The popularity of video services such as video call or video on-demand has made it impossible for people to live without them in their daily lives. It can be anticipated that the explosive growth of vehicular communication owing to the widespread use of in-vehicle video infotainment applications in the future will result in increasing fragmentation and congestion of the wireless transmission spectrum. Accordingly, effective bandwidth management algorithms are demanded to achieve efficient communication and stable scalability in next-generation vehicular networks. To the best of our current knowledge, a noticeable gap remains in the existing literature regarding the application of the latest advancements in network communication technologies. Specifically, this gap is evident in the lack of exploration regarding how cutting-edge technologies can be effectively employed to optimize bandwidth allocation, especially in the realm of video service applications within the forthcoming vehicular networks. In light of this void, this paper presents a seamless integration of cutting-edge 6G communication technologies, such as terahertz (THz) and visible light communication (VLC), with the existing 5G millimeter-wave and sub-6 GHz base stations. This integration facilitates the creation of a network environment characterized by high transmission rates and extensive coverage. Our primary aim is to ensure the uninterrupted playback of real-time video applications for vehicle users. These video applications encompass video conferencing, live video, and on-demand video services. The outcomes of our simulations convincingly indicate that the proposed strategy adeptly addresses the challenge of bandwidth competition among vehicle users. Moreover, it notably boosts the efficient utilization of bandwidth from less crowded base stations, optimizes the fulfillment of bandwidth prerequisites for various video applications, and elevates the overall video quality experienced by users. Consequently, our findings serve as a successful validation of the practicality and effectiveness of the proposed methodology. As the greenhouse effect worsens, environmental regulations for vehicles are now becoming more stringent in numerous countries. In order to meet the increasingly stringent regulations on greenhouse gas emissions and to solve the problems associated with traditional engine vehicles, such as air pollution, climate change, and high fuel prices, electric vehicles (EV), which use green energy to reduce carbon emissions, have been recognized as the future alternative to traditional automobiles.Affected by the COVID-19 epidemic that started in late 2019, academics and organizations have been turning to video conferencing to match the COVID-19 precautionary measures, as well as to improve efficiency and convenience. Video conferencing applications account for an increasing share of Internet applications and bandwidth usage , and theEncoding plays a vital role in modern digital media, ensuring efficient and reliable transmission and playback of videos in various situations. Currently, a significant portion of videos use Advanced Video Coding (AVC)  as theirCommencing in 2019, the official deployment of 5G witnessed the incorporation of sub-6 GHz and millimeter wave (mmWave) frequencies . In respBeyond tackling the issues of the next-generation network by enhancing network architecture and optimizing algorithms for resource allocation, the forthcoming generation of networks will predominantly revolve around 6G technology. Thus, 6G promises to usher in an era characterized by continuous connectivity, immersive experiences, robust support for a multitude of simultaneous users, ultra-low latency, universal accessibility, unmatched data capacity, unwavering reliability, and stringent security measures . In receScholars have already conducted research on the applications of THz in vehicle communications. Li et al.  analyzedTo address these limitations, the dense deployment of base stations is required to extend coverage. Moreover, the expenses associated with THz equipment are substantial . To exteAlongside the THz frequency range, another set of frequencies currently unutilized in existing communication standards is VLC. This alternative spectrum brings forth specific advantages over other communication technologies. Firstly, VLC is relatively safe for human eyes  and can ectively . The aboBeyond the realm of 6G technology, the significance of edge computing has risen substantially within contemporary communication networks. This strategy, involving the proximity of computation and resources to users, harmonizes seamlessly with the high-speed and low-latency benefits inherent in 6G. It is foreseeable that within the landscape of vehicular networks in the years to come, the fusion of 6G technology and edge computing will engender heightened efficacy in data processing and real-time applications. The advancement of mobile edge computing has also inspired the development of edge transcoding technology, where service providers can distribute transcoding tasks from central servers to edge servers closer to users for video transcoding. Edge transcoders can convert high-bitrate video into low-bitrate versions for user selection, improving the performance of video services by reducing transmission delay . FurtherAs the demand for future multimedia traffic continues to rise, bandwidth shortages become unavoidable during peak periods. At present, multiple research endeavors have introduced techniques to allocate bandwidth and improve mobile network throughput, aiming to tackle the challenge of allocating network resources efficiently among users. Yuan et al.  introducThe advent of 6G technology holds the promise of significantly enhancing vehicular mobility. Vehicles operating at high speeds can leverage the capabilities of 6G connectivity to establish cooperative communication, thereby ensuring safe following distances and smooth traffic flow . ConsequBased on the literature cited above, it is evident that most recent studies have primarily focused on RSUs and base stations for video downloading and transmission, while overlooking the potential of vehicular communication technology to enhance these processes and neglecting the prioritization of real-time applications. With the expanding user base of video applications, it is apparent that perceived video quality could be adversely affected by bandwidth constraints during peak traffic hours. In view of different characteristics and requirements of multimedia applications, future bandwidth allocation schemes should be planned according to the multimedia requirements so that the real-time multimedia applications can be prioritized to receive sufficient bandwidth.To the best of our knowledge, there is a noticeable gap in the existing literature when it comes to exploring the utilization of the most recent 6G network communication technologies for distributing bandwidth in multimedia applications within upcoming vehicular networks. In light of this, our paper employs THz base stations, as well as mmWave and sub-6 GHz band base stations, to fulfill the bandwidth requirements for video applications targeting EV users. Due to the continuous growth of video traffic, service providers need to offer high-quality streaming approaches to meet user expectations. In addition, this paper adopts EVs as edge devices, enabling them to provide edge computing, storage, and communication capabilities. VLC technology is being utilized in V2V communications to provide high data rate and high security for inter-vehicle video transmissions. Considering the different characteristics and requirements of multimedia applications, this paper employs the most widely used AVC with high encoding speed for real-time video conferencing sessions and live videos, and adopts the VVC with high compression rate for non-real-time VoDs, so that the users can watch high-resolution videos at a lower bit rate.In view of the significant time delay of traditional centralized computing for multimedia applications during peak hours and the increasing computational power of edge nodes, a decentralized computing architecture is adopted in this paper.Through the utilization of the fundamental technologies of 6G, such as THz frequencies, in conjunction with the existing 5G mmWave and sub-6 GHz base stations, this paper facilitates the creation of a network environment characterized by elevated transmission rates and extensive coverage.In order to ensure uninterrupted real-time video playback for EV users, this paper chooses the low-latency AVC method as the preferred approach. This decision is especially crucial for applications such as real-time video conferencing and live video. Moreover, the introduced algorithm places high priority on efficiently allocating bandwidth for real-time video content. All of these efforts are directed towards achieving the best possible performance standards for users of EVs.This paper demonstrates the capability to employ VLC for V2V communication, thereby enabling the redistribution of bandwidth from less-congested base stations located in alternate road sections. Furthermore, this paper capitalizes on base stations equipped with ample bandwidth and fosters collaboration among other EVs to pre-download video segments. This strategic approach leads to noteworthy improvements in bandwidth availability for various video applications, while also markedly enhancing the efficient utilization of bandwidth resources from less-congested base stations. Additionally, this paper successfully mitigates prolonged delays in downloading video content from distant servers and alleviates congestion in vehicular networks arising from a substantial influx of video applications by EV users during peak hours. Consequently, this paper effectively heightens users’ perceived video quality across all genres of video applications.The main contributions of this paper can be outlined as follows:This paper employs a decentralized computing architecture, as illustrated in In the realm of advancing chip technology, there is a prevailing anticipation that forthcoming next-generation vehicular networks will prominently integrate chips for a diverse range of computational functions. Addressing the burgeoning demand for decentralized computing, as introduced in this paper, dedicated servers are strategically deployed at both RSUs and base stations. Their primary purpose is to facilitate multimedia processing and computational transmissions.Within the context of RSUs, these servers assume a pivotal role in several key aspects. They diligently record the bandwidth requirements of electric vehicle users within their respective managed segments. Concurrently, these servers store crucial information regarding the available bandwidth originating from base stations. Moreover, these servers harness their computational prowess to efficiently execute various RSU modules, optimizing their operational performance.On the flip side, base stations also reap the benefits of these servers. Once an EV user initiates a video service application, the server situated at the base station undertakes the task of intelligently prioritizing the storage of specific video files. This strategic maneuver effectively mitigates potential download latency concerns, enhancing the overall user experience. Additionally, leveraging the robust computational capabilities of these servers, video transcoding emerges as a feasible capability. This translates to offering users an array of video resolutions to choose from, tailored to their preferences and requirements.If the coverage area of the base station of the road section that the EV traverses cannot meet the bandwidth requirement for the EV user’s video application, the managing RSU of the road section will activate the “Real-time Bandwidth Allocation” module to assist in allocating the bandwidth to meet the minimum requirement for the video application according to the characteristics of the video application and the pre-set video quality requirement of the EV user. In the case of video conferencing or live video, the RSU starts with the EV, adds other EVs arriving at the road section at the same time to form a fleet, and continues to expand the fleet until the last fleet member is on a road section where the base station’s coverage can provide bandwidth to the requesting EV. For the scenario involving VoD, this paper proposes a strategy wherein a separate EV traversing the same road segment pre-downloads the necessary video segment when in a bandwidth-accessible area. Subsequently, when the two EVs cross paths, the pre-downloaded video segment is transmitted from the previously prepared EV to the requesting EV user via V2V communication. Notably, the EV using the video application will also track the EV users’ satisfaction with the video playback quality at regular intervals during the video playback process, and if there is a need to adjust the video playback quality, it will notify the “Real-time Bandwidth Allocation” module of the managing RSU(s) for subsequent bandwidth adjustments of the video usage.The modules shown in Before the start of the EV, the EV user starts the OBU to set the departure point, departure time, and destination, and then starts to run this module. The EV first downloads the global real-time road traffic information from the cloud, and uses Dijkstra’s algorithm to estimate the shortest route from the departure point to the destination based on the average traveling time of each road section. Since the arrival time of EVs at each road segment is affected by the traffic conditions at the time of arrival at the road section, this module calculates the arrival time at each road section based on the latest traffic condition information of each road segment of the shortest driving route, and notifies the RSU managing the road section of the driving route and the estimated time of arrival at each road section.To avoid discrepancies between the latest estimated arrival times of EVs and their expected arrival times at road sections due to ad hoc changes in itineraries by EV users or road congestion during peak hours, this module recalculates the arrival time at each road section at regular intervals based on the latest traffic condition information sent from the RSU that manages each road section the EV travels through, and uses a machine learning technique to recalculate the arrival time at each road section. If the recalculated arrival times at the road sections are too different from the original predicted times, the module sends the updated times to the RSUs that manage the road sections of the traveled route. Given the effectiveness of machine learning in predicting road travel times in the literature ,59, the The steps of this module are described below.Step 1: Before the EV starts its journey, it first downloads the global real-time traffic condition information from the cloud, and after setting the starting location and time as well as the destination, it estimates the shortest path from the starting location to the destination using Dijkstra’s algorithm based on the cost of the average traveling time of each road section.Step 2: The estimated time of arrival at each road section of the traveled route is given by:Step 3: The estimated time of arrival at each intersection is transmitted to the RSU that manages each road section, along with the EV’s route.Step 4: This module performs the background execution mode here. After the preset time interval, the latest traffic condition information is obtained from the RSU managing the road section, and the arrival time at each road section of the traveled route is recalculated using Equation (1).Step 5: If the updated EV arrives at the traveled section in a time that exceeds the system’s predefined thresholds due to a temporary trip change or peak hour congestion, the RSU governing the traveled section will be notified of the revised arrival time.Step 6: Before the EV reaches its destination, go back to step 4 to continue.After an EV user activates the video application while the EV is in motion, this module obtains the requirements and specifications of the application from the server of the video application software provider, and adjusts the quality and bandwidth requirements of the video application in a timely manner according to the user video quality requirements pre-set by the EV user. Then, this module transmits the video bandwidth demand to the managing RSU of each road section that the application travels through during the video usage period, and each RSU carries out the bandwidth allocation according to the demand specification of the video application while the EV traverses on the managing road section.The steps of this module are described below.Step 1: After an EV user activates a video application, the requirements and specifications for the video application is retrieved from the video application software vendor’s server.Step 2: The RSU along the route informs the minimum bandwidth that can be provided by the base station coverage of the road section it manages.Step 3: Using the driving durations of EVs across individual road sections and considering the resolution prerequisites for video applications by EV users, the calculation of the essential minimum bandwidth required for video application within each time slot or video segment throughout the driving duration takes place. This calculation is followed by an examination of the bandwidth provisioned by the base station within the coverage area of the corresponding road section to ascertain if it aligns with the stipulated requirements of the video application.As shown in Equations (2) and (3), if the quantities of Equation (6) clarifies that the pre-download of a video segment must be completed before the playback can begin. Meanwhile, Equation (7) guarantees that the buffer space available in the EV is sufficient to accommodate a video segment prior to its playback.Step 4: If all of the base station coverage areas of the EV routes can meet the minimum bandwidth requirement, this module notifies each RSU of the road section of the bandwidth used in the road section and proceed to Step 6. On the other hand, this module notifies the RSUs along the road sections with insufficient bandwidth to assist in adjusting the bandwidth. The optimization objectives concerning the video quality requirements of EV users can be formulated by:Equation (8) allocates the required bandwidth for the video application in terms of the EV user’s perceived video quality. Equations (9) and (10) delineate the upload and download durations for video conferencing/live video during each time slot. Equations (11) and (12) present the distinct quality metrics utilized to assess the effectiveness of video conferencing and live video, following the guidelines outlined in the cited reference . FurtherEquations (14)–(16) ensure that the video resolution remains equal to or exceeds the minimum resolution defined by the video service provider. Simultaneously, Equation (17) guarantees the complete pre-download of individual video segments before initiating their playback. Moreover, Equations (18) and (19) delineate the rebuffering time for each video segment.Equations (20) and (21) establish the prerequisite that the base stations covering the road segments traversed by the electric vehicle (EV) must possess the necessary upload and download bandwidth to support video conferencing and live video, as required. Similarly, Equation (22) imposes an analogous requirement for VOD. Additionally, Equation (23) ensures that the buffer space within the EV is appropriately dimensioned to accommodate a video segment before its playback.To be specific, the optimization problem outlined in Equation (8) is being approximated in this scenario by lowering the requested video resolution from the EV user to align with the minimum resolution established by the video service provider.Step 5: Should the bandwidth obtained in the previous step continue to be inadequate for supporting the minimum resolution specified by the video service provider, the EV user will receive a notification.Step 6: This module operates in the background execution mode. Following the time interval established by the system, the process returns to Step 2 to readjust the quality and bandwidth prerequisites of the video application, provided that the video application remains active.If the video bandwidth requirement of the EV user cannot be met when the EV arrives at the road section managed by the RSU, this module assists in allocating the bandwidth according to the characteristics of the video application. If the user’s video application is video conferencing or live video, the bandwidth originally allocated for other VoD downloads in the same time slot will be reallocated to the required video conferencing or live video. Should the video bandwidth requirement remain unfulfilled, the EV will assume the role of the ultimate member within a fleet. Subsequently, the fleet will undergo expansion until the leading EV member enters a road segment where the base station’s coverage can sufficiently accommodate the demanded video bandwidth. The bandwidth is then transferred from the leading EV member to the requesting EV through V2V communication.In the case of VoD, if a video segment cannot be downloaded in time before the video segment is played, the RSU checks the routes of other EVs that arrive at the same road section at the same time as the EV playing the VoD to find out whether there is a base station that can provide bandwidth for pre-downloading the required video segment. Once a base station that can support bandwidth is found, the EV traveling through the road section covered by the base station will download the required video segment to the on-board storage of the EV. When the EV storing the downloaded video segment arrives at the same road section as the requesting EV, the video segment can be transmitted to the VoD user via V2V communication.The steps of this module are described below.Step 1: For VoD, proceed to Step 8.Step 2: The RSU allocates the bandwidth of other VoD(s) in the same time slot to the demanding video conferencing/live video.Step 3: If the bandwidth requirement for video conferencing/live video is satisfied, go to Step 6. Otherwise, proceed to the next step.Step 4: In cases where the bandwidth necessary for video conferencing or live video is inadequate, the RSU initiates the process by including the EV as the final member of a fleet for bandwidth transfer and incorporating other EVs into a fleet. This fleet expansion persists until the foremost fleet member reaches a road segment where the base station’s coverage can sufficiently supply the required bandwidth for the requesting EV. The establishment of the fleet must fulfill the subsequent requirement:Equation (24) serves as the foundation for configuring the fleet established during the transmission relay, optimized for the minimum fleet length. Building upon this, Equation (25) outlines the specific composition of the fleet, where Equation (26) identifies the designated EV as the terminal component of this fleet. To guarantee a harmonized sequence, Equation (27) specifies the scheduling of the initiation time for video conferencing or live video subsequent to the EV’s departure, while also ensuring the timely conclusion of the application before the EV reaches its destination.Equations (28) and (29) guarantee that the leading fleet member reaches a road segment where the base station’s coverage can adequately provide the necessary bandwidth for the requesting EV. Additionally, Equations (30) and (31) establish that the V2V communication bandwidth between two successive fleet members must not fall below the relayed bandwidth acquired by the requesting EV.To provide specific details, the process of forming the fleet as defined in Equation (24) entails a step-by-step assessment of all EVs that reach the same road segment as the requesting EV. Starting from the selected EV, the expansion of the fleet persists until the farthest member of the fleet enters a road segment where the coverage from the base station is proficient in supplying the required bandwidth for the EV that initiated the request.Step 5: In instances where a certain VoD allocates bandwidth to video conferencing/live video, resulting in an inability to meet the minimum bandwidth requirement of the VoD due to reduced bandwidth availability, this module advances to the subsequent step in order to acquire the necessary bandwidth for the VoD. Conversely, the module concludes.Step 6: To examine whether there are base stations in the coverage area of the road sections that can provide bandwidth for EVs to pre-download the required video segment(s):Step 7: If bandwidth is available in the base station coverage area of another road section, pre-download the video segment from the base station to the on-board storage of the EV while passing through the base station coverage area. Notify the managing RSU of the base station and this module ends. If not, proceed to the next step.Step 8: Check if other EVs arrive at the same road section as EV Step 9: If it is not possible to find an EV that arrives at the same time on the same road section as EV Step 10: View the routes of the EVs arriving at the same section of the road at the same time as Step 11: If EV In this paper, the proposed algorithm is simulated using a personal computer with an Intel Core i7 2.9 GHz CPU and 64 GB RAM. To assess the effectiveness of the proposed algorithm, two comparison targets are employed. The first target is the conventional first-come, first-served (FCFS) method. The second reference benchmark is a contemporary state-of-the-art algorithm that combines the DQN and AQCS [The historical traffic data are obtained from a website of traffic volume counts for New York City . Video aThree types of base stations, including THz , mmWave The red curve represents the bandwidth requirements of video applications.The yellow curve depicts the bandwidth allocated to video applications using the conventional FCFS method.The green curve showcases the bandwidth allocated to video applications when employing the DQN+AQCS algorithm.Finally, the purple curve demonstrates the bandwidth allocation achieved by video applications when utilizing the proposed algorithm.The yellow curve in As observed in the purple curve in However, as depicted by the yellow curve in Conversely, as shown on the purple curve in Although some studies in the literature have proposed bandwidth allocation algorithms to provide video services to EV users, there are no bandwidth allocation algorithms for video services that utilize emerging communication technologies for next-generation vehicular networks. In view of this, this paper integrates the THz base stations of 6G wireless networks with the existing mmWave and sub-6 GHz band base stations to provide the required bandwidth for EV users. A bandwidth management mechanism that suits the video quality requirements of different EV users is proposed to allocate the bandwidth from the three types of base stations mentioned above to the in-vehicle video services. Meanwhile, VLC technology is utilized in V2V communications to provide a high data rate and high security for inter-vehicle video transmissions.A series of simulations is conducted to comprehensively compare the performance of the proposed algorithm against both the conventional FCFS method and a contemporary state-of-the-art approach known as DQN+AQCS. This rigorous evaluation process allowed for a thorough assessment of how the proposed algorithm performed in comparison to these two benchmark methods. The simulation results clearly demonstrated the efficacy of the proposed mechanisms, including video pre-downloading for EV users and bandwidth relay, in conjunction with the utilization of VLC for V2V communication. These mechanisms collectively enhanced the adaptability of base station bandwidth allocation, particularly during peak hours. This enhancement ensures that video conferencing, live video, and VoD applications for EV users can reliably access the necessary bandwidth support even in scenarios of bandwidth scarcity on congested road segments during peak times. Ultimately, the perceived video quality for EV users can be maintained at satisfactory levels.In summary, the algorithm presented in this paper offers a dual advantage. Specifically, it effectively addresses the challenge of bandwidth contention among EV users, which stems from the constraints of base station bandwidth. Additionally, it represents a notable advancement over both the FCFS and DQN+AQCS approaches. To be more precise, it ensures access to sufficient bandwidth for real-time live video applications and guarantees uninterrupted playback of the vast majority of video applications even during periods of heightened demand. This enhancement significantly elevates the overall quality of the video viewing experience for EV users. Remarkably, even when the available bandwidth from congested base stations reaches its peak capacity, the proposed algorithm demonstrates a substantial improvement of 30% and 17% in average video quality compared to the FCFS approach and the DQN+AQCS method, respectively. This further solidifies the effectiveness of our proposed algorithm in providing satisfactory video quality even within the constraints of bandwidth limitations.


The last five decades have witnessed an inordinate number of advances in the diagnosis and management of congenital heart defects (CHDs), as reviewed elsewhere . These aIn the first paper, Vecchiato and associates from Padova and Naples, Italy, discuss the overshoot of the respiratory exchange ratio during recovery from maximal exercise testing in young patients with congenital heart disease (CHD) . The autIn the second paper, Sganga and her colleagues from Harvard Medical School, Boston, MA, and Stanford University School of Medicine, Palo Alto, CA, USA review quality improvements in a pediatric echocardiography laboratory . The autIn the third paper, Dr. Pop from the University of Medicine Pharmacy Sciences and Technology of Tirgu Mures and the Tirgu Mures Emergency Institute for Cardiovascular Diseases and Heart Transplant, Tirgu Mures, Romania, compares different contrast agents  used for computed tomographic angiography (CTA) studies in infants referred for aortic arch evaluation . Dr. PopIn the paper to follow, I review clinical aspects of mitral atresia with normal aortic root . Mitral In the next paper, Dr. Singh from the Baylor College of Medicine/The Children’s Hospital of San Antonio, San Antonio, TX, USA, reviews “as low as reasonably achievable” (ALARA) in pediatric electrophysiology laboratory . Dr. SinIn the sixth paper, Dr. Divekar and associates from the University of Texas Southwestern Medical Center/Children’s Medical Center, Dallas, TX, USA, and the Cleveland Clinic Children’s Hospital, Cleveland, OH, USA, review transcatheter device therapy and how to integrate advanced imaging with invasive procedures in the management of CHD . These aIn the subsequent paper, Dr. Arar and his colleagues at the University of Texas Southwestern Medical Center/Children’s Medical Center, Dallas, TX, USA, review the role of cross-sectional imaging in pediatric interventional cardiac catheterization . This paIn the next paper, Dr. Betancourt and her associates from The Children’s Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA, review the utility of a three-dimensional printed model in the biventricular repair of complex CHDs . They rep = 0.27). In addition, no difference in time to first oral feed (2.0 days (1.1–4.5) vs. 3.1 days (1.8–4.4), p = 0.34) and time to goal feed (6.0 days (3.2–8.3) vs. 6.9 days (5.0–9.0), p = 0.15) was detected. Furthermore, no variance in establishing all oral feeds in one year: 88% vs. 98%, p = 0.16 was identified. However, the delayed group performed substantially worse on all the above parameters. The authors conclude that immediate and early groups demonstrated no variations in feeding outcomes or length of stay in their investigation, while the delayed group performed worse on all measures. Consequently, they recommend that caregivers focus on extubating the babies within 3 days following surgery to enhance feeding outcomes while reducing hospitalization duration.In a subsequent paper, Kepple and his associates from Creighton University School of Medicine and University of Nebraska Medical Center, Omaha, NE, USA, review the impact of extubation time on feeding outcomes after neonatal cardiac surgery . The autIn the final paper of this series, Dr. Sharma and associates from The Children’s Hospital of San Antonio/Baylor College of Medicine, San Antonio, TX, USA, and the Cohen Children’s Medical Center, New York, NY, USA, discuss advances in the prenatal management of fetal cardiac disease . They stThe papers included in this Special Issue, while not addressing all the advances that occurred in the last 50 years , have in


Individuals with stroke are at high malnutrition risk in both the acute and chronic phases. This study aimed to assess the validity of different malnutrition screening tools for stroke patients in rehabilitation phase. Participants in this study were 304 stroke patients from three hospitals in the East-Coast region of Peninsular Malaysia from May–August 2019. The concurrent validity of the Malnutrition Risk Screening Tool-Hospital (MRST-H), Mini Nutritional Assessment-Short Form (MNA-SF), Malnutrition Screening Tool (MST), Malnutrition Universal Screening (MUST) and Nutritional Risk Screening (NRS-2002) was assessed with the diagnostic criteria for malnutrition proposed by the Global Leadership Initiative on Malnutrition (GLIM-DCM). Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the curve were computed. MUST and MRST-H demonstrated good validity regardless of different age groups (> 80% sensitivity and specificity); meanwhile, MST and MNA-SF had fair validity, yet NRS-2002 had poor to fair validity with GLIM-DCM. Only MRST-H and NRS-2002 were significantly correlated with all anthropometric indices, dietary energy intake, and health-related quality of life in both age groups. In conclusion, MRST-H and MUST showed good concurrent validity with GLIM-DCM and can be considered as appropriate malnutrition screening tool in discriminating malnutrition among stroke individuals attending rehabilitation centre in Malaysia regardless of their age groups. The differences in the prevalence could be attributed to methodological and respondent characteristics differences between the studies 5. There is no gold standard to assess malnutrition. Malnutrition has been defined based on a single or combination of nutritional parameters such as body mass index (BMI), calf circumference (CC), mid-upper arm circumference (MUAC), triceps skinfold, changes in body weight, or clinical laboratory parameters 5. The European Society of Clinical Nutrition and Metabolism (ESPEN) and the American Society of Parenteral and Enteral Nutrition (ASPEN) and the Academy of Nutrition and Dietetics had published definitions of malnutrition, although discrepancies between these definitions are apparent7. Other experts however have suggested clinical assessment by a nutritionally trained professional (e.g. dietitian), or using the Subjective Global Assessment (SGA) for all adults, and the full form of Mini Nutritional Assessment (MNA) for elderly as the semi-gold reference standards8.Individuals with stroke are subjected to high malnutrition risk, with prevalence at 46–91% in the rehabilitation phase9. The Global Leadership Initiative on Malnutrition (GLIM) proposed a two steps approach encompasses of malnutrition risk screening (step 1) followed by assessment for diagnosis (step 2). The GLIM suggested the use of any validated screening tools in the step 1 process9. These included the Mini Nutritional Assessment-Short Form (MNA-SF), Malnutrition Screening Tool (MST), Malnutrition Universal Screening (MUST), and Nutritional Risk Screening (NRS 2002).Recently, a core leadership committee with representatives of several of the global clinical nutrition societies  have come into a consensus on the diagnostic criteria for malnutrition (DCM)8. There are screening tools developed and validated specifically for the local population in Asian countries, namely Chinese Nutrition Screen (CNS) (China), Malnutrition Risk Screening Tool-Hospital , Malnutrition Risk Screening Tool-Community , and the 3-Minute Nutrition Screening (3-MinNS) (Singapore)13. Although different screening tools are in use, their levels of validity, agreement, reliability, and generalizability vary14. Additionally, age-, disease-, or setting-specific screening tools exist , although these are subjected to practical limitations. Some tools such as MUST and MST have been widely used for adults and validated in acute and community settings8. Meanwhile, MRST-H and MNA-SF were specifically designed for the elderly population in acute and community settings15. In contrast, NRS-2002 was developed mainly for adults in the acute setting16. There is however no preferred malnutrition screening tool to screen malnutrition risk for stroke individuals in rehabilitation phase. Evidence on validity of malnutrition screening tools in the rehabilitation setting is limited17.However, most of these screening tools were developed in western countries, and their validity among the Asian population is questionable and warrants further investigation8. To our best knowledge, no studies have compared the criterion validity of these different malnutrition screening tools with the diagnostic criteria proposed by GLIM. It is important to validate these screening tools with the newly proposed GLIM diagnostic criteria since it will affect the number of participants being assessed in the following step. For example, some individuals who were screened as not having a malnutrition risk by the MST would have been identified as malnourished on the basis of a BMI < 18.5 kg/m2. In order to improve the nutritional status of patients with high risk of malnutrition, clinicians need to know the most valid screening tools for identifying malnutrition risk in Malaysia context to allow further assessment and early treatment. Therefore, the main objective of this study is to compare the concurrent validity of different malnutrition risk screening tools with the GLIM-DCM among stroke survivors. The validity of these screening tools was also compared among elderly and non-elderly groups.Previous studies have compared the criterion validity of these malnutrition screening tools with different reference standards proposed by different expert groups, namely clinical assessment by dietitian, SGA, MNA- long forms, ESPEN, and ASPENRespondents in this cross-sectional study were individuals with stroke recruited from three general public hospitals in the East-Coast region of Peninsular Malaysia from May to August 2019. During their waiting hours at the neurology and rehabilitation departments, these respondents were invited.Participants who were more than 18 years old and had received a stroke diagnosis as confirmed by a medical doctor (ICD 160–169) were eligible to participate in the study. Participants were excluded if they were suffering from hemiparesis or contracture deformity that affected anthropometric assessment. All stroke participants who have attended the Neurology and Rehabilitation departments in the three selected hospitals during the study period were approached and screened based on inclusion and exclusion criteria. All participants who agreed to join the study were recruited. All eligible participants were assessed and interviewed face-to-face by a clinically trained dietitian.α is the standard normal deviate, P is the expected sensitivity of the screening tool, and W is the width of the confidence interval (CI):We calculated the sample size using the formula below, where Z17.Marshall et al. reported that the sensitivity of MST in detecting malnutrition in geriatric rehabilitation was 80.8%. By referring to Marshall et al.'s finding, a standard normal deviate at 1.96 (with a 95% CI), a width of the CI being ± 0.10, and a 20% non-response rate, the required sample size was 300The following sociodemographic and clinical profiles were collected during the survey: sex, ethnicity, age, educational level, household income, underlying comorbidities, duration of a stroke, types of stroke and episodes of stroke. Besides, participants were also asked whether they always faced problems (Yes or No) such as nausea, vomiting, chewing, swallowing, loss of appetite, speech, memory, constipation, diarrhoea, and paresis of the dominant arm.20.The risk of malnutrition was assessed by the MRST-H, MNA-SF, MST, MUST, and NRS-2002. Screening criteria and scores in each screening tool are displayed in Table 9. The GLIM proposed five criteria: non-volitional weight loss, low body mass index, reduced muscle mass, reduced food intake or assimilation, and disease burden/inflammation9. According to the GLIM-DCM, a participant is diagnosed with malnutrition if he or she fulfils at least one phenotypic criterion and one etiologic criterion. Since skeletal muscle index (SMI) was not being measured in this study, thus alternative indicators such as MUAC, CC and handgrip strength (HGS) were being used. Cut-off points for low muscle mass were proposed by the Asian Working Group for Sarcopenia 2019 and other studies22.This study used the malnutrition diagnosis criteria as proposed by the GLIM Table 9. The GL2). Low BMI was defined as having BMI < 18.5 kg/m2 for age < 70 years old and < 20 kg/m2 for age ≥ 70 years old9.Body weight was measured using an electronic scale  to the nearest 0.1 kg, and body height was measured using a portable stadiometer  to the nearest 0.1 cm. Two consecutive measurements were taken, and the average of the two was used. The BMI of the participants was calculated using the Quetelet’s index: BMI = body weight (kg)/ height , had surgery on their hands or wrists in the past three months, participants refuse to take the measurement or unable to obtain a proper testing form. The Asia Working Group for Sarcopenia proposed low handgrip strength as males < 28 kg and females < 18 kg and decreased calf-circumference as males < 34 cm and females < 33cm21.A trained clinical dietitian performed physical examinations to identify reduced muscle mass by measuring MUAC and CC. MUAC was measured on the non-paralytic arm using a measuring tape from the midpoint on the triceps between the acromion and the olecranon process. Similarly, CC was measured in a sitting or supine position with the non-paretic knee bent at 90 degrees. Additionally, handgrip strength was measured using the Takei Digital Grip Strength Dynamometer (Model T.K.K.5401) following the user manual's25. Meanwhile, for elderly participants aged more than 60 years old, the Schofield sex- and age-specific equations based on body height were used26. The equations used to estimate BMR are shown in Table 27. A higher stress factor was used if the participant was underweight (BMI < 18.5 kg/m2 for < 65 years old and BMI < 22 kg/m2 for ≥ 65 years old) during the time of the survey28. Energy requirements were calculated by multiplying the individual BMR value by the PAL value and stress factor. The percentage of energy intake adequacy was calculated by dividing the energy intake with the estimated energy requirement. Low or suboptimal energy intake was defined as having less than 50% of the estimated energy requirement for more than one week or any reduction (< 75%) for more than two weeks9.The daily means of energy intake of the participants were assessed using the 7-day Dietary History Questionnaire by a trained clinical dietitian through face-to-face interviews. Dietary analysis was conducted using the Nutritionist Pro™ Nutrition Analysis software. In order to determine whether patients achieved their individual energy needs, their basal metabolic rate (BMR) for participants aged 19–60 years old was estimated using the Malaysian sex-specific equations based on age and body weight9. Meanwhile, participants were identified as having mild to moderate inflammation if presented with chronic diseases such as chronic obstructive pulmonary disease, cancer, congestive heart failure, chronic renal disease, liver disease, and rheumatoid arthritis. However, this study did not collect proxy of inflammation such as serum C-reactive protein, albumin, or pre-albumin since all the stroke participants were not in their acute phase of stroke.Participants’ underlying medical conditions were charted from the latest medical records. Any recent acute disease/injury such as major infections, burns, trauma, and closed head injury are indicators of severe acute inflammation9.Additionally, the severity of malnutrition was further classified into either moderate malnutrition or severe malnutrition based on either one of the phenotypic criterion shown in Table 430. The participants were asked to rate their health today in five dimensions of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, based on a five-point scale (1–5), indicating increasing severity of problems. An EQ-5D summary index was computed based on a formula that attaches values (weights) to each of the levels in each dimension, with reference to the Malaysian EQ-5D-5L value set published by Shafie et al.30.Participants' health-related quality of life was assessed using the EuroQoL-5 Dimensions- 5 Levels questionnaire. The Malay version of the questionnaire has been validated in the Malaysian populationt-test or Mann–Whitney U-test was used for continuous variables. Analysis of sensitivity, specificity, positive predictive value (PPV) tests, negative predictive value (NPV) tests, the area under the curve (AUC) and correlation coefficients were conducted to evaluate the concurrent validity of the different malnutrition screening tools against malnutrition GLIM-DCM in stroke patients. Participants were classified into either elderly (≥ 65 years old) or non-elderly (< 65 years old) group. The rating of the validation results  for the malnutrition screening tools was given based on the cut-off values proposed by the MaNuEL Consortium (2018)8. A screening tool was classified as “good” if both sensitivity and specificity were > 80% and AUC was > 0.8; “fair” if sensitivity or specificity are < 80% but both were > 50% and AUC was in the range of 0.6–0.8; and “poor” if sensitivity or specificity was < 50%, and AUC was < 0.68. Besides, correlation coefficient between different malnutrition screening tools with BMI, MUAC, CC, HGS, dietary energy intake, and EQ-5D summary index were computed using the Spearman Rank test.All statistical analyses were performed using the IBM SPSS version 25.0 for Windows. Chi-squared or Fisher’s test was used to compare differences in the categorical variables between two groups. Meanwhile, Student’s The Medical Research and Ethics Committee in Ministry of Health, Malaysia [NMRR-19-4024-47231 (IIR)] and UniSZA Human Research Ethics Committee [UniSZA/UHREC/2019/102] approved the study protocol. Written informed consent was obtained from cognitively intact elderly stroke individuals or their proxy if they were having severe aphasia, hearing, vision or cognitive issues.This study screened 448 respondents from three hospitals during the survey; however, 124 respondents were excluded based on exclusion criteria, and 20 refused to participate. Hence 304 respondents were recruited. More than half of the respondents were males, nonelderly, of Malay ethnicity, had married, were not working, and had attained secondary education levels Table . The majMeanwhile, 25.3% of the stroke participants were diagnosed as malnourished according to the GLIM criteria, with 67.5% of them were severely malnourished. Compared to the non-elderly group, the elderly group was much older, had stroke onset at an older age, and had a higher number of comorbidities. Additionally, a significantly higher proportion of them was from poorer socioeconomic status (not working and lower education levels) and had ischaemic types of strokes than their counterparts. Despite this, the prevalence of malnutrition risk was found to be similar between the two groups across different malnutrition screening tools except for the NRS-2002. The elderly group had significantly higher prevalence of malnutrition risk as compared with the non-elderly group when screened with NRS-2002.Table Tables This study shows that both MRST-H and MUST exhibited high sensitivity, high specificity, strong positive and negative predictive values, and good AUC with the GLIM-DCM in both elderly and non-elderly stroke patients. Meanwhile, MST, MNA-SF and NRS-2002 showed poor to fair validity with the reference standard. Only MRST-H and NRS-2002 scores were significantly correlated with all nutritional parameters , dietary energy intakes, and health-related quality of life in both age groups.31. Shimizu et al., however, showed a higher prevalence at 64.8% among older stroke patients (mean age ± SD = 78.9 ± 7.7 years) with oropharyngeal dysphagia. Similarly, studies in Japan and Australia found a higher prevalence of malnutrition at 46.0–52.0% among older adults admitted to rehabilitation wards (not specific to stroke cases)33. The discrepancy in results may be due to differences in patient characteristics (younger versus older adults) and assessment time (chronic versus subacute phase). However, our study had found that two-thirds of these malnourished patients had severe malnutrition, raising the possibility of delayed nutritional treatment due to inadequate nutritional screening or worsening nutritional status during the rehabilitation phase34. Sremanakova et al., in a clinical audit, showed that malnutrition risk screening (using MUST) was absent in one-third of the stroke patients admitted to the ward in the UK. Additionally, resources for nutritional screening and care may be more limited in the rehabilitation phase than in the acute phase. Early identification of malnutrition risk using a valid malnutrition screening tool allowed better nutritional care and lower malnutrition incidence in the clinical setting35. Malnutrition among stroke survivors is undesirable as it is associated with poor functional recovery and clinical outcomes 37. Thus, early identification of malnutrition with validated malnutrition screening tools is highly recommended.According to the GLIM-DCM, the overall prevalence of malnutrition diagnosis was 25.3%, which was in line with previous findings among Japanese stroke patients in the acute phase (28.7%)38. When choosing the appropriate malnutrition screening tools, a clinician must ensure that the tool is validated, with good sensitivity and specificity to the targeted population. For instance, NRS-2002 was developed mainly for adults in the acute setting; meanwhile, MRST-H and MNA-SF were specifically designed for the elderly population in acute and community settings16. This might explain the discrepancy in the prevalence of malnutrition risk detected across different tools. Unsurprisingly, NRS-2002 was the least preferable screening tool in the rehabilitation setting, given its poor to fair sensitivity and specificity against GLIM-DCM. This is probably because one of the important criteria in the NRS-2002, namely severity of disease in the acute phase, was less applicable among community-dwelling stroke patients.The prevalence of malnutrition risk as screened using different screening tools ranged between 22.4 and 51.3% in this study. Our prevalence was higher than those reported at 18.1–38.5% in a Vietnam study in acute care which included adults patients from medical and surgical wards but excluded those under rehabilitation care39. Similarly, Nishioka et al. suggested that MNA-SF may potentially overestimate the prevalence of malnutrition among elderly stroke patients in the rehabilitation phase (due to its low specificity), with a prevalence of 91–99% being reported in the Asian population41. This was because it was difficult to differentiate the characteristics of malnutrition with stroke-related impairments, including reduced mobility caused by hemiparesis, communication problems due to aphasia, and unintentional muscle atrophy following stroke, causing sub scoring of many items in the MNA-SF42. As compared to our study, Marshall et al.17 and Nishioka et al. (2019) reported higher sensitivity (100%) but lower specificity (1.7–22.6%) for MNA-SF among patients in rehabilitation. Differences in the methodology might explain the discrepancy in the results. First, we excluded unfit patients for anthropometric measurements, thus providing better accuracy for the BMI assessment. Second, the reference standard used, namely GLIM-DCM, ESPEN-DCM, and ICD-10-DCM, would result in differences in the malnutrition prevalence. The ESPEN-DCM has similar phenotypic criteria to the GLIM-DCM ; however, it does not include the aetiology of malnutrition (inflammatory conditions or reduced food intake)6. Meanwhile, although the ICD-10-DCM includes an assessment of BMI, weight loss, food intake and muscle loss, yet details regarding a timeframe for weight loss or the degree of reduced food intake are absent43. Shimizu et al. showed that the GLIM-DCM, which includes the aetiology of malnutrition as a component, could identify malnutrition more frequently than the ESPEN-DCM in geriatric rehabilitation care units32.In contrast, the prevalence of malnutrition risk was the highest when screened by the MNA-SF. However, we noticed that MNA-SF has the lowest specificity as compared with other screening tools, thus might increase the chances of inappropriate referrals for further assessment for those who are not truly malnourished. Specificity is particularly important to consider in service provision and staffing resources33. Similarly, other Australian studies reported fair validity of MST when validated against ICD-10-DCM and SGA among patients in the rehabilitation facilities : sensitivity 72.2–80.8% and 67.7–83.8% specificity44. Despite its fair validity, MST is the quickest and easiest to administer screening tool since only two items are involved, and no anthropometric measurements are needed. Further evidence from Asian countries, however, should be obtained before concluding the usefulness of MST in the rehabilitation/stroke patient.On the other hand, our study showed that the accuracy of the MST in reference to GLIM-DCM was fair regardless of the age group. This is in line with previous data, which reported fair validity of MST when validated against GLIM  among geriatric rehabilitation patients in Australia45. Tan et al.15 conducted concurrent validation of the MRST-H against Subjective Global Assessment (SGA) in hospitalized and outpatient visiting elderly. The sensitivity and specificity values of the MRST-H were reported at 67% and 90%, respectively. In contrast, Tran et al.38 conducted validation of different screening tools, namely MUST, MST, NRS-2002 and MNA-SF, among adults admitted to medical and surgical wards. The study, however, found that NRS-2002  and MUST  showed fair validity, meanwhile MST  and MNA-SF  had poor validity when compared to the reference standard SGA and BMI.We observed that MRST-H and MUST had high sensitivity and specificity against GLIM-DCM in both age groups, which seemed to be an appropriate screening tool for the stroke population. It is unlikely to compare our findings with previous data since MUST and MRST-H have not been validated among stroke survivors or rehabilitation setting. However, these screening tools have been validated among adults in either community or residential care, with fair to good validity36. Similarly, Zhang et al. showed that MUST scores were significantly associated with the modified Rankin Scale at 12 months post-discharge from a stroke event in China46. Meanwhile, Marshall et al.17 showed that neither the MST nor MNA-SF could predict rehospitalization, institutionalization, or discharge location among older adults in rehabilitation. The validity of MRST-H in predicting clinical outcomes among stroke survivors in Malaysia, however, was not being examined in this study and thus need further investigation.Apart from concurrent validity and reliability, the ability of the malnutrition screening tool to predict specified clinical outcomes is also important. Studies in the UK have demonstrated that MUST is an independent predictor of mortality, length of stay and hospitalization costs at six months after stroke36 and an increased energy need, particularly for those who underwent surgical intervention47. The relationship between stroke subtypes and nutritional status remained insufficiently investigated and warrants further study. Additionally, the prevalence of stroke-related impairments was common among the stroke patients regardless of their age in this study. Neurological deficits post-stroke, such as dysphagia, hemiparesis, cognitive impairment, visual and speech deficits, have hindered their ability to consume adequate nutrition48.Surprisingly, we did not observe a significant difference in the prevalence and severity of malnutrition between the elderly and non-elderly groups across most of the screening tools except for the NRS-2002. This is probably because only NRS-2002 considered age ≥ 70 years as an additional risk of malnutrition in the screening tools. The insignificance results might also be explained by differences in the stroke subtypes where a higher prevalence of haemorrhagic stroke was observed in the non-elderly patients. Some studies have shown that as compared to ischaemic stroke, haemorrhagic stroke is more likely to be associated with high malnutrition riskAll of the screening tools were significantly associated with BMI, MUAC, CC, energy intake, and health-related quality of life. However, only MRST-H and NRS-2002 were significantly associated with HGS in both age groups. This is probably because the MRST-H had included muscle mass (MUAC and CC); meanwhile, NRS-2002 considered age as an additional malnutrition risk as part of the screening items. Although HGS has been treated as one of the nutritional markers indicating early nutritional deprivation, HGS is confounded by other factors such as the presence of hemiparesis in stroke, stroke recovery process and ageing. Meanwhile, the correlation between MNA-SF with EQ5D-index was the highest when compared to other screening tools. This is probably because MNA-SF has included mobility and depression items, which are part of the parameters in computing the EQ5D summary index.40. Unlike the Geriatric Nutritional Risk Index, all these screening tools do not require any laboratory data; thus, they are more cost-effective and are considered non-invasive tools. Fourth, to reduce the screening burden on patients and clinicians, most screening tools have relatively few items to administer, with the lowest items found in MST (2 items) and the highest seen in MNA-SF (7 items). Last but not least, MUST, MNA-SF and NRS-2002 considered the acute disease effects in its criteria, and only MNA-SF included psychological stress factor. Further investigation on the feasibility and predictive validity of these malnutrition screening tools is required in future studies.Apart from accuracy in predicting malnutrition, clinicians should be aware of the limitations and advantages of each nutrition screening tool. First, unlike MNA, MUST and NRS-2002, MST and MRST-H do not require measurement of BMI. Measuring accurate weight and height is challenging, particularly among stroke patients with hemiparesis, and thus it is often not routinely conducted in the clinical setting. Our study had excluded almost one quarter of the eligible participants since they could not stand properly. Second, only MRST-H and MNA had considered the use of CC . CC is a good predictor of muscle wasting and correlates well with a functional capacity which is important in stroke recoveryThis was probably one of a few multicentre studies which examined the validity of different malnutrition screening tools with the latest GLIM-DCM in an Asian rehabilitation setting. Therefore, we believed that the study findings will contribute important information regarding importance of choosing the appropriate malnutrition screening tools in stroke rehabilitation setting. Despite this, since the study was confined to two states of Malaysia; thus, the generalisation of the findings to the whole Malaysian population was limited.We can conclude that the MUST and MRST-H showed good concurrent validity with GLIM-DCM and can be considered as appropriate malnutrition screening tool in discriminating malnutrition among stroke individuals attending rehabilitation centre in Malaysia regardless of their age groups. The prevalence of malnutrition among stroke individuals in rehabilitation phase was high at 25.3%. Therefore, screening and assessment for malnutrition should be incorporated into the standard stroke care to allow early treatment of malnutrition, improve patient and health outcomes and prevent complications.


Mycobacterium marinum soft-tissue infection after an iguana bite in Costa Rica that was diagnosed through 16S rRNA sequencing and mycobacterial culture. This case informs providers of potential etiologies of infection after iguana bites.Infections after reptile bites are uncommon, and microbial etiologies are not well defined. We describe a case of  Mycobacterium marinum infection after an iguana bite to inform clinicians of potential infectious etiologies of lizard bites.Zoonotic infections associated with animal bite injuries are common and can result in severe illness . Mycobacterial culture (Middlebrook 7H11 agar) incubated at 30°C grew photochromogenic colonies after 2 weeks that were consistent with M. marinum. The patient was started on rifampin and clarithromycin and gradually improved over the next 2 months.Surgical excision revealed a 2-cm, thick-walled mass adherent to the extensor tendons of the third and fourth digits, with extrusion of a thick, white, purulent material. Histopathology revealed extensive necrosis and necrotizing granulomatous inflammation with acid-fast bacilli seen by Fite staining  are colonized , escaping the phagosome into cytoplasm and triggering an inflammatory response to spread to other macrophages (M. marinum causes disease in immunocompetent and immunosuppressed hosts; however, the incidence of cutaneous infections among children is low (M. marinum infections include subacute to chronic papulonodular skin lesions on the hand with a sporotrichoid spread, as the infection spreads along lymphatic vessels to regional lymph nodes (M. marinum, are resistant to β-lactams because of β-lactamases, decreased cell permeability, and low affinity to penicillin-binding proteins, explaining why this patient did not respond to amoxicillin (M. marinum in culture is challenging because it is slow growing, requiring 28°C–32°C for optimal growth in vitro and incubation over several weeks (M. marinum (M. marinum infection after an iguana bite in this report could inform clinicians of less commonly known bacterial etiologies after unusual zoonotic exposures.Isolation of


Noncardiac anomalies (NCAs) in patients with congenital heart defects (CHDs) are crucial for perioperative management and etiology studies. This study aimed to investigate NCAs in Chinese children with CHDs.Medical records for CHD-diagnosed children hospitalized from 1 January 2015 to 31 December 2019 were collected and subjected to retrospective analyses to excavate potential association rules between CHDs and noncardiac malformations.P = 3.7 × 10−9) while AVSD had a higher percentage (P = 0.0018).A total of 3,788 CHD patients were included in this study. The main phenotypes of CHD were Ventricular Septal Defect , Atrial Septal Defect , and Tetralogy of Fallot . A total of 887 (23.42%) cases showed noncardiac anomalies, which were mainly associated with the central nervous system (34.61%), nose/ear/mandibular/face (19.39%), genitourinary system (15.78%), and musculoskeletal system (15.56%). Compared to other CHD subtypes, septal defects had a lower percentage of associated NCAs (NCAs are prevalent among CHD-diagnosed children in China, and the spectrums of NCAs in different CHD subcategories were different. Multiple organs originate from a common germ layer and can be regulated by shared signaling pathways . MoreoveReported frequencies of NCAs in CHD-diagnosed patients range widely from 4.53% to 50% –15. Diff2.2.1.Children diagnosed with a CHD and hospitalized in the Department of Cardiac Surgery, Children's Hospital of Fudan University from 1 January 2015 to 31 December 2019 were eligible for inclusion. Data collection and analysis processes were conducted with the permission of and under the guidance of the ethics committee. Written informed consent to participate was obtained from the guardians. Medical histories, surgical records, imaging data, outpatient medical records, and genetic test results of enrolled patients were collected and examined retrospectively. CHD diagnoses were confirmed by clinical assessment, echocardiography, cardiac catheterization, and, if necessary, surgical observations. Patent foramen ovale, patent ductus arteriosus (PDA) in premature infants, and a PDA that resolved within 3 months after birth were excluded. The analyses did not include patients with cardiomyopathies, cardiac arrhythmias, or primary pulmonary hypertension.2.2.Individual patients' CHDs were classified based on anatomy and etiology –23 into Diagnosed NCAs were summarized and aggregated according to affected systems. All developmental delays, including growth retardation, intellectual disability, mental delays, learning difficulties, and language/motor deficits, were classified as central nervous system (CNS) anomalies . We igno2.3.χ2 test or Fisher's exact test was applied to compare the proportions of isolated CHD between different genders and different CHD subtypes. The apriori principle (R (version 4.1.2), R Studio (version 1.4.1717), and SPSS (IBM version 20) were used for statistical analysis. Analysis of description was used to provide the whole picture of CHD and NCAs; Pearson's rinciple  was used3.3.1.A total of 3,788 CHD-diagnosed children were identified retrospectively, of which 2,065 (54.51%) were male and 1,723 were female (45.49%) with a median age of 3.96 years . The proportions of level 1 and level 2 diagnostic classifications are reported in 3.2.n = 262, 29.54%), inguinal hernia , and cryptorchidism and hydrocele .A total of 887 (23.42%) cases of CHD were associated with noncardiac malformations, comprising 587 (15.50%) with one malformation, 228 (6.02%) with two malformations, and 72 (1.90%) with three or more malformations .There we3.3.P = 3.7 × 10−9) and D-TGA with an intact ventricular septum , are less likely to associated with NCAs. Furthermore, there were a higher probability of combined NCAs in children with AVSD (P = 0.002) and vasc ring malformations (P = 0.007).The level 1 diagnoses with the highest percentages of isolated CHDs were septal defects, wherein about four fifths of each were isolated . ConversP < 0.05), whereas the situation is opposite in LVOTO and RVOTO diagnostic groups.Although NCAs involving the CNS, nose/ear/mandibular/face, genitourinary system, and musculoskeletal system were common for most CHD subtypes, the distribution of NCAs differed slightly . NCAs af3.4.With support and confidence levels set to 0.01 and 0.1, respectively, we attained 213 rules between CHD subtypes and NCAs. After filtering out low-value rules (lift < 3), 11 rules were retained , showing4.In the present study sample, 23.42% of CHD diagnosed children had coexisting NCAs, a value about midway between the wide range of percentages reported in the literature (4.53%–50%) –15 and sOur findings indicating that the most common NCAs observed were CNS anomalies, nose/ear/mandibular/face anomalies, genitourinary system anomalies, and musculoskeletal system anomalies are largely in agreement with previous reports , 29–31. Regarding NCA risk among different CHD phenotypes, we found that AVSD, PTA, vasc ring malformations, LVOTO, and heterotaxy had relatively high incidences of associated NCAs, whereas VSD and APVD had relatively low incidences. It could be that CHDs that emerge in earlier stages of morphogenesis are more likely to be associated with multiple and complex defects . BoundarOur finding of a specific link between VSD/LVOTO/PDA presence and CNS anomalies should be explored. Interestingly, the impact of AVSDs on CNS anomalies and nose/ear/mandibular/face anomalies could potentially relate to the well-known correlation between AVSDs and Down syndrome , 43, 44.5.It was difficult to conduct a stratified analysis to correct for confounding factors as we did not obtain data related to risk factors for birth defects. We also did not capture associated CHD patterns in rural China, where there is a high prevalence of unrecognized CHDs . Thirdly6.Han Chinese children with CHDs were found to have a high prevalence of NCAs, including CNS, nose/ear/mandibular/face, and musculoskeletal anomalies. Different CHD subtypes had different NCA probabilities and spectrums. Compared to other CHD subtypes, septal defects had a lower percentage of associated NCAs while AVSD had a higher percentage. Clinicians treating patients with CHDs should be attentive to the risk of NCAs, particularly for perioperative management but also for long-term prognosis determination.


Short video communities have proliferated recently, opening up a new channel for the promotion of online businesses. The main challenge in marketing with short videos is how to inspire consumers.This study employs viewer social identification and self-expansion as its entrance point to to explain how uploader-viewer similarity affects viewers’ short video inspiration. We use empirical investigation method based on the data of 310 short video viewers to test our conceptual model.We found that there is a double-edged relationship between uploader-viewer similarity and short video inspiration. Particularly, uploader-viewer similarity enhances perceived social identification while reducing perceived self-expansion. The association between Uploader-viewer similarity and short video inspiration is moderated by viewers’ cognitive demands.These results provide a new perspective for enterprises to manage the relationship between viewers and media. According to data from the China National Copyright Administration, short video users made up 88.27% of all online users, and Chinese mobile internet users use short video applications more than a quarter of the time every day. Short videos appear to have replaced graphics and voice as the “third language” of the mobile internet and have been incorporated into people’s daily lives. For users, short videos are a relief valve for emotions, a vane for consumption, an assistant in life, and an aggregator of knowledge according to 2019 Short Video Marketing White Paper, released by Zhimeng Bejing Company. For internet businesses, short videos are a new medium for promoting products and establishing and maintaining good relationships with their customers. The problem of how to successfully inspire customers to make purchases by capturing their interest while they watch videos still needs to be addressed. Researchers in the field of marketing have recently given the idea of consumer inspiration more consideration  with them . ResearcWe expect that in the context of the short video, uploader–viewer similarity will become an important variable in the realization of social behavior; specifically, the perception of similarity is conducive to activating viewers’ short video inspiration. The collection, recontextualization, and compression of short videos are not only information but also individual cognition. In the context of short videos, viewers are more likely to be influenced by similar people. Similarity can bring about mutual attraction, increase interaction, inspire a sense of connection, change attitudes, and promote the occurrence of implicit behaviors .However, researchers such as Aron believe that in some situations, similarity does not have a relationship with attraction and may even destroy attraction . EvolutiTherefore, as a general principle, similarity can indeed bring attraction, but in certain situations, differentiation is more attractive, and similarity at this time has a certain repulsive effect. Moreover, some aspects of similarity that can be attractive are also different from person to person. Because people are complicated in life, the psychology and behavior of viewers in the context of short videos are also different from those in real life. There is still a long way to go to study whether uploader–viewer similarity in short videos is attractive.2.2.Social identification is a person’s perception of the group to which he belongs, as well as the perception of oneself . The degOn the short video platform, viewers gather under a loose community label to form a virtual community or circle. In the video platform, the gender, personality, age, status, education level, values, interests, and preferences of the video uploader are all elements that attract viewers and form social identification. Research on interpersonal attraction in social psychology has shown that people like others who share similarities with themselves because human beings are social animals. When people interact with similar others, they will experience smoother communication and better understanding, and they will be able to predict the reactions of the other person. In addition, similarity can stimulate a feeling of connection to others, which is consistent with the principle of attraction in social media. According to social response theory, which was proposed by However, it is worth noting that when viewers have a stronger willingness to participate, initiative, and a sense of efficacy, self-expanded cognition appears. Self-expansion refers to the psychological change or process of an individual through the expansion of self-identification into another person . In the In the context of short videos, when viewers interact with uploaders who provide new perspectives, resources, and identities in a short video context, they will find opportunities for self-expansion. Self-expansion theorists do not emphasize the motivation of future behavior but rather focus on the motivation of acquiring resources to expand personal self-awareness . TherefoHypothesis 1: Uploader–viewer similarity positively affects the viewer’s perception of social identification.Hypothesis 2: Uploaded–viewer similarity negatively affects the viewer’s perception of self-expansion.2.3.Viewer inspiration in the context of the short video refers to the inspiration that the short video brings to the viewer, which changes the viewer from “inspired by external factors ” to “inspired to practice new ideas (such as purchase behavior occurs)” the activation of state transition . Short vUploader–Viewer similarity not only increases perceived social identification (“the blade of benefit”) but also weakens perceived self-expansion (“the blade of disadvantage”). The positive side is that viewers can gain a sense of identity through interaction with similar uploaders. The process of interaction, feedback, exchange, and sharing of information between the uploaders and viewers of short videos create a sense of psychological security that is very important. Smooth communication increases positive emotions , which iOn the other hand, for the blade of disadvantage, uploader–viewer similarity can make viewers feel that their self-expansion is restricted. Although existing studies have pointed out that similarity can satisfy the individual’s sense of identification, belonging, and control from a cognitive perspective, this type of research is limited to situations where the individual’s sense of belonging and lack of control, such as a completely unfamiliar shopping environment, user experience of new products, etc. When the individual is at a normal level of control, the existence of uploader–viewer similarity will limit the individual’s perception and cannot expand itself. Improving self-efficacy by expanding one’s self is a basic motivation for people. Furthermore, the experiment of Drawing on the self-extension model, in the short video platform community, the longer the relationship between the uploader and the viewer lasts, the less self-extension can be obtained, and vice versa, the more loyal they become . If the The current literature on similarity effects focuses on the positive effects of similarity, such as enhancing attractiveness, enhancing persuasiveness and compliance, enhancing trust and preference, and enhancing social relations , there iHypothesis 3a: Perceived social identification positively affects viewers’ short video conceptual inspiration.Hypothesis 3b: Perceived social identification positively affects viewers’ short video action inspiration.Hypothesis 4a: Perceived self-expansion positively affects viewers’ short video conceptual inspiration.Hypothesis 4b: Perceived self-expansion positively affects viewers’ short video action inspiration.2.4.The viewer’s cognitive need will moderate the relationship between uploader–viewer similarity and the viewer’s self-expanded cognition. The need for cognition (NFC) is an important personality trait that reflects differences in individual cognitive motivation. Cognitive needs are the tendency of an individual to participate and enjoy thinking. It mainly considers whether the individual is willing to think actively when facing cognitive tasks . High NFHypothesis 5a: The higher the viewer’s cognitive needs are, the stronger the negative impact of uploader–viewer similarity on the viewer’s self-expansion.Hypothesis 5b: The lower the viewer’s cognitive needs are, the less significant the influence of uploader–viewer similarity on viewer self-expansion.The Stimuli-Organism-Response Model (SOR) provides a framework that describes “uploader–viewer similarity” as a stimulus, while “perceived social identification” and “perceived self-expansion” are different types of organism, and the “viewer’s inspiration” is a type of response.For the stimuli, previous research on short video shopping has indicated that the experience of users in differs from offline shopping, as consumers have social interactions with sellers  and otheFor the organism, most human behaviors are driven by mental states, which are often affected by how we relate to a specific stimulus. This type of organism includes cognitive and affective reactions. Previous environmental psychology research defined cognitive reactions as ‘the mental process occurring in individuals’ minds when they interact with the stimulus’, and affConsistent with the S-O-R model, the response represent the final outcomes and decisions of users based on cognitive and affective reactions and include approach or avoidance behaviors . In the 3.3.1.Questionnaire StarDouyin, Kuaishou, and Xiaohongshu, the typical social commerce applications for reviewers to watch short videos and do some purchasing in Mainland China, as the participants. The short videos are social networking-based communities, where viewers can directly communicate with the uploader or other viewers in the same video community. The viewers’ idea of purchasing decisions are often influenced by the uploader’s presentation and recommendation. Meanwhile, these short video applications are also e-commerce, thus, there is a direct path or a link for purchasing online for all viewers. Therefore, it is common knowledge among viewers that these applications are online communities where people can easily communicate with the uploader, also can purchase the product in these communities.“Short video” is a relatively new social application based on mobile intelligent terminals. In this study, convenience sampling was conducted among active users of short videos, questionnaires were compiled through the Because this study was conducted in Mainland China, the scales in the questionnaire went through a translation and back translation process with the assistance of two doctoral students. First, one student translated the instruments from English to Chinese, and then, the other student translated them from Chinese to English. The two English versions of the scales were compared, and all inconsistencies were resolved to improve the quality of the questionnaire. Further, we invited experts, including professors and doctoral students who majored in psychology and marketing, to review the questionnaire to examine the face validity of the survey instruments, refine the questionnaire wordings, assess logical consistencies, judge the ease of understanding, and identify areas for improvement. Overall, the questionnaire was viewed as concise and easy to complete. They also proposed several suggestions for the formatting and wording of the questions, which were incorporated in the revised version of the questionnaire.Douyin, Kuaishou, and Xiaohongshu, to ensure that all successful respondents had prior experience with short video shopping activities. This method is consistent with previous studies that adopted screening questions to identify the most appropriate respondents , and 78% of the respondents had a bachelor’s degree or above . The proportions of male and female viewers were 47.8 and 52.2%, respectively. Therefore, the sample characteristics of this study can reflect the overall characteristics of short video viewers.According to the Pew 3.2.We use the following The Cronbach’s alpha value of each variable was above 0.80, indicating high reliability. All items were measured using a 7-point Likert scale ranging from “1 = strongly disagree” to “7 = strongly agree.” Online surveys conducted without random assignment may increase the likelihood of individual differences in the system, affecting the results. Therefore, this study includes some general control variables to measure the characteristics of viewers on social networking sites, such as gender, income, and residence. Experience with internet use was also taken into consideration.3.3.In this study, the least square method (PLS) was used to calculate the measurement model and structural model, and SPSS 26.0 software and its supporting plug-in PROCESS were used to analyze the data for descriptive statistical analysis and regression analysis.Descriptive statistics showed that 12.62% of the samples using short videos (N = 310) were mainly used to acquire knowledge information; 24.35% for social communication; 52.43% for leisure and entertainment; and 10.60% for shopping. In terms of the use frequency of short videos, 5.81% of users were less than 1 h per day; 36.13% were1-3 h per day; 45.81% were 3–6 h per day; 12.26% more than 6 h a day; and 0 people choose “never.” In terms of internet using experience, 3.87% were less than 1 year; 7.74% were 1–3 years; 12.26% were 3–5 years; 27.1% were 5–8 years; and 49.03% were over 8 years.3.3.1.The scale reliability was tested by Cronbach’s α and complex reliability (CR). The results showed that Cronbach’s α coefficients of all variables were greater than 0.8 and the CR was greater than 0.9, indicating that the scale had good internal consistency and a high-reliability level. The calculation of the standard load of the measurement item showed that the load of all items was greater than 0.7, and the average variance extraction value (AVE) of the latent variable was greater than 0.5, indicating that the variable measurement item had good convergence validity see .The square root of the latent variable AVE on the diagonal of the table matrix is greater than the correlation coefficient between variables see , indicat3.3.2.R2 of perceived social identification was 0.601, the explanatory validity coefficient R2 of perceived self-expansion was 0.324, the explanatory validity coefficient R2 of short video conceptual inspiration was 0.456, and the explanatory validity coefficient R2 of short video action inspiration was 0.472, indicating that the structural model had the good explanatory ability. For the calculation of endogenous variable prediction correlation Q  was used to identify the goodness of fit of the partial least squares structural model. 0.1 < GoF < 0.25 indicated low goodness of fit, 0.25 ≤ GoF < 0.36 indicated good goodness of fit, and GoF ≥ 0.36 indicated high goodness of fit. According to the calculation, the GoF of perceived social identification, GoF of perceived self-expansion, GoF of short video conceptual inspiration, and GoF of short video action inspiration in this study are 0.575, 0.345, 0.423, and 0.446, respectively, indicating that the model has good goodness of fit. See Partial least squares structural equation modeling software SmartPLS 3.0 and SPSS 26.0 were used for testing. In the structural model, the explanatory validity coefficient lation Q , 0 < Q2 3.3.3.β = 0.361, p < 0.001). Short video uploader–viewer similarity had a significant negative effect on perceived self-expansion , and H1 and H2 were verified. Perceived social identification positively affected both conceptual inspiration and action inspiration , and H3a and H3b were validated. Both conceptual inspiration and action inspiration were positively affected by perceptual self-expansion , and H4a and H4b were verified.The partial least squares algorithm of structural equation modeling software SmartPLS 3.0 and bootstrapping  were used to analyze the path relations and indirect effects assumed in this study. p < 0.001, 95% confidence interval did not include 0. The indirect effect of perceived social identification on short video action inspiration was 0.478, p < 0.001, 95% confidence interval did not include 0. The indirect effect of similarity on short video conceptual inspiration was −0.413, p < 0.001, 95% confidence interval excluding 0. The indirect effect of perceived self-expansion on short video action inspiration was −0.205, p < 0.001, 95% confidence interval excluding 0. In this study, the bootstrapping method was used to test the mediating model of viewers’ social identification and self-expansion. A total of 5,000 samples were repeatedly selected with a 95% confidence interval. Model 4 was used to test the mediating model of “perceived social identification,” and Model 7 was used to test the moderated mediating model of “perceived self-expansion.” The indirect effect of perceived social identification on short video conceptual inspiration was 0. 362, 3.3.4.p < 0.001. The need for cognition regression coefficients was 0.236, p <0.001, playing a significant role in the short video context. The variable of need for cognition plays a regulatory role in the relationship of the uploader–viewer similarity and self-expansion when the viewer cognitive demand is higher; While the uploader–viewer similarity has a stronger negative effect on viewers’ self-expansion; When the viewer’s cognitive needs were lower, the similarity between short video uploader and viewer had no significant effect on viewers’ perceived self-extended, and H5a and H5b were verified.4.4.1.From the perspective of uploader–viewer similarity, this paper explores the mechanism of viewer inspiration in the short video community and explains the cognitive dilemma in short video usage. Through the questionnaire survey and analysis of short video viewers, it is found that uploader–viewer similarity has a positive effect on viewers’ social identification but has a negative effect on viewers’ self-expansion. Both social identification and self-expansion have a positive effect on short video inspiration. In other words, the similarity between short video uploaders and viewers can improve the social identification of viewers but limit their self-expanding cognition. Therefore, the positive role of uploader–viewer similarity should be played in practice, and its negative role should be avoided.First, the interpersonal similarity is an important source of attraction for viewers’ inspiration for short videos. The results show that uploader–viewer similarity can explain 45.5% of the variation in viewers’ conceptual inspiration and 47.2% of the variation in viewers’ action inspiration in short videos, indicating that uploader–viewer similarity plays an important role in short videos. Second, uploader–viewer similarity has a “double-edged sword effect,” which has both positive and negative effects. Third, cognitive needs regulate the relationship between uploader–viewer similarity and self-extended cognition.The internal logic of this mechanism, on the one hand, is that the framework of the short video fits the logic of contemporary communication. Similarity enhances three characteristics of short video inspiration: the need for communication , assumed similarity (the perception that uploaders and viewers using the same medium are close to each other), and simplified social cues . As Van Dijk points out in his book “Connected: A Critical History of Social Media” when discussing the relationship between connectedness and connectivity of social media platforms, the convergence of interpersonal connection and automatic connection occur when people’s social activities are translated into algorithmic recommendations of the platform.According to media compensation theory, communication can be achieved naturally through short videos. Due to the same or similar internal schema of communication, although media changes the external characteristics of communication , it does not change the essence of communication. The similarity between short video uploaders and viewers makes communication smoother. Although there is a certain amount of information loss in this process compared to face-to-face communication, such simplified social cues can also achieve relationship connection in a shorter cognitive time. For example, similarity factors are more likely to trigger altruistic consciousness and promote the occurrence of online prosocial behavior. This has implications for reshaping the symbiotic relationship between individuals and social communities as well as a way to deal with risks.On the other hand, uploader–viewer similarity benefits social capital. For those who find it difficult to find social capital offline, the internet can be used as a mechanism or means of compensation . In part4.2.First, the “similar-attraction theory” is a well-known theory of interpersonal attraction. Similarity leads to attraction, promotes interaction, and provokes feelings of connection. This study also verified that the “similarity effect” in social psychology can activate viewers’ short video inspiration in a short video context.Second, existing studies focus more on similarity in face-to-face situations and focus on the biased positive conclusion that “similarity leads to attraction,” ignoring the negative effects of similarity. In particular, it does not explain why in some situations similarity plays a less important role in attractiveness or even prefers dissimilar people. Based on the contradiction between viewers’ social identification and self-expansion, this study suggests that similarity can both improve viewers’ social identification and weaken their self-expansion. In other words, similarity brings social identification to viewers, while dissimilarity brings self-expansion. Therefore, from the perspective of the self-expansion dimension, uploader–viewer similarity will make viewers experience a sense of alienation in online communication, resulting in the phenomenon of network exclusion.Third, according to learning theory, learning is a kind of dialog that includes the internal dialog of individuals and the external dialog of interpersonal individuals. Hrastinski further believes that internet learning is also a process of participating in interaction . Some sc4.3.First, the short video communities and platforms should give full play to the positive role of uploader–viewer similarity, present the similarity between viewers, establish a sense of connection between viewers, increase social identification and activate the inspiration of short videos.Second, there are many factors affecting network exclusion, among which information acquisition is an important one. When viewers obtain less and less different information in the video, it means that others are no longer important to their self-expansion.Third, short video enterprises should aware of viewers with high cognitive needs will choose more diverse and higher-quality dialogs or interactions to improve their self-expansion ability. Therefore, for viewers with high cognitive needs, the suggestion or presentation of uploader–viewer similarity should be reduced; for viewers with low cognitive needs, the use of uploader–viewer similarity can be increased. Especially with the deepening of the interaction between viewers and media, it is necessary to explore various specific cognitive elements of viewers in the context of short videos in a more diversified way, which provides a new perspective for further research on the relationship between viewers and media.5.The shortcoming of this study is that cross-sectional data are adopted. Future investigations can be conducted at multiple time points in the same short video community, and the causal relationship between similarity and short video inspiration and other variables can be explored through statistical analysis of data at different stages. In addition, future research can also try to use more subdivided short video websites, explore the cognitive differences of viewers in different cultural contexts, and explore the influence of the similarity effect between uploaders and viewers on viewers’ cognition and relationship.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.SF made substantial contributions to the conception of the work, the experimental design, the acquisition of data, the analysis and interpretation of data, and drafting the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. HD made substantial contributions to the analysis and interpretation of data and revising the manuscript critically. All authors contributed to the article and approved the submitted version.This research was supported by Philosophy and Social Science Planning Project of Guangdong Province, China (GD20YGL02) and Natural Science Foundation of Guangdong Province, China (2021A1515011438).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Arteriovenous malformations (AVM) are extremely rare on the face and especially on the lip. Lip can be more easily exposed to traumas due to their anatomical location. Especially superficial AV malformations are very susceptible to trauma and can bleed very seriously after being exposed to such effects. AVMs management generally based on their hemodynamic characteristics and growth modalities. The surgical treatment requires elaborate planning and multidisciplinary approach. When evaluating a mass with a clinical manifestation of lip swelling, ruling out a vascular anomaly before any intervention is also crucial.Arteriovenous malformations (AVM) are abnormal fistulas between an artery and a vein, without an intervening capillary bed. AVM may occur everywhere in the body, with the brain being of particular concern, as AVM can be complicated by bleeding. Herein, we present the case of a patient with a very atypical AVM location consisting of a lip mass. Given the possibility of hemorrhage and airway obstruction, early detection and timely intervention are mandatory. On examination a soft, pulsatile, immobile mass was observed on the upper lip Figure . The masAV malformations are extremely rare on the face, particularly the lips. The lips can be more easily exposed to traumas because of their anatomical location and can bleed seriously, posing a risk to the patient because of airway obstruction. Although rare, it is important to include AVM in the differential diagnosis of lip masses.2Arteriovenous malformations can be congenital or acquired. Head and neck AVM are rare and occur in up to 0.1% of the population, typically in the brain. Extracranial involvement is present in only 8.1% of head and neck AVM.3Acquired AVMs are quite rare in the lip region. They may result life threatening bleedings, lip ischemia, airway obstruction, and high‐output cardiac failure. Hence, early diagnosis and prompt treatment of such cases is necessary. The surgical treatment requires elaborate planning and multidisciplinary approach. This case report provides an overview of acquired AVMs in the lip.Ashok Kumar Ariboyina: Investigation; methodology; resources; supervision; validation; visualization; writing – original draft; writing – review and editing. Ozgur Tatli: Resources; software; visualization; writing – original draft; writing – review and editing. Lakshmi Goriparthi: Resources; supervision; visualization; writing – review and editing. Narendra Achanta: Formal analysis; methodology; resources; visualization; writing – review and editing. Suresh Kumar Thirumoothy: Methodology; resources; writing – original draft; writing – review and editing. Suha Turkmen: Methodology; resources; validation; visualization; writing – review and editing.The authors have no conflicts of interest or financial disclosures to declare.Informed consent was obtained from the patient to publish this case report. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.