alexa-fluor-conjugated secondary antibodies were from Thermo Fisher Scientific .For Western blot analysis, antibodies to detect GFAP  were from Sigma-Aldrich, those for vimentin  were from Abcam and for neurocan  were from Millipore-Chemicon. A peroxidase donkey anti-rabbit IgG  from Jackson ImmunoResearch was used as secondary antibody.Two brain sections separated by at least 500 μm were selected from each sample for immunolabelling with each marker. Brain sections from 3 days after stroke were used to assess possible changes in the properties of microglia and tissue macrophages by immunolabelling for Iba1 together with either CD68 or Ki67. Brain sections from 29 days after stroke were used in the investigation of longer-term changes in astrogliosis and angiogenesis using antibodies against GFAP and collagen IV respectively. All sections were also co-labelled with the NeuN antibody to visualize the infarct and assist in identifying the peri-infarct region for analysis .The protocols for immunohistochemistry are essentially as described in detail in previous studies , 37. FreThe methods for image acquisition and analysis used in the present study were largely as described in detail previously , 37. MinWhole immunolabelled sections, other than those immunolabelled for collagen IV, were batch-scanned using the Pannoramic 250 Flash II slide scanner . Images from the peri-infarct and equivalent contralateral regions were then extracted using the CaseViewer software  into TIFF files for analysis in ImageJ (ver 1.51j8) .For sections immunolabelled for collagen IV, images were acquired using an Olympus IX71 inverted microscope with the 10× objective lens. Two adjacent images were captured and stitched together in ImageJ for each hemisphere to create a field of view covering the entire infarct and the equivalent contralateral region.Responses of microglia and macrophages within the peri-infarct tissue were assessed using the parameters of circularity and area fraction of particles in Iba1-immunolabelled sections. Two rectangular regions of interest (ROIs) were analyzed. These encompassed the entire cortical layers extending 500 μm from the lateral edge of the infarct beginning where NeuN immunoreactivity was preserved). Two corresponding ROIs in the contralateral hemisphere were also analyzed see Fig. A. ImagesCounts for CD68-positive and Ki67-positive particles were assessed using ROIs defined using the same approach as for Iba1 and background subtraction was performed using the same parameters. The images were thresholded using the “Otsu” method and the particles analyzed with particle size set at 120-infinity pixels (diameter 2 μm or greater) and circularity at 0.00–1.00.The results for CD68 and Ki67 from these analyses for each brain sample are the average of two sections. Iba1 was co-labelled with each of these two markers resulting in four sections analyzed and averaged for each brain sample for the circularity and area fraction analyses.GFAP and collagen IV immunolabelling were analyzed using methods described previously . The areFor analysis of GFAP immunolabelling, the raw unprocessed images were analyzed. The ROIs within the contralateral region were thresholded using the “Triangle” method in ImageJ and the same thresholding level was applied to the ROIs within the peri-infarct region. The area fraction of GFAP immunolabelling was then determined using the “Measure” function.For collagen IV labelling, background noise was first reduced by applying the “subtract background” function with “rolling ball radius” set at 5 pixels and “sliding paraboloid” option selected, after which the “Despeckle” function was applied. The ROIs within the peri-infarct tissue and equivalent contralateral regions were thresholded using the “Li” method and the area fraction of collagen IV immunolabelling within each ROI was determined using the “Analyze Particle” function with the particle size set to a lower limit of 20 pixels (to exclude debris).Rats were decapitated under anesthesia induced by intraperitoneal injection of ketamine (100 mg/kg) and xylazine (10 mg/kg) at 7 days after stroke induction. For each rat, the brain was rapidly removed from the skull and the infarct was identified from the paleness of the tissue on the surface of the cortex. Cerebral cortex containing the infarct plus approximately 2 mm of surrounding tissue was dissected out for analysis.The tissue samples were homogenized in a buffer containing 10 mM Tris, 1 mM EDTA, 0.32 M sucrose, pH 7.4 and a protease inhibitor cocktail (Sigma-Aldrich) using a Retsch TissueLyser  at a frequency of 30 Hz for 2 min. Western blot analysis for the vimentin, GFAP and neurocan were as described previously . Total pSamples for Western blot analysis were initially prepared from 6 rats in each of the two treatment groups. Although all samples were handled identically, in initial investigations to detect vimentin and GFAP, two samples from olomoucine-treated rats showed a substantially reduced content of these proteins and additional immunoreactive bands at lower molecular weights indicating protein degradation  and the intensity of protein labelling in a full-length transect of each lane was measured as described by Colella et al. . ChemiluAnalysis was performed using SPSS  and Stata .Results from the tests of forelimb function are presented as box plots. The effect of olomoucine treatment on recovery of forelimb function was analyzed using linear mixed effects models. The models included both fixed effect and random effect terms. The random effects component consisted of a random intercept for each rat, thereby allowing variability around the overall fixed effect for each of the individual rats and accounting for the correlation across time for each rat. The fixed effects terms consisted of the day, which was treated as categorical variable and a day X treatment interaction term, in order to test whether the recovery curves differed between treatments across time. When testing for the significance of the interaction, we first tested for global significance of the day X treatment interaction terms, and, when significant, then assessed at which of the time points the difference in treatment effects occurred using the separate day X treatment interaction terms from the model. For analysis of the forelimb placing test, data for all assessments from 3 h to 28 days after stroke were used. For the skilled reaching test, initial post-stroke performance was approximated by assigning a constant value of 3 for total success and 1 for first attempt success, based on values obtained on day 1 (see “Results” section).t tests. For the data obtained from analysis of images of immunolabelled brain sections, the effects of olomoucine treatment and distance from the infarct  were analyzed using two-way analysis of variance for each brain hemisphere. Results for immunolabelling with CD68 and Ki67 were analyzed after log transformation as the untransformed data showed significant differences in variance across the groups.The results for infarct volume, parameters derived from analysis of the immunohistochemistry and band intensity of the Western blots are shown as mean ± standard deviation. The effects of olomoucine treatment on infarct volumes and band intensities from the Western blots were assessed using Student’s A two-sided type 1 error rate of alpha = 0.05 was used for all hypothesis testing.p = 0.604; Student’s t test) between the brains of rats treated with olomoucine (17.8 ± 2.3 mm3) and those treated with vehicle (16.8 ± 4.0 mm3) when assessed at 3 days after stroke.There was no significant difference in infarct volume . Performance between the two groups was significantly different on days 14, 21 and 28  and the number of successes at the first attempt out of 20 were evaluated  and first-attempt success  in the skilled reaching test . In equivalent tissue from the contralateral hemisphere, a statistically significant increase (p < 0.01) in the numbers of these cells was seen in the olomoucine-treated rats.The effects of olmoucine on the number of cells in peri-infarct tissue expressing CD68 was also investigated. CD68 is a protein produced by subpopulations of Iba1-positive cells within the first few days of stroke induction. Reductions in these cells have been seen previously following various treatments that led to improved functional recovery , 43–45. 2 at 0 to 250 μm, 69 ± 71 particles per mm2 at 250 to 500 μm; vehicle-treated, 217 ± 110 particles per mm2 at 0 to 250 μm, 92 ± 71 particles per mm2 at 250 to 500 μm).Immunolabelling for the cell-cycle protein, Ki67, was also measured at 3 days to assess possible downstream changes in cell proliferation resulting from the olomoucine treatment. There was substantial variability in Ki67 immunolabelling between rats but cells containing Ki67 were again most prominent in tissue adjacent to the infarct  in tissue from olomoucine-treated rats compared with that from vehicle-treated rats . In The skilled reaching task, which showed a better recovery following olomoucine treatment, is a complex learned response that requires targeted movements and fine motor control in the forelimb. Rats in the present study were tested 12 times between 6 and 29 days. The multiple sessions in this period probably contributed to the extent of recovery as post-stroke training has been found to promote spontaneous recovery , 54, 55.Previous investigations of the effects of several other interventions on functional recovery in rodent models of stroke have also identified marked differences in the effects on general assessments of motor function or gross neurological performance compared with skilled tasks. However, the responses to different tests of limb function are generally not as markedly divergent as that following olomoucine treatment. A pattern broadly consistent with the effects of olomoucine was seen in response to a treatment involving forced use of the affected forelimb following both ischemic and hemorrhagic stroke , 55, 56.Multiple changes in the brain are thought to contribute to recovery following stroke. This includes altered neuronal activity, axonal sprouting, synaptogenesis, neurogenesis and gliogenesis within the peri-infarct tissue as well as modifications to the activity and connectivity of neurons at more distant locations –8. The sPhotothrombosis occludes vessels in the pia and cortical parenchyma, producing a region of permanent ischemia . Under tOur use of photothrombotic stroke rather than a model involving temporary arterial occlusion also has implications for the potential relevance to stroke in humans. Early reperfusion results in major differences in the progression to tissue damage when evaluated in animal models  and is aProliferation of microglia is an important component of the response of these cells in peri-infarct tissue in the first few days after stroke , 19, 23.In the present study, both the circularity of Iba1-immunopositive cells and the area fraction of Iba1-immunolabelling were analyzed at 3 days when these responses are at or near the maximum. Circularity increases primarily as a result of morphological changes in the cell associated with activation of the microglia. It reaches maximal values by 24 h in peri-infarct tissue and these increases are largely maintained at 3 days . The areOlomoucine treatment produced a small increase in the circularity of Iba1-immunolabelled cells and a small decrease in the Iba1 area fraction in peri-infarct tissue. However, similar changes also developed in tissue from the contralateral hemisphere. Thus, the treatment with olomoucine apparently did not lead to specific modifications of these key responses of peri-infarct Iba1-positive cells to the ischemia-induced tissue damage.Tissue macrophages derived from circulating monocytes express Iba1 and contribute to the changes in Iba1-positive cells in peri-infarct tissue. However, these macrophages are apparently present at much lower numbers than microglia in the peri-infarct tissue at 3 days after stroke. A recent detailed analysis detected tissue macrophages derived from circulating monocytes in the infarct and peri-infarct tissue at 3 days after photothrombotic stroke in mice . These cAnalysis of the numbers of CD68-positive cells indicated that olomoucine also had limited effects on an additional aspect of the response of microglia surrounding the infarct. CD68 is a member of the LAMP family of proteins that is predominantly localized intracellularly in the membranes of lysosomes and late endosomes , 68, 69.The numbers of cells immunopositive for the cell cycle protein, Ki67, was also not significantly affected by olomoucine treatment when assessed at 3 days after stroke. As Ki67 expression develops early in the cell cycle , a blockTogether, the measures of Iba1, CD68 and Ki67 immunoreactivity strongly suggest that treatment with olomoucine did not substantially modify key elements of the microglial response in peri-infarct tissue including the marked morphological changes, proliferation, migration towards the tissue damage and CD68 expression.The most prominent change seen in glial-cell related parameters in response to olomoucine treatment was in vimentin, a cytoskeletal protein that is markedly increased during reactive astrogliosis. Vimentin content was reduced by 30% in samples of tissue that included the infarct and neighbouring peri-infarct tissue at 7 days after stroke induction, when increases in expression of this protein are near maximal , 46, 47.A reduction in aspects of reactive astrogliosis, indicated by the decreased vimentin, is broadly consistent with a previous report in which GFAP content was reduced in the absence of significant changes in infarct volume when olomoucine treatment was initiated early after induction of middle cerebral artery occlusion . ModificInterventions that decrease aspects of reactive astrogliosis can impair or enhance functional recovery following stroke , reflectThe treatment protocol in which olomoucine was injected twice in the initial 24 h after stroke was chosen to increase chances of influencing the early proliferation in peri-infarct glia and also because this protocol had been shown previously to modify a component of reactive astrogliosis without altering infarct volume . NonetheOlomoucine treatment early after photothrombotic stroke modified recovery of motor function in a task-dependent manner without affecting infarct volume. To our knowledge, this is the first demonstration that treatment with a cell cycle inhibitor can influence post-stroke recovery in the absence of significant effects on size of the infarct. The findings add to evidence for differences in the cellular responses underlying recovery of general neurological function compared with skilled tasks requiring training. The study further demonstrated that olomoucine treatment leads to reductions in an important component of reactive astrogliosis in peri-infarct tissue. In contrast, there was little effect on key properties of peri-infarct microglia even though some of these cells divide early after infarct development. Alterations induced in aspects of reactive astrogliosis could modify adaptive responses of neurons in peri-infarct tissue and influence recovery of neurological function.Additional file 1: Fig. S1. Western blot of GFAP in samples of the infarct plus peri-infarct tissue at 7 days after photothrombotic stroke. Rats were treated with olomoucine (O) or vehicle (V). The investigator responsible for the Western blotting was blinded as to the treatment of the rats and had no control over the order of the samples. The numbers show the total protein for each sample as determined from chemiluminescence after transfer to the polyvinylidene fluoride membrane expressed relative to the mean intensity of all the lanes. Samples from olomoucine-treated rats in lanes 5 and 10 show evidence of marked degradation of the GFAP compared with the other samples and were not used in the subsequent analysis. Fig. S2. Unprocessed images of Iba1 immunolabelling in coronal sections of the peri-infarct tissue and equivalent tissue from the contralateral cortex from a rat treated with olomoucine and one treated with vehicle. The upper edges of the images from the peri-infarct tissue run parallel to the edge of the infarct as shown in Fig. Fig. S3. Western blots of vimentin and neurocan in samples of the infarct plus peri-infarct tissue at 7 days after photothrombotic stroke. Rats were treated with olomoucine (O) or vehicle (V). The investigator responsible for the Western blotting was blinded as to the treatment of the rats and had no control over the order of the samples. The numbers in the vimentin blot show the total protein for each sample as determined from chemiluminescence after transfer to the polyvinylidene fluoride membrane expressed relative to the mean intensity for all the lanes. In the neurocan blot, the full-length protein (approximately 250 kDa) and major fragment (approximately 150 kDa) detected by the antibody are indicated. Results for this protein were determined as a ratio of the full length protein to the fragment. The break in the blots is due to the removal of lanes that were not used in the analysis of vimentin or neurocan content.


IntroductionAfter detailed anatomical delineation of the anterolateral ligament (ALL) of the knee, there is a surge in research on this anatomical structure. Owing to the anatomical variation and lack of experience in the identification of this structure, magnetic resonance (MR) evaluation of the ALL produces mixed results. It was aimed to evaluate the ALL using the routinely performed MR imaging of the knee and to determine any associated factors with ALL injuries.Materials and methodsThirty-six MR images of the knee from 31 patients from January 1, 2017, to June 30, 2017, are evaluated. MR sequences performed include T1-weighted, T2-weighted, proton density (PD), and PD fat saturation (FS). All MR images were double-read by two authors and approved by a consultant radiologist with more than 20 years of radiological experience. The ALL was divided into three portions: femoral, meniscal, and tibial, and the ALL was considered fully visualized when all three portions were seen on MR images.ResultsAt least a portion of the ALL was visualized in 27 scans (75%), and it was fully visualized in 20 scans (55.6%). The femoral portion was the most commonly identified (75%), followed by the meniscal portion (69.4%) and the tibial portion (58.3%). ALLs were best visualized on coronal view in PD FS with the lateral inferior genicular artery as a guide to locate the bifurcation of the meniscal and tibial components.ConclusionThe ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via a PD-weighted sequence with fat saturation on the coronal plane. The ALL injury was associated with an anterior cruciate ligament (ACL) injury. The anterolateral ligament (ALL) of the knee was described by Segond in 1897 as “a pearly, resistant fibrous band which shows tension during forced internal rotation” -5.In 2013, Claes et al. delineate the ALL as a distinct ligamentous structure with consistent origin and insertion sites that subsequently renew the study interest on anterolateral soft tissue structures of the knee -8. With Alongside anatomical studies, biomechanical studies also demonstrate that ALL is involved in the stabilization of knee rotation, especially during knee flexion of angles more than 30 degrees -15. ThisClinically, ALL reconstruction, in addition to ACL reconstruction, yields favorable outcomes. A meta-analysis by Kunza et al. shows that combined ACL and ALL reconstruction improves pivot shift and offers comparable clinical and functional outcomes compared with ACL reconstruction alone with no added complication . A reviePrevious studies in the identification of ALL with magnetic resonance imaging (MRI) revealed a mixed result. By utilizing a 3-Tesla (T) MRI, Hooda et al. managed to identify ALL in all 31 patients . On the This is a cross-sectional study to review MR images of knees performed in patients with suspected ligamentous injuries from January 1, 2017, to June 30, 2017. All the MRI knees are performed using a 1.5T MR scanner  and Tx/Rx 15-channel knee coil (Siemans) with the following sequences: coronal proton density-weighted with fat saturation, T1 sagittal, sagittal proton density-weighted with fat saturation, T2 sagittal, and T2 axial  are assessed and are labeled as either visualized or not visualized. When all three components of the ALL are seen, it is classified as a fully visualized ALL. Next, the ALLs are assessed for any abnormality, as evidenced by any obvious discontinuity in the fibers, irregular contours associated with periligamentous edema, or proximal or distal avulsion, with or without associated bone fragment -23. OtheThe findings of the ALL components are presented with a descriptive method. The association between ALL injuries and other intra-articular or extra-articular structural injuries is evaluated via Fisher’s Exact test.A total of 36 knee MR images from 31 patients are included in this study period, with five patients being excluded (3 tumor cases and 2 postoperative scans). The demographic data is summarized in Table We are able to delineate ALL fully in 20 scans (55.6%), and it is partly visualized (at least one part of the ALL was characterized) in 27 scans (75%). Out of the three components, the femoral part is the most commonly identified structure , followed by the meniscus part  and the tibial part n=21, 58.3%). ALLs are best visualized on PD FS coronal view, with the lateral inferior genicular artery acting as a guide to locate the bifurcation of the meniscal and tibial components  have ALL injuries. There are also 19 knees (52.8%) with evidence of ACL injuries. This is followed by injuries of the medial meniscus , lateral meniscus , PCL , and lateral collateral ligament . There is no medial collateral ligament injury identified among all the knee MR images in this series. Among the 19 knees with evidence of ACL injuries, nine of them have concomitant ALL injuries. The association of ALL injuries with injuries of other ligamentous structure are highlighted in Table Paul Segond was the first to describe avulsion fracture of the proximal lateral tibia secondary to forced internal rotation of a flexed knee . MultiplDespite detailed delineation of the ALL, MRI evaluation of the ALL remains challenging because of the anatomical variations and the fine thickness of this structure ,24. AsidSimilar to the findings of Helito et al., we find that the ALL is best visualized on the coronal plane . It shouFor beginners to identify the ALL, we adopt the recommendations of Helito et al, in which the inferior lateral geniculate artery (ILGA), whenever it is present, is used as a landmark to identify the bifurcation of the meniscal and tibial portions of the ALL . We findIn this series, a total of 11 scans (30.6%) reveal ALL injuries. As in our expectation, ALL injuries are associated with ACL injuries. This result mimics the one reported by Claes et al. and Ferretti et al., as there is an increased prevalence of ALL abnormalities in ACL-injured knees -26. A vaLimitationThis study is limited by its small sample size and retrospectively collected data from a single institution, making it difficult to generalize the results to the whole population of Malaysia. As the MRI evaluation of ALL is at an inchoate stage, this study does not examine the inter-observer differences, as this pilot study is aimed to familiarise both the orthopedic surgeons and radiologists with the anatomy and technique to identify the ALL in the MR images. In this series, we examine MR images of both acute and chronic injuries, which might lower the detection rate of the ALL injury, as the ensuing fibrosis may mask the ALL injury . Lastly,The ALL can be visualized in routine 1.5-T MR imaging, either full delineation (55.6%) or partially visualized (75%). It is best characterized via PD-weighted and T2 sequences with fat saturation on the coronal plane. The most common identifiable part of the ALL is the femoral portion, whereas the least identified portion is the tibial part.


Appointment nonadherence is common among people with glaucoma, making it difficult for eye care providers to monitor glaucoma progression. Our objective was to determine whether the use of patient navigators, in conjunction with social worker support, could increase adherence to recommended follow-up eye appointments.A randomized, controlled trial evaluated the effectiveness of an intervention that used patient navigators and social workers to improve patient adherence to follow-up eye care compared with usual care. Participants with glaucoma and other eye diseases (N = 344) were identified at primary care clinics in community settings through telemedicine screening of imaging and then randomized to enhanced intervention (EI) or usual care (UC). Data on participants’ visits with local ophthalmologists were collected for up to 3 years from randomization. Groups were compared for timely attendance at the first visit with the local ophthalmologist and adherence to recommended follow-up visits.P < .001). Rates of adherence to recommended annual follow-up during year 1 were 18.6% in the EI group and 8.1% in the usual care group . The aRR across years 2 and 3 was 3.92 .Timely attendance at the first visit was higher for EI than UC (74.4% vs 39.0%; average relative risk [aRR] = 1.85; 95% CI, 1.51–2.28; An intervention using patient navigators and social workers doubled the rate of adherence to annual recommended follow-up eye care compared with usual care in community settings, and was effective at increasing connections with local ophthalmologists. Interventions to further improve long-term adherence are needed. Nonadherence to follow-up eye care is common among people with glaucoma and other eye diseases. Use of patient navigators and social workers can increase adherence to eye care appointments.The results of a randomized, controlled trial of patients with glaucoma and other eye diseases showed that a patient navigation and social work intervention doubled the rate of follow-up adherence in community settings.Involving patient navigators and social workers in ophthalmic care could improve care and reduce disease progression.Glaucoma is a chronic eye disease resulting in visual field defects and progressive vision loss and is the leading cause of irreversible blindness worldwide . Among oPatient navigators and social workers can help address barriers to appointment adherence. Patient navigators direct patients to appropriate health care resources, coordinate and schedule appointments, verify insurance status, and arrange transportation ,13. PatiSocial workers assess, track, and lessen psychosocial barriers to care to improve quality of life and patient well-being ,18. SociThe combined use of social workers and patient navigators to improve appointment adherence among glaucoma patients has not been investigated previously in a controlled, prospective adult study. Our objective was to determine whether the use of patient navigators and social workers could increase adherence to recommended follow-up eye appointments among a high-risk population with glaucoma or other eye diseases.The Philadelphia Telemedicine Glaucoma Detection and Follow-up Study was a prospective, randomized clinical trial that aimed to address the issue of poor adherence to follow-up eye examinations by providing patient navigator and social worker support to directly guide participants through the eye care process . The 5-yIn Phase 1, the study aimed to identify people with undiagnosed glaucoma and other eye diseases and facilitate their referral to local ophthalmologists. A targeted sample at high risk for eye disease was recruited from 12 community partner organizations and consisted of African American, Hispanic, and Asian adults over age 40; adults over age 65 of any race/ethnicity; and people over age 40 with a family history of glaucoma or currently diagnosed with diabetes. We enrolled only people who had not seen an ophthalmologist in the previous 12 months (N = 906). After informed consent was obtained, participants underwent a brief vision screening in their primary care provider’s (PCP’s) office (Visit 1), which included measuring visual acuity and intraocular pressure (IOP), and using fundus (retina) photography. Both retina and glaucoma specialists used telemedicine to read the images at Wills Eye Hospital. If the IOP was greater than 30 mm Hg, participants were immediately referred to a local ophthalmologist (fast-tracked). Otherwise, participants with findings suggestive of sight-threatening disease, such as glaucoma, diabetic retinopathy, or hypertensive complications, or with unclear screening results were invited to return to the same location for a comprehensive eye examination by an ophthalmologist (Visit 2). At Visit 2, visual acuity and IOP were assessed again in addition to an ophthalmologic examination. Visual field tests were also performed, and vision-related quality of life was assessed by using the National Eye Institute Vision Function Questionnaire (NEI-VFQ). Previous publications  report eAll participants who completed Visit 2 or who were fast-tracked were invited to participate in Phase 2 of the study. Phase 2 was a randomized controlled clinical trial designed to evaluate whether an enhanced intervention (EI) using patient navigation and social worker support improved patient adherence to follow-up eye care over usual care (UC) among those with newly diagnosed or suspected glaucoma or other ocular conditions.Recruitment and randomization. Participants consenting to participate in Phase 2 were randomized to either the UC group or the EI group at a fixed 1:1 allocation ratio by using a masked method of random permuted blocks. Study coordinators retrieved the randomization and allowed participants to select an ophthalmologist they would like to follow up with over the next several years from a list of 20 participating offices located within 5 miles of the screening site.Usual care. Participants randomized to UC were given their selected ophthalmologist’s contact information and a copy of their eye examination results. UC participants were instructed to schedule an initial appointment with the ophthalmologist (Visit 3). Once connected to that ophthalmologist, services provided by each local ophthalmology practice generally included telephone calls and/or text message reminders before appointments. No practices provided patient navigator or social worker assistance as part of their usual care during the study period.Enhanced intervention. Participants randomized to EI received a team-based intervention that included comprehensive assessment by a licensed social worker and assistance from patient navigators. The social worker called EI participants up to 3 times within 2 weeks to conduct an initial assessment, explain the EI process, assess participants’ understanding of their new or existing ocular diagnosis, and document current and past barriers to obtaining eye care. The social worker provided community resources for participants in need of food and medications at no cost or at a reduced cost and discussed options for transportation to the local ophthalmologist. The social worker also assessed the participant’s ability to complete their activities of daily living and provided emotional support. EI participants interacted by telephone with the social worker at least 3 times per year over 2 years.Wills Eye Hospital study managers, ocular technicians, and research assistants served as patient navigators for EI participants. Their responsibilities included calling participants to schedule appointments; confirming appointments by mail, email, and/or text messaging; arranging transportation through Customized Community Transportation and Philadelphia Paratransit Service; and scheduling language interpreters with medical training to participate in eye examinations as needed. Patient navigators were able to identify cultural and language differences and were aware of health literacy issues. When possible, navigators were race and language concordant with the patient population.Management and follow-up examinations. At Visit 3 and each follow-up visit, the local ophthalmologist assessed the participant’s ocular, medical, and family history and conducted a comprehensive eye examination based on their clinical practice. The ophthalmologist would reconfirm ocular diagnoses, perform testing, adjust treatment recommendations as needed, and recommend follow-up intervals for the participant.Final study visit. All randomized participants were invited to a final visit at their PCP’s office at the end of the follow-up period. At this visit, the NEI-VFQ was re-administered, visual acuity and IOP were measured, and overall participant satisfaction with the study was assessed.Outcome assessment. The research staff visited local ophthalmologists’ offices to record visit dates, indications, findings, and treatments for up to 3 years from Visit 2. Data collection closed in March 2019.Annual adherence. The primary outcome measure was adherence to recommended follow-up eye care appointments after Visit 3. Adherence was assessed annually on the basis of the expected follow-up schedule defined at the index visit for that year. In the first year, the follow-up recommendation given at Visit 3 by the ophthalmologist was classified into 1 of 4 categories: return within 2 months, return in 3 to 4 months, return in 6 months, or return in 12 months. This follow-up recommendation was then translated into the corresponding expected number of visits per year: 6, 3, 2, or 1. Participants were classified as adherent if the number of visits made within 13 months of Visit 3 (395 days) met or exceeded this expected number. Those who attended fewer visits or did not attend the initial visit with the local ophthalmologist within 12 months were deemed nonadherent for the first year. Adherence in the second and third years of follow-up was similarly defined; however, the follow-up recommendation used to define the required number of visits was based on the patient’s most recent visit with the ophthalmologist before the start of that follow-up year. That is, the last visit that occurred during the first year of follow-up determined the follow-up schedule applied to the second year; similarly, the last visit that occurred during the second year of follow-up determined the follow-up schedule for the third year. When no visit occurred during a given year, the previous follow-up recommendation was carried forward. Additional measures of intervention effectiveness were explored, as detailed below.Visit 3 attendance — initial visit with local ophthalmologist. The study evaluated the intervention’s effectiveness in achieving the initial connection with the local ophthalmologist through timely attendance at Visit 3. Timely attendance was defined as having a first visit within 12 months of randomization.Visit 4 attendance — first follow-up visit with local ophthalmologist. Adherence to the first follow-up visit (Visit 4) was assessed on the basis of the follow-up recommendation of the local ophthalmologist at Visit 3. Participants with follow-up recommended within 2 months were deemed adherent to the first follow-up visit if they returned within 3 months; for recommended follow-up of 3 to 4 months, 6 months, or 12 months, patients were considered adherent to Visit 4 within 6, 12, or 15 months, respectively.Total number of visits with local ophthalmologist. The total number of visits included all visits on distinct days occurring after randomization, including Visit 3.Satisfaction. A brief questionnaire was administered at the final study visit to assess overall satisfaction. By using a 4-point Likert-type scale, participants were asked to state their satisfaction with the study and the local ophthalmologist, perceived helpfulness of the study toward understanding their recommended eye-care, and likeliness to continue with follow-up care at the local ophthalmologist.The study was designed to detect a 20% difference in adherence rates between groups during the first year of follow-up by using a 2-tailed test with α = 0.025. With a final sample size of at least 135 participants per group, power to detect such a difference was 86% when the overall adherence across both study arms was 50%.Participant characteristics at Visits 1 and 2 were summarized by randomization arm by using means and SDs or number and percentages. Adjusted estimates of the relative risk (aRR) of timely attendance at Visit 3 were calculated by using Poisson regression in a generalized estimating equation framework . An exteIn the longitudinal model, 2 relative risks were calculated and 2 hypotheses were tested: 1) comparing randomization groups at year 1 to assess differences in early adherence and 2) calculating the average effect of randomization group across years 2 and 3 to test the long-term efficacy of the intervention. Each test was performed with α = 0.025. Supporting analyses compared groups with respect to the percentage of participants who attended any visits with the local ophthalmologist, the percentage of participants who were adherent to their first post-Visit 3 visit, and the total number of visits after randomization. Analyses of dichotomous end points used the same approach as Visit 3 analysis. Number of visits was modeled by Poisson regression with follow-up time from randomization as the offset. An exploratory subset analysis was performed for participants with glaucoma-related diagnoses . All analyses were performed by using SAS 9.4 and SAS/STAT 14.3 (SAS Institute).From April 2015 through February 2017, 906 participants completed the telemedicine eye vision screening (Visit 1) with their PCP as part of Phase 1 of this 5-year study  22). On. On22). The mean age of participants was 59.9 years at screening; most (59%) were women and 66% were African American . RoughlyTimely Visit 3 attendance. About half of participants  attended the initial visit with the local ophthalmologist within 12 months of randomization (P < .001). The effect was similar in the subset of participants with glaucoma-related diagnoses . Among those who made timely contact with the local ophthalmologist, the median time to first visit was 57 days (interquartile range [IQR]: 39–92) in EI and 47 days (IQR: 27–82) in UC. Rates of any attendance at the local ophthalmologist were also higher in EI  indicating that the intervention significantly increased the rate of adherence (P = .02). Results were similar in an exploratory analysis of the glaucoma-related diagnosis subset with an aRR of 2.30 for year 1 adherence  and 3.44 across years 2 and 3  , the rate was 56.4% for EI group and 22.7% for UC  . The aveFinal study visit and satisfaction survey. One-hundred forty-three participants attended the final study visit at the PCP office . Both groups were satisfied or very satisfied with participation in the study , and most participants in both groups found the study very helpful in understanding and taking care of their eyes .In analysis of our primary outcome, we found that an intervention combining the support of patient navigators and social workers doubled adherence to recommendations for follow-up with a local ophthalmologist during the first year. These effects were similar for participants with or without glaucoma-related diagnoses. Much of this effect was likely due to an 85% relative increase in timely attendance at the initial visit with the ophthalmologist (Visit 3) for those randomized to the intervention arm (EI). After the first year, adherence rates dropped, but were still higher in the EI group.Our results are similar to previous studies. The UC group in our study had only 39% attendance at the initial ophthalmologist visit, similar to results from the Hoffberger program, which provided free community-based eye screenings to residents of Baltimore, Maryland, at high risk for eye disease . In anotPatients with glaucoma may face barriers to receiving follow-up eye care, which should be recognized and addressed. A questionnaire presented to patients in a glaucoma clinic who were referred to a medical social worker found that the most frequent barrier to receiving eye care was emotional distress; additional barriers were cost of visits, lack of insurance, transportation, impairment of daily activities, and language . AnotherOur low annual adherence rates may be because adherence for the year was defined on the basis of the follow-up recommendation at the beginning of the year. For example, if a participant was given a recommendation during Visit 3 to follow up in 2 months, this was considered the desired follow-up interval throughout the following year. However, recommendations for follow-up could have varied during the year, and this may have affected our annual adherence results.Our study had several limitations. First, in spite of the improved adherence in the EI, annual adherence was still unacceptably low compared to what is necessary for adequate treatment. Second, our sample size for year 3 limited our ability to assess the long-term benefit of the intervention. Lastly, different ophthalmologists’ offices used diverse measures to remind patients to return for follow-up eye examinations, which were not controlled and could have affected our results.This study targeted a diverse, urban population at risk for glaucoma but not receiving regular eye care. Study results would likely be generalizable to similar settings, although access to care, insurance rates, and existing support systems are likely to differ in other geographic areas and may affect the benefit of the intervention.Future studies could consider combining additional interventions to further increase rates of adherence to follow-up eye care. Other interventions that may show promise include providing incentives such as free eyeglass prescriptions or free eyeglasses  and prov


This study assesses the construct validity and sensitivity to change of the Short Warwick-Edinburgh Mental Well-being Scale (SWEMWBS) as an outcome measure in the treatment of common mental disorders (CMD) in primary care settings.127 participants attending up to 5 sessions of therapy for CMD in primary care self-rated the SWEMWBS, the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7) scales. SWEMWBS’s construct validity and sensitivity to change was evaluated against the PHQ-9 and GAD-7 across multiple time points in two ways: correlation coefficients were calculated between the measures at each time point; and sensitivity to change over time was assessed using repeated measures ANOVA.Score distributions on SWEMWBS, but not PHQ-9 and GAD-7, met criteria for normality. At baseline, 92.9% (118/127) of participants scored above clinical threshold on either PHQ-9 or GAD-7. Correlations between SWEMWBS and PHQ-9 scores were calculated at each respective time point and ranged from 0.601 to 0.793. Correlations between SWEMWBS and GAD-7 scores were calculated similarly and ranged from 0.630 to 0.743. Significant improvements were seen on all three scales over time. Changes in PHQ-9 and GAD-7 were curvilinear with greatest improvement between sessions 1 and 2. Change in SWEMWBS was linear over the five sessions.This exploratory study suggests that SWEMWBS is acceptable as a CMD outcome measure in primary care settings, both in terms of construct validity and sensitivity to change. Given patient preference for positively over negatively framed measures and statistical advantages of measures which are normally distributed, SWEMWBS could be used as an alternative to PHQ-9 and GAD-7 in monitoring and evaluating CMD treatment. The Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) was developed in 2007  to suppoThe concept of mental wellbeing was developed in the context of positive psychology . It is nCommon mental health disorders (CMDs) comprise of depression, anxiety, panic attacks, and obsessive compulsive disorders and are highly prevalent being experienced by 14.7% of men and 23.1% of women in the UK according to 2014 estimates . Only 39Qualitative studies have indicated that mental health service users and their carers would choose WEMWBS over other commonly used measures for monitoring and evaluating the effect of interventions on their mental health . WEMWBS The aim of this study was to investigate the construct validity of SWEMWBS as an outcome measure in patients with CMD undergoing psychological therapy in comparison to two widely used primary care based clinical outcome measures, the Patient Health Questionnaire 9 (PHQ-9)  and the The data for this study were gathered using electronic software developed by the Pragmatic Research Network, a collaboration of professionals promoting service-based evaluation and feedback-informed treatment. The software allows session by session administration of outcome measures, producing reports for feedback to clients and therapists to inform the progress of the therapy and service evaluation.Data were collected by therapists practicing a form of psychotherapy, cognitive hypnotherapy (CHT). Therapists were informed about the proposed study through an online forum and invited to participate in the research. Fully anonymised data from consented participants and therapists was made available for the study. The Pragmatic Research Network supervised data collection for those who consented to take part, providing an initial training day and a combination of face-to-face, telephone and e-mail support to ensure an appropriate standard was reached.CHT uses induction into a trance-like state to access unconscious problematic thoughts, feelings, and memory patterns. Therapy focuses on interrupting faulty pattern matching by changing the context, structure, process or consequence of the problem pattern and is individually tailored to clients’ needs . It starParticipants were adults seeking CHT as treatment for mental health problems, mainly anxiety and depression, at the private, fee paying practices of participating therapists between October 2014 and April 2016. All participants were informed about the research objectives and written consent was obtained. 127 participants were recruited and provided data at the first session (Therapy 1) and at least one more session, enabling measurement of change over time; 34 participants provided data for five consecutive sessions.Participants completed three measures for the first time before Therapy 1 and each subsequent treatment session. Measures were given to participants to complete using the web based ‘pragmatic tracker’ software either via email link or on arrival to their session. The three measures were the SWEMWBS ; PHQ-9  and GAD-SWEMWBS is a seven item self-report measure of mental wellbeing . Construth edition (DSM-IV) disorders, mood, anxiety, somatoform, alcohol, and eating . The nine item PHQ-9 is the depression module of the full PHQ and consists of the nine criteria on which the diagnosis of DSM-IV depressive disorders is based [PHQ-9 is a self-administered version of Primary Care Evaluation of Mental Disorders (PRIME-MD), an instrument developed to assist primary care clinicians in making criteria-based diagnoses of five types of Diagnostic and Statistical Manual of Mental Disorders, 4is based . PHQ-9 sis based , 41.The GAD-7 is a self-rated tool for screening for generalised anxiety disorder (GAD) and assessing its severity in clinical practice and research. Initial items were based on DSM-IV diagnostic symptom criteria for GAD and existing anxiety scales. The seven item anxiety scale (GAD-7) has been shown to have good reliability as well as criterion, construct and factorial validity when administered in primary care settings . Cut offT-test was used to assess change from baseline to last measurement for participants who completed two, three, four and five sessions respectively.Analyses were performed using SPSS 24.0. Score distributions for each scale were assessed by visual inspection and the Shapiro–Wilk test for normality. Mean and standard deviation (SD) scores for SWEMWBS, PHQ-9 and GAD-7 were calculated at baseline (assessment) and at each subsequent time point. A paired samples Spearman’s Rho was used to assess the correlation between the measures at different time points.Internal consistency was calculated for SWEMWBS in this clinical sample using Cronbach’s Alpha at Time 1 and Time 5.Time series analyses were conducted  to assess significance of change over time for participants attending two, three, four and five sessions respectively across each clinical outcome measure. Within subject effects tests were carried out to assess difference of scores over repeated sessions, and further within subject contrast tests were carried out where data for more than two time points were available to identify polynomial contrasts . Corrections were applied where the data did not comply with the assumption of sphericity, in order to maintain the power of the test and reduce the chance of type 2  errors. Greenhouse–geisser corrections were applied when Mauchly’s test of sphericity resulted in ε < 0.75 and Huynh Feldt when Mauchly’s test of sphericity resulted in ε > 0.75 The mean age of the participants N = 127) was 38.0 (95% CI 35.4–40.6) years; 74.8% (N = 95) were female and 96.1% (N = 105) White. The majority were employed, lived with a partner and not on medication  at each time point; coefficients ranged from -0.60 at Therapy 1 to − 0.79 at Therapy 5 (Table P < 0.005) at each time point with coefficients ranging from -0.63 at Therapy 1 to − 0.74 at Therapy 5 (Table P < 0.005).Correlations between SWEMWBS and PHQ-9 scores were negative and significant ( 5 Table . Correla 5 Table . SlightlP < 0.005) change was seen between baseline and last measurement on all three measures  end of the mental health spectrum and SWEMWBS may be more sensitive to change at the less unwell end of the spectrum. Differences in the trend of change over time for SWEMWBS and clinical measures and correlation at less than 0.9 at different time points could be due to differences in the measurement properties of the different scales, particularly ceiling effects with the mental illness measures. This suggestive finding needs corroborating in other studies; if it proves valid it would be consistent with the intended purposes of the different scales.These results suggest that SWEMWBS shows construct validity as a clinical outcome measure for patients with CMD and can be used to assess change over multiple time points. This, together with patients’ preference for positively focused measures , makes SOur findings align with those of a sample of clinical patients with Severe Mental Illness undergoing psychological therapy, where change with similar effect size was seen using WEMWBS when compared to clinical measures , 25. A pSWEMWBS could be considered either on its own or in conjunction with clinical measures, which may provide greater sensitivity at the onset of intervention when patients have worse levels of mental health. The lack of tapering suggests that SWEMWBS enables measurement beyond clinical cut-off points for CMD and thus meets the need for a measure that is appropriate and valid across public health and clinical interventions. The respective sensitivity of the scales at higher levels of mental health as patients enter recovery phases should be investigated in future research. Given the small sample size and limited diversity of the sample, the findings in this study should be further investigated in larger datasets such as in the NHS where SWEMWBS and WEMWBS are both being used in clinical populations A recent population-based psychometric analysis  of WEMWBFew studies collect data using both positive and negative outcome measures over multiple time points to allow the comparisons made in this study, but the relatively small sample, consisting of mainly white women who were able to pay fees for private therapy, limits conclusions with regard to the changes which might be observed in a more diverse and wider population. Although there is no a priori reason to suppose that the relationship between these scales would be different in different population groups, conclusions drawn would be strengthened by validation in other populations.Within this cohort the majority of participants completed two sessions. The number of participants with analysable data reduced with each consecutive session. In 46.5% of instances this represented documented planned endings and in others the ending may have been mutually agreed given the nature of the practice. Nonetheless, the possibility remains that the groups completing up to five sessions may have differed to those completing fewer sessions: those who were motivated to attend more sessions may have had a greater capacity to reach higher levels of wellbeing; or those who were not experiencing benefit may have terminated sessions earlier. These limitations would be important if the data were being used to evaluate the effectiveness of CHT, but this was not the purpose of this study. They do not impact the validity of conclusions relating to the measurement properties of the three scales.Reflection on scores of all three scales during therapy sessions may have introduced social desirability bias but there is no a priori reason to believe that this would have affected responses to the three measures differentially.In this exploratory analysis, SWEMWBS demonstrates construct validity and sensitivity to change as a clinical outcome measure for patients with CMDs in primary care, demonstrating inverse correlation and comparable sensitivity to change over a course of clinical treatment when compared to two widely used clinical outcome measures. These analyses provide support for the use of SWEMWBS use as an outcome measure for clinicians and services who wish to respect clients’ preference for SWEMWBS over negative and illness focused measures . Results


Pattern 1 predicted CAP with bacterial and mixed bacterial and viral etiologies with positive predictive values of 99%  and 97% , respectively. Pattern 2 ruled out mortality with a negative predictive value of 95% , respectively. In this study, LUS was useful in predicting a diagnosis of CAP, the bacterial etiology of CAP, and favorable outcome in patients with CAP.To assess the usefulness of lung ultrasound (LUS) for identifying community-acquired pneumonia (CAP) among adult patients with suspected lower respiratory tract infection (LRTI) and for discriminating between CAP with different cultural statuses, etiologies, and outcomes. LUS was performed at internal medicine ward admission. The performance of chest X-ray (CXR) and LUS in diagnosing CAP in 410 patients with suspected LRTI was determined. All possible positive results for pneumonia on LUS were condensed into pattern 1  and pattern 2 . The performance of LUS in predicting culture-positive status, bacterial etiology, and adverse outcomes of CAP was assessed in 315 patients. The area under the receiver operating characteristic curve for diagnosing CAP by LUS was significantly higher than for diagnosis CAP by CXR (0.93 and 0.71, respectively;  According to guidelines, the demonstration of an infiltrate on chest X-ray (CXR) in patients with LRTI acquired in the community suggests a diagnosis of community-acquired pneumonia (CAP)2. However, several studies point to CXR’s low sensitivity for diagnosing CAP6. There are increasing data on the use of lung ultrasound (LUS) to diagnose pneumonia6. Most of those works enrolled patients with a suspect of CAP which was neither standardised nor reproducible. This issue may impact massively both in the diagnostic performance of LUS and in the generalizability of the results. Additionally, even though ruling in/out pneumonia in patients with suspected LRTI acquired in community is a common issue in clinical practice, the diagnostic performances of CXR and LUS have never been compared in this cohort of patients9.Lower respiratory tract infection (LRTI) acquired in the community is one of the most common reasons for hospitalization among adults16, while viruses were identified in approximately one-third of cases18. More recently, the recognition of viral pathogens in the etiology of CAP has increased1. At hospital admission, clinical features of bacterial or viral CAP frequently overlap and cannot be used reliably to distinguish between the two etiologies19. Even CXR findings are not sufficiently specific to determine the causative agents of infection and influence treatment decision. Finally, since CAP is associated with high mortality and morbidity, there is an urgent need for early detection of a severe disease course13.In many studies of adult patients with CAP, bacteria were shown to be the most commonly detected organismsIf LUS was confirmed to be an accurate diagnostic method for identifying CAP among undifferentiated patients with suspected LRTIs, one might hypothesize that it could also be useful in helping physicians predict the etiology of CAP and CAP outcomes. However, studies do not exist that attempted to associate unique LUS features with these factors in patients in whom the etiology of CAP was established with reasonable certainty.first, is LUS more useful than CXR to predict diagnosis of pneumonia among patients with a standardised and reproducible suspect of community-acquired LRTI ?second, is LUS helpful to predict the etiology of CAP in patients in whom the causative agents of pneumonia are established according to a broad microbiological work-up ?third, is LUS useful in predicting favorable/unfavorable outcome of CAP ?Therefore, we conducted a prospective study to answer to three questions:2 were recruited in a 45-bed internal medicine ward (IMW) at the University Hospital of Trieste, Italy. Enrollment of the patients started on January 1, 2018, and ended on January 1, 2020  a specific cultural status, 2) the need for empirical antibacterial therapy, and 3) the need to escalate/de-escalate the intensity of treatment in patients with a definitive diagnosis of CAP. The inclusion and exclusion criteria of the first and second analyses are available in the 6. The results of LUS were not incorporated into the final diagnosis assessment. For the second analysis, the frequency of each LUS result (positive/negative) and positive pattern (pattern 1 and pattern 2) were compared in the following cohorts: 1) patients with culture-positive CAP vs those with all culture-negative CAP, 2) patients with all bacterial CAP vs those with viral CAP and CAP due to coinfection vs those with viral CAP, and 3) deteriorating patients vs nondeteriorating patients with CAP and nonsurviving vs surviving patients with CAP. Since bacteria and pattern 1 were the most common pathogen and LUS pattern, respectively, in patients with CAP in this study (Table Continuous data are expressed as medians (interquartile ranges) according to their distribution. Categorical variables are expressed as numbers and percentages. Pearson’s chi-square test was used to analyze categorical variables, and the Mann–Whitney test was used to analyze continuous variables. Bonferroni correction was applied when more than two groups were compared. In the first analysis, the number of positive and negative results for CAP of both CXR and LUS were put side by side in patients with suspected LRTI. The “gold standard” for CAP was the definitive diagnosis of CAP recorded by the physician in charge at the end of the clinical work-upThe study protocol was approved by the medical ethical committee of Trieste. Informed consent before study enrolment was obtained from all patients or their legal representatives or surrogates.p < 0.001. Figure Of the 420 patients with suspected LRTI eligible for inclusion, 9 patients refused to participate. In 1 patient, aspiration was witnessed. A total of 410 patients underwent both CXR and LUS at IMW admission and were included in the first analysis Fig. . At the p = 0.043). Pattern 1 was strongly associated with culture-positive CAP (p = 0.038). The same pattern was also more commonly found in patients with all bacterial CAP, CAP due to coinfection and bacterial CAP when they were individually compared with patients with viral CAP . The clinical characteristics of the patients with CAP who exhibited pattern 1, pattern 2, and negative LUS results are shown in Table p = 0.015) and mortality at 30 days (p = 0.006). All 8 patients with CAP who were showed false negative LUS results survived at 30 days; none of them were culture-positive at the end of the microbiological work-up. The performance of LUS in predicting all the outcomes of the second analysis is provided in Table Out of the 328 patients with a definitive diagnosis of CAP, 13 patients were excluded from the second analysis because a minimum microbiological work-up was not performed (11), they were diagnosed with mycobacterial infections (1), or they were diagnosed with fungal infections (1). Thus, 315 patients with CAP were included in the second analysis Fig. . The cliThis study assessed the usefulness of LUS performed at hospital admission in supporting physicians in several aspects of CAP management from diagnosis through the identification of patients in whom cultures are likely/unlikely to provide useful diagnostic information and of patients in whom empirical antibacterial therapy is mandatory to prognostication.6. However, the diagnostic performance of LUS was worse than that of CCT  with false positive LUS results received a diagnosis of lung cancer. Pattern 1 was identified in all of them. It is possible that some features of pattern 1 that are not specific to CAP may have misled the independent physicians who performed LUS, causing them to give misdiagnoses. For example, fluid bronchogram reflects not only airways filled with fluid but also secretions following airway obstruction. Several factors have been hypothesized to justify false negative LUS results, such as small-dimension echographic artifacts and their deep parenchymatous location (LUS may only detect consolidations reaching the pleura)6. We suspected that these features could be related to a specific cultural status and etiology of CAP. In fact, in the present work, out of the 8 patients with CAP not identified by LUS, 7 patients had culture-negative CAP , and 1 patient was presumed to have viral CAP.LUS was proven to be more useful than CXR in diagnosing CAP in patients with suspected LRTI in this work Fig. b. Their CCT Fig. a: 9 patiCCT Fig. a. These 10. Thus, the choice of whether to culture patients with CAP is challenging: it should be based on the severity of clinical presentation, local ecological considerations, and local antimicrobial stewardship processes10. We aimed to assess the usefulness of LUS in supporting this decision. In this study, among patients with CAP and known cultural status at the end of minimum microbiological work-up, a negative LUS result ruled out the need for cultures with a high negative predictive value (100%). This resulted in the identification at hospital admission of 3% of all the patients with CAP in whom cultures did not provide useful diagnostic information. Unfortunately, the predictivity of a positive LUS result for culture-positive status was poor in this study (PPV 42%).Although cultures could improve the quality of treatment in patients with CAP, guidelines do not support their routine collection in relation to the low quality of studies demonstrating clinical benefit10, the possibility of predicting the etiology of CAP following hospital admission could represent an important step forward. In our work, the performance of LUS in predicting the need for empirical antibacterial therapy was excellent because pattern 1 ruled in CAP of bacterial etiology and bacterial coinfection with high PPVs . Notably, in the latter cohort, pattern 2 exhibited a good performance for ruling out the need for antibacterial therapy (NPV: 93%). Host response seems to support the observed correlation of pattern 1 with CAP of bacterial etiology and that of pattern 2/negative LUS results with its viral etiology . This result might also be explained by the fact that the vast majority (97%) of patients with CAP due to coinfection exhibited pattern 1 on LUS  by two internal medicine residents with less than 6 months of experience with point-of-care ultrasonography: a substantial agreement was observed between the two observers . Additionally, our condensed classification of all the positive LUS results may reduce the time need to perform LUS. This aspect is massively important in patients with bacterial CAP complicated by organ dysfunction in whom there is the need to start antibacterial therapy as quick as possible27. In this study, they represent the vast majority of the patients with CAP AP Table . FinallyIn this study, LUS performed at IMW admission was proven to be useful for ruling in the diagnosis and bacterial etiology of CAP and for ruling out mortality in patients with CAP. Larger prospective studies, performed in other settings, are warranted to support our findings.Supplementary Information.