This qualitative study aimed to provide an in‐depth understanding of nurses’ experiences with near‐miss errors and report omissions known to be direct or indirect causes of medical accidents in hospitals and cited as precursors of serious medical accidents.This study collected experiences of research participants through an interview as a qualitative research method and confirmed the meaning through an inductive approach.We selected nine nurses with various levels of experience from 27 May to 10 June 2019 for analysis. We adopted phenomenological research methods and procedures proposed by Colaizzi  and established the feasibility and integrity of our results based on narrative studies proposed by Lincoln and Guba .This study demonstrated that near‐miss errors and report omissions experienced by professional nurses could be merged into the following themes: lack of cognitive susceptibility to near‐miss errors; confusion about the reporting system for near‐miss errors; lack of knowledge about near‐miss errors; disappointment with results of reporting near‐miss errors; and fear of reporting near‐miss errors. These results strongly suggest the need to improve recognition efforts based on a socio‐educational viewpoint involving the so‐called openness about failures. This study suggests that sharing the process and results of near‐miss errors in clinical field sites will provide an important foundation in securing the safety of patients.This study suggests that sharing the process and results of near‐miss errors will contribute to the development of not only individual nurses but also the whole hospital community.This study suggests that sharing the process and results of near‐miss errors by openly acknowledging those mistakes will provide the best learning opportunity and serve as a cornerstone for improving clinical practice.1Near‐miss errors are errors that occur to a patient. However, the patient is never harmed because of fortuitous or appropriate intervention Capucho, . AlthougDespite remarkable progress has been made for skill levels of medical staff and medical technology, there has not been significant progress in reducing the occurrence of medical accidents and subsequent damages . Six nurses worked at large hospitals in Seoul and three worked in Gyeonggi‐do Province. In terms of their academic backgrounds, five nurses had graduated from nursing colleges and the remaining four held four‐year degrees. Table 5.2In the early days of my career, I did not know which mistake was a serious one or a minor one, and I just did what I was told to do. At that time, there was a preceptor who would take responsibility. However, when I became a senior nurse, these problems that I had overlooked or habitually done were not big things, and so I did not think it was necessary to report them. This was the way I worked. There are no clear criteria to tell which mistake is big or small. I just did it as I was instructed to do, so it was not my fault. For instance, when a patient complained of indigestion after taking a drug that was routinely administered, a senior nurse told me that as the drug was administered without causing any problems, it was highly unlikely that it was a side effect. So, I thought it was not necessary to report a minor side effect. The senior nurse's word is a kind of law. It is very exhausting to deal with patients in the outpatient ward. This story occurred a year ago. If patients have the same name, I usually check their dates of birth. On that day, I just saw the name but failed to check the date of birth. As a result, I was looking at the treatment history of another patient. I did not instruct the staff (a patient manager in front of the treatment room) to check the patient's date of birth because we had an outpatient with the same name that day. Based on responses, it was found that study participants did not notice that they made near‐miss errors. In other words, they did not have near‐miss error sensitivity. They did not realize the seriousness of such errors or they did not report them. None of them had ever felt an urgent need to address such errors. Study participants perceived near‐miss errors as part of a mechanical routine. They even considered such errors as natural mistakes. They said that they did not report near‐miss errors by ignoring them, treating them as they had always been treated and justifying them as everyday errors. In terms of cognitive susceptibility, these nurses perceived near‐miss errors not as malicious, but as part of their daily job routines Table .In the e5.3I do not know exactly to whom I have to report when a near‐miss error occurs. I do not know whether I have to report to my immediate boss or a person in a higher position. I do not know what I have to prepare to report it. My heart trembles, which makes me feel the situation even harder. And I do not know to whom I can report it to or to whom I can talk about it. Whenever a near‐miss error occurs, I feel scared and burdened. When a near‐miss error happens, I feel alone. It seems that no one can help me out and I feel lonely. I talked about it to one of my colleagues one day, but it ended up in miscommunication, which put me in a more difficult situation. Study participants’ confusion about reporting near‐miss errors took two main forms. One, nurses in this study discussed the lack of clear guidelines about who should report near‐miss errors and to which department or institute they should report them because there were no clear written or oral reporting procedures at their hospitals. Two, these nurses mentioned that there was no clear definition of a near‐miss error. There were no contexts or guidelines for distinguishing one's own mistakes from those of others’, attributing causes of errors, or clear delineation of responsibility in the event of multiple errors. The lack of clear guidelines is a visible factor. However, the latter factor is invisible. All study participants reported that both visible and invisible factors led to their confusion about near‐miss errors, making it difficult for them to know how to report them and which caused reporting omissions Table .I do not5.4There is an acknowledged difficulty in articulating clear definitions of types and scope of near‐miss errors that occur in hospitals or clear responsibilities for such occurrence. However, nurses need to have basic knowledge about the concept of near‐miss errors including the importance of both countermeasures and reporting in the event of near‐miss errors. In this study, the lack of this conceptual knowledge played a major role in study participants’ experiences with near‐miss errors and reporting omissions.I heard the word of “near‐miss error” for the first time after joining the hospital. I might have heard the term during a preliminary nursing curriculum, but the concept is something I do not know very well. I do not remember that I learned the word “near‐miss error” when I was in college. I do not think that the term has ever appeared in any exam. After entering the hospital, senior nurses provided many different instructions concerning work. I have learned the procedures and methods to perform those instructions without making mistakes. When I made a mistake, I have never been told by anyone whether it was a near‐miss error or not. In fact, I know that a near‐miss error is a minor error, but I do not know the exact concept or meaning. The operating room is divided into a strict sterile field and a non‐sterile field. Because they are not visibly divided, I do not think seriously when I see a contaminated thing inside a non‐sterile field. If I think of it now, it is the most serious thing that could have happened. I did not understand whether that was a near‐miss error or not. Of course, I did not report it. ?When I checked my patient’s vital signs one day in the early period of my career, I made a mistake of forgetting to check the blood pressure. So, I just filled in a similar number without taking an actual measurement. The next day, the patient's blood pressure went up too high and I had to report it. I made an excuse by saying that I did not see any abnormality when I checked it the day before. So, is this a near‐miss error. For example, beginner nurses in this study were unaware of the term “near‐miss errors” and its usage before they joined their hospitals. On the contrary, nurses with many years of career experience who were aware of near‐miss errors and reasons for reporting still did not feel the need for such reporting. It can be hypothesized that all practices derive from the recognition of problems and unawareness of near‐miss errors and their importance will decrease the probability of reporting. Nurses who do not perceive such errors will not think or know to report about them Table .I heard 5.5Is it because there is no disadvantage caused by a near‐miss error? Even after reporting a near‐miss error, I did not hear that any measures were taken to address the issue. Even when a near‐miss error was reported after its occurrence, I did not remember how it was handled, and I did not think I received any education about it. It might have been handled through a non‐official route, or it might have been discussed personally with the concerned person, but there were no follow‐up measures. Therefore, I feel I am just making a fuss out of nothing, so I just skip reporting it. Maybe I made a mistake because I felt tired due to overwork the previous day. I did not know exactly what kind of mistake I made and hesitated to report it. If I had reported it, I should have been informed about the cause and the effect of the near‐miss error, but that was not the case. It might not be a problem if there is a clear definition of responsibility. But if several people are involved, I am concerned whether I might be more disadvantaged than others. Of course, I doubt whether the report could represent me well or not. In most cases, people tend to support those who are closer to them. Nine participants had experiences of reporting formally and informally about near‐miss errors and omission of reporting. Study participants were sceptical about how a systematic and detailed reporting of routine and minor mistakes such as near‐miss errors could contribute towards the prevention of actual safety accidents. These participants said that irrespective of their direct or indirect experiences with near‐miss error reporting, similar errors continued to happen. Moreover, because immediate measures such as education and information sharing did not occur frequently before, they doubted effects of a near‐miss error reporting. In addition, these nurses perceived reporting to be meaningless because when they had reported such errors, they had never been informed about the progress of any follow‐up measures even when they had submitted detailed reports about such incidents. These experiences had eventually led participants to think that reporting near‐miss errors would fall on deaf ears, which in turn gave nurses negative impressions about near‐miss error reporting. These nurses’ perspectives within this theme indicated low perceptions of the value of noting and reporting near‐miss errors Table .Is it be5.6I made a mistake because I felt extremely tired due to overwork the day before. It might sound like an excuse. I am afraid that people might think I made a mistake not because I was too tired but because I am incompetent. I doubt whether my situation can be properly represented. When I make a near‐miss error, I might openly admit it as my own. Still, I cannot imagine what kind of disadvantages or penalties I would have to undergo after that confession. It is a really scary thing to experience. I might have to endure salary reduction or other disadvantages. What is scarier than this is what other peer nurses might think of me. There are a lot of things to worry about. I am worried about how my subordinates think of me. I am also afraid that I might not get promoted because of that mistake. If one of my colleagues makes an unpleasant comment when I make a near‐miss error, or if I make the same displeasing comment when my colleague makes a mistake, either case can hurt my relationship with the colleague. Sharing the responsibility for near‐miss errors is actually like sharing one’s own mistakes, but it is not easy to admit one’s own mistake and share everything about it. If we share information about near‐miss errors, we probably will not repeat the same mistakes. But it is not easy. I do not think it will work unless we reveal everything about what have happened. A near‐miss error is an obvious mistake, whether it is officially reported or not. Therefore, individuals have a psychological and emotional repulsion of mistakes made during the performance of their work. Nurses often avoid reporting near‐miss errors because they are responsible for their own mistakes. In interviews of this study, nurses confessed that they deliberately ignored and avoided these responsibilities and explained that this was due to disadvantages of reporting near misses Table .I made a6Results of this study are as follows. Study participants’ experiences with near‐miss errors and omissions of reporting near misses were due to the following: (a) lack of near‐miss sensitivity, (b) confusion regarding near‐miss reporting systems, (c) lack of near‐miss knowledge, (d) distrust of near‐miss reporting effects and (e) fear of near‐miss reporting. First of all, lack of near‐miss sensitivity, confusion regarding near‐miss reporting systems and lack of near‐miss knowledge have different contents and circumstances. However, they are all due to ignorance. Because of this ignorance of near misses, study participants have accepted these events as part of their daily routine. These participants’ ignorance of near‐miss acts was manifested as a distrust of near‐miss reporting effects, leading to further distrust of the importance of thorough reporting, information sharing, and the effect of reporting. That is why these nurses do not feel the need to report minor near misses, leading to the fear that near‐miss reporting will result in actual and implied disadvantages. In this study, the experience of omitting near‐miss reporting was not limited to one factor, but was caused by multiple factors. The experience of a near miss and “the omission of near‐miss reporting” stated by nurses who participated in the study reflected results of a previous study that reported that 76.5% of hospital nurses did not report near‐miss errors (Kim et al., According to previous studies, causes of reporting omissions can be summed up as follows: nurses perceive near‐miss errors as simple mistakes that are harmless to patients (Kim et al., The proverbs and adages about mistakes in Western and Oriental worlds commonly say that human deeds are inevitably premised on mistakes and failures. They provide consolation that humans learn lessons from their failures and mistakes to pursue new success and perfection. This viewpoint of leveraging individual mistakes and failures to improve practice has attracted much attention in the discourse of educational sociology. From a behavioural perspective, because failure interferes with performance and triggers negative emotions such as frustration and helplessness, individuals will try to avoid the experience of failing (Bartels & Ryan, From the viewpoint of a supervisor, it is inevitable to control errors and failures which can be considered antagonistic to success. However, for the performer, the only two choices are failure and success. In that context, mistakes that do happen can be concealed. Accumulated hidden mistakes can eliminate opportunities for improvement. Such failure to improve is highly likely to lead to learned unconcern which is related to learned helplessness (Nanda et al., In this regard, disclosure of academic failure (Cannon & Edmondson, 7Up to date, discussions on near‐miss errors have mainly focused on identifying their causes and substantially reducing them. Researchers have also discussed near‐miss errors from a more macroscopic viewpoint (Lee et al.,On the contrary, we propose sharing the process and results of near‐miss errors. Also, it is inferred that disclosing failure is the best learning opportunity for improving practices as a cornerstone for further progress. If near‐miss errors become perceived as opportunities for individual and institutional development rather than as failures, they can prompt active and lively discussions on previously hidden near‐miss error cases. Such changes represent a foundation for mutual development of nurses and hospital communities and for patient safety.8This study has the following limitations. First, because this was a qualitative study and the main purpose of the study was to interpret subjective experiences of participants and discuss their meaning, it was difficult to generalize results of this study. Second, it was difficult to collect various cases because participants’ geographical areas in this study were limited to easily accessible areas.9To reduce near‐miss errors, clinical nurses must make efforts in the following three dimensions. First, negative impressions of near‐miss errors must be reframed and viewed as opportunities or cases to enhance nursing practice. Especially from the viewpoint of lifelong essentials for professionals like nurses, near‐miss errors are important issues that must be shared and learned. More concrete and practical efforts must be made for hospital cultures to perceive near‐miss errors as opportunities to learn lessons. Second, supplementary training should be provided to currently practising nurses to raise their awareness about the nature and importance of near‐miss errors and to systematically manage and distribute lessons learned from them. Lastly, a more systematic and effective transfer of knowledge about near‐miss errors is needed for the education of prospective nurses. In this study, nurses with relatively shorter career experience said that they had not heard the term “near‐miss error” until they started working for hospitals. This shows that education on near‐miss errors is rarely included in the curriculum for prospective nurses. Thus, an in‐depth discussion has to be undertaken regarding the reestablishment of empirical and theoretical systems for near‐miss errors and incorporation of them into nursing curriculum.No conflict of interest has been declared by the authors.


Objectives: Brain arteriovenous malformation (AVM) is one of the most common causes of intracranial hemorrhage in young adults, and its expeditious diagnosis on digital subtraction angiography (DSA) is essential for clinical decision-making. This paper firstly proposed a deep learning network to extract vascular time-domain features from DSA videos. Then, the temporal features were combined with spatial radiomics features to build an AVM-assisted diagnosis model.Materials and method: Anteroposterior position (AP) DSA videos from 305 patients, 153 normal and 152 with AVM, were analyzed. A deep learning network based on Faster-RCNN was proposed to track important vascular features in DSA. Then the appearance order of important vascular structures was quantified as the temporal features. The structure distribution and morphological features of vessels were quantified as 1,750 radiomics features. Temporal features and radiomics features were fused in a classifier based on sparse representation and support vector machine. An AVM diagnosis and grading system that combined the temporal and spatial radiomics features of DSA was finally proposed. Accuracy (ACC), sensitivity (SENS), specificity (SPEC), and area under the receiver operating characteristic curve (AUC) were calculated to evaluate the performance of the radiomics model.Results: For cerebrovascular structure detection, the average precision (AP) was 0.922, 0.991, 0.769, 0.899, and 0.929 for internal carotid artery, Willis circle, vessels, large veins, and venous sinuses, respectively. The mean average precision (mAP) of five time phases was 0.902. For AVM diagnosis, the models based on temporal features, radiomics features, and combined features achieved AUC of 0.916, 0.918, and 0.942, respectively. In the AVM grading task, the proposed combined model also achieved AUC of 0.871 in the independent testing set.Conclusion: DSA videos provide rich temporal and spatial distribution characteristics of cerebral blood vessels. Clinicians often interpret these features based on subjective experience. This paper proposes a scheme based on deep learning and traditional machine learning, which effectively integrates the complex spatiotemporal features in DSA, and verifies the value of this scheme in the diagnosis of AVM. Digital subtraction angiography (DSA) is the most important imaging technique for cerebrovascular disease diagnosis . As a tyRecent studies on AVM diagnosis have focused on AVM nidus extraction and vessel classification based on 4D CTA (computed tomography angiography) or 3DRA  medical images –7 and foFaster-RCNN is an algorithm, and it used to recognize the blood vessels of a DSA video in our method. It is widely used in target detection and recognition in natural images –12 and aAutomated AVM diagnosis is helpful to make the diagnosis of AVM more objective and reliable. Designing an automated AVM diagnosis model based on a DSA video is a challenging task because of the following obstacles. First of all, most of the existing medical image diagnosis models are based on static images. DSA reflects the perfusion of a three-dimensional vascular network that changes with time. The existing modeling methods based on static images are not suitable. Secondly, in DSA imaging, the sequence of vascular appearing reflects differences in vascular perfusion, and these differences are essential for the diagnosis of cerebrovascular diseases. Because of the complexity of the cerebrovascular network, it is difficult to quantitatively evaluate the sequence of key blood vessels. Thirdly, the assessment of images depends on the experience of doctors, and inconsistencies of the results among different doctors for the same case are likely to occur.To overcome these challenges, an automatic detection model of the blood vessel phase based on Fast-RCNN is proposed. This model can automatically identify the early arterial phase, the late arterial phase, the early venous phase, the late venous phase with one sinus, and the late venous phase of the cerebral vessels. According to the results of the time phase detection, the time characteristics contained in the DSA image can be obtained. Then the key frames in the DSA image are extracted to calculate the radiomics features. Finally, the temporal features and radiomics features are fused to establish the final AVM diagnostic model.This study protocol was approved by the ethics committees of the Huashan Hospital, Fudan University, and informed consent was waived since the retrospective study. From January 2010 to December 2013, 1,025 patients with cerebrovascular diseases who underwent DSA examination before operation or conservative treatment were reviewed. All 2D-DSA were conducted by senior neurosurgeons or neuro-interventional radiologists with more than 10 years of experience, on a Philips UNIQ FD20 digital subtraction biplane angiographic system. After a sheath  was placed inside the femoral artery and an angiopointer  was placed at the beginning of ICA or VA, the contrast agent was injected by a contrast delivery system (Angiomat Illumena). During the 6-s anteroposterior position digital subtraction angiography image acquisition, 6 ml of the contrast agent was injected at a rate of 4 ml/s under a pressure of 200 Pa to obtain frames, where rates of Philips' instrument varied from 166 to 333 ms/frame.AVM cases that are included in this study must satisfy the following aspects: (1) cases have anteroposterior position 2D-DSA videos; (2) lesions are visible in anteroposterior position images by experienced doctors; and (3) AVM cases without other diseases such as moyamoya disease and brain tumor , which mFinally, a total of 305 cases (153 non-AVM vs. 152 AVM) were collected. Among the 153 non-AVM cases, 31 were diagnosed with cavernous hemangioma by MRI, and 46 were diagnosed as aneurysm-negative by DSA, but confirmed as spontaneous subarachnoid hemorrhage in CT. Thirty-six cases were negative in DSA anteroposterior position images but were confirmed with aneurysms in three-dimensional rotational angiography (3DRA). Forty cases were suspected of aneurysms by computed tomography angiography (CTA) or magnetic resonance angiography (MRA) but proved to be normal or artery ectasia by DSA. AVM will change the perfusion characteristics of the patient's cerebrovascular network. In a DSA video, doctors mainly diagnose AVM and judge its severity based on the sequence of appearance of the main blood vessels and the structural characteristics of the vascular network. Because of the complex structure of cerebral blood vessels, it is difficult for the human eye to accurately quantify the order of appearance of the main blood vessels. We conducted a target detection algorithm, Faster-RCNN, to obtain DSA sequence information. Two specialists, who have been engaged in clinical cerebrovascular disease for more than 5 years, annotated the vascular structures in different phases, as shown in In the vessel structure recognition, we have annotated the key vessels in the DSA video. As shown in The order in which important blood vessels appear defines the different phases of the DSA video . Accordivia wavelets to obtain additional information, obtaining 280 features.In addition to the temporal feature, the distribution structure of the vascular network is also an important feature for AVM diagnosis . TherefoTo verify the significance of the proposed features, three sets of features were determined:i The temporal features. ii The radiomics features. A total of 1,750 (350 × 5) radiomics features were extracted from each sample. This group of features was set to represent the vessel distribution characteristics for AVM diagnosis.iii The combined features. These two feature sets were concatenated into an integrative dataset, and a model was expected from two types of features with higher accuracy that should capture static and dynamic information from input images.To exclude redundant and irrelevant features, we applied the iterative sparse representation (ISR) for feature selection , 25. A pWe applied the support vector machine (SVM) as our classifier, which is efficient in machine-learning tasks with limited samples –28.For AVM diagnosis, 305 cases were randomly divided into two groups: an independent testing cohort and a cross-validation cohort at a ratio of 3–7. We also applied the leave-one-out (LOO) cross-validation test diagnosis model with different feature sets. Then, the independent validation set was used for further evaluation of the diagnostic performance of the diagnosis model. We calculated the area receiver operating characteristic (ROC) curve to establish the overall performance of the models.For AVM grading, a total of 152 AP series with visible nidus were considered as cross-validation cohorts, shown in The overall flowchart was shown in Based on the predicted results, we calculated the Precision–Recall (P-R) curve of five types of blood vessel ROI and calculated the area under the P-R curve (average precision) to measure the model's detection precision of each blood vessel structure. We used the target detection model to calculate the AP values of the internal carotid artery, the Willis circle, the large vein, the venous blood vessel, and the venous sinus, respectively. The results are shown in The model had good performance in discriminating the circle of Willis and deficient in discriminating veins. The mAP of the five types of blood vessel, detected by this model, was 0.902. We can conclude that this model had good performance in the detection of vascular structure based on DSA. Then, we visualized the detection results of the representative images. The model can detect the positions of the internal carotid artery and the circle of Willis in the arterial phase images, as shown in After feature selection, the feature contribution of the combined features is shown in p <0.001), probably due to the stimulus of larger nidus to the cortex.As shown in Considering the small number of cases and the imbalance of data at all scores, we were able to design both high  and low  level classification tasks. To verify the effectiveness of temporal features, combined, and radiomics features were considered in this task. The model's indicators with and without temporal features are shown in Being relatively convenient and non-invasive, CTA and MRA usually serve as the primary tools for screening brain AVM after patients suffer from headache or seizure. Depending on postprocessing, CTA and MRA often demonstrate insufficient resolution and artifacts. Moreover, CTA and MRA could only reveal the whole brain vessels in a static image. Therefore, they cannot be used to accurately evaluate AVM. In contrast, through contrast injection into one single brain inflow artery, DSA is able to clearly delineate the feeding and draining vessels of AVM. The primary diagnosis of AVM needs to be ultimately confirmed by DSA. In addition, one of the classic grading systems on brain AVM, the Spetzler–Martin (SM)  grade coThe DSA video provides both dynamic information and static information, which is valuable for cerebrovascular disease diagnosis. The characteristics of DSA imaging are as follows: as the contrast medium flows in the cerebrovascular, the developed structure will gradually change, and the number of frames in each case is unpredictable . DSA vidHowever, these classic video classification methods are not suitable for DSA videos for three reasons: First, the number of DSA frames is not fixed, which is usually between 20 and 50 frames. The development status of each frame is related to the patient's blood flow rate and the shooting interval of the machine. In other words, when random frames from each case are selected, the change of the image in time dimension will be different. Second, there are interference, noise, and artifacts that will influence the image quality. Therefore, it is difficult to obtain effective information. Finally, the number of DSA data is limited in our research, which makes it hard to meet the conditions of deep learning.The Faster-RCNN model achieves good performance in vessel structure detection, and the temporal feature, which was introduced in this study, provides the temporal features of the real-time image. We can use Faster-RCNN to obtain reliable temporal features and eliminate the undeveloped frame automatically. First, from the beginning to the end of the development frame, five frames are selected in equal proportions, representing the pre-arterial phase, the late arterial phase, the capillary phase, the early vein, and the sinus phase, respectively. Then, we extract image features in selected frames. Finally, two types of features are combined to train the SVM model. It is obvious that a better performance classifier can be achieved if we manually select the frame that contains the biggest nidus and annotate the ROI area to make training datasets, or even collect the time sequence features through human eyes. However, this method increases the burden of the medical staff, violates the original intention of automatic diagnosis, and cannot be applied to clinical diagnosis. In our proposed method, although the Faster-RCNN may make mistakes occasionally in the structure detection of abnormal cases, we take the structure detection results of all frames into consideration when calculating the temporal features to avoid those mistakes. Therefore, if one or two frames are detected incorrectly during the whole process, it will not affect the final temporal features. Based on the reasons above, there is no external intervention in the acquisition of static image features and temporal features in the proposed method.In our study of AVM diagnosis, the model trained by radiomics features performs poorly on the independent testing set, while temporal features showed surprising performance with only five time sequence features; moreover, fusion features have high robustness, producing an AUC of 0.942 and an ACC of 0.889 in the diagnosis. For AVM grading, the group with temporal features obtained an AUC of 0.871 and an ACC of 0.840, which were better than the one without temporal features. The results can be understood in the way that radiomics features represent static image features. and temporal features represent effective temporal features. Combined features integrate changes in the DSA series with radiomics features that can describe DSA videos more completely.Several limitations should be noted. First, samples should be excluded when the nidus is too large that it covers the vascular structures because it will affect the credibility of temporal features extracted by the detection model. Second, multiposition images were not included to establish the DSA radiomics model. Although many studies have reported that multimodality images are helpful for classification tasks, multiposition images are not available for all included patients in the current study –40. TherDSA videos provide an important basis for the diagnosis of cerebrovascular disease and provide a reference plan for surgical treatment, which is of great significance for the study of cerebrovascular disease. Our results suggest that temporal features obtained from DSA videos are representative and highly correlated with real-time medical images classification. DSA radiomics features combined with temporal features provide better performance in AVM analysis with high ACC.However, DSA is a two-dimensional image that cannot describe blood vessels' shape or the blood flow rate. In the future, by combining CTA and DSA videos, more comprehensive modeling of cerebral blood vessels can be carried out. The influence of drainage veins and supply veins on the size of AVM can also be analyzed.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Huashan Hospital affiliated to Fudan University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.KS and WX collected all the data and carried out the experiments. KS and WX wrote the manuscript with support from GW, YX, and YL. JY and YG helped supervise the project. All authors contributed to the article and approved the submitted version.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.


Perforation of the ileal J-pouch after restorative proctocolectomy and ileal pouch–anal anastomosis are extremely rare. There has been no report of perforation of the ileal J-pouch occurring twice over several years. We report the first case of perforation at 6 and 18 years following restorative proctocolectomy.The patient was a 52-year-old man who underwent a two-stage restorative proctocolectomy with a hand-sewn ileal J-pouch anal anastomosis due to familial adenomatous polyposis and sigmoid colon cancer at 34 years of age. At the age of 40, he underwent ileal pouch resection at its blind end, abdominal drainage, and anastomotic dilatation. The patient had a perforation of the blind end of the ileal J-pouch from increased intraluminal pressure, with anastomotic stricture and pervasive peritonitis. The patient had no symptoms for a few years; however, 18 years after the initial surgery and 12 years after the first perforation, the patient presented with severe abdominal pain. Computed tomography demonstrated pneumoperitoneum; accordingly, laparotomy was performed. Upon opening the abdominal cavity, contaminated ascites and inflammatory changes were documented involving the ileum. A 2-mm perforation involving the blind end of the ileal J-pouch was also observed and repaired, followed by temporary loop ileostomy creation. Postoperative endoscopy revealed an ulcer in the ileal J-pouch and a stricture located directly at the anastomosis.The blind end of the J-pouch repeatedly perforated over the years due to recurrent anastomotic stricture. Regular surveillance is, therefore, considered necessary for the release of stricture, maintenance of anastomotic patency, and prevention of ileal J-pouch perforation. Familial adenomatous polyposis (FAP) is a genetic complex syndrome estimated to affect 1–8 out of every 1000 people. It has a high incidence of more than 100 adenomas in the colon, and almost 100% of patients with this condition develop colorectal cancers by the age of 60 years . TherefoA 52-year-old man presented with FAP. At the age of 34 years, he underwent a two-stage restorative proctocolectomy and a hand-sewn ileal J-pouch anal anastomosis at a previous hospital because of FAP co-presenting with sigmoid colon cancer. The clinical stage according to the TNM 8th edition was T3 N1b M0, Stage IIIB. Adjuvant chemotherapy was not prescribed and regular observation was undertaken. He had no other symptoms, including constipation, and he did not visit the hospital for follow-up 1 year postoperatively. However, 6 years following surgery, he experienced abdominal distension and constipation. He visited our emergency department with complaints of severe pain in his lower abdomen. On physical examination, signs of peritoneal irritation were observed throughout the abdomen, and anal strictures were palpable upon digital examination. Laboratory examination demonstrated an elevated white blood cell (WBC) count of 13,800/μl and a C-reactive protein (CRP) level of 2.19 mg/dl. Computed tomography (CT) of the abdomen revealed a pneumoperitoneum (Fig. FAP is an autosomal dominant inherited neoplasm that causes multiple adenomatous polyps in the colon and is caused by a pathological variant of the adenomatous polyposis coli gene in the germline. The correlation between genotype and phenotype in FAP is useful for making decisions regarding its screening and surgical management . With thSalmonella typhimurium infection [E. coli, which was believed to be derived from intestinal perforation and was not the cause of perforation.Several reports of ileal pouch perforation have been reported in the literature, all of which are listed below –20 Tabl. Hsu andnfection , volvulunfection , and idinfection . Shapironfection . Takahasnfection . Dogan eHolubar et al. stated that obstruction from pouch–anal anastomosis stricture is common and requires surgical dilation with Hegar dilators and endoscopic balloon dilation. Needle–knife stricturotomy, chronic self-dilation at home, and a hand-sewn reanastomosis are required in refractory cases . In our There are several reports on IPAA methods in patients with FAP. Konishi et al. reported that PRC in FAP patients were lower in stapled IPAA than in hand-sewn IPAA. In contrast, there were no differences in overall complication rates, fecal incontinence scores, ostomy rates, and overall survival between the two techniques. Therefore, they concluded that stapled IPAA might be a safer option for FAP patients to reduce PRC . GanschoThe blind end of the J-pouch repeatedly perforated over the years due to recurrent anastomotic stricture in our patient. Regular surveillance is necessary in these cases and may prevent perforation of the ileal pouch when strictures are released on time and anastomotic patency is maintained.


Studies have shown that the skeletal muscle index at the third lumbar vertebra (L3 SMI) had reasonable specificity and sensitivity in nutritional assessment and prognostic prediction in digestive system cancers, but its performance in lung cancer needs further investigation.A retrospective study was performed on 110 patients with advanced lung cancer. The L3 SMI, the Patient-Generated Subjective Global Assessment score (PG-SGA score), body mass index (BMI), and serological indicators were analyzed. According to PG-SGA scores, patients were divided into severe malnutrition (≥9 points), mild to moderate malnutrition (≥3 points and ≤ 8 points), and no malnutrition (≤2 points) groups. Pearson correlation and logistic regression analysis were adopted to find factors related to malnutrition, and a forest plot was drawn. The receiver operating characteristic (ROC) curve was performed to compare the diagnostic values of malnutrition among factors, which were expressed by the area under curve (AUC).P = 0.024; OR = 1.100, 95%CI: 1.034 ~ 1.170, P = 0.002). Furthermore, the neutrophil to lymphocyte ratio (NLR) of the severe malnutrition group was significantly higher than that of the no malnutrition group, with statistical significance. The difference between the mild to moderate malnutrition group and the no malnutrition group were not statistically significant, with NLR of 4.07 ± 3.34 and 2.47 ± 0.92, respectively . The L3 SMI of patients in the severe malnutrition and mild to moderate malnutrition groups were significantly lower than that of the patients in the no malnutrition group, with statistical significance. The L3 SMI of patients in the severe malnutrition group, mild to moderate malnutrition group, and no malnutrition group were 27.40 ± 4.25 cm2/m2, 38.19 ± 6.17 cm2/m2, and 47.96 ± 5.02 cm2/m2, respectively .1. The age of patients in the severe malnutrition group, the mild to moderate malnutrition group, and the no malnutrition group significantly differed, with mean ages of 63.46 ± 10.01 years, 60.42 ± 8.76 years, and 55.03 ± 10.40 years, respectively  but negatively correlated with L3 SMI . The L3 SMI was also negatively correlated with age .2. The Pearson correlation analysis showed that the PG-SGA score positively correlated with age .3. The multivariate analysis showed that the L3 SMI was an independent risk factor for malnutrition (OR = 0.446, 95%CI: 0.258 ~ 0.773, 1. The differences in the L3 SMI was statistically significant among advanced lung cancer patients with different nutritional statuses.2. In the nutritional assessment of patients with lung cancer, the L3 SMI was consistent with the PG-SGA.3. The L3 SMI is an independent predictor of malnutrition in patients with advanced lung cancer. Cancer is a social and public health problem worldwide. According to statistics in 2012, the incidence and mortality of cancer in China exceeded the average level of the world . The oveA retrospective analysis was performed on patients with lung cancer admitted to the Cancer Center of the First Hospital of Jilin University from January 2017 to June 2017. A total of 272 patients with lung cancer were searched from the database. Case inclusion criteria: (1) Lung cancer confirmed by pathology and TNM stage IV according to the 7th edition of American Joint Committee on Cancer;(2) The Eastern Cooperative Oncology Group (ECOG) performance status scored 0 or 1; (3) Patients with abdominal CT scan; (4) No nutritional support before assessment. Exclusion criteria: (1) Patients merged with other types of tumours; (2) Patients died within 30 days of admission; (3) Patients with incomplete materials. As shown in the study schema, 110 patients were finally included according to the inclusion and exclusion criteria 2. BIA is a technique for measuring body composition using capacitance (Xc) and resistance (R) of biological tissues. In this study, resistance and capacitance were directly measured in ohms at 50 kHz, 800 mA by Inbody S10 (Biospace Co®). As the equation generated an indicator of body composition, phase angle (PhA) (Resistance/Capacitance) * (180/π).All patients received PG-SGA, abdominal CT, anthropometric measurements, laboratory biochemical testing, and bioelectrical impedance analysis (BIA) within 24 h of admission. Age, sex, height, weight, and albumin (ALB), pre-albumin (PA), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in the peripheral blood were recorded. BMI was calculated by weight (kg)/ height 2)/height2(m2).SliceOmatic 5.0 software (TOMOVISION Canada) was used to analyze abdominal CT images on two consecutive planes of the L3 level. The skeletal muscle areas were measured at each plan, and the average was adopted as skeletal muscle mass, including the psoas major, erector spinae, quadratus lumbar muscles, transverse abdominis, external oblique, and internal oblique. Then the L3 SMI was calculated by skeletal muscle area . Patients were divided into three groups: severe malnutrition , mild-to-moderate malnutrition  and no malnutrition . Kolmogorov-Smirnov test was used to confirm the normal distribution of the data. Differences between groups were analyzed by T-test. Pearson correlation analysis was used for correlation analysis among variables. Univariate logistic regression was performed to analyze the association of variables and malnutrition, and all significant variables were included into multivariate logistic regression taking PG-SGA group C as the reference. Then a forest plot was drawn. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) was used to explore the diagnostic value of different variables for malnutrition (PG-SGA ≥ 3 points). A total of 110 patients with lung cancer were included in this study, according to the inclusion and exclusion criteria. Among them were 73 males (66.36%) and 37 females (33.64%), aged from 32 to 82 years, with an average age of 59.98 ± 9.91 years. There were 30 patients in group A, accounting for 27.3%, 54 patients in group B, accounting for 49.1% and 26 patients in group C, accounting for 23.6%. See Table 2/m2, that of the mild-to-moderate malnutrition group was 38.19 ± 6.17 cm2/m2, and that of the no malnutrition group was 47.96 ± 5.02 cm2/m2. Statistical differences were detected in both PG-SGA A and B groups compared to the PG-SGA C group (P < 0.001). Besides, age, PA and PhA differed between PG-SGA A and B groups compared to PG-SGA C group (P < 0.005). NLR was different in severe and no malnutrition groups (P = 0.037), but no difference was observed between mild-to-moderate malnutrition group and severe malnutrition group (P = 0.097). See Table (1) The mean value of L3 SMI of the severe malnutrition group was 27.40 ± 4.25 cmr = − 0.857, P < 0.001). As for age, ALB NLR and BMI, no relation or simply weak relation were observed among them with PG-SGA and L3 SMI. See Table (2) Pearson correlation analysis showed that the PG-SGA score negatively correlated with L3 SMI . The NLR of patients in the severe malnutrition group was significantly higher than that in the no malnutrition group, with statistical significance ; however, there was no statistically significant difference in NLR between the mild-to-moderate malnutrition and no malnutrition groups. The PhA of patients in the mild-to-moderate and severe malnutrition groups was significantly lower than that in the no malnutrition group, with statistical significance . The L3 SMI of patients in the mild-to-moderate and severe malnutrition groups were significantly lower than that of patients in the no malnutrition group, with statistical significance . See Fig. (3) In patients with advanced lung cancer, the univariate analysis showed that the PA of patients in the mild-to-moderate malnutrition and severe malnutrition groups were significantly lower than that of patients in the no malnutrition group, with statistical significance  and forest plots were drawn. Thus, the L3 SMI is an independent risk factor for malnutrition in advanced lung cancer. See Fig. (4) Based on the results of the univariate analysis, we included age, PA, ALB, NLR, BMI, PhA and L3 SMI as confounders in the multivariable analysis. With the no malnutrition group as the reference group, the multivariate logistic regression showed that the L3 SMI of patients in the mild-to-moderate and severe malnutrition groups statistically differed from that of patients in the no malnutrition group  Taking PG-SGA ≥ 3 points as the cut-off point for diagnosing malnutrition, the ROC curve was used to explore the diagnostic value of L3 SMI and traditional indicators. The AUC of the L3 SMI, PhA, PA, BMI, PLR and NLR were 0.958, 0.821, 0.697, 0.500, 0.357 and 0.384, respectively, which implied the novel diagnostic value of L3 SMI. See Table Previous studies have confirmed the prognostic value of nutritional status in malignant tumors . With thPrevious studies have shown that the sensitivity and specificity of diagnosing malnutrition are the best when PG-SGA = 3 and PG-SGA = 9 are used as cut-off values . The 110Serological examination, as one of the most widely used examinations, is an important part of the nutrition assessment of patients with cancer and has great importance in clinical work. ALB, hemoglobin, etc., are common biochemical markers that reflect nutritional status and are frequently used in clinical work. A considerable number of studies have confirmed the diagnostic value of these indicators. In recent years, new types of inflammation serological indicators, such as NLR and PLR, have gradually been recognized to represent the inflammation-immune state of patients. Relevant studies have shown that tumor inflammatory response plays an important role in malnutrition and muscle loss, which in turn coordinate and jointly promote the development of cancer . The nutTaking into account the invasiveness of serological examination and the complicated operation of PG-SGA, it is more likely to use a simpler and non-invasive means of nutritional assessment in clinical work, in which case, the SMI came into being. Compared with patients’ weight loss and BMI, skeletal muscle loss can more accurately and quantitatively reflect the condition of lean body tissue and nutritional status , 25, 26.r = − 0.875, which indicated that the L3 SMI had a good correlation with the PG-SGA score. The L3 SMI in severe and mild-to-moderate malnutrition groups were significantly lower than those in the no malnutrition group, with statistical significance in multivariate logistic regression analysis. It could be speculated that low L3 SMI is a risk factor for malnutrition in patients with advanced lung cancer. At the same time, we also observed that ALB, NLR and age differed between the malnutrition and no malnutrition groups, and their OR values were all greater than 1. Although this difference did not reach statistical significance, it could also reflect that there were indeed changes in metabolism and inflammation in malnutrition group patients, which was consistent with the results of previous studies. We further used PG-SGA ≥ 3 points as the cut-off point for diagnosing malnutrition and drew a ROC curve to compare the L3 SMI with serological indicators. The results showed that the L3 SMI had a good diagnostic efficacy on malnutrition in patients with advanced lung cancer, and the diagnostic efficacy was even better than the serological index. These results suggested that the L3 SMI is consistent with the serological index and PG-SGA, which largely confirmed its application value in the nutritional assessment of patients with advanced lung cancer.In this study, the sliceOmatic 5.0 software was used to analyze the abdominal CT of all patients and calculate the L3 SMI. The L3 SMI of patients in the severe, mild-to-moderate, and no malnutrition groups were statistically analyzed. In order to explore the application value of the L3 SMI, we conducted a Pearson correlation analysis between L3 SMI and traditional nutrition evaluation indicators. It was shown that the L3 SMI negatively correlated with the PG-SGA score with The decrease in SMI was obvious in advanced lung cancer patients who developed malnutrition. We believe that this is because changes in skeletal muscle mass and function occur over a long-term accumulative process, which is affected by the side effects of anti-tumor therapy, tumor biological characteristics, nutrition consumption, abnormal energy metabolism, and other factors. Malnutrition in patients with malignant tumors is affected by tumor type, stage, location, treatment method, and others , 31. ComTo our knowledge, this study is the first to apply the L3 SMI to nutritional assessment in patients with advanced lung cancer. The results of this study provide a strong verification for promoting the application of L3 SMI in nutritional status assessments of patients with cancer. The L3 SMI reflects the state of the patient’s skeletal muscle. The decrease in skeletal muscle mass is related to patients’ immune function and inflammation state , 38, whiIn summary, a low L3 SMI is an independent risk factor for malnutrition in patients with advanced lung cancer. We believe that the L3 SMI has excellent sensitivity and specificity for the nutritional assessment of patients with advanced lung cancer, which is consistent with the PG-SGA and has good efficacy in diagnosing malnutrition. The L3 SMI obtained by CT, as a new nutritional evaluation index, has the advantages of being non-invasive, objective, and accurate, thus being a promising quantitative evaluation index in the future.To sum up, the correlation between the L3 SMI and malnutrition was investigated. We chose the Asian population as the research object, first observed that the L3 SMI statistically differed among patients with advanced lung cancer with different nutritional status. The regression model suggested the L3 SMI was an independent risk factor for malnutrition, and we further confirmed the applicability of it in advanced lung cancer patients. The L3 SMI has good diagnostic value in nutritional assessment.


The Be Sweet to Babies video demonstrates the analgesic effects of breastfeeding, skin‐to‐skin care, and sweet‐tasting solutions as interventions to reduce pain during blood sampling in newborns. Although effective and safe, these strategies are implemented inconsistently in clinical settings. Given the increasing popularity of social media, there is a potential to disseminate and promote health information through it. The study aim was to  evaluate the use of Facebook as a means of disseminating the Be Sweet to Babies video in Portuguese, and to evaluate respondents’ prior knowledge, previous use of the three pain management strategies and intent to use the strategies in the future. We conducted a cross‐sectional study, using the “virtual snowball” sampling method. A Facebook webpage was created, in which the video was posted along with a brief survey. Data analyzed included number of views and visits to the page, number of views of the video, likes, dislikes, and survey responses. One year after posting, the page had 70 753 views and 2199 accesses; there were 1553 “likes”, no dislikes, and 43 positive comments. The survey was completed by 930 respondents (42% response rate based on the page access). Over two thirds of the respondents had previous knowledge about breastfeeding, skin‐to‐skin care, and sweet solutions for pain relief. After watching the video, 87% of the respondents intended to use breastfeeding or skin‐to‐skin care in the future, and 71% intended to use sweet solutions. Almost all viewers rated the video as very useful , easy to understand , and easy to apply in real‐life situations . Using Facebook to deliver and evaluate an intervention is feasible, rapid in obtaining responses, low cost, and it is promising for data collection and knowledge dissemination. Further studies are warranted to evaluate the actual impact of the use of social media in practice change. The video presents user‐friendly language and is available in multiple languages.All healthy newborns undergo at least one blood sampling for newborn screening, and preterm and sick infants undergo many more blood sampling procedures during hospitalization.In order to reduce gaps between what is known and what is done, researchers are increasingly using social media to promote quality information about health and to evaluate the impact of using social media as a strategy for translating knowledge into practice.The specific aims of this study were to (a) evaluate the use of Facebook as a platform to share and evaluate the Be Sweet to Babies video; (b) evaluate viewers’ prior knowledge, viewers’ previous use of the three pain management strategies, and viewers’ intention to use the strategies in the future, and (c) evaluate acceptability, usefulness of the video.2This was a cross‐sectional study using Facebook to host the video and the survey.https://www.facebook.com/sejadocecomosbebes). The Portuguese version of the Be Sweet to Babies (Seja Doce com os Bebês) video was produced and initially uploaded to YouTube in 2014, then revised and re‐uploaded in January 2016. The Portuguese Be Sweet to Babies video was produced in the audiovisual department of the Children's Hospital of Eastern Ontario (CHEO) in Ottawa, Canada (https://www.youtube.com/watch?v=nk2w‐CAVVG0). Figure Firstly, an open‐access page on Facebook was created, supported by experts in advertising, who advised on choice of colors and layout, all inspired by the “Be Sweet to Babies” logo , whose first language was Portuguese, evaluated the Facebook page in terms of functionality and clarity of the survey questions. The data collection process was also evaluated at this point. No changes were suggested or required; therefore, no modifications were made to the page or data collection processes.Once the page was launched on September 26, 2016, invitations to access the page, to watch the video, and to complete the brief survey were distributed by e‐mail to colleagues and researchers from various states in Brazil. In addition, invitations were made through the Facebook page using “the snowball method”.2.1Data were collected for a 12‐month period, from September 26, 2016, to September 26, 2017. Facebook analytics in terms of number of views, geographic location where the page was viewed from, length of viewing time (to establish percentage of video viewed), number of likes, dislikes, and comments relating to the video were retrieved. The online survey was developed in Typeform, and respondents were assigned a unique ID to prevent duplicate responses. Data were exported to 18.0 SPSS software (SPSS Inc) for analysis.2.2Descriptive statistics were used to analyze Facebook analytics and survey data. The responses regarding users’ knowledge before and after watching the video were made using McNemar's test, with the significance level set at .05.Comments were reviewed by the three authors and organized by consensus into codes. Direct quotes are used to demonstrate coding of the comments.The use of the video, including the Portuguese translation, and the study was approved by the mothers and nurses shown in the video and the Ethics Committee of the Children's Hospital of Eastern Ontario (CHEO) Research Institute, to which the last author is affiliated (REB protocol 14/108X).3During the 12‐month period of data collection, there were a total of 70 753 views of the Be Sweet to Babies Facebook page and a total of 2199 individuals visited the page, based on individual identifying profiles. There were 930 responses to the survey, a response rate 42.3% based on the 2199 individuals who accessed the page , easy to understand n = 926, 99%), and easy to apply in real‐life situations . After watching the video, 928 respondents (99.8%) intended to use or advocate for the use of all three pain management strategies and only two respondents answered they would not recommend the video to others. After watching the video, respondents stated they wished to use breastfeeding or skin‐to‐skin contact , while 659 (71%) intended to use sucrose. Table 6, 99%, aThe majority of viewers agreed the duration of the video was ideal  with only 118 13%) reporting the video as too long. On the Facebook page, the video received 1553 “likes” and 43 positive comments. The comments were organized into three categories: usefulness, general praise, and recommendations. For example, the comment “The study brought me simple practices with scientific foundations that really work! My rating is excellent! I will share and put into my professional practice” was coded into usefulness. General praise included comments such as “Exemplary work and the most beautiful of all is to see the care and care that each one has with the babies”. The comment “Super recommend breastfeeding while the baby takes the vaccine…” was coded into Recommendations. Key comments which best illustrate the three codes were translated by the first author and second author and summarized in Table % reportiThere were no dislikes or negative comments posted into the Facebook page.4After 1 year, the Portuguese language Be Sweet to Babies video, posted on the Facebook social media platform, had a large number of views (70 753) and the Be Sweet to Babies Facebook page was accessed 2199 times by healthcare professionals, parents, and researchers across 45 municipalities from different states of Brazil. There were 930 surveys completed , which highlights the potential value of Facebook for disseminating information, increasing awareness of evidence, and also for data collection.Social media platforms are being used increasingly by healthcare professionals and researchers to share information about health and research evidence.Although these results are promising in terms of the extremely wide reach of the information posted onto social media, using these platforms to collect participants’ data in order to evaluate acceptability and effectiveness of the information shared has been less successful to date. For the three studies discussed above,Based on the completed surveys for this current study, the two other newborn pain studies,Information shared on social media may create awareness of best practices and may provide motivation to change but it is not yet known whether the information directly changes behaviors. Although this process represents an opportunity to share common interest or engage parents, it is a challenge to present information and build credibility.In another study, a video demonstrating pain management strategies recommended during infant vaccination, which included breastfeeding, sucrose, and topical anesthetics, was shown at prenatal classes.4.1This study of the use of Facebook to disseminate the parent‐targeted Be Sweet to Babies video and evaluating respondents’ perceptions of the video resulted in large numbers of views, visits to the page, and a good survey response rate. The response rate of 42% of viewers who accessed the Facebook page is much higher than previous studies evaluating the video when posted onto YouTube. In addition, using Facebook as the social media platform for sharing information is at a low cost when compared to administering surveys in person, or by post, and can reach large numbers of people in diverse geographic regions. However, as per previous studies by this team and others, positive findings regarding potential implementation of the evidence‐based information shared using social media platforms can only inform intention to use the information in the future, and not the actual impact, and whether the recommended practices are actually put into practice. Furthermore, it is not known if viewers completed the survey more than once. Using more traditional research methods to evaluate whether the knowledge translation products, such as the Be Sweet to Babies videos, in conjunction with dissemination through social media, are warranted to evaluate actual practice change in the clinical area. In addition, although using social media results in widespread sharing of information, using Facebook does involve time and commitment in developing and monitoring pages, and keeping information up to date and targeted at the intended audience.5The brief parent‐targeted Portuguese language Be Sweet to Babies video demonstrating use of breastfeeding, skin‐to‐skin care, and sweet‐tasting solutions for newborns during painful procedures, and shared through the Facebook page, had a large number of views in a 1‐year period, and based on access to the page, the survey had a good response rate of 42%. The video was considered useful and persuasive in terms of future intent to use the pain management strategies. Widely disseminating the video to the public, and using Facebook to collect viewers’ data, was feasible, and a quick and inexpensive method to obtain responses. Although the results are positive, further studies evaluating whether the viewing of the video actually changes clinical practices in terms of neonatal pain management strategies are warranted.


Laodelphax striatellus , is an important agricultural pest that causes significant losses by sucking and transmitting multiple plant viruses, such as rice black-streaked dwarf virus (RBSDV). Insecticides are commonly used to control planthoppers and cause the induction or overexpression of cytochrome P450 monooxygenases (P450s) from the CYP3 and CYP4 clades after insecticide application. However, little is known about the roles of insecticides and P450s in the regulation of viral replication in insects. In this study, RBSDV-infected L. striatellus were injected with imidacloprid, deltamethrin, pymetrozine, and buprofezin, respectively. The insecticide treatments caused a significant decrease in RBSDV abundance in L. striatellus. Treatment of piperonyl butoxide (PBO), an effective inhibitor of P450s, significantly increased the RBSDV abundance in L. striatellus. Fourteen P450 candidate genes in the CYP3 clade and 21 in the CYP4 clade were systematically identified in L. striatellus, and their expression patterns were analyzed under RBSDV infection, in different tissues, and at different developmental stages. Among the thirty-five P450 genes, the expression level of CYP6CW1 was the highest, while CYP6AY3 was the lowest after RBSDV infection. Knockdown of CYP6CW1 and CYP6AY3 significantly increased the virus abundance and promoted virus replication in L. striatellus. Overall, our data reveal that CYP6CW1 and CYP6AY3 play a critical role in the regulation of virus replication in L.striatellus.The small brown planthopper,  Laodelphax striatellus, Sogatella furcifera, and Nilaparvata lugens. The rice planthoppers can cause losses by feeding. Besides, they also transmit a variety of plant viruses, causing severe yield losses in rice-producing regions. For example, S. furcifera can transmit Southern rice black-streaked dwarf virus, while N. lugens can transmit rice grassy stunt virus and rice ragged stunt virus [Laodelphax striatellus can transmit rice stripe virus, rice black-streaked dwarf virus (RBSDV), maize rough dwarf virus, northern cereal mosaic virus, and barley yellow striate mosaic virus [Rice production is severely affected by planthoppers, such as nt virus ,2. Laodeic virus ,4,5,6,7.CYP4CE1, CYP6AY1, and CYP6CW1 [CYP2E1 and CYP1A1 resulted in the susceptibility to chronic Hepatitis B virus infection [Cytochrome P450 monooxygenases (P450) are a group of heme-thiolate enzymes that catalyze a variety of reactions related to metabolism and chemical toxicity . The P45 CYP6CW1 ,10,11. M CYP6CW1 ,13,14. Anfection , suggestL. striatellus. It is the causal agent of rice black-streaked dwarf and maize rough dwarf disease, which cause considerable yield losses in East Asia [Fijivirus of the family Reoviridae. Its genome includes ten double-stranded RNA (dsRNA) segments (S1 to S10) and encodes thirteen proteins. Each segment of S5, S7, and S9 encodes two proteins. P5-1, P6, and P9-1 proteins, which are encoded by the segments of S5-1, S6, and S9-1, are the components of the viroplasm [S10 segment, is the outer capsid protein, which plays a key role in viral infection process [L. striatellus is a barrier for RBSDV infection [L. striatellus population is still one of the important strategies to control the viral disease. High-efficiency, low-toxicity, and low-residue insecticides, such as mesoionic insecticide, triazinone insecticide, pyrethroid insecticide, neonicotinoid insecticide, and insect growth regulator, are most widely used to control planthoppers in the fields [L. striatellus strain [CYP6CW1 was involved in the resistance to buprofezin and pymetrozine in L. striatellus populations [CYP4C71 in L. striatellus [L. striatellus is largely unknown.Rice black-streaked dwarf virus is one of the important viruses transmitted by ast Asia . RBSDV biroplasm ,18,19. R process ,21. Midgnfection . Currente fields . Imidacls S1 to S and encoe fields , while de fields . Pymetroe fields . Buprofee fields . Fourtees strain . Overexpulations . Imidacliatellus . The funL. striatellus interaction system. Four representative insecticides, including imidacloprid, deltamethrin, pymetrozine, and buprofezin, were selected to study whether insecticides affect RBSDV infection in L. striatellus. We showed that the application of these four insecticides reduced the RBSDV abundance in L. striatellus. Furthermore, inhibition of the P450s activities by P450s inhibitor piperonyl butoxide (PBO) significantly decreased the RBSDV abundance in L. striatellus. Knockdown of P450s CYP6AY3 and CYP6CW1 negatively regulated the RBSDV abundance and replication in L. striatellus. These results demonstrated that insecticides and P450s can regulate virus infection in the insects. In this study, the effect of insecticides on viruses was investigated using RBSDV and L. striatellus were collected from Haian  in 2004 and maintained in the laboratory. The L. striatellus was reared on rice seedlings at 25 ± 1 °C with 70−80% humidity and a photoperiod of 16 h light/8 h dark in a growth chamber. The 3rd-instar VF nymphs of L. striatellus were reared on RBSDV-infected (RB) rice plants for two days. After rearing on healthy rice seedlings for another three days, the nymphs were collected as RB L. striatellus. The virus-free (VF) populations of TM RT reagent kit with gDNA Eraser  according to the manufacturer’s instruction. Quantitative PCR reactions were conducted on iQ5 real-time PCR system  using SYBR PrimeScriptTM RT-PCR Kit . Each PCR reaction included three independent technical and biological replications. Ribosomal protein L5 (RPL5) was used as an internal reference gene [−ΔΔCt [RT-qPCR was adopted to analyze the relative gene expression as previously described . Total Rnce gene . The rele [−ΔΔCt . The priCYP6CW1, CYP6AY3, and enhanced green fluorescent protein (EGFP) were amplified by PCR using the special primers  according to the manufacturer’s instructions. The VF 3rd-instar nymphs were collected and injected with 100 nL dsCYP6CW1 and dsCYP6AY3 (2 μg/μL) by a FemtoJet microinjector , respectively. Meanwhile, the VF 3rd-instar nymphs were injected with the dsEGFP as a control. The RNAi efficiency was determined by calculating the relative expression levels of CYP6CW1 and CYP6AY3 at one, three, five, and seven days after dsRNA injection. For the RNAi assay, partial sequences of  primers . Then, tCYP6CW1 and CYP6AY3 on virus abundance and replication, the VF 3rd-instar nymphs were reared on RB rice plants for two days and, then, collected for injection with 100 nL dsCYP6CW1 and dsCYP6AY3 (2 μg/μL) by FemtoJet microinjector , respectively. The RB nymphs were injected with the dsEGFP as a control. After injection, the nymphs were transferred to healthy rice seedlings for another three days and collected for RT-qPCR and immunofluorescence assay. The experiments were repeated three times independently, and each sample contained thirty insects.To analyze the effect of 50 or LC50. The VF 3rd-instar nymphs were reared on RB rice seedlings for two days and collected as RB L. striatellus. Each insecticide (100 nL) was injected into thirty RB nymphs in the conjunction between prothorax and mesothorax by FemtoJet microinjector . Acetone was injected as a control. The injected nymphs were transferred to healthy rice seedlings for three days. The effects of insecticides on virus abundance were determined by changes in the relative expression levels of S5-1, S6, S9-1, and S10 by RT-qPCR. The RT-qPCR experiments were conducted on a iQ5 real-time PCR system  using SYBR PrimeScriptTM RT-PCR Kit . The experiments were repeated three times independently, and each sample contained thirty insects.The insecticides technical of imidacloprid (96.70%), deltamethrin (98.00%), pymetrozine (98.00%), and buprofezin (97.50%) were purchased from Sigma-Aldrich . The four insecticides were dissolved in dimethyl sulfoxide (DMSO) and diluted to 3.50 mg/L, 1.00 mg/L, 9.27 mg/L, and 1.35 mg/L in acetone according to LDL. striatellus were reared on RB rice plants for two days and injected with 100 nL PBO  using a FemtoJet microinjector . Acetone was injected as a control. The injected nymphs were transferred to healthy rice seedlings for three days. Thirty nymphs were collected for each sample. The RBSDV abundance in L. striatellus was determined by analyzing the expression of S10 using RT-qPCR and labeling the P10 protein in vivo by immunofluorescence. Each sample contained thirty nymphs, and the experiment was repeated three times.The 3rd-instar VF nymphs of L. striatellus genome (http://dx.doi.org/10.5524/100361 (accessed on 20 July 2019); BioProject: PRJNA393384, PRJNA398597) [http://www.ncbi.nlm.nih.gov/BLAST (accessed on 1 August 2019)) by BLASTx . The redundant transcript fragments and faulty annotated sequences were also removed. All of the identified sequences of P450s were further annotated and classified by blast against the non-redundant (Nr) protein database (http://www.ncbi.nlm.nih.gov/ (accessed on 1 August 2019)). The CYP3 and CYP4 clades of identified P450s were obtained according to the classification of insect P450s [The potential sequences of P450s were obtained from the A398597) . We firsct P450s . L. striatellus were dissected from VF adult. The L. striatellus were rinsed three times with 75% ethanol and, then, washed three times with sterilized-deionized water. The tissues were dissected in chilled 1× phosphate-buffered saline  under a stereomicroscope using sterile forceps. Each tissue sample was dissected from fifty VF L. striatellus. The 1st-instar to 5th-instar nymphs, male and female adults, were collected from VF L. striatellus. The relative expression of P450 genes at the mRNA level in different tissues and different developmental stages was detected by RT-qPCR method. The experiments were repeated three times independently, and each sample contained thirty insects.The tissues of midgut, fat body, ovary, and salivary gland of L. striatellus were reared on RB rice plants for two days and, then, transferred to healthy rice seedlings until 5th-instar nymphs. The surviving 5th-instar nymphs were collected as RB L. striatellus samples and used to analyze the expression of P450 genes under RBSDV infection. The VF nymphs reared on healthy rice seedlings at the same time were collected as VF control. RT-qPCR was performed to detect the relative expression of P450 genes at the mRNA level. Each sample contained thirty nymphs, and the experiment was repeated three times. To analyze the effect of RBSDV infection on P450s expression, VF and RB L. striatellus were prepared. The VF 3rd-instar nymphs of CYP6CW1, and CYP6AY3 on RBSDV abundance in L. striatellus midgut was determined by labeling the P10 protein by immunofluorescence. The effect of CYP6CW1 and CYP6AY3 on RBSDV replication in L. striatellus midgut was determined by labeling the dsRNA with an anti-dsRNA (J2) antibody and the virus viroplasm component P9-1 protein by immunofluorescence. The RB midgut of L. striatellus was dissected and fixed in 4% paraformaldehyde for 1 h. Midguts were permeabilized using 2% Triton X-100 for 30 min and blocked in 3% BSA for 2 h. Then, anti-RBSDV P10 mAb conjugated with FITC was incubated with the samples to label the RBSDV. To label P9-1 and dsRNAs in the midgut, the samples were incubated with the primary antibody of P9-1 pAb and J2 mAb overnight at 4 °C, respectively, and subsequently incubated with fluorescence secondary antibody goat anti-Rabbit TRITC  and goat anti-Mouse Alexa Fluor Plus 405  for 45 min at room temperature. The actin filaments were labeled by phalloidin . The confocal images were taken by an LSM 710  confocal microscope. The effect of PBO, t-test. One-way analysis of variance (ANOVA) was used to analyze the expression abundance of selected genes in different tissues and different developmental stages. Data were shown as mean ± standard error (SE) from at least three independent experiments. The p values < 0.05 and 0.01 were considered statistically significant and very significant differences, respectively. Different letters indicated significant differences at p value < 0.05. The ANOVA F statistic is listed in Statistical analyses were performed by SPSS 20.0 software . The differences between treatments were compared using the student’s L. striatellus. The relative expression of RBSDV replication related genes, S5-1, S6, and S9-1, and coat protein gene, S10, were analyzed in RB L. striatellus injected with the four insecticides or acetone control. All the four insecticide treatments significantly decreased the relative expression of RBSDV S5-1, S6, S9-1, and S10 in L. striatellus  and disrupt feeding behavior of B. tabaci [Frankliniella occidentalis [L. striatellus. The results in the present study demonstrated that application of four types of insecticides caused a significantly decrease in RBSDV abundance in L. striatellus. The result was in keeping with the finding observed in B. tabaci, whose insecticide application reduced virus infection in insect vector [Hikaru genki homolog of the leafhopper Nephotettix cincticeps restrained the spread of the nucleorhabdovirus rice yellow stunt virus (RYSV) in the central nervous system of vector [L. striatellus’ feeding behavior, and buprofezin may reduce RBSDV infection by influencing L. striatellus’ metabolic system. These studies suggested that insecticides have different effects on different viruses in insects. These insecticides have multiple properties such as high efficiency, low toxicity, and low residue. These four types of insecticides are most widely used to control planthoppers in the fields, and insecticides should be used interchangeably. Suitable insecticides were selected according to the resistance and virulence of pests in the field. A previous study showed that application of flupyradifurone and acetamiprid, two neonicotinoid insecticides, in potato could significantly inhibit . tabaci . Conversdentalis . It needt vector . Imidaclf vector . We specf vector . PymetroNilaparvata lugens [L. striatellus after PBO treatment, indicating that P450s are involved in regulating virus infection in L. striatellus. P450s are divided into CYP2, CYP3, CYP4, and mitochondrial CYP clades. They play critical roles in xenobiotic metabolism and insecticide resistance in insects, especially CYP3 and CYP4 clades. For instance, CYP3 and CYP4 clades played positive roles in neonicotinoid insecticide resistance in a lugens . Furthera lugens ,24,25. CL. striatellus [L. striatellus. Among them, sixteen P450s were significantly changed after virus infection. Similarly, a previous study has shown that the relative expression levels of detoxification enzyme genes were altered after plant virus infection in B. tabaci [CYP6CW1 was the gene that increased the most, while CYP6AY3 decreased the most after RBSDV infection in L. striatellus. Knockdown of CYP6CW1 and CYP6AY3 could increase the RBSDV abundance in L. striatellus, indicating that these two P450 genes are required for insects resisting virus infection. How these two P450 genes regulate virus infection remains to be investigated. L. striatellus might upregulate the expression of CYP6CW1 to suppress RBSDV infection, while CYP6AY3 expression was downregulated by RBSDV to promote virus infection. In addition to CYP6CW1 and CYP6AY3, there are another five P450 genes in the CYP3 clade and eight P450s in the CYP4 clade that are responsive to RBSDV infection; these genes may also be involved in the regulation of virus infection in L. striatellus.Although P450s in many insects were already identified, they were not systematically analyzed in iatellus ,32,33. S. tabaci . Our resCYP6CW1 and CYP6AY3 suggest they have different roles during virus infection in insects. The high expressions of CYP6CW1 in the midgut and in RB L. striatellus suggest that CYP6CW1 may play a critical role in the inhibition of virus infection in the midgut. CYP6AY3 is downregulated after RBSDV infection, indicating that RBSDV suppresses the expression of CYP6AY3 to facilitate its infection in L. striatellus. The low expression of CYP6CW1 in females and CYP6AY3 in males and females suggest that they may facilitate virus infection in adults. Opposite to the expression pattern of CYP6AY3, CYP6CW1 had the highest expression level in male. The high expression level of CYP6CW1 may enhance the ability to metabolize insecticides and to inhibit virus infection in male of L. striatellus. In insects, the high expression level of CYP6CW1 and CYP6AY3 was reported to associate with insecticides metabolism in resistant strains, and insecticides treatment could upregulate the expression of CYP6CW1 and CYP6AY3 [CYP6CW1 was related to buprofezin resistance in a lab-selected resistant strain, and CYP6AY3v2 can hydroxylate imidacloprid in L. striatellus [L. striatellus to insecticides. The midgut in an insect vector is an infection barrier and the salivary gland is a release barrier for the persistent virus transmitted by the insect . The dif CYP6AY3 . CYP6CW1iatellus ,35. RBSDL. striatellus. Treatment of P450s inhibitor PBO reduced the abundance of RBSDV in L. striatellus. The P450 genes in CYP3 clade and CYP4 clade were systematically identified. CYP6CW1 and CYP6AY3 in P450s CYP3 clade were differentially expressed under RBSDV infection and were required for RBSDV replication in L. striatellus. These results provide new understanding the effects of P450 genes on virus infection in the insect vector and provide a theoretical basis for guiding the control of plant virus disease in the field.Taken together, our results revealed the effect of insecticides and P450s on virus infection in insects. Application of four commonly used insecticides inhibits RBSDV abundance in


This study was conducted to report long-term outcomes of the frameless robotic stereotactic radiosurgery (SRS) for brain arteriovenous malformation (AVM) at Ramathibodi Hospital.Retrospective data of patients with brain AVM (bAVM), who underwent CyberKnife SRS (CKSRS) at Ramathibodi Hospital from 2009 to 2014, were examined. Exclusion criteria were insufficient follow-up time (<36 months) or incomplete information. Patients’ demographics, clinical presentation, treatment parameters, and results were analyzed. Excellent outcome was defined as AVM obliteration without a new neurological deficit. Risk factors for achieving excellent outcome were assessed.From a total of 277 CKSRS treatments for bAVM during the 6 years, 170 AVMs in 166 patients met the inclusion criteria. One hundred and thirty-nine cases (81.76%) presented with hemorrhages from ruptured bAVMs. Almost two-thirds underwent embolization before radiosurgery. With the median AVM volume of 4.17 mL, three-quarters of the cohort had single-fraction CKSRS, utilizing the median prescribed dose of 15 Gray (Gy). In the multisession group (25.29%), the median prescribed dose and the AVM volume were 27.5 Gy and 22.3 mL, respectively. An overall excellent outcome, at a median follow-up period of 72.45 months, was observed in 99 cases (58.24%). Seven AVMs (4.12%) ruptured after CKSRS but 1 patient suffered a new neurological deficit. Two patients (1.18%) were classified into the poor outcome category but there were no deaths. Negative factors for excellent outcome, by multivariate regression analysis, were the male sex and multisession SRS delivery, but not age, history of AVM rupture, previous embolization, or AVM volume.Despite relatively larger bAVM and utilizing a lower prescribed radiation dose, the excellent outcome was within the reported range from previous literature. This study offers one of the longest follow-ups and the largest cohorts from the frameless image-guided robotic SRS community. Colombo et al reported early results in 279 patients, treated with CK robotic SRS, with a median follow-up of 31 months. Subgroup analysis of the 102 cases, who had a follow-up duration of ≥36 months, showed an overall 71.5% rate of AVM obliteration. Apart from this report, other studies by Gupta et al, Ding et al, Wowra et al, Oermann et al, and Feutren et al comprised 9, 11, 20, 26, and 48 subjects, respectively.–19 Thus, to furnish results from a greater number of patients with a longer follow-up period, a database of patients undergoing AVM treatment by CyberKnife SRS (CKSRS) at Ramathibodi Hospital was evaluated.Arteriovenous malformation (AVM) of the brain is a common cause of spontaneous intracranial hemorrhage in the young. Current treatment options for brain AVM (bAVM) are observation, surgical excision, endovascular embolization, and stereotactic radiosurgery (SRS).22.1 The mRBAS were arranged into ranges of scores, ≤1, 1.01 to 1.5, 1.51 to 2 and >2, for further examination. The CKSRS treatment parameters from the included AVM were retrieved.After approval by the Institutional Review Committee, a retrospective study of patients with bAVMs who underwent CKSRS from 2009 to 2014 was undertaken. Cases with incomplete data were excluded. Pre-SRS demographics of each patient such as age, sex, history of hemorrhage, previous AVM treatment , neurological status and clinical presentation were recorded. In those with unruptured AVMs, their initial symptom(s), such as seizure or incidental finding, were documented. Patients’ age, AVM volume, by milliliter, and location were taken into account for the calculation of modified radiosurgery-based score (mRBAS) as per the following equation: AVM score = (0.1 × volume [mL]) + (0.02 × age [year]) + (0.5 × location [0 or 1]). One point was assigned for deep locations , whereas 0 points were given for the non-deep areas.2.2A moldable plastic, custom-made, mask was individually fitted for each patient before obtaining the CKSRS protocol, with 1.2 mm cuts, and a contrast-enhanced computerized tomography (CT) scan. In addition, selected series of magnetic resonance imaging (MRI) consisting of thin-sliced (1–3 mm) gadolinium-enhanced T1, proton-density, and contrast-enhanced magnetic resonance angiography (MRA) were uploaded to the CK planning station. Subsequent integration of the MRI/MRA with the CT was done. The target (AVM nidus) as well as critical structures were delineated before treatment planning. For bAVMs with a diameter <30 mm, or volume <15 mL, a single-fraction SRS was employed. For larger targets, a multisession, in 5 daily deliveries, SRS regimen was utilized. An appropriate prescribed radiation dose, 15 to 20 Gray (Gy), was selected for the single-fraction SRS plan whereas 4 to 6 Gy/fraction for 5 consecutive fractions was applied for the multisession regimen. The prescribed dose was typically assigned to the 50% to 75% isodose line. A ray-tracing algorithm was exercised for dose calculation.2.3 The percentage of the aforementioned outcomes were stratified into groups based on the ranges of mRBAS, as described earlier. Owing to the nature of this retrospective chart review, the clinical and radiographic outcomes, documented by multiple examiners and radiologists, were not blinded.After the CKSRS treatment, appointments for clinical evaluation were scheduled at a 6-month interval. MRI and MRA scans at 24 or 36 months were typically obtained to determine complete obliteration of the AVM. At that time, those with apparent nidus or remaining flow, evident by early draining vein(s), were examined by annual neurologic tests, MRI, and MRA. In patients with nondetectable AVM nidus and no venous outflow by MRI/MRA, cerebral angiography would have been performed except in the event of patient refusal. For post-CKSRS assessment of outcomes, the included cases must have had at least 36 months of follow-up duration. The outcome of each patient, at his/her latest follow-up, was determined by the classification described by Pollock and Flickinger as follows: excellent, good, fair, unchanged and poor outcome, and death. Complete obliteration of the AVM without a new neurological deficit was defined as excellent outcome. Patients with AVM obliteration were classified into good outcome if they had minor deficit, and into fair outcome if they suffered major deficit that resulted in a decline of their functional status. If the AVM was not obliterated, the unchanged outcome was given to those without a new deficit while poor outcomes were patients who sustained a new deficit. Death was the last category of outcomes if it was believed to be directly related to the AVM or the SRS treatment.2.4t test or the Mann–Whitney U test for continuous variables, and the χ2 or Fisher exact test for categorical variables. Univariate and multivariate analyses were utilized to identify predictors for excellent outcomes by the logistic regression model with odds ratios and 95% confidence intervals (CI) computation. Kaplan–Meier survival graph of the proportion of AVM obliteration over time would be generated by linear regression analysis. All statistical tests were performed with Stata version 14 software . Statistical significance was considered with a P value <.05.Patient, treatment, and outcome data would be presented as mean ± standard deviation (SD) or median (interquartile range [IQR]), where appropriate, for continuous variables and as percentage for categorical variables. To investigate patient and treatment factors influencing an excellent outcome, the data were compared using the Student 3From 2009 to 2014, there were 277 bAVM patients who underwent CKSRS at our institute. The excluded subjects were 22 patients whose data could not be retrieved and another 89 cases with insufficient follow-up (<36 months). This resulted in a study cohort of 166 patients, harboring 170 AVMs. Two cases underwent CKSRS twice during the study period. Both of them had a substantial volume reduction in their AVMs but did not achieve complete obliteration. The other 2 subjects had 2 AVM nidi at different locations. A summary of the patients’ demographics is shown in Table Table P < .001). Its actuarial post-SRS AVM obliteration rates were 9.3%, 11.75%, 31.6%, and 43%, at 3, 5, 8, and 10 years, respectively. No patient with AVM eradication suffered a new neurological deficit; hence, the rate of excellent outcome was maintained at 58.24% and none was classified into good or fair categories. Among the nonobliterated AVMs, 69 patients had no new deficit, resulting in the proportion of 40.59% for the unchanged outcome group. After CKSRS, 7 overall occurrences of AVM hemorrhage (4.12%), in 6 patients, were recorded. The events arose at as early as 6, but no later than 67 months after treatment  months, 99 patients (58.24%) had complete AVM obliteration, confirmed by cerebral angiography in 72 72.73%), and by MRI/MRA in 27 (27.27%) cases. The median time to obliteration was 39.4 (24.63–60.8) months , AVM volume (P = .021), multisession SRS (P < .001), isodose line (P = .018), and time to AVM obliteration (P < .001). In contrast to many publications, we did not find a history of AVM rupture (P = .672) or previous embolization (P = .632) to correlate with untoward results. Moreover, the age (P = .908) and deep location (P = .338) were not associated with excellent outcome, although the mRBAS appeared to be related (P = .013). Further evaluation by uni- and multivariate analyses for independent predictors of excellent outcome was performed. The AVM volume , mRBAS , and isodose line  were insignificant, by multivariate examination, whereas the male sex  and multisession SRS  were confirmed to negatively affect the outcome  along with the larger target volume. The overall rate of post-SRS hemorrhage was also within the reported 1% to 5% range.,14,17–19Stereotactic radiosurgery is an established treatment modality for bAVM.,8,25 This study concurred with previous publications with regard to the AVM volume and multisession SRS. It should reflect the substantial magnitude of targets that automatically mandated fractionation of radiotherapy rather than the poor selection of treatment options. On the other hand, the excellent outcome was not inversely affected by age, history of AVM rupture and deep location, as previous studies validating radiosurgery-based AVM scoring systems might suggest.–28 Although most of the SRS series did not find sex to be associated with outcomes, this study, in a multivariate analysis, identified the male sex as an independent negative predictor. Frager et al published a similar observation and Bir et al found that female patients had a higher proportion of AVM obliteration. On the contrary, Yang et al found the male sex to be one of the protective factors against the post-SRS rebleeding and Liscak et al demonstrated that male patients achieved a higher percentage of AVM obliteration.Recognized negative factors, for AVM eradication by SRS, include patient factors, such as age, deep location, history of hemorrhage or large AVM volume, and treatment factors, that is, prescribed dose.,33 At Ramathibodi Comprehensive Neurovascular Center, there has always been a significant proportion of AVM patients whose pre-SRS embolization were necessary. In contrast, our statistical analysis contradicted those facts. Similar findings, of no untoward effect from prior embolization, were previously published by few centers.,35 Oermann et al noted that the previously embolized AVMs had a significantly worse rate of obliteration after SRS. However, upon multivariate analysis, it failed to prove the case but, instead, the AVM architectural complexity was the actual negatively-affecting variable. We have not explored this particular matter in the present study.In addition to the above-mentioned negative factors, it is largely well-known that pre-SRS embolization hinders the probability of AVM obliteration.,17–19 Despite the largest number of subjects in their study, Colombo et al performed the assessments of outcomes from 102 patients who had at least 36 months of follow-up. Therefore, with 170 AVMs and the median follow-up duration of 72.45 months, our study represents the largest cohort demonstrating long-term results among the published series of frameless image-guided robotic SRS for bAVM  for lack of data or insufficient follow-up duration. It could have affected the overall obliteration rate or the incidence of complications as shown by Heffez et al.6These results, with a considerable number of patients and extensive follow-up duration, confirmed the efficacy and safety of the frameless image-guided robotic stereotactic radiosurgery for brain AVM. Identified risk factors hindering achievement of excellent outcome were the male sex and multisession treatment.The authors thank Miss Suraida Aeesoa for her assistance in statistical analyses of the study and Dr. Nattaphong Rattanavirotkul for manuscript corrections.Conceptualization: Pritsana Punyawai, Mantana Dhanachai, Chai Kobkitsuksakul, Ake Hansasuta.Data curation: Pritsana Punyawai, Nicha Radomsutthikul.Formal analysis: Pritsana Punyawai, Ake Hansasuta.Investigation: Pritsana Punyawai, Nicha Radomsutthikul.Methodology: Pritsana Punyawai, Mantana Dhanachai, Ake Hansasuta.Project administration: Ake Hansasuta.Supervision: Mantana Dhanachai, Chai Kobkitsuksakul, Ake Hansasuta.Validation: Pritsana Punyawai, Ake Hansasuta.Writing – original draft: Pritsana Punyawai, Ake Hansasuta.Writing – review & editing: Mantana Dhanachai, Ake Hansasuta.