The study describes the successful treatment of a rare type of arteriovenous malformation (AVM) in the sole using hybrid surgery, which consists of open resection and embolization. Moreover, the possibility of utilizing ultrasound during examination in addition to angiography for the diagnosing of AVM of the sole is proposed. Moreover, the possibility of utilizing ultrasound during examination in addition to angiography for the diagnosing of AVM of the sole is proposed.Herein, the authors have described a case of a 31‐year‐old female suffering from AVM of the sole who was treated via hybrid surgery (open resection and endovascular embolization).2A 31‐year‐old female patient was presented to the Golestan Hospital, affiliated with Ahvaz Jundishapur University of Medical Sciences. The patient was suffering from an incrementally increasing severe pain in the sole of her right foot over a six‐month period since the referral date, especially during walking.The patient's medical history was unremarkable, showing no history of surgery or trauma to the lower limbs. Physical examination showed no discoloration or skin lesions; however, a pulsating mass of 7 cm was felt behind the ankle. Multiple tender pulsatile masses up to 4 cm in diameter were also observed on the sole.Ultrasound of the sole revealed an aneurysm in the posterior tibial artery in the ankle region, and numerous prominent vessels were observed in the sole.The decision to perform a diagnostic angiography was based on the physical examination and ultrasound findings, which revealed an aneurysm in the posterior tibia artery behind the ankle, along with an AVM in the sole Figure . Due to Spinal anesthesia was applied to the patient, and the skin was incised across the posteromedial of the malleolus. The aneurysmal part of the posterior tibia artery was carefully released, and proximal and distal aneurysms were controlled using tape Figure . Using aPost‐operation angiography was then carried out, revealing that a significant part of the AVM was closed Figure .After controlling the proximal and distal aneurysmal part of the posterior tibial artery, the aneurysmal section was removed. The saphenous vein of the same side was used to interpose the posterior tibial artery graft. After ensuring hemostasis, the skin was sutured, and the wound was bandaged. In the postoperative examination, the patient had no movement disorders, and the pulsating mass on the sole was not palpable. Following the patient's discharge, several evaluations were carried out at various periods, revealing that the patient had no subsequent problems putting her weight on her sole Figure .3An AVM is a rare condition in as such that the incidence and prevalence of AVM are 1/100,000 and 10/100,000. The literature on the subject indicates that gender, race, and ethnicity do not increase the risk of AVM; moreover, AVMs are believed to result from abnormal differentiation of the vascular system throughout embryogenesis.In most cases, symptoms begin between the ages of 35 and 40 but can occur at any time.While AVMs exist at birth, they are asymptomatic; however, during puberty and pregnancy, AVMs can become symptomatic due to the influence of hormones.The Solitary AVM in healthy individuals is considered an anomaly; however, multiple lesions are associated with congenital syndromes, including Klippel and Trenaunay, Sturge Weber, Parkes Weber, and Proteus syndromes.Noninvasive investigations such as ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are frequently used to diagnose peripheral lesions; however, for diagnosing AVM, an invasive investigation using angiography can also be applied.The primary treatment for AVM of the sole is surgical excision with ligation or embolization of the feeding vessels.Numerous agents, such as gel foam, coils, PVA particles, glue, and detachable balloons, have been utilized for embolization. Selecting the most suitable agent depends on two parameters: (1) the size of the vessel and (2) the temporary or permanent closure of the vessel.In the current investigation, the most critical issue was the aneurysm formation of the posterior tibial artery. The aneurysm was larger than normal and painful. Moreover, the aneurysm had the potential to rupture at any time. There was also a risk of aneurismal rupture in case of primary AVM surgery through retrograde angiography from the femoral artery. Due to the location of the aneurysm, which was behind the ankle, a stent graft procedure was impossible; therefore, the vascular surgery team decided to use a hybrid technique to simultaneously perform surgery on both the aneurysm and AVM.4The authors presented a rare AVM in the sole, for which hybrid surgery consisting of open resection and embolization was applied as the proposed treatment. Due to its rarity, most surgeons have seldom dealt with AVM of the sole during their routine practice, which in itself emphasizes the importance of considering AVM when treating chronic pain in the plantar region. A combination of ultrasound examination and angiography could also aid physicians in diagnosing AVM of the sole.Iraj Nazari: Writing – original draft; writing – review and editing. Seyyed Masoud Mousavi: Writing – original draft; writing – review and editing. Mohammad Amin Zargar: Writing – original draft; writing – review and editing. Seyed Mohammad Amin Alavi: Writing – original draft; writing – review and editing.No sources of funding were declared for this study.The authors have no conflict of interest to declare.Permission from the ethics committee was not required for case reports at the institution where the research was carried out.Written informed consent for publication of the case report has been signed by the patient and is available upon request from the editors.


A primigravida 22-year-old woman, at a gestation of 23 weeks, experienced bleeding from a pial arteriovenous malformation (AVM) located in the right cerebellum. After interdisciplinary consensus and with the informed consent of the patient and her family, AVM embolization was performed. Complete occlusion of the AVM was achieved by embolization with PHIL (precipitating hydrophobic injectable liquid). The calculated dose in the uterus was less than 1 µSv, which represents a negligible risk of harmful effects on the fetus. She delivered a baby at 37 weeks of gestation by cesarean section without complications. No congenital disorders were diagnosed by standard screening methods until the age of the newborn was two years. The angiography protocol must be optimized to minimize the radiation dose. Adequate shielding protection of the uterus is important. Premature termination of pregnancy is not necessary. Multidisciplinary care of neurologists, neurosurgeons, interventional radiologists, anesthesiologists, neonatologists, and obstetricians is necessary. Brain arteriovenous malformations (bAVMs) are uncommon vascular lesions  composed of feeding arteries , a nidus (with shunt), and draining veins. bAVMs are typically present in young adults with spontaneous intracranial hemorrhage, seizures, or headaches ,3. BrainThe prevalence rate of bAVMs is approximately 0.01–0.5%, and they generally present symptoms between 20 and 40 years of age, most commonly at 30 years of age, and equally affect men and women [The annual risk of bleeding from unruptured bAVMs was estimated from retrospective studies at 4%, but it has recently been reported in a range of 1–2.2% ,7. It waICARUSS investigators positively confirmed a drainage vein diameter as a specific risk factor for AVM rupture with a cutoff ≥ 5 mm .Compared to a nonpregnant period in women with AVMs, the potential risk of intracranial hemorrhage increases 3.27 times during pregnancy and puerperium . BecauseThe main characteristics of brain AVMs are listed in At zero doses, there is zero risk of harm. In general, the ALARA principle (As Low As Reasonably Achievable) assumes that exposure to radiation poses a risk. This fundamental principle is even more crucial to adhere to during pregnancy.The civil population is constantly exposed to radiation from natural sources. Today, the medical use of X-rays represents the largest source of man-made radiation. Selected radiation doses are listed in There is no definitive evidence to support the risk at all doses. This remains an active area of research. Depending on the study, approximately 100 mSv, 50 mSv, or 10 s mSv may be quoted as a level below which evidence is difficult to determine . Better The European Directive 2013/59/Euratom provides a relevant and beneficial practical impact on European radiology . The dosThe International Commission on Radiological Protection (ICRP) recommends that the maximum dose of radiation to the uterus during pregnancy be less than 100 mGy to minimize the teratogenic risks to the fetus ,19.The approximate fetal doses from radiological examinations are listed in It is extremely important to constantly train medical professionals on how to adequately reduce radiation associated with medical imaging techniques . OperatoAn absorbed dose threshold to the patient’s brain of 0.5 Gy is exceeded quite often during cerebral embolization procedures, and optimizing the protocol is crucial. Brain doses are almost doubled when the field increases from 8 to 15 cm or more .It is necessary to avoid or at least minimize abdominal fluoroscopy in pregnant patients. The fetal limit can be approached if the fluoroscopy time exceeds 7 min . The shiSpot fluoroscopy represents an innovative approach to adequately reducing radiation dose in neurointerventional procedures that led to a reduction of 50% of the total fluoroscopic dose-area product .A new generation of 76 µm pixel high-resolution high-definition (hi-def) zoom mode was developed for use in interventional procedures that require superior image quality over a small field of view .Endovascular treatment of brain arteriovenous malformations has evolved considerably over the last few decades. Adaptively, it represents an alternative therapy to and not only a useful adjuvant technique to conventional neurosurgery.Enormous progress has been made in the development of liquid embolic materials and microcatheters. New polymers enable better penetration of an AVM nidus and a more excessive rate of complete AVM occlusion. Current commercially available liquid embolic materials are listed in The availability of detachable microcatheters optionally allows for long-time injection of embolic material. The distal tip (1.5 to 5 cm) of these microcatheters can be left naturally in the access vessel, and the proximal part of the catheter is carefully removed at the end of the treatment procedure. The unique combination of the new embolic material and the detachable microcatheter typically allows for the performing of control angiography during the complex procedure. The injection of embolic material can be interrupted and continued several times as needed.New imaging techniques are highly needed for the selection of the optimal treatment strategy, a more precise visualization of the origin of the main draining vein of the bAVM, and the depiction of more accurate intranidal aneurysms ,37.Endovascular embolization by the transarterial approach is preferred in most bAVMs as a conventional technique. The purpose of this technique is to reduce intranidal pressure before occlusion of the drainage vein. Such embolization can be used as a single therapeutic procedure or as neoadjuvant therapy prior to microsurgery or stereotactic radiosurgery.A possible combination with microsurgical resection can also be used for grade III–V bAVMs as well. A high rate of total obliteration was achieved: 96.8% (in 30/31) was achieved with relatively low rates of permanent morbidity and mortality .Specific modifications of the transarterial technique traditionally represent the plug technique, the pressure cooker technique, the occlusion balloon technique, and multiple catheter techniques.The plug mitigates the potential risk of backflow and catheter entrapment, thus the “reverse plug then push” technique, allowing the operator to inject higher volumes of embolic material at greater injection rates .Detachable microcatheters allow for long-time injection. A higher rate  of AVM obliteration was achieved with prolonged intranidal injection compared to the technique previously used .The pressure cooker technique was designed to block the backflow of embolic material to the nontarget artery by quickly creating an antireflux plug by trapping the detachable part of the microcatheter with coils and glue .The modified coil-protected transarterial n-butyl cyanoacrylate injection technique using a single microcatheter to typically prevent reflux can be efficiently preferred when rapid hemostasis and short procedure time are required in hemodynamically unstable conditions .The dual-lumen balloon catheter technique was uniquely created to minimize the necessary procedure and fluoroscopy times to promptly form an adequate proximal plug that allows the forwarding of nidal penetration while preventing reflux and nontargeted embolization .The present generation of modern devices (the Scepter Mini) can be additionally handled for superselective flow arrest and navigation support due to its ability to be correctly placed on small-diameter feeders .Balloon catheters also play a substantial role in AVM embolization. Inflation of a compliant balloon in the parent artery immediately after the origin of the feeder is a simple but effective maneuver during microcatheter navigation .Occlusion of the draining veins before complete exclusion of the nidus typically carries a procedural risk of bleeding. Two or more arterial feeders can be catheterized and simultaneously embolized to achieve total embolization of the nidus before reaching the venous drainage ,47.Unlike the transarterial approach, curative embolization of AVMs can be achieved more easily with a transvenous approach. The proposed indications for this approach include a small (diameter < 3 cm) and compact AVM nidus, deep AVM location, hemorrhagic presentation, single draining vein, lack of an accessible arterial pedicle, exclusive arterial supply by perforators, and en passage feeding arteries .Transvenous retrograde AVM nidus sclerotherapy under controlled hypotension (TRENSH) technique using temporary systemic hypotension with or without temporary occlusion of the main arterial feeders was first conceptualized by Massoud and Hademenos . ExtensiHudak established a novel strategy of combined transarterial and transvenous embolization with a new liquid embolic agent based on pol-urethane. A combined transarterial and transvenous embolization technique was carefully applied for 46 high-grade bAVMs. Patients experienced subarachnoid or intracerebral hemorrhage (29/46), drug-resistant epilepsy, and/or severe focal deficit (17/46). The principal author precisely measured the local arterial and venous pressure of the nidus during the specific procedure. Transarterial embolization was initially used at the beginning of the complex procedure. After a sufficient reduction in the inflow to the nidus, temporary controlled systemic hypotension was typically induced. At the last moment, the new liquid embolic agent performed a proper transvenous penetration of the nidus. Despite the exclusive inclusion of high-grade bAVMs in the published study, the contributing author achieved complete occlusion of AVMs in 20 specific patients. In the remaining 26 cases, an occlusion rate of 80–90% was reasonably achieved . The funIn most published data, the transvenous approach is typically used in extraordinary cases with the infeasibility of arterial embolization, including supply by tiny perforating arteries, feeders ‘in passage’, or no clear arterial pedicle, and/or in combination with other arterial approaches where the intention of the intervention was endovascular cure. There was an exceedingly higher rate of complete AVM obliteration  and excellent functional outcomes  in patients with ruptured and unruptured AVMs treated with transvenous embolization in another prospective study. The mean size of the AVM nidus was 2.8 ± 1.2 cm, and low Spetzler-Martin grade AVMs comprised 41.5% of the lesions. Most of the patients  were treated in one session. The new Dyna 4D technique was incorporated into the preprocedural analysis. The distinguished authors slowly injected Onyx and tolerated a maximum reflux of 3 cm. After completion of the operative procedure, the microcatheter was typically cut at the optimal level of the jugular sheath .In the review of the literature of 13 studies (69 patients with 70 AVMs) on transvenous embolization, the complete AVM obliteration rate was reported in 93% of specific cases .The transvenous retrograde pressure cooker technique using coils and n-butyl-2-cyanoacrylate as a venous plug can be curative if the main inclusion criteria (AVM < 3 cm and single main drain vein) are accepted without reserve .Solely transvenous embolization can be used in selected small-sized ruptured bAVMs. Fusion of magnetic resonance imaging and 3D angiography is helpful in controlling and fully achieving bAVM penetration by the embolic agent .Selective temporary flow arrest during transvenous endovascular embolization (TFATVE) represents a novel adaptation of the transvenous approach, which employs hyper-compliant balloons intraarterially for the careful blocking of arterial feeders at the time of injection of ethylene-vinyl copolymer to reduce intranidal pressure and increase nidus occlusion rates .Modern dual microcatheterization techniques with arterial and/or venous access, graciously according to angioarchitecture, was curative for low-grade Spetzler-Martin (SM I vs. II was 22% vs. 78%) bAVMs in 95%. More than 60% of prospective patients had ruptured AVMs .Combined embolization therapy appears to be safe and potentially curative for certain deep AVM, e.g., in the basal ganglia, insula, and thalamus. Such a specific location is extremely demanding for all treatment techniques, and microsurgery might not be indicated. Complication rates that may, fortunately, reach radiosurgery profiles were demonstrated in a cohort study of 22 patients. A single transarterial approach was used precisely in nine (41%) unique cases, double catheterization in four (18%) cases, and the transvenous approach was required in eight (36%) cases. The mean size of the AVM was 2.98 ± 1.28 cm, and the mean number of sessions was 2.1 per patient. Most of the patients had cerebral hemorrhage , and three (14%) patients had a deteriorated neurological state  at presentation. Sixty-eight percent of ruptured AVMs had a size ≤ 3 cm .The ongoing study of the transvenous approach for the treatment of cerebral arteriovenous malformations (TATAM) was designed to adequately test the hypothesis that transvenous embolization is superior to transarterial embolization for obliteration of arteriovenous malformations .A primigravida 22-year-old female with no medical history, at a gestation of 23 weeks, experienced bleeding from a pial arteriovenous malformation (AVM) located in the right cerebellum. She presented with acute-onset headache with accompanying meningeal and cerebellar syndrome, nausea, and vomiting. The patient underwent magnetic resonance imaging, which confirmed bleeding from the right cerebellar AVM.Less than 2% of infants <24 weeks’ gestation and approximately half of infants from 24 to 27 weeks’ gestation survived to discharge home from the neonatal intensive care unit . CompareAll the mentioned arguments were discussed in detail during the interdisciplinary meeting. After interdisciplinary consensus and with the informed consent of the patient and her family, AVM embolization was performed. The procedure was performed under general anesthesia. The abdominal area of the patient was protected with the shielding of a lead skirt with a 0.5 mm lead equivalency.The right common femoral artery was punctured under ultrasound guidance, and a 6F short sheath was placed by the Seldinger technique. The patient was not heparinized. Over the guidewire, the sheath was replaced by a 6F 80 cm long introducer, which was placed in the aortic arch without the use of fluoroscopy. Fluoroscopy was used only in the head and neck area of the patient. The procedure continued by positioning the introducer into the left subclavian artery. Then a 6F guiding catheter was advanced and positioned coaxially into the left vertebral artery. All catheters were flushed continuously with saline solution. The left vertebral artery angiogram confirmed the pial AVM located in the right cerebellum, which was supplied by three branches of the right superior cerebral artery and drain into the straight sinus . Apollo The Allura Clarity biplane interventional X-ray system  was used. A low X-ray dose level mode was selected except for the time of critical embolization moments. A maximum of 12.5 frames per second fluoroscopy rate was used. The total fluoroscopy time was 33 min and 20 s. The dose in the uterus, calculated by the Monte Carlo program for calculating patient doses in medical X-ray examinations, PCXMC 2.0 software version, was less than 1 µSv. She delivered a baby at 37 weeks of gestation by cesarean section without complications. No congenital disorders were diagnosed by standard screening methods until the age of the newborn was two years. The patient recovered without a focal neurological deficit and returned to her normal life. The follow-up magnetic resonance confirmed total AVM occlusion.Ruptured pial AVM in pregnancy is a rare but extraordinarily complex situation, associated with high maternal and fetal mortality ,11. MostThe International Commission on Radiological Protection (ICRP) recommends that the maximum dose of radiation to the uterus during pregnancy be less than 100 mGy to minimize the teratogenic risks to the fetus ,19. ExtrNagayama et al. reported an average exposure dose to the abdominal surface in the presence of lead sheets during stereotactic radiosurgery of 14.05 mGy, and the fetus was exposed to a radiation dose of 8.26 mGy . RadiosuSurgery must be indicated in active hydrocephalus requiring shunting, associated with signs of imminent herniation, progressive neurological deficit, or both .Visipaque 320 (iodixanol) is not contraindicated in pregnancy . Only 54Different embolic materials were used for embolization during pregnancy, including NBCA, Glubran, and Onyx—There are no definitive guidelines on how to properly treat ruptured bAVMs during pregnancy. Only a few authors report the radiation dose to the fetus, which is a limit to creating a comparison group. Our center reports only one case. There are no definitive guidelines on how to properly treat ruptured bAVMs in pregnancy. The decision is challenging due to its rarity. Patients may benefit from early therapy due to a higher rate of excessive rebleeding during pregnancy. The purpose of treatment is to preserve the life of the mother as well as the viability of the fetus. Limited data on the dose of fetal radiation during embolization are published, but the available data are acceptable and smaller compared to radiosurgery. Embolization of ruptured AVMs during pregnancy can be used alone as a curative treatment or as an essential part of therapeutic management. Embolization of ruptured AVMs during pregnancy is a feasible treatment technique. The angiography protocol must be optimized to minimize the radiation dose. Adequate shielding protection of the uterus is important. In our case, the calculated dose in the uterus was less than 1 µSv, which represents a negligible risk of harmful effects on the fetus. Premature termination of pregnancy is not necessary. Multidisciplinary care involving neurologists, neurosurgeons, interventional radiologists, anesthesiologists, neonatologists, and obstetricians is necessary.


Aggressive behaviour is a challenge for society. There continues to be considerable debate over whether the consumption of violent video games affects aggression, as violent video game content has become more accessible in recent years due to the growing use of online distribution platforms. Personality traits often linked to aggression, such as narcissism and self-esteem, have been considered in the context of violent video game play and their relationship with aggression.We surveyed an international population of 166 game players on their personality traits and their three favourite video game choices, which were classified as violent or non-violent, using Pan European Game Information (PEGI) 16 and 18 ratings.We found that violent video game choice is a predictor of verbal aggression alongside narcissism, and hostility alongside self-esteem. A categorical regression highlighted the desire to impersonate society’s undesirable role models  as one of the motivations for aggression and violent video game choice.These findings show that video game violence should be considered a risk factor for aggression, as in other violent media, as it provides a social reinforcement of aggressive behaviour and observational learning of aggressive models, calling for the introduction of stricter online age verification procedures on online game platforms to safeguard children from violent video game content; and increased use of parental controls on content fruition. More granularity should be considered in the PEGI classifications. AggressTo date, experiments into the effects of video games on aggression have produced mixed results. In recent literature, a longitudinal study by All literature findings above present a convoluted picture that still does not allow us to answer whether violent video games cause aggression easily. Previously, The first public debate over violence in video games began in the United States in the early-1990s. In 1993 and 1994, the United States Congress held two successive hearings on violence in video games . These hThere have been considerable advances in the complexity, detail and distribution formats of violent video games since these regulations were introduced in the 1990s. In 2018, digital video game sales accounted for 83% of all video game sales . DigitalIn short, the video games and aggression debate is controversial. New technologies have changed the level of immersion in video games and dramatically shifted the manner in which most users access the content. Yet, regulation appears not to have kept pace with this change. This study attempts to reintroduce the research question of whether violent video games cause aggression by considering personality variables previously unaccounted for, that are already considered in relation to aggression, such as narcissism and self-esteem, in the context of age-appropriate video game play.Narcissism is characterised by excessive self-focus and self-interest. Narcissistic individuals are more likely to disregard others’ feelings to focus on themselves. Although research has shown that narcissism is linked to aggression, there is a disagreement as to whether aggression occurs more widely or is specific to the narcissism type. Researchers like On the contrary, Although the literature on the relationship between narcissism and aggression is broad, not many studies have considered this in relation to video games, or violent video games. Self-esteem is a person’s positive or negative attitude towards oneself . BrummelIn the literature, there appears to be a lack of consensus amongst researchers studying the relationship between self-esteem and aggression, with modern studies distinguishing between different self-esteem types and obtaining significant results for the relationship between the two. Older studies, such as that of There is also a lack of studies on the link between self-esteem, aggression and violent video games. As such, we broaden this literature review also to consider studies looking at the connection between general video game use, aggression and self-esteem. The most relevant study on this topic, Our study also considers gaming motivation, as it might provide valuable insight into the relationship between video games and aggression. In broad terms, occasional players seem to be driven by extrinsic motivations , whilst more dedicated players are driven by intrinsic motivations  . A commoBased on the intrinsic motivations for video gameplay, Taken together, there is a noticeable literature gap in the study of violent video games and aggression in relation to the personality variables of narcissism and self-esteem. Narcissism literature, although broader in this field, has failed to answer the question of whether the relationship between narcissism and aggression is stronger in violent video game players. The self-esteem literature, on the other hand, has ignored the link between self-esteem and aggression in the context of video games, even though there is now a march towards the belief that self-esteem and aggression are somewhat linked. Therefore, it is paramount to investigate whether both narcissism and self-esteem and aggression could be mediated by the extent of engagement with violent video games.Violent video games often involve a multiplayer aspect, replicating a social environment virtually. It is therefore not implausible to suggest that narcissists who are socially excluded  will display heightened aggression, as per the findings of As such, the primary aim is to investigate whether the relationship between narcissism and aggression dimensions or self-esteem and aggression dimensions is enabled solely by violent video game choice when it is considered a mediator , 2.H1a: Violent video game choice will mediate the relationship between narcissism and aggression dimensions.H1b: Violent video game choice will mediate the relationship between self-esteem and aggression.The secondary aim is to investigate whether there will be a relationship between the aggressive gaming motivations, aggression, and violent video game choice. Aggression will be considered as a composite due to the nature of the surveyed aggressive gaming motivations concerning factors within the game , 4.H2a: There will be a relationship between aggressive gaming motivations and aggression.H2b: There will be a relationship between aggressive gaming motivations and violent video game choice.2.2.1.M = 25.2, SD = 8.05. The average amount of time spent playing video games per week was coded in increments of 1, where 0–5 h was assigned a value of 0, and 41+ hours was assigned a value of 8. The coded data has descriptive statistics of M = 3.65, SD = 2.07, which suggests that the average time spent playing games was around 20 h per week.One hundred and sixty-six participants took part in the study, 113 males and 53 females, with age statistics of Participants volunteered to take part in the study after seeing an advert on Reddit or Discord. The study was posted on the Reddit communities r/samplesize, r/narcissism and r/truegaming; and on the Discord servers Cluster B Circus, r/NPD Official and NPD Recovery 2.0. Permission to post the link to the study experiment was granted by community moderators. The inclusion criterion was that only those who actively play video games should participate.The study was conducted in December 2021, as many countries, and especially those providing the biggest sample, had lifted their COVID-19 lockdown restrictions for the holiday season. Therefore, this study instigates the impact of video games post-lockdown. As seen in 2.2.The experiment was carried out on participants’ computers, using an online link to a Gorilla Experiment Builder questionnaire.2.2.1.This questionnaire collected data on age, gender, country of origin, three most played video games, and time spent playing video games per week.2.2.2.BPAQ was used to measure the level of aggression in each participant. This questionnaire was chosen as it is the preferred method of investigating aggression levels in psychological research .The scale comprised 29 items on four dimensions, physical aggression , verbal aggression , anger  and hostility . Responses were collected on a Likert scale, from 1 (extremely uncharacteristic of me) to 5 (extremely characteristic of me). The composite range of this scale was 29–145. Two items  were reverse scored. For H1a and H1b, this questionnaire will be analysed by splitting it into its dimensions. For H2a and H2b, this questionnaire will be analysed as a composite of all the dimensions. The internal validity of the BPAQ as a composite, measured by Cronbach’s alpha, was excellent, α = 0.901. The internal validity of the individual dimensions ranged between good and acceptable – good for anger, α = 0.819, good for physical aggression, α = 0.852, acceptable for hostility, α = 0.735, and acceptable for verbal aggression, α = 0.767.2.2.3.NPI-16 was used to measure narcissism levels in each participant. This scale estimates both healthy and unhealthy narcissism, where higher scores lean toward pathological narcissism. NPI-16 was preferred over other narcissism questionnaires due to its good consistency scores relative to its short form. It also enabled us to conduct a quick test of the level of narcissism that would not exhaust the attention span of the volunteers .α = 0.768.The scale comprised 16 statement pairs, and the participant chose whichever statement reflected their thoughts. The range of this scale was 0–1. The internal validity of the NPI-16, measured by Cronbach’s alpha, was acceptable, 2.2.4.RSES was used to measure the self-esteem of each participant. This questionnaire was chosen as it is the preferred and the most standardised self-esteem measure in psychological research. This questionnaire allows us to examine the escapism theory, as argued by α = 0.900  to 3 (strongly agree). The range of this scale was 0–30. The internal validity of the RSES, measured by Cronbach’s alpha, was excellent,  = 0.900 .2.2.5.GIMS was used to test for motivations behind video game engagement. The scale comprised 31 items split into 11 motivation types: survival, self-identification, collecting, greed, protection, aggressiveness, revenge, competition, communication, curiosity and colour appreciation. The responses were collected on a 5-point Likert scale, from 1 (never) to 5 . However, only the aggressiveness items were used in analyses. These were: “Killing enemies” (Agg1), “Be a thief or killer” (Agg2) and “Conquering a territory” (Agg3). These were analysed as ordinal variables, with range of 1–5. The internal validity of the GIMS as a composite, measured by Cronbach’s alpha, was excellent, α = 0.907. However, the internal validity of the aggressiveness dimension of GIMS was unacceptable, α = 0.316, and is likely a result of analysing single items, rather than the scale as a whole.2.2.6.We introduced a novel measure of violent video game choice. The researchers categorised the three most played video game titles provided by the participants as violent or non-violent based on the game’s PEGI rating. PEGI is currently the video game rating system used in Europe, established after the ESRB. It replaced many national rating boards to provide a unitary rating system across all European Countries, including the UK, and it is legally binding. PEGI ratings were sourced from the online PEGI database . PEGI raAs only 36.5% of video games bearing the ‘Violence’ content descriptor have been rated as suitable for more mature audiences (16+) , the ‘ViThe ESRB ratings were also collected as a secondary measure of violence. Certain games, usually games not released in the European market, or mobile games, lack PEGI ratings but have ESRB ratings. In such instances, we classified games as violent if they both had the ESRB rating of M 17+ and had the content descriptors of Violence or Intense Violence. ESRB ratings were sourced from the online ESRB database .Finally, if both the PEGI and ESRB ratings were not available, the researchers screened the game for its gameplay and assessed the gameplay against PEGI/ESRB ratings and descriptors, assigning them with a probable violent/non-violent judgement.Participants reported three of their favourite video games. These would then be assessed against the PEGI and ESRB databases. This provided three dichotomous variables, where a value of 0 was given for non-violent games (≤PEGI 12) or 1 for violent games (≥PEGI 16). The three scores would then be summed up to produce a violent video game choice score in the range from 0 (plays 0 violent video games) to 3 (plays 3 violent video games).2.3.Participants volunteered to take part in the study after viewing a post on Reddit or Discord. They clicked on a link that sent them to the Gorilla experiment. They first read the Participant Information Sheet and provided informed consent. After, they were shown a screening question asking them whether they played video games. Participants were automatically rejected if they answered ‘No’ to this question. If they answered “Yes,” they would proceed to the demographic questionnaire. Upon completion, the participants would enter the testing phase. It comprised four questionnaires administered in a counterbalanced order using Gorilla’s Latin square Order node. These were: BPAQ, RSES, NPI-16 and GIMS. All questionnaires had to be completed to finish the testing phase. Participants had to click ‘Next’ to fully submit the data, after which the experiment was over.2.4.f2 = 0.15, the error probability was set at α = 0.05 and the expected power was set at power = 0.80. For H1a and H1b, for both the a-path (1 tested predictor) and the b-path (2 tested predictors), the minimum sample size was 55. For H2a and H2b, for both the categorical regressions (3 predictors), the minimum sample size was 77. As such we have exceeded the minimum sample size requirements set out by a priori analyses, by recruiting 166 participants in total.Prior to data collection, the minimum sample size was calculated using G*Power . This waParticipants who failed to complete all questionnaires were excluded from the dataset. The data was analysed with IBM SPSS 27. All mediation analyses were carried out using the PROCESS Macro package  and checSome data cleaning was performed. Firstly, the dataset was checked for outliers; none were flagged by the SPSS 27 package. Secondly, as noted earlier, some games given by participants  lacked PEGI ratings. A total of 57 data points out of 498 (11.4%) did not have associated PEGI ratings and were classified using the ESRB or direct observation of the gameplay. Thirdly, some participants reported playing fewer than three games. In such instances, the violent video game choice would be computed as though the missing games were non-violent . This method was employed as it was judged to be the most conservative.3.3.1.As seen in 3.2.3.2.1.Firstly, we carried out a correlation analysis to ensure all aggression dimensions were fit for further mediation analyses. As seen in Interestingly, VVGC returned a significant correlation for Hostility and Verbal Aggression. This would imply that violent video game choice influenced the hostility and verbal aggression scores.3.2.2.t(164) = 5.64, p < 0.001, β = 0.403. However, in Step 2, the regression of Narcissism onto VVGC returned a not significant coefficient of Narcissism, t(164) = 0.299, p = 0.766, β = 0.123. Further steps were not analysed. There was no mediation of VVGC on the relationship between Narcissism and Anger.In Step 1 of the model, the direct effect of Narcissism on Anger, ignoring the mediator, returned a significant coefficient for Narcissism, F = 31.783, p < 0.001, R2 = 16.2%. The coefficient for Narcissism was significant, β = 0.400, t(164) = 5.63, p < 0.001. In contrast, the coefficient for VVGC was not significant, β = 0.139, t(164) = 1.97, p = 0.051. This showed that Narcissism predicted Anger. VVGC did not predict Anger  = 3.53, p < 001, β = 0.267. However, in Step 2, the regression of Narcissism onto VVGC returned a not significant coefficient of Narcissism, t(164) = 0.299, p = 0.766, β = 0.123. Further steps were not analysed. There was no mediation of VVGC on the relationship between Narcissism and Physical Aggression.In Step 1 of the model, the direct effect of Narcissism onto Physical Aggression, ignoring the mediator, returned a significant coefficient for Narcissism, F = 7.76, p < 0.001, R2 = 7.6%. The coefficient for Narcissism was significant, β = 0.264, t(164) = 3.53, p < 0.001. In contrast, the coefficient for VVGC was not significant, β = 0.125, t(164) = 1.67, p = 0.097. This showed that Narcissism predicted Physical Aggression. VVGC did not predict Physical Aggression  = 7.14, p < 0.001, β = 0.487. However, in Step 2, the regression of Narcissism onto VVGC returned a not significant coefficient of Narcissism, t(164) = 0.299, p = 0.766, β = 0.123. Further steps were not analysed. There was no mediation of VVGC on the relationship between Narcissism and Verbal Aggression.In Step 1 of the model, direct effect of Narcissism on Verbal Aggression, ignoring the mediator, was significant, F = 31.770, p < 0.001, R2 = 28.0%. The coefficient for Narcissism was significant, β = 0.482, t(164) = 7.257, p < 0.001. The coefficient for VVGC was also significant, β = 0.208, t(164) = 3.12, p = 0.002. This showed that both Narcissism and VVGC predicted Verbal Aggression  = −7.84, p < 0.001, β = −0.20. However, in Step 2, the regression of Self-esteem onto VVGC returned a not significant coefficient for Self-esteem, t(164) = 0.039, p = 0.97, β = 0.001. Further steps were not analysed. There was no mediation of VVGC on the relationship between Self-esteem and Hostility.In Step 1 of the model, the direct effect of Self-esteem on Hostility, ignoring the mediator, was significant, F = 33.8, p < 0.001, R2 = 29.4%. The coefficient for Self-esteem was significant, β = −0.516, t = 7.84, p < 0.001. The coefficient for VVGC was also significant, β = 0.166, t = 2.52, p = 0.013. This showed that both Self-esteem and VVGC predicted Hostility  into nominal variables that can be used to predict values of continuous variables  via a linear regression.F = 6.37, p < 0.001, 2R = 22%, However, upon the inspection of the coefficients, only Agg2 was significant, β = 0.374, F(3) = 19.2, p < 0.001. Agg1 and Agg3 were not significant, β = −0.202, F(1) = 2.16, p = 0.14, and β = 0.166, F(3) = 1.16, p = 0.33, respectively. This result suggested that only the ‘Be a thief or killer’ motivation was related to aggression  = 5.64, p < 0.001, 2R = 14.4%. As with the regression on aggression, only Agg2 returned a significant coefficient, F(3) = 6.14, p < 0.001, β =0.364, and Agg1 and Agg3 were not significant, F(2) = 1.50, p = 0.23, β = 0.127, and F(1) = 0.241, p = 0.62, β =0.065, respectively. This result suggested that only the ‘be a thief or killer’ motivation predicted whether participants would be likely to play more violent video games  as well as PEGI 18 (gross violence) as violent. This is a novel result that can inform future investigations into the relationship between video games and aggression. The findings contradict past literature. The analysis of aggressive motivations in terms of aggression returned significant results, but this was solely due to the ‘Be a thief or killer’ motivation. The same pattern of results emerged when the same regression analysis was carried out on violent video game choice. We can speculate that players engage with more violent video game content to immerse themselves in roles that are undesirable in society, and that they perhaps would never undertake in the real-world. Thus, the fun of playing video games could also be doing things which one would not normally do in the real-world.4.2.Our study opens a wider discussion about the possible impact of violent video game content on aggressive behaviour.Online age verification is still widely underutilised in online media distribution and consumption. Cinemas enforce age restrictions for films that are not age-appropriate for children, and sometimes such films can be seen by young people only with adult supervision. This is still largely unaccounted for in Internet media. In fact, it is only recently that there has been a legislative drive to require age verification to view websites containing pornographic content in the United Kigdom .Many digital content distribution platforms, for both films and games, rely on parental guidance and discount age verification via identification (players are asked to input their date of birth at most). This can enable younger players to purchase games that are not age appropriate.Considering the findings, the authors suggest digital content delivery platforms to consider revising their age verification procedures to prevent younger players from being exposed to inappropriate game material.4.3.This study has a few limitations. The sample was largely composed of players from the United States. Although the diversity of the remaining part of the sample was broad, it is possible that our findings might only be applicable to the players from the United States.Only one of the aggressiveness gaming motivations provided by GIMS returned significant results when assessed against the aggression scores. This might suggest that the aggressive motivations studied by GIMS might not have been relevant to aggression in our study. If this is true, this limits the conclusions that can be made regarding players’ motivations or suggest that these motivations might not be relevant to studying aggression.The measures of personality traits might not have been sensitive enough to detect the granularity needed to make viable comparisons. Looking at narcissism specifically, NPI-16 was chosen due to its short-form presentation. Additionally, RSES has been argued to only consider global self-esteem , and as Finally, our study did not incorporate any qualitative/mixed research methods which would have allowed participants to explain their gaming motivations in more detail.4.4.This study investigated the link between personality traits (narcissism and self-esteem), and violent video game choice. The results show that participants scored higher on the aggression scale the more violent games they played. Playing violent video games predicted verbal aggression, alongside narcissism, and hostility, alongside self-esteem. Furthermore, we found that narcissism was a predictor of verbal aggression, physical aggression and anger, whilst self-esteem was a predictor of hostility. With further research, violent video game choice, assessed by the summation of PEGI ratings classified as violent, can become a factor in a toolbox of the psychology of aggression and violence.Thus, the authors suggest that greater consideration should be given to the player’s age and their frequent access to games displaying violence. In PEGI 12, which we considered as the cut-off for the non-violent games classification in this study, violence is committed against non-human characters. Future research might consider further lowering the cut-off point. Future research could seek to apply the current procedure to younger samples (age 17 and below) to see whether the results and implications of the present research still stand.Furthermore, it is possible to sample narcissism and self-esteem binomially and analyse them in a between-subjects manner to observe significant results for the relationship between such variables, violent video game choice and aggression. As such, future studies should strive to collect binomial samples to investigate the disparity between the two extremes of the investigated variables. Moreover, future research should confirm whether violent video game choice is a superior method of analysing aggression in relation to video games than time spent playing per week.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 University College London Department of Information Study Ethics Chair. The patients/participants provided their written informed consent to participate in this study.The wider research question of violent video games and aggression was brought up by SO, who also reviewed the literature and prepared the online experiment. The experimental design and variables were chosen by SO and DR, who both carried out the data analysis and critically revised the manuscript prior to publication. All authors contributed to the article and approved the submitted version.


Veterinary telemedicine has only been adopted to some degree. One aspect that needs to be evaluated is clinical examinations using video. The objective of this study was to evaluate agreement between a traditional physical clinical examination and a clinical examination using recorded video using finishing pigs with umbilical outpouchings  as the study unit. A total of 102 finisher pigs with umbilical outpouchings were clinically examined and recorded on video. Four experienced pig veterinarians were allowed to examine each pig for approximately 10 min and were individually asked to fill out a predesigned clinical record. Approximately 1 month after the physical examinations, the veterinarians individually reexamined all 102 pigs in a blinded manner, utilizing the video recordings and filling in a predesigned clinical record.2 on the umbilical outpouching (mean Kappa range 0.67–0.87). Fair agreement was observed for the presence of perineal soiling, ear wounds, pendulation of umbilical outpouching, umbilical outpouching touching the legs, skin not movable over the umbilical outpouching, and umbilical outpouching wound characteristics: type, presence of crusts, active bleeding, thick wound edges, connective tissue (mean Kappa range 0.21–0.40). Slight agreement was observed for umbilical outpouching characteristics: shape, macroscopic vascularization of the skin covering the outpouching, and the presence of scars, excoriations, and fistulas (mean Kappa range 0.10–0.20). Poor agreement was observed for the presence of granulation tissue (mean Kappa =  − 0.05).For all measurements using a ruler, a high Pearson correlation coefficient was observed between physical and video examinations (range 0.69–0.95). In comparison, the visual bodyweight estimation had a lower Pearson correlation coefficient (range 0.57–0.64). Substantial to almost perfect agreement was observed between the physical and video examinations for abnormal weight distribution on any leg, restricted gait movements, lameness, signs of pain, fitness for transportation, presence of wounds, and categorization of the number of wounds > 4 cmThe agreement between a physical clinical examination and a clinical examination using recorded video of the same pig varies from poor to almost perfect, depending on the clinical sign and the executing veterinarian.The online version contains supplementary material available at 10.1186/s13028-023-00689-8. The developments in information and communication technologies (ICT) have rapidly been adopted in several human medical disciplines. Tele-radiology, -dermatology, -pathology and -psychology were the first to evolve. However, today “telemedicine” or “telehealth” are used in a broader consumer facing approach as health services are delivered by professionals such as nurses, pharmacists, etc. . The excVeterinary telemedicine has only been adopted to some degree, including phone consultations. The information can be exchanged between a veterinarian and a client (a farmer or pet owner) focusing on a single animal or a group of animals. Recently, some Danish companion animal clinics started offering teleconsultation out of hours as an additional triage service, and one pig practice started offering videoconsultation for the evaluation of sows in sick-pens in addition to the ordinary farm-visits. Literature in veterinary telemedicine often describes its application in the information exchange between the general practitioner and the specialist in order to improve diagnostics in companion animal medicine . In addiIn a veterinary context, the technology has some obvious applications in regards to farmed animals: It would save the veterinarian's traveling time and therefore potentially optimize the veterinarian-client contacts. The extended internet networks and mobile devices facilitate access to veterinary knowledge in rural areas. Making decisions would be easier with a veterinarian online, who could assist unexperienced farmers or staff and potentially alleviate “care gaps” or make follow-ups easier. One potential application of telemedicine is clinical examinations and making a diagnosis on farmed animals. A veterinarian working remotely might use live or recorded videos to assess an animal’s fitness for transport or make choices about whether to administer antibiotics. Implementation of teleservices in veterinary medicine has raised discussion among professionals. Veterinary telemedicine is often compared to pediatrics because the patients  are not able to communicate their feelings or complaints . Legal aUmbilical outpouchings are a clinical term for umbilical hernias, cysts, and abscesses in the umbilical region of pigs, and this condition is highly prevalent in Danish pig production . UmbilicThe objective of this study was to evaluate agreement between a traditional physical clinical examination and a clinical examination using recorded video, using finishing pigs with umbilical outpouchings as the study unit.During 4 days, 102 finisher pigs  with umbilical outpouchings were selected. A wound on the umbilical outpouching was selected by the leader of the experiment for 49 pigs for separate assessment. All the pigs originated from two herds owned by the same Danish farmer. The pigs were housed in sick pens together with other pigs with different kinds of umbilical outpouchings. Each pig was individually ear-tagged the day before the experiment was carried out. On the day of the experiment, one by one, each pig was separated in a smaller compartment, recorded on video, and examined by 4 experienced (8–20 years in pig practice) pig veterinarians (Vet 1–4). After the general examination was performed, the outpouchings (and the wounds) were examined. The video recordings from each pig were edited and blinded with new pig ID numbers (Video Case 1–102). Approximately 1 month after the physical examinations, the veterinarians individually reexamined all pigs in a blinded manner, utilizing the video recordings and filling in a predesigned clinical record. In this manner, two sets of clinical assessments were generated, a physical (EX_PHYS) and a video-based (EX_VIDEO), for each pig by all four veterinarians.No definition of any clinical sign and condition was provided, and no calibration between veterinarians was performed. The clinical record was designed as a pre-printed paper version of a questionnaire with closed questions using dichotomous or polytomous answer possibilities for categorical outcomes. Questions demanding quantitative outcomes were designed as open questions with a predefined unit on a continuous scale. The record was divided into a general part, a part regarding the outpouching, a part regarding the selected wound on the outpouching, and a part with a final conclusion. Each clinical record was provided with the veterinarian's initials and pig ID, either the ear tag number (EX_PHYS) or the video case number (EX_VIDEO). Tables All four veterinarians examined each pig in a separate compartment for about 10 min, and they were not allowed to discuss their findings with each other during any part of the physical clinical examinations. Each veterinarian was equipped with a 30 cm ruler and pre-printed clinical records to be completed. The pigs were not fixated, and the veterinarians were allowed to touch, palpate, and attempt to reduce the outpouching into the abdomen. Troubled pigs were managed by holding them in place with a driving board. If a wound was selected by the leader of the experiment, a dedicated part of the record was filled in before the final conclusion was stated. The examination stopped when all veterinarians expressed that they had finished filling out the records.The video sequences were obtained from a Samsung Galaxy S9 + 64 GB  smart phone camera mounted on a DJI Osmo Mobile 4 magnetic stabilizer . The footage was obtained in a 16:9 format with 30 frames per second and stored as MP4 files. The flash light was set in automatic mode. However, when filming was performed underneath the pig, the flash light was applied.The video filming of the pigs was conducted immediately before the physical examination by the two leaders of the experiment and in the absence of the veterinarians. One was holding the stabilizer with the camera, and the other person presented the pig in front of the camera. First, the ear tag was shot in close-up for identification of the pig. The pig was shot from the right and left sides, from behind, and from the front. The pig was urged to walk and turn around in order to present its movements. The face was filmed, and the outpouching was shot in close-up from both sides at a perpendicular camera angle. The person presenting the pig held a ruler in front of the outpouching for the size of the outpouching to be readable. Likewise, the ruler was held so that the distance from the abdominal wall to the deepest point of the outpouching and the distance from the outpouching to the floor were readable. The outpouching was lifted out in order to present the bottom of the outpouching to the camera. In addition, the outpouching was palpated and urged to be reduced into the abdomen by the presenting person. Any wounds were filmed in close-up, and a ruler was held in front of the wound to assess the size of the wound. Sequences between 3 and 7 min were recorded for each case, depending on the willingness of the pig.The video sequences were edited using the Adope Premium Pro software . A random video case number between 1 and 102 was added, and junk sequences were deleted. The ear tags were masked with the Gaussian blur effect. After the general presentation of the pig and the outpouching, a still frame was added with an instruction to stop the video and fill in the clinical record. If no wound was selected, the spectator was then asked to skip the selected wound section and complete the conclusion section. If a wound was selected, a dynamic red circle around the wound was added by using the mask and ramp features. Thereafter, the spectator was asked to fill in the wound section and complete the clinical record. The edited video sequences were between 1.48 and 3.43 min long, and the sound was muted throughout the whole sequence in order to mask the conversation between the scientific team members during the video recording. The edited sequences were exported in H.264 format and stored as MP4 files . The coding and distribution were checked for each variable before importation into SAS Enterprise Guide 7.1 . For all the continuous measured clinical signs, Pearson correlation coefficients between EX_PHYS and EX_VIDEO were performed using the proc corr command. The mean Pearson correlation coefficient for veterinarians 1–4 were calculated across the continuous measured clinical signs. For categorical variables, comparison between the EX_PHYS and EX_VIDEO was done by estimating simple agreement and Cohen’s Kappa values  by using the exact agree statement in the proc freq procedure. Pairs of observations (EX_PHYS and EX_VIDEO) where the EX_PHYS outcome was missing were deleted before any agreement analysis. Calculations of mean Kappa values were performed for each clinical sign across the four veterinarians and for each of the four veterinarians across the clinical signs. Kappa values were interpreted as < 0 indicating poor agreement, 0–0.20 as slight agreement, 0.21–0.40 as fair agreement, 0.41–0.60 as moderate agreement, 0.61–0.80 as substantial agreement, and 0.81–1 as almost perfect agreement [Summary prevalence tables of the clinical signs recorded from the physical and video examinations are found in the Additional files 2, and the pig’s fitness for transportation (mean Kappa range 0.67–0.87). The presence of perineal soiling, ear wounds, pendulation of the umbilical outpouching, touching of the legs, the skin over the outpouching was not movable, wound type, the presence of crusts, active bleeding, thick wound edges, and connective tissue had a fair agreement (mean Kappa range 0.21–0.40). The agreement between the physical and video examinations of the umbilical outpouching's shape, macroscopic vascularization of the skin covering the outpouching, and the presence of scars, excoriations, and fistulas was slight (mean Kappa range 0.10–0.20), while the agreement of the presence of granulation tissue had a poor agreement (mean Kappa =  − 0.05). All four veterinarians concluded that fewer pigs were fit for transportation based on video examinations compared to physical examinations.The results from weight estimation and measurements using the ruler are shown in Table For those clinical signs in Table Approximately half of the mean Kappa values between the physical and video examinations were found to have moderate, substantial, or almost perfect agreement, the other half had agreements ranging from slight to fair, and one clinical sign had a poor agreement between the physical and video clinical examinations. We found a large variation in the agreement among the clinical signs between the physical and video examinations. It was also shown that there was a difference between the veterinarians, where veterinarian 1 performed best and had the highest mean Kappa value and the smallest variation compared to the other veterinarians. However, this variation was not evident for the continuous outcomes, where measurements using a ruler had high Pearson correlations for all four veterinarians. It is worth noting that there seemed to be a tendency toward assessing animals as sick instead of normal based on the video. For example, this was the case with transport suitability, and more wounds were also assessed as “open” or “severe” during the video examinations compared to the physical examinations. This could possibly be a sign that the veterinarian has deemed it more difficult from the video and has therefore tended to assess something as being abnormal instead of normal. Alternatively, the possibility to pause the video during examination and the fact that the wounds were presented as magnified and better enlightened in the close-up video material could have disclosed the true status of the wounds.Overall, the assessment of wounds seemed to be one of the things that was difficult for many of the veterinarians, as it was subject to more variation than many of the other clinical signs. A training of the veterinarians in advance of the study, including guidelines on how to assess the wounds according to the clinical record, would probably have resulted in less variation. Further, the terms “severe” and “open” were used for the classification of wounds, as these are included in the European Union legislation on fitness for transportation. However, these terms were not defined and were therefore assessed rather subjectively by each veterinarian.Finally, the veterinarians were asked in respect of each animal if it was assessed to be fit for transportation under normal conditions or under special consideration for extra comfort. There was clearly a very different view of these terms among the veterinarians. Interestingly, the decision based on the video and physical examination was more consistent for each veterinarian than the decision amongst veterinarians. The study confirms results from previous studies that showed variation between veterinarians when performing clinical examinations , 8.Agreement for many of the clinical signs could not be assessed because of low or no prevalence. This was expected because the pigs chosen for this study all had umbilical outpouchings, while the occurrence of other clinical signs was low. If the pigs in question had more variation in other clinical signs, the study could also have been used to assess the possibilities of utilizing video for other conditions than umbilical outpouchings. However, the pigs were selected with the exact purpose of representing large finisher pigs with umbilical outpouchings, which in many cases must be assessed for their transport suitability. In addition, we chose wounds on the umbilical outpouching, which was used as a model for evaluation of wounds irrespective of the location on the animal. In this way, the pigs represented finisher pigs with umbilical outpouchings well, as various sizes, shapes, and wounds were represented among the selected animals.In this study, each veterinarian only performed one physical and video examination for each pig. It would have improved the strength of the study if each veterinarian could have performed repeated examinations of each pig, both physically and on video. This would have allowed for the estimation of intra-observer agreement for each veterinarian. However, this was not possible for practical reasons.With regard to the purely practical circumstances during the video recording, the conditions were sufficient and very standardized on the farms used for examination. Furthermore, the video quality appeared adequate, and the use of the light source from the mobile phone provided a good light setting in respect of the things that needed to be clinically assessed. Regarding the implementation of clinical video examinations, we recommend custom-made pilot studies to be conducted. Specific clinical signs and the study group must be carefully selected with enough variation in order to evaluate the agreement. The use of rulers and other objective tools should be included whenever possible. In our view, when using recorded video, it is completely central to either use a predesigned clinical record, such as in this study, or alternatively use synchronous live video, making it possible for the observer to direct the person video recording, thereby getting further visualization of specific parts that the observer wants to examine further. We recommend that the presentation of each animal follow a set of criteria that must be fulfilled. The use of cameras and lights should also be standardized. However, a good smartphone camera with a magnetic stabilizer to minimize vibrations can be used in many cases. Finally, we recommend that training of the observers to be conducted in order to decrease the inter- and intra-observer variation.We suggest that employing video recordings in clinical practice has a lot of potential in the future, provided that all of these conditions are met. It not only offers veterinary aid in remote places, but it also gives the working veterinarian more freedom during a typical workday because some animals can be examined remotely. The use of telemedicine in veterinary medicine has increased and is already applied in different situations . HoweverThe agreement between a traditional physical clinical examination and a clinical examination using recorded videos varies from poor to almost perfect agreement depending on the type of clinical sign and the executing veterinarian. This highlights the fact that video-examination may be a valid method for some conditions and clinical signs but not for others. Before clinical video-examinations can be used for the assessment of fitness for transport of finishing pigs with umbilical outpouchings, we strongly recommend further research be done to prevent compromised animal welfare.Additional file 1: Video showing an example of a video case.Additional file 2: Occurrence of clinical signs recorded during a traditional physical clinical examination in the stable  and a clinical examination of the same pigs (n = 102 pigs) performed by watching recorded video approximately 1 month after the physical examination (Video). The pigs all had umbilical outpouchings and were selected from two herds. Video recording of the individual pigs was made immediately before the physical examination was performed. All pigs were examined both physically and using video by the same four experienced pig veterinarians.Additional file 3: Clinical examination results of umbilical outpouchings in finishing pigs (n = 102 pigs). The umbilical outpouchings were clinically examined during a traditional physical clinical examination in the stable  and a clinical examination of the same pigs performed by watching recorded video approximately 1 month after the physical examination (Video). The pigs all had umbilical outpouchings and were selected from two herds. Video recording of the individual pigs was made immediately before the physical examination was performed. All pigs were examined both physically and using video by the same four experienced pig veterinarians.Additional file 4: Clinical examination results of wounds (n = 49 wounds) located on umbilical outpouchings in 49 different finishing pigs. The wounds were clinically examined during a traditional physical clinical examination in the stable  and a clinical examination of the same wounds performed by watching recorded video approximately 1 month after the physical examination (Video). The pigs all had umbilical outpouchings and were selected from two herds. Video recording of the individual pigs was made immediately before the physical examination was performed. All pigs were examined both physically and using video by the same four experienced pig veterinarians.Additional file 5: Fitness for transport evaluation of 102 finishing pigs performed by four experienced pig veterinarians. All pigs were clinically examined during a traditional physical clinical examination in the stable  and a clinical examination of the same pigs was performed by watching recorded video approximately 1 month after the physical examination (Video). The pigs all had umbilical outpouchings and were selected from two herds. Video recording of the individual pigs was made immediately before the physical examination was performed. All pigs were examined both physically and using video by the same four experienced pig veterinarians.


Brunner’s gland hyperplasia is a benign tumor that occurs primarily in the duodenal bulb. Endoscopic resection is indicated when there is bleeding, obstructive symptoms, or the lesion is large and malignancy cannot be ruled outA 30-mm pedunculated submucosal tumor was found in the duodenal bulb near the pylorus . As bioVideo 1 Gel immersion endoscopic mucosal resection for pedunculated Brunner’s gland hyperplasia in the duodenal bulb near the pylorus.GI-EMR was considered useful for resection of large Brunner’s gland hyperplasia in the duodenal bulb near the pylorus.Endoscopy_UCTN_Code_TTT_1AO_2AG


Mobile instant messaging (IM) apps  have been widely used by the general population and are more interactive than text-based programs (SMS text messaging) to modify unhealthy lifestyles. Little is known about IM app use for health promotion, including alcohol reduction for university students.This study aims to explore university student drinkers' perceptions of using IM apps for alcohol reduction as they had high alcohol exposure  and the proportion of IM app use in Hong Kong.A qualitative study was conducted with 20 Hong Kong Chinese university students (current drinkers) with Alcohol Use Disorder Identification test scores of ≥8 recruited using purposive sampling. Semistructured individual interviews were conducted from September to October 2019. Interview questions focused on drinking behaviors, quitting history, opinions toward IM app use as an intervention tool, perceived usefulness of IM apps for alcohol reduction, and opinions on the content and design of IM apps for alcohol reduction. Each interview lasted approximately 1 hour. All interviews were audio-taped and transcribed verbatim. Two researchers independently analyzed the transcripts using thematic analysis with an additional investigator to verify the consistency of the coding.Participants considered IM apps a feasible and acceptable platform for alcohol reduction intervention. They preferred to receive IMs based on personalized problem-solving and drinking consequences with credible sources. Other perceived important components of instant messages included providing psychosocial support in time and setting goals with participants to reduce drinking. They further provided suggestions on the designs of IM interventions, in which they preferred simple and concise messages, chat styles based on participants' preferences , and peers as counselors.Qualitative interviews with Chinese university student drinkers showed high acceptability, engagement, and perceived utility of IM apps for alcohol reduction intervention. IM intervention can be an alternative for alcohol reduction intervention apart from traditional text-based programs. The study has implications for developing the IM intervention for other unhealthy behaviors and highlights important topics that warrant future research, including substance use and physical inactivity.ClinicalTrials.gov NCT04025151; https://clinicaltrials.gov/ct2/show/NCT04025151?term=NCT04025151 Alcohol use is one of the leading risk factors for premature death and disability-adjusted life year loss (DALY) in young adults aged 18-25 years) [5 years . AlcoholAs communication technologies advanced, mobile phones provided a new avenue to deliver behavioral change intervention . EvidencIM apps  provide more alternative modes of communication. For example, it allows video chats, voice calls, and the exchange of pictures and animation with participants, which overcome most of the limitations of SMS text messaging and have been widely used by the general population . Our stuHK is the most westernized city in China and has zero tax on liquor with an alcoholic percentage of <30% . Novel iWe recruited university students from 3 local universities using purposive sampling in HK and used semistructured, individual interviews. The eligibility criteria included (1) being a HK resident aged ≥18 years, (2) studying at a local university, (3) being able to communicate in Cantonese, (4) drinking alcohol at least monthly , and (4) using a smartphone with installed IM apps. Participants with a history of psychiatric disorders or those participating in any alcohol treatment program were excluded. We recruited participants through universities' mass emails, posters, and social media  with embedded QR codes. The QR code directed the students to the baseline questionnaire. Eligible participants who filled out the baseline questionnaire were invited to participate in the individual interview. To increase heterogeneity, we selected participants of different sex, years of study, and drinking patterns at baseline. Recruitment ceased after achieving information redundancy (no new information emerged).The study was approved by the institutional review board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 19-103). Individual interviews were conducted in a confidential area. We obtained verbal and written informed consent from all participants before the interview began. The institutional review board also allowed secondary analysis without additional consent. This study strictly followed the Consolidated Criteria for Reporting Qualitative Research guidelines . A coupoWe interviewed 20 university students from September to October 2019. Each interview lasted approximately 1 hour. All interviews were conducted in a meeting room at the University of Hong Kong. Participants completed a web-based baseline questionnaire on their sociodemographic and drinking characteristics before being invited for the interview.A research nurse (SLC) conducted the individual interviews. Only the research nurse and interviewee were present throughout the interview. The discussion began with the interviewer asking the participants to describe their perception of drinking, cues of drinking, and previous quit attempts as opening questions. Following the interview guide  analyzed the transcripts using thematic analysis . The resRigor was assured by following the systematic and step-by-step process of thematic analysis guidelines strictly . Data coWe identified 2 major themes from the data by thematic analysis. These included (1) the perceived important components of the IM intervention for alcohol reduction and (2) suggestions for designing the proposed IM intervention.Participants considered using an IM app as a feasible and acceptable platform for providing alcohol reduction intervention. They preferred an IM app to other platforms  as it allowed for real-time interaction with the counselor and was able to provide drinking advice when needed.Email is boring and sometimes too lengthy to read. Sending messages by WhatsApp is more direct and much easier. You can interact with the counselor using IM apps anytime and anywhere you want, which cannot be achieved by email or other means.#8, female, year 2We further identified 4 subthemes on the type of messages that the participants wish to receive. They preferred to receive instant messages based on personalized problem-solving, providing drinking consequences with credible sources, providing psychosocial support in time, and setting drinking goals with participants.Participants perceived IM apps as a useful platform to obtain information about quitting and to inquire about personalized drinking advice when needed.I think you can provide more personalized feedback based on their characteristics, like sex. For example, females may care more about their appearance, and you can tell how drinking affects their skin. I would be attracted to that information.#20, female, year 2The importance of providing in-time drinking advice was further highlighted by the participants.I always go out with my friend to have drinks on Friday night and end up drunk every time. It would be helpful if you could immediately give me some drinking advice to ease my drunkenness.#4, female, year 4Regular receipt of messages related to negative consequences of drinking was considered by participants as a persuasive motivation to quit drinking. They indicated that these messages would create a daunting effect and encourage them to monitor their drinking amount.I have gained several pounds these years because I have been drinking a lot of beers to reduce my academic stress. If you can show me more scientific evidence of the harm of drinking, I will definitely start to control my drinking amount.#2, female, year 4Participants considered drinking a way to cope with stress, such as academic pressure. They would appreciate if the counselor could provide timely psychological support via an IM app to facilitate their quitting process.I want to quit drinking but have found it difficult as all my friends drink. I think having someone encouraging me can push me harder to stop drinking.#20, female, year 2Participants further suggested that simple messages, such as appreciating the effort of quitting, will motivate them to stay on the right track.Quitting is not easy. I drank a lot again because no one even appreciate my quitting efforts. I need someone who can acknowledge my hard work and support my quitting.#6, male, year 3Participants highlighted the importance of having a sense of achievement from quitting. They suggested that the counselor personalize the objective and monitor each participant's progress regularly, which can strengthen their commitment to quitting.I think you can set a target, like first cutting down my weekly alcohol consumption from 5 bottles to 3 bottles of beer and then checking my progress in WhatsApp. This would motivate me to quit.#16, female, year 1Participants provided suggestions on the designs and methods for delivering the proposed intervention. These suggestions included (1) optimal text length and delivery frequency, (2) adding interesting elements in the chat, and (3) peer as a counselor.When asked about the design of the intervention, participants proposed that the messages should be simple and concise. They also preferred not to receive messages every day. They referred lengthy and frequent messages as aversive and not necessary.I prefer to keep the messages short and precise. If you send me a long message every day, I will find it annoying and just delete it.#10, male, year 1Participants further suggested sending the messages specifically on weekends as they may have more time to drink.I don't have much time to drink from Monday to Friday due to schoolwork and part-time. It may be helpful if can remind me on the weekends, like Saturday night.#20, female, year 2Participants preferred adding more personalized emojis or stickers in the chat, which would create a more casual and closer relationship with the counselor. Some recommended adding specific emojis relevant to the texts, and they described these messages as more noticeable.I think adding relevant emoji or stickers in the texts can make the messages more eye-catching. For example, when you are talking about the harm of drinking in the text, you can add a “skull” emoji next to it. People will immediately understand alcohol is bad for health.#10, male, year 1Other participants preferred to receive pictures or animation besides written language. They believed the media would be a convincing way to reinforce the idea of quitting.Videos, especially cartoon animation about the harm of drinking and the benefits of quitting, sound more impressive and credible compared with only written language.#8, female, year 1Some participants suggested that having a peer as a counselor to give drinking advice would help strengthen the intervention. They believed that peers could better understand their drinking history and empathize with their challenges while quitting.Talking to someone of similar age would be easier to communicate, as we may have similar struggles in life.#12, male, year 3This study explored the perceptions of using IM apps for alcohol reduction intervention in Hong Kong university students who speak Chinese or are of Chinese origin. Participants considered an IM app as a feasible and acceptable platform for delivering drinking advice. Based on their preference, they preferred to receive IMs based on personalized problem-solving , drinking consequences with credible sources , in-time psychosocial support , and goal setting to reduce drinking  . They alParticipants considered the ability to provide in-time drinking advice to them as one of the primary merits of using IM apps. A similar finding was obtained in another formative study of developing a text messaging–based intervention for alcohol reduction in the United States . EvidencApart from addressing personal needs, the ability to provide credible information on the harm of drinking was regarded by participants as a crucial motivator to reduce drinking. Unlike mobile health trials of smoking cessation, smokers preferred receiving gain-framed messages  to loss-framed messages  as they were already aware of the harm of smoking . EmerginParticipants emphasized the importance of receiving emotional support from the counselor during the process of quitting when using IM apps. A study showed that in-time person-to-person psychosocial support was one of the important factors for successful quitting in substance use treatment, as sustained external emotional support was a key mediator for achieving long-term abstinence . By usinApart from using IM apps for providing alcohol reduction intervention, the proposed intervention may also inform the design of similar interventions for treating other adverse health behaviors, including using IM apps for substance use treatment. The IM intervention would need counselors to deliver a chat messaging intervention to participants, which may incur higher operational costs than conventional text messaging–based interventions. Nevertheless, as mobile IM apps are freely available in the market and are widely used by the general population, and artificial intelligence–based technologies are becoming more advanced and mature, the development of chatbots would reduce the operational cost of IM interventions in the future .This study has some limitations. First, as it focused on using IM apps for alcohol reduction intervention, non–smartphone owners were excluded. The views expressed during the interview were specific to university student drinkers who own a smartphone; they are typically younger and have higher digital literacy than the general population . Second,This formative study has informed the designs and contents of an IM intervention for alcohol reduction in university student drinkers. It provides an alternative to traditional SMS text messaging–based intervention. The proposed intervention will be evaluated in a randomized controlled trial with Hong Kong university settings (NCT04025151).