Arteriovenous malformation(AVM) have long-term “blood stealing” characteristics, which result in complicated hemodynamic features. To analyze the application of intraoperative indocyanine green angiography with FLOW 800 software in AVM surgeries.Data on 17 patients undergoing surgery with ICG fluorescence were collected in Beijing Tiantan Hospital. To analyze the hemodynamic features of AVM and the influence on the peripheral cortex of AVM resection, we assessed the following hemodynamic parameters: maximum intensity, slope of rise, time to half-maximal fluorescence, and transit time from arteries to veins.P < 0.05). The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05). After AVM resection, cerebral flow increased in the cortex, and local cycle time becomes longer, although the differences were not significant (P > 0.05).In the 17 superficial AVMs studied, the time-delay color mode of the FLOW 800 software was superior to the traditional playback mode for identifying feeding arteries, draining veins, and their relation to normal cortical vessels. The maximum fluorescence intensity and slope of the ICG fluorescence curve of feeder arteries and draining veins were higher than those of normal peripheral vessels (Hemodynamic parameter analysis provided quality guidance for the resection of AVMs and could also be used in estimating changes in blood flow in the local cortex to identify abnormal hyperperfusion and residual nidus. Arteriovenous malformations (AVMs) are responsible for about 2% of all hemorrhagic strokes, mainly in children and young adults , 2. DespIntraoperative indocyanine green (ICG) videoangiography is used widely in neurosurgery and has proven a useful addition to neurovascular surgery –6. FLOW In this study, we analyzed hemodynamic changes in AVM nidus and normal peripheral vessels during surgery using ICG videoangiography and the FLOW 800 software.The study protocol and written informed consent form were reviewed and approved by the Institutional Review Board of Beijing Tiantan Hospital , which is affiliated with Capital Medical University  (KY 2017-012-02).We enrolled 17 patients who were admitted to our department with AVM during March to November 2016  with peak spectral absorption at 805 nm and peak emission at 835 nm [All operations were performed using two microscopes available in our department . Both microscopes had near-infrared video integration and were able to perform ICG videoangiography.Under illumination with a near-infrared light source (excitation range 700–780 nm), real-time microscope images were recorded. An optical filter that allowed only fluorescence in the ICG emission range (820–900 nm) was used. To obtain optimum illumination, we set the standards for AVM resection as follows: the microscope diaphragm was automatically adjusted to a wide setting; the illuminated field diameter was set in the middle position; the illumination intensity was set to 50%; the recommended working distance of the scope was set at 300 mm; and the Pentero microscope zoom was set to 5 ×.ICG fluorescence angiography clearly showed the AVM nidus. Feeder arteries and draining veins were mainly chosen as the hotspots. We selected three to five feeder arteries and draining veins, along with peripheral cortical arteries, as the hemodynamic parameter collection points using the FLOW 800 software.FLOW 800 is an analytic color visualization tool that can evaluate the fluorescence video sequences obtained by microscope-integrated ICG fluorescence angiography using INFRARED 800. It provides an objective evaluation of results, visually and in different colors. Using this visualization tool, the ICG transit curve intensities were recorded, and maps of maximal fluorescence intensities were saved. Then, two-dimensional visual maps (including color maps) of the AVM were created according to maximal fluorescence intensities or time to half-maximal fluorescence. The intensity diagram function can provide a variable shape that reflects variation in the blood flow of the feeders, drainers, and peripheral vessels before and after AVM resection. Related parameters were defined as follows: time to half-maximal fluorescence was defined as the time required for the ICG fluorescence intensity to reach 50% of the maximum value (T1/2 peak); transit time was defined as the time required for blood to flow from artery to vein (arteriovenous transit time); rise time was defined as the interval between 10% and 90% of the maximum signal; and cerebral blood flow index slope was defined as the ratio of maximum fluorescence intensity to rise time.The indication for each ICG video during the AVM resection was recorded. As recommended by Hanggi et al. , 9, the t test. Two-tailed P values < 0.05 were considered statistically significant.Values are presented as the mean ± standard deviation. The statistical analysis was performed using the Statistical Package for the Social Sciences ver. 16.0 . The mean measurements of the computed tomographic angiography (CTA) and three-dimensional model were compared using one-way analysis of variance followed by Fisher’s least significant difference test. Comparisons between two groups (survey scores) were achieved using Student’s Our study enrolled 17 AVM patients who were judged suitable for surgical resection surgery under general anesthesia. The demographic characteristics of the patient population are listed in Table A total of 51 ICG fluorescence angiographies were performed; 15 patients received angiography three times, 1 received it two, and 1 patient received angiography four times. Blood pressure was maintained at 100–120 mmHg (105 ± 12 mmHg). Fourteen patients underwent digital subtraction angiography (DSA) or CTA after the operation, and all tests showed that the AVM was totally removed.No side effects or adverse reactions were noted after ICG administration in any of the patients.P < 0.05; Figs. In the 17 superficial AVMs, the time-delay color mode provided by the FLOW 800 software proved more useful than the traditional playback mode in identifying feeding arteries, draining veins, and their relations to normal cortical vessels. The transit times in AVMs were significantly shorter than those in normal peripheral vessels (P < 0.05), indicating that AVMs exhibited hemodynamic characteristics of high flow and high perfusion  was significantly earlier than that for cortical arteries (T1/2 peak 22.59 ± 3.13 s), which could serve as a basis for identifying feeder arteries. The slope of arterial feeders (144.95 ± 38.08 AI/s) was significantly greater than that of normal cortical arteries . This observation could be helpful in identifying draining veins , slope of the ICG fluorescence curve (178.66 ± 15.09), and T1/2 peaks (20.79 ± 3.42 s) of draining veins were higher than those of normal peripheral vessels (7 ± 90.41P < 0.05). The microvascular transit time (MVTT) of the cortical arteries was 2.08 ± 1.42 s before and 2.59 ± 1.21 s after resection. The cerebral flow in the cortex increased, and the local cycle time became longer, although these differences were not significant . Nonetheless, the results showed the tendency of AVM removal to affect the cortical veins.Although we found that cerebral flow in the cortex increased and local cycle time became longer, these differences were not significant . The results showed that cortical blood perfusion was increased; in some local areas, hyperperfusion was noted. The delayed cycling time showed that AVM resection may have caused local cortical venous reflux.In a previously published hemodynamic study, Ng et al. showed that ICG videoangiography was useful in different phases of AVM surgery . FurtherAfter AVM resection, the slope of ICG fluorescence in the peripheral cortical arteries was significantly increased (from 69.20 to 106.63), the maximum fluorescence intensity was enhanced, and image develop of cortical arteries was earlier than before surgery. This showed that cortical perfusion was increased after the AVM resection; indeed, some parts exhibited hyperperfusion. However, the time of circulation was prolonged, suggesting venous reflux due to obstruction in some parts of the cortex, a phenomenon termed “venous overload.” Wilson et al. proposed that venous overload was caused by thrombosis in a draining vein due to clogging by an AVM remnant . Our resWe compared the T1/2 peak fluorescence rate, slope, and maximum fluorescence intensity of the draining and cortical veins. The results showed that the timing of the T1/2 peak fluorescence rates was earlier for the draining than for the cortical veins, and the slope and maximum fluorescence intensity of the draining veins were greater than those of the cortical veins. These findings may prove useful in identifying abnormal draining veins. The real-time feedback regarding blood flow provided by FLOW 800 could help the surgeon to determine or modify the operative strategy for a safe and complete AVM resection .A combination of intra- and postoperative DSA is regarded as the gold standard for identifying AVM remnants after surgery, especially in small and deep AVM surgery . But disIntraoperative ICG videoangiography combined with analysis of hemodynamic parameters obtained by the FLOW 800 software is a convenient and effective method for evaluating the hemodynamic features of superficial AVMs by identifying the feeding arteries, draining veins, crossing arteries, and cortical vessels, and to provide quality guidance for AVM resection. Furthermore, hemodynamic parameter analysis can be used for estimating changes in blood flow in the local cortex, thereby identifying residual nidus and vessels contributing to abnormal hyperperfusion.


Our study highlighted a vulnerability in ADHD children: they would exhibit more addictive behaviors with respect to video games (Addiction score: 1.1025 in ADHD Group vs. 0.6802 in Community-Control Group) and prolonged periods of use. We also observed a correlation between the severity of ADHD symptoms and excessive use of video games (p = 0.000). Children with severe ADHD showed significantly higher addiction scores and, in a multiple regression analysis a combination of gender and ADHD explained the excessive use of video games.Video game addiction in young children is relevant, but it is especially important for children with ADHD. In order to obtain more data about the use of video games by Canadian children, and in particular by ADHD children, we explored the modalities of use  and compared them between ADHD and non-ADHD children. We then examined associations between addiction and ADHD symptoms and explored innovative results about the gender impact. Our study was cross-sectional, multicenter in child psychiatrist departments, exploratory and descriptive. We recruited three groups of children aged 4–12 years: the ADHD Group, the Clinical-Control Group and the Community-Control Group. For each group, the material used consisted of questionnaires completed by one of the parents. Data collection took place from December 2016 to August 2018 in Montreal ( Children and adolescents report playing video games frequently, and we can see that this use is being reported at ever-younger ages . For exaThe period between 4 and 12 years is therefore an important stage where children are increasingly exposed to video games and as such represents a relevant developmental period to study factors linked to excessive or addictive use of video games. Studies tend to show that ~2.0–5.5% of adolescents/young adults exhibit an addiction to video games .In 2018, the World Health Organization (WHO) introduced Gaming disorder (GD) to the International Classification of Disease-11 (ICD-11)  and highThe association between attention deficit hyperactivity disorder (ADHD) symptoms and video game addiction is observed among children and adolescents, but it is as yet not understood . The relWe've seen the major role that video games play in today's society, particularly among teenagers but also among increasingly younger children. Video gaming is typically a leisure activity, but its practice among some people can turn into an addiction and have negative consequences. Following an overview of the literature, we observed that the majority of studies on this topic are cross-sectional and prospective. These studies are conducted among teenagers and young adults without a control group and have seldom targeted children and only very rarely young (preschool or early primary school-aged) children. The scales used to measure video game addiction are highly variable and unvalidated. Furthermore, diagnosis of ADHD or other comorbidities is not generally confirmed through use of validated scales or by a specialized doctor .In this context and with a view to adding to knowledge about video gaming and its potential risks in potentially vulnerable populations, we sought to compare, in an exploratory manner, children aged 4–12 from a clinical population  with children aged 4–12 from the general population through use of standardized, validated scales. Based on our hypotheses, we expected to see an increase in addictive video gaming behaviors and in duration of video game use among children in the ADHD subgroup in comparison to the community population. Another of our hypotheses was that the intensity of ADHD symptomatology correlates positively with addictive behaviors.In order to better understand the relationship between video game use/addiction and ADHD in preschool/school children, we conducted a descriptive and exploratory study with the following objectives:(1) To determine the modalities of use of video games  in children with ADHD compared to children without ADHD.(2) To examine the associations between video game addiction and ADHD symptoms.(3) To explore the gender difference in video game use, the type of video games played by children with ADHD and the impact of parents on gaming.The participants were children aged 4–12 who comprised the three study groups. The first group was made up of children with ADHD ; the second was made up of children presenting one or more mental health diagnoses other than ADHD ; and the third was made up of children from the general community (community control group). All participants' parents had to be able to speak and understand French. The only exclusion criteria were the inability to read, write and understand French, and the presentation of an intellectual handicap or active psychotic symptoms.The age range of 4–12 was selected in order to more specifically target video gaming among school and preschool-aged children. It would be more difficult to direct our research questions at a broader age range in light of the inherent heterogeneous aspect already present in the children. With this in mind, the aspects evaluated as part of this study were not specific but rather related to individuals' general functioning.Participants in the clinical and clinical control groups were recruited at the outpatient pediatric (ADHD and development) and child psychiatric  clinics at the CHU Sainte-Justine, and the outpatient child psychiatric clinics at the Hôpital-Rivière-des-Prairies of the CIUSSS du Nord-de-l'Île-de-Montréal (CIUSSS NIM). These persons were recruited by a research assistant while waiting for an appointment in the waiting room at the outpatient pediatric or child psychiatric clinic. The assistant proposed participating in the study to all waiting patients and their parents and informed them about the project. The third group (community control group) was recruited at day camps in the Montreal, Laurentides and Lanaudière regions. Parents with their children were approached by a research assistant as they arrived at or left the day camp. The recruitment procedure followed was identical to that detailed above.The exclusion criteria for parents and children were being unable to read, write and understand French. Participants ought not to have an intellectual disability or to be actively psychotic.The study was cross-sectional, multicentre  in child psychiatric departments, exploratory and descriptive. The material used consists of questionnaires to be completed by one of the parents for each group. Data was collected between December 2016 and August 2018 in Montreal. This study is a first step toward evaluating this type of problem. The tools used consisted of validated questionnaires (three questionnaires described below in the Measures section) to be completed by one of the parents in one sitting (with a 30-min estimated completion time). After obtaining consent, a numbered envelope was given to each participant containing the questionnaires and a recruitment letter). This letter restated the main information concerning the research project and the project procedure and provided the telephone number of the research coordinator at the CHU Sainte-Justine in the event that participants needed additional information.In the clinical group, in addition to the questionnaires, participants' medical records were consulted once by a research assistant to verify psychiatric diagnoses. All ADHD and/or psychiatric diagnoses were made by a child psychiatrist from the CHU Sainte-Justine or the CIUSSS NIM. Diagnoses were arrived at following a comprehensive, multidisciplinary assessment based on the validated diagnostic criteria from the reference diagnostic guide in psychiatry in North America, the DSM-5 .The tools used consisted of three questionnaires completed by one of the parents in one sitting: the Sociodemographic Questionnaire with added questions on video game use among children and parents, the SDQ (Strengths and Difficulties Questionnaire) and the Questionnaire sur l'attention et l'ordinateur (questionnaire on attention and computers) (QUATTORD).General sociodemographic data were documented, including participant age, sex, current education level or last level achieved, family status, ethnic origin, etc., as well as the time of year of questionnaire completion. A standard sociodemographic questionnaire was used to collect this information supplemented by questions about screen time and, in particular, video game use. The added questions included questions about total screen time devoted to video gaming or to watching movies or television during the week and on weekends/holidays, frequency of use by game type and number of electronic devices in the child's possession. We added questions concerning video game use that we then categorized based on gaming habits. Although there was no consensus concerning this classification, video games can generally be divided in the following groups: creative games, educational games, non-violent character-based games and violent character-based or non-character-based games. We also added questions to this questionnaire for parents about their own video gaming habits and their perceptions concerning their children's gaming habits with a view to collecting preliminary data to guide our subsequent research questions .This is a questionnaire to evaluate ADHD symptoms and video game use. It includes 19 questions on ADHD symptoms , nine questions on screen use (descriptive) and 11 questions on video game addiction symptoms . The questions on ADHD symptoms and addiction symptoms are based on the diagnostic criteria from the DSM-5 . The resThe SDQ is a validated questionnaire consisting of 25 items evaluating strengths  and difficulties  in children aged 4–16 . The goaThe research project was approved by the research ethics board of the CHU Sainte-Justine (the main project center). Confidentiality and anonymity were maintained throughout the study and during data transcription. The participants' identities were coded using the numbers indicated on the envelopes. The questionnaire results were organized in an Excel spreadsheet and identified using these numbers. The computer holding this data is stored under lock and key in the research offices of the recruitment centers. If parents agreed voluntarily to participate after explanations were provided, they could then sign the consent form. Consent forms were signed in duplicate with one copy given to the parents. We also asked the children for their consent.post-hoc analyses (Hochberg and Games-Howell). Correlation analyses were then used to assess associations between the severity of ADHD symptoms and SDQ items in relation to dependency. We then conducted a multiple regression analysis to explore the combination between the gender and having ADHD or a clinical diagnosis.First, ANOVA  were conducted to compare video game playtime and addiction scores according to QUATTORD between the three study groups and between age categories for each group . We then clarified the differences identified by via the QUATTORD) and income, parental video gaming habits and parental perceptions concerning the impact of video gaming on their children .Lastly, we used multiple linear regression to evaluate associations between playtime and addiction score . With regard to gender, the proportion of boys and girls in the study for each group is also presented in A total of 280 participants completed the study: 98 participants (35.0%) in the ADHD Group, 37 participants (13.2%) in the Clinical-Control Group and 145 in the Community-Control Group (51.8%) . Participost-hoc analysis between the three groups were significant and identical with regard to video game playtime on weekdays and weekends. They indicated a longer time spent on video games in the ADHD Group   .p = 0.000 for ANOVA and post-hoc analysis)  .post-hoc analysis in this group only. We found that time spent on video games was significantly higher for the 10–12 age group compared to the 4–6 age group during weekdays and weekends  for each ADHD symptom  and video game addiction. The strongest correlation was with impulsivity .r = 0.182 for p-value = 0.003) between hyperactivity symptoms and weekend use time. There was no significant correlation for the other symptoms (inattention and impulsivity) and the time of use during the weekend. Similarly, we did not find a positive correlation for ADHD symptoms and the time of use of video games during the week.There was a significant correlation , conduct disorders (0.293), hyperactivity (0.242) and peer problems (0.201); and negative correlation with prosocial abilities (−0.272).All correlations between SDQ items and video game addiction scores found by the QUATTORD are highly significant with p < 0.01). Correlations between SDQ items and playtime during the weekend are positive and highly significant (p < 0.01) for emotional problems (0.242), conduct disorders (0.164), and hyperactivity (0.229).Correlations between SDQ items and playtime during the week are positive and significant for hyperactivity (0.151) and peer problems (0.143) as well as emotional problems . That is, the boys in the study showed more dependence if they belonged to one of the two clinical groups  and, more specifically, ADHD boys had the highest addiction scores. We did not find this trend for girls with equivalent addiction scores, regardless of the group .With respect to the types of games played, 62 participants (24.8%) often played creative games , 66 participants (26.5%) often played educational games , and 51 participants (8.4%) often played violent games  .With respect to parents, we found that only 17.4% of parents played video games. A negative association was then identified between average household income with addiction score and children's playtime, indicating that video game use (playtime and addiction) varies inversely with income. This corresponds to the data from the scientific literature indicating that a low socioeconomic stratum is associated with development of video gaming addiction and increased playtime . Using lResearch on the relationship between ADHD and video game addiction has mainly been conducted among adolescents and young adults, and studies like ours that focus on children are rare . Our stuThe duration of use was significantly higher in the ADHD Group compared to the Community-Control Group, during both the week and the weekend. We also found that, in accordance with the literature, when ADHD symptoms are more severe, playtime would be significantly longer . These rFurthermore, the degree of video game addiction was also significantly higher in children with ADHD compared to children in the community group. In the former, we indeed found, as early as preschool age, a higher tendency to develop addictive behaviors toward video games compared to children of the same age without ADHD. This would be even higher in ADHD children with behavioral problems since they might be less able to accept a certain control over their playtime. In addition, ADHD patients are at risk of addictive behavior and, more specifically, an ADHD diagnosis should increase the risk of being dependent on online video games .The explanatory mechanisms of this attraction by ADHD patients to video games include becoming bored quickly, intolerance to waiting, difficulties with self-control, difficulties being motivated, the need for intense stimulation and difficulties in interpersonal relationships . On the The only significant difference found was in the ADHD Group for the 10–12 age category compared to the 4–6 age category with a longer playtime among 10–12 year-olds during the week and the weekend. According to Lemmens, the younger the video games are played, the higher the risk of developing addiction during adolescence, a period of vulnerability to addictive behavior . Indeed,ADHD children seem to show an increase in video game playtime as they get older, while the other two groups of children do not differ by age. This may mean that early exposure by a young ADHD patient is a risk factor for increasing use as they get older, especially at the onset of puberty and during adolescence. Indeed, adolescence is a high-risk period for addictions among young ADHD patients .We observed a significant correlation between all ADHD symptoms and those of video game addiction. According to Yen, ADHD symptoms  among ADHD patients who are also cyberaddicts would indeed appear with more intensity than in ADHD patients who are not. More specifically, inattention seems to be the most aggravated symptom of video game abuse . HoweverThus, there appears to be a link between ADHD symptoms and the excessive use of video games, although at this stage it is not possible to predict the direction of causation. Moreover, it is important to differentiate the ADHD symptoms that result from an excessive use of video games from ADHD as a neurodevelopmental disorder.We found a highly significant positive association between behavioral problems on one hand, and video game addiction and playtime during the weekend on the other. The uncontrolled use of screens during childhood, whether for video gaming or otherwise, would therefore lead to a high risk of behavioral difficulties. Similarly, according to a study by Poulain et al. among children aged 2–6, the use of screens (including video games) is a major risk factor for the development of behavioral difficulties . MoreoveWe obtained a positive and significant correlation between socialization difficulties and video game addiction and playtime during the week, while the association between video game addiction and prosocial abilities was negative. Indeed, according to the literature, there is a strong association between increased screen time and reduced social development in children . SocialiWe looked for the implication of gender and more specification for the use of video games. First, a majority of boys were in both clinical groups . This corresponds to the clinical and epidemiological reality where the gender ratio for ADHD is two boys for one girl and where other neurodevelopmental disorders are also predominantly found in males. Moreover, according to Paulus et al., more boys than girls have video game consoles, and more girls than boys are non-players . We lookIt should be noted that studies on video games do not usually take into account the type of video games played, yet it seems essential to begin to make such distinctions if we want to make accurate recommendations. There are indeed many different types of video games and different ways of playing that likely have an impact on potential overuse. In this preliminary study, we tried to describe the games played by the children in order to get an initial overview of the situation. We found that the most popular video games played among 4–12 year-olds were educational rather than violent games. Educational games (those designed for a primary purpose other than pure entertainment) have pedagogical virtues that can be particularly useful for children with learning difficulties . This tyThe data from the literature also suggest that the relationship between ADHD symptom severity and video game addiction severity depends on the type of game preferred or played most often. This relationship may also depend on the level of reinforcement of the most-played game; that said, the reinforcement strategies of video games are constantly evolving to attract more and more players and become as addictive as possible. These changes have been bolstered by the initial success of massively multiplayer online role-playing games (MMORPGs), which have strong reinforcement structures, followed by other games that have increased reinforcement levels while creating a potentially higher risk of developing excessive use .No data exists regarding the use of video games by parents. In our study, we found that a majority of parents do not play video games at all. This has an impact on the parents' understanding and management of video games. Ideally, it is recommended that screen time be shared between parents and children according to the Canadian Pediatric Society guidelines . Poor reWe identified a negative association between income with addiction score and playtime, indicating that video game use (playtime and addiction) varies inversely with income. This corresponds to the data from the scientific literature indicating that a low socioeconomic stratum is associated with development of video gaming addiction and increased playtime . RadeskyWe explored video game use by parents, since the literature was weak in this area . ParentaWe found a positive correlation between video game use in children (playtime and addiction score) and parental perception of negative impact on their children's behavior after playing video games. To our knowledge, the links between video game use among children and this negative perception have never been discussed. As part of this exploratory analysis, we were consequently able to collect preliminary data on this topic, and it may be interesting to look at other possible correlations based on the data collected through our questionnaires. It is important to note that these results apply only to a clinical population . Although parental concerns are underscored, they may also be somewhat directed in that parents completing the scales for the project could be particularly concerned about this issue in relation to their children. According to Schneider et al., a positive perception of video gaming could lead to more frequent usage problems in children , whereasWe wanted to include this information, as it could create a bias in relation to data collection concerning video game use in that the majority of questionnaires were completed during the summer, when, based on our observations in the clinical setting, in the context of vacation and the absence of a structured schedule, children very likely spend more time playing video games. Recruitment levels were also higher due to the availability of research students.Although certain limitations and strengths were identified, we wish to take the reflection process further. The study has a certain number of strong points, such as the facts that the population was made up of children at least 4 years of age in the literature on video gaming and that the study was multicentre to ensure that the population was as varied as possible, thereby corresponding more closely to the general population. Our study is also very interesting in that it included control groups, the use of which enhances validity, particularly since the study involved evaluating behaviors in a specific segment of the population. The comparisons in the study are all the more relevant and useful since, in addition to the community group, we had a clinical control group, making even more detailed comparisons possible. From a statistical viewpoint, we took care to perform, with support from statisticians, appropriate analyses for our variables taking our hypotheses into account. We were successful in fully characterizing the population and the data on parents. Lastly, we were able to establish a highly comprehensive overview of the current knowledge based on a review of the literature.We used multiple validated, reliable, standardized measures; a wide variety of measurement scales on video game addiction have been used in research on that topic, but none has been validated. Additionally, numerous studies have used non-representative, self-selected samples and/or small samples. This both compromises the comparability of results and raises questions as to diagnosis validity in participants. In this regard, the lack of consensus and use of overly broad criteria imply the overly broad use of the diagnosis of video game addiction in cases that could instead be classified as excessive behaviors not resulting in functional impairment and falling within the societal reality of screen use.Similarly, in contrast to the majority of ADHD studies, in which the diagnosis is not confirmed, the ADHD diagnosis of our participants was made following comprehensive assessment at specialized clinics. The same applies to diagnosis in the clinical control group. What is more, the use of multiple comprehensive questionnaires further supports the validity of our results.The results of this study should be interpreted in light of its limitations. Since the questionnaires are completed by the parents themselves, there may be a measurement bias with regard to their subjectivity. In addition, the possibility of an ADHD diagnosis in the community population has not been eliminated and could lead to a bias in the results. Lastly, it must be noted that the study is not longitudinal, and we were also not able to test any mechanisms that could explain patterns of findings. Additionally, questions are asked only about video game use at T0 of questionnaire completion, which does not allow for a broader perspective over time. Playtime may also be underestimated, since the measures are based on scales completed by the parents, who may have been influenced by lack of knowledge about actual playtime and/or social desirability to indicate values lower than actual. The possibility of ADHD diagnosis in the community population was not ruled out and could lead to a bias in the results.The data collected on video gaming and parents are exploratory. These topics are of interest, and based on these initial results, we can now delve further into our hypotheses and direct our research questions. Next, diagnoses in the clinical control group were documented but not analyzed and could be incorporated into future subanalysis efforts to explore the impact of other diagnoses in child psychiatry . In addition, the questionnaires were completed by only one of two parents, which could lead to different responses if parents were separated or had different approaches to managing screen time . However, in our characterization of the population, we noted that a large majority of parents in our sample were not separated. We also did not track refusals, and the parents who consented appeared very willing to assist, which could indicate underlying problems (at least in their view).This project lacks a longitudinal aspect, which is conspicuously absent from the literature. To create the most accurate portrait possible of video game use, this activity would have to be tracked over time, while also avoiding situational use. For example, we observed that the majority of recruitment took place in the summer, whereas use doubtless varies depending on whether school is in session or children have a structured schedule as well as their options for outdoor activities.The current COVID-19 pandemic has greatly affected lifestyles and screen time. Already omnipresent in our lives, screens have become the only means of working, entertaining ourselves, keeping in touch with loved ones, socializing and learning. Moreover, screens became a go-to solution for keeping children busy while parents continued working from home and daycare facilities and schools remained closed. With regard specifically to video gaming during the pandemic, video game use increased significantly during lockdown periods , but this greater use could also be only temporary.A next step would be to undertake analyses and explore the impact of video games on family dynamics and academic performance, document the types of video games used and identify any comorbidities potentially influencing this use. Then, although we have studied the adverse effects of video gaming in terms of addiction, it would be useful nonetheless to examine any benefits it may also have. For example, video games may also help to develop certain skills   and offeKnowledge about video game addiction continues to grow, and we continue to learn more about potential vulnerability to this addiction among certain individuals based on their mental health diagnosis. In particular, an ADHD diagnosis appears to be a major factor in the development of a video gaming addiction, although this association also appears bidirectional and is not yet fully understood. At the same time, studies on the relationship between ADHD and video game addiction have been conducted primarily in teenagers and young adults and have rarely targeted children. Our study consequently underscores the vulnerability of children with ADHD to excessive video gaming and the consequences of gaming on their symptomatology. We wanted to supplement the analysis component of our study by exploring the role of internal  and external  factors, thereby corroborating the concept of a multifaceted relationship behind addictive video gaming behaviors.ADHD symptoms and video game addiction appear to have a bidirectional relationship in which the ADHD symptoms make video gaming appealing, while play itself exacerbates the ADHD symptoms by providing an activity that continually reinforces the need for instant gratification. Long hours of video gaming may further reinforce and consolidate children's propensity to uncontrolled reactivity and pervasive impatience without coaching to develop more reflection-oriented behaviors. As stated previously, the time dedicated to video gaming is spent at the expense of leisure activities such as sports, music and the arts, which would assist in developing children's attention, self-assurance, behavioral inhibition, discipline, team skills, and socialization. In this context, related studies provide opportunities to reflect on the potential impact on our practice. By exploring the consequences of intensive video gaming for these young children, it is possible to develop intervention approaches to propose to professionals.Although we understand that video games present risks, it would still be interesting to look at the benefits they can bring. Indeed, it is important to note that they can also help in developing skills such as a sense of control and coordination . There iThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Centre de recherche du CHU Sainte-Justine. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


Topic analyses revealed that excessive alcohol consumption was most correlated with references to drinking with friends (r = 0.20), family (r = 0.15), and driving under the influence (r = 0.14). Using the American Community Project classification, we found a number of cultural markers of drinking: religious communities had a high frequency of anti-drunk driving tweets, Hispanic centers discussed family members drinking, and college towns discussed sexual behavior. This study shows that Twitter can be used to explore the specific sociocultural contexts in which excessive alcohol use occurs within particular regions and communities. These findings can inform more targeted public health messaging and help to better understand cultural determinants of substance abuse.Excessive alcohol use in the US contributes to over 88,000 deaths per year and costs over $250 billion annually. While previous studies have shown that excessive alcohol use can be detected from general patterns of social media engagement, we characterized how drinking-specific language varies across regions and cultures in the US. From a database of 38 billion public tweets, we selected those mentioning “drunk”, found the words and phrases distinctive of drinking posts, and then clustered these into topics and sets of semantically related words. We identified geolocated “drunk” tweets and correlated their language with the prevalence of self-reported excessive alcohol consumption . We then identified linguistic markers associated with excessive drinking in different regions and cultural communities as identified by the American Community Project. “Drunk” tweet frequency (of the 3.3 million geolocated “drunk” tweets) correlated with excessive alcohol consumption at both the county and state levels ( Excessive alcohol consumption, including binge and heavy drinking, is responsible for approximately 88,000 deaths per year in the US, making it the third leading preventable cause of death and a major public health concern ,2,3. BinA key element of public health alcohol interventions is the monitoring of binge and heavy drinking ,8. TradiSocial media analysis provides an untapped resource for monitoring alcohol consumption at the population level. Social media provides autobiographical language expressing thoughts, emotions, and behaviors, and with the application of machine learning models to such language data, individual psychometric assessments  can be Popular social media platforms in the United States include Facebook, Twitter, Instagram, and Snapchat. Twitter is a free social media platform that allows users to send and receive “tweets” . As of the last quarter in 2017, Twitter averaged 330 million monthly active users, creating an estimated 500 million tweets per day ,22,23.Twitter language data have been used to predict alcohol consumption rates at the county level . Curtis In this study, we examined the feasibility of using Twitter to monitor binge drinking with a focus on regional and cultural differences. Specifically, we addressed the following questions: (1) Do Twitter messages expressing language indicative of excessive alcohol use correlate with county-level alcohol consumption rates? (2) What are the contents of these binge drinking-related tweets? (3) What insights can we gain from examining the regional and cultural variations in the language of these tweets? Finally, (4) can linguistic features, such as pronoun use and valence, help to characterize drunk content within communities? Our aim was to examine the efficacy of social media language analysis as an emerging tool for public health monitoring and intervention.N = 2192; [The BRFSS is a population-based cross-sectional phone health survey of US adults aged ≥ 18 years conducted by state health departments with funding and technical assistance provided by the Centers for Disease Control and Prevention. From the BRFSS (2006–2012), we obtained the prevalence of self-reported binge drinking and heavy drinking . ExcessN = 4120), “bar” (N = 2218), and “ale” (N = 2124). Additionally, most keywords did not co-occur within the same tweet. Therefore, we chose to limit our data set to tweets which contained the word “drunk”, to focus on tweets describing the act of drinking itself, rather than its effects .In order to identify tweets related to excessive drinking, we started with 46 drinking-related, unambiguous keywords, such as “hangover”, “tailgate”, “vodka”, and “wasted”, introduced in Cavazos-Rehg et al.  in additN = 1573 counties in our final data set. Summary results are given in A random 10% of Twitter data were collected between June 23, 2009 to April 17, 2014, augmented with a 1% sample from April 17, 2014 to February 5, 2015 ,27. ThisN = 1570 counties (with Aging Farmlands dropped due to the fact insufficient data).In addition to county- and state-level analyses, we also looked at 15 community types identified by the American Communities Project (ACP) . The ACPThe set of English-filtered “drunk” tweets (19.3 million) were used to create a set of 100 “drunk” topics using latent Dirichlet allocation (LDA) . To creaIn their natural form, tweets exist as strings of text which need to be broken up into words whose frequency can be recorded. Early versions of this process (“tokenizing”) used white spaces to split a sentence into words, but we used a more modern version designed to handle social media language data !” to be broken up into “:)” and “!”) . This alIn Step 2, we found the words and word phrases associated with “drunk” tweets. We randomly sampled 1 million random tweets from our “drunk” set and gathered 1 million random “non-drunk” messages  from roughly the same time span. We then calculated a weighted log odds ratio, using an informative Dirichlet prior to estimate the difference in frequency of a word across two corpora  ,34. Thisnot within the top 5000 significantly correlated tokens was removed from the tweet). Using these 19.3 million filtered messages, we created 100 topics using LDA. The LDA topics were estimated using Gibbs sampling [In the third step, we filtered each of the 19.3 million drunk messages to only contain 5000 tokens most associated with “drunk” tweets , the probability of a topic given a token, was derived via the LDA process and P(token|county) was estimated using the relative frequency of the token in the county. These topic frequencies were then used as independent variables in the statistical analysis.Finally, in Step 4, we calculated county-level topic loadings for each of the 100 drunk topics using:We first explored the relationship between Twitter language data identified as “drunk tweets” and excessive drinking by correlating the frequency of drunk tweets  with the BRFSS measure of excessive drinking. We did this at the county, state, and ACP levels .p-value associated with its coefficient in a logistic regression. For both (1) and (2), we applied a Benjamini–Hochberg correction to the significance threshold (p < 0.05) of the false discovery rate for multiple comparisons [We use differential language analysis (DLA) to identify (1) language characterizing counties higher and lower in excessive drinking and (2) drunk language most associated with individual ACP communities . For theparisons .We looked at references to self and other drinking in our drunk tweets. For each county, we calculated the relative frequency of the word “I” (self) in our drunk tweets as well the frequency of “he”, “she”, and “they” (other). We then standardized  both the “self” and “other” scores. Finally, we examined the relationship between sentiment and personal pronouns. To measure personal pronoun use, we used the “personal pronoun” dictionary in the Linguistic Inquiry Word Count (LIWC) which contains 93 distinct pronouns . This mer = 0.26) and state (Pearson’s r = 0.45) level as shown in r = 0.55, p = 0.053), seen in the linear relationship in The frequency with which people tweet the word “drunk”  is moderately correlated with excess drinking at both the county  and low income.d). These communities and topics provide insight into the kind of social contexts in which drinking is discussed.In terms of the ACP, African American communities, besides showing higher use of African American English , also mentioned (night) clubs . CollegeTweeting about drinking may both reference one’s own behaviors (“I am drunk and fell asleep”) as opposed to references to others’ behaviors (“He was drunk and fell down the stairs”). To differentiate these kinds of references, we compared mentions of the word “I”  against mentions of “he”, “she” and “they”  among drinking-related tweets in How does the personal/impersonal nature about tweeting relate to the way drinking is perceived across types of communities? how much they tweet about drinking and how they tweet about drinking. This suggests that Twitter can be used to estimate trends in health behaviors across counties and that a similar methodology can be applied to comorbid conditions such as substance use, depression, and anxiety. In light of our research questions, how much addresses our first question: do Twitter messages expressing language indicative of excessive alcohol use correlate with county-level alcohol consumption rates. The how addresses the remaining three questions: What are the contents of binge drinking-related tweets? Can pronoun use and valence help characterize drunk tweet content? Finally, what insights can we gain from examining the regional and cultural variations in the language of these tweets?In this study, we found that Twitter can be used as a lens into regional and community context around excessive alcohol use. Communities differed both in First, we answer our initial research question in the affirmative: we found that the frequency of “drunk tweeting” accurately captured the trend in the rates of excessive drinking captured by phone surveys administered by the CDC. This finding dovetails with previous studies that showed that simple keyword searches on Twitter predict county-level outcomes  . This fihow communities Tweet about drinking, we found two main dimensions of distinction addressing our research questions on the content of drunk-related tweets and how this content varies regionally and culturally. Topic analyses revealed that drinking may get discussed either in the form of celebratory endorsements of the cultural practice of drinking  or in a cautionary manner . Communities also differed in how much discussions around drinking take the form of personal behaviors (of both oneself and others) versus how much they are referenced impersonally as cultural practices. Between these two dimensions, we found a trend suggesting that disclosures with personal pronouns tended to be more negative, and more impersonal references to cultural norms and practices tended to be more positive. This was mostly the case in College Towns. This suggests that drinking may be perceived positively as a shared practice and negatively “when it happened to me last night”. While the interpretation of these differences of language use around drinking requires additional research to confirm, they represent interesting and potentially important avenues to explore the relevance to public health intervention and messaging to these communities. For example, changing the view of drinking as a social practice towards the negative may prove fruitful, perhaps akin to the successful messaging around smoking which made a “cool” practice a distasteful one.Second, in regard to There are also suggestions of strong regional differences in mentions of family  with Hispanic Centers having a number of significant family-related topics. We note that Hispanic Centers were highest in self-drinking and, therefore, these communities were talking about both family drinking and self-drinking.A notable standout in terms of communities was College Towns, which tweeted about drinking at a much higher frequency than the excessive drinking rate would suggest. We suspect this reflects a younger and more social media friendly population than most of the other ACP communities. Sexual themes were also associated with College Towns. We note that both porn  and significant others  were contained within the same topic. Previous studies have found both substance abuse and pornography consumption as risk factors for male sexual aggression on college campuses .spatially connected regions . The present study differs in that drunk tweets were contextualized across culturally connected regions, namely, the American Communities Project classification—counties grouped via socio-demographic measures as opposed to groups of adjacent counties.Using publicly available Twitter data as a surveillance system has been used across a number of health-related outcomes including excessive drinking . A similThis study was limited in several ways. These analyses were conducted using aggregated Twitter data and regional drinking figures drawn from large-scale surveys conducted by the CDC. These findings should be replicated using individual-level data with linked self-reports and language. Similar studies have shown associations between self-reported behavior and tweet content. In particular, Unger et al.  showed tThere is also the potential for a selection bias. It may be that only certain types of people tweet about being drunk. However, people do tweet a lot about smoking marijuana, even when and where it is illegal . It may Twitter bots can be a source of noise as well as false behaviors and attitudes. Previous studies on social media and e-cigarettes have shown that bots are more likely to reference new e-cigarette products than human Twitter users . One canThe words, phrases, and linguistic themes that emerge from natural language processing are predictive of outcomes of interest, yet care must be taken when interpreting the results, and for final validity, they should be tested in confirmatory studies that test the identified associations as hypotheses.Excessive alcohol use was reflected and detectable in patterns of social media language. Regions and communities differed both in terms of the quantity and content of social media posts about drinking. We found that tweets about being drunk were predictive of different “styles” of excessive drinking behavior across types of communities derived from demographic and socio-economic indicators in the American Communities Project. The particular words, phrases, and linguistic themes most associated with particular regions and communities can provide insight into sociocultural alcohol use contexts and may help to shape more personalized public health messages and interventions to these populations.


Self-harm and drinking are both serious problems in adolescents and many studies presented evidence of their association. However, gender differences in this association are seldom deeply discussed. Our study aimed to evaluate the prevalence of self-harm and explore its association with drinking behaviors by gender and investigate the extent to which the gender differences exist in the association between self-harm and drinking.A total of 32,362 students in grades 7 to 12 in Beijing, China were anonymously surveyed and included in our study using two-stage, stratified probability proportion sampling. Self-harm, drinking behaviors and other basic information were obtained from an anonymous questionnaire. Demographic variables, self-harm and drinking behaviors were analyzed using the Chi-square test and the Gamma test between genders and the gender differences in this association were analyzed by Log-binomial regression.χ2 =0.352, P = 0.553). The prevalence of self-harm in girls decreased with age . Self-harm was associated with drinking behaviors in both boys and girls. The Log-binomial regression demonstrated that girls in the 16–19 years old group were at lower risk of self-harm than girls in the 12–15 years old group while this association was weaker in boys (1.493 vs 1.128). The higher OR for self-harm was found among girls with early drinking experiences compared with boys (2.565 vs 1.863). Girls who had previously drunk (i.e. drunk at least once) (2.211 vs 1.636), were currently drinking (3.400 vs 2.122) and performed binge drinking (6.357 vs 3.924) were at greater risk of self-harm than boys.The total prevalence of self-harm was 13.7% with no significant gender difference (Among high school students, self-harm has a significant positive association with drinking and girls with drinking behaviors are at higher risk of suffering self-harm. Identifying adolescents’ drinking behaviors is of vital importance to self-harm prevention and special attention should be focused on younger girls. Self-harm is defined as a person’s harming of his or her own body on purpose such as self-injury and self-poisoning, irrespective of the motive or the extent of suicidal intent –5. Self-hidden behavior’ whereby less than 13% of the self-harm episodes led to hospital presentation [An ‘iceberg model’ is often raised to describe the situation of suicide, which also reflects self-harm as it is recognized as a ‘entation , 7, 15. entation . Thus, cDrinking is also a serious public health concern in adolescents and the rate of current drinking  among Chinese adolescents ranged from 7.3 to 25.2% and the rate of alcohol ever use ranged between 50.9 and 54.1% –23. AmonChina is now undergoing an epidemiological change in which the main health burden of adolescents is switching from communicable diseases and undernutrition to non-communicable diseases and especially, mental health disorders . During Key school’ . The lesee Fig. . The invThe questionnaire was derived from the 2003 Youth Risk Behavior Surveillance survey in the United States , which w“In the past 12 months, have you ever deliberately committed self-harm ”. Many scales or studies for estimating self-harm adopted similar questions to determine whether the participant had the experience of self-harm [never, once, twice or three times and four times or more.The frequency of self-harm behaviors was asked in the questionnaire as elf-harm , 10, 42,elf-harm . The choHow old were you when you had your first drink of alcohol other than a few sips?” Having one’s first drink before 13 years old was considered as early drinking experience [no alcohol use, non-recent alcohol use (lifetime use but no use in the past month), recent alcohol use (use in the past month but no binge use), and binge drinking . The initial questions for the four categories were as follows, “Have you ever had your first drink other than a few sips?”; “In the past 30 days, on how many days did you have at least one drink containing alcohol?” and “During the past 30 days, on how many days did you have ≥ 5 drinks of alcohol in a row?”Two variables of drinking behaviors were adopted to look into the association between different aspects of drinking behaviors and self-harm. The age of one’s first drinking was asked by “perience . The conperience , 44. Theperience , 33. A rKey schools or Non-Key schools).Four basic demographic variables were controlled in the analysis for the association between self-harm and drinking behaviors, which included gender, age, urban or suburban area and school type . One thousand three hundred thirty-two participants were excluded due to missing information, logic error or unqualified age. The response rate of self-harm was 99.9%  and of drinking behaviors was 98.2% . No differences were found between the excluded participants and the remaining sample in gender and age. The final sample size was 32,362. The number of participants included in our study are shown in Fig. P < 0.05, two-tailed. All data were analyzed using SPSS20.0 for Windows  or Stata 15 SE (Stata Corp LLC).A descriptive analysis was conducted to present the general information of the sample and the association between self-harm and drinking behaviors. The Chi-square test was used to compare the difference between non-ordered groups such as whether the subjects committed self-harm in different gender groups. The Gamma test was used to compare self-harm frequency, which was an ordered variable, between different age groups, different settings and different school types. A Log-binomial regression was conducted to test the differences of the association between self-harm and drinking behaviors by gender. To be prudent, three models for different risk factors of self-harm were established due to the correlations between each other. All analyses were executed by gender. The gender disparity in the association between self-harm and drinking behaviors were evaluated by adding one interaction term of drinking behaviors and gender in each model. Significance level was accepted at The final sample size was 32,362, including 16,103 boys (49.8%), 16,241 urban students (50.2%), 12,065 Key school students (37.3%) and 15,672 12 ~ 15 years old (48.4%).χ2 =0.352, P = 0.553). Totally, the prevalence of self-harm decreased with age in girls  but the prevalence of self-harm in boys seemed to be fluctuating with age . The gender differences existed in both younger and older adolescence, but with different directions, within the adolescents younger than 16, the prevalence of self-harm was higher in girls than boys , while the boys showed higher prevalence than girls when they were in older adolescence . Girls who were in Key schools were less vulnerable to self-harm compared with those in non-Key schools  but the prevalence showed no difference between school types among boys . The prevalence of self-harm in different demographic groups was shown in Table The total prevalence of self-harm was 13.7%. Among all surveyed students, 7.1% reported that they had self-harmed more than once. No significant difference was found in the prevalence of self-harm between genders  and drinking behaviors were more prevalent among boys . The more severe the extent of drinking condition was, the more frequency of self-harm was found in both boys  and girls . Among those girls who were current drinkers and binge drinkers, the prevalence of self-harm was as high as 21.4% and 39.4% respectively .Boys were more likely to have early drinking experience than girls  were at higher risk of self-harm than girls in older adolescence (16–19 years) but this association was not that strong in boys. Participants with early drinking experiences had a higher risk for self-harm compared to those who did not (AOR = 1.854). Higher AOR for self-harm was found among girls with early drinking experiences (2.565 vs 1.863). Both genders with any extent of drinking condition presented higher risk for self-harm. Girls who had previously drunk (i.e. drunk at least once) (2.211 vs 1.636), were currently drinking (3.400 vs 2.122) and binge drinking (6.357 vs 3.924) were of higher risk for self-harm than boys. All the AORs for self-harm mentioned above were shown in Table –15 yearsWe found obvious gender differences in the prevalence of self-harm in our study, in which during the earlier age, the prevalence of self-harm was higher in girls than boys while boys exceed girls in the older age. However, in whole age sample, the gender differences tended to disappear. The trends in self-harm prevalence of boys and girls were similar to Boeninger et al.’s study of suicide in Americans aged 11 ~ 19. In their study, the prevalence of suicide ideation and attempts was higher in girls of earlier age and boys’ prevalence surpassed girls’ in late teenage. Puberty occurred earlier in girls mostly and this period could be a temporary risk factor for girls since some psychological disorders , such asA developmental gap between puberty and brain development was assumed to exist as the prefrontal cortex, the part of one’s brain regulating cognitive control , was undχ-ADH of women resulted in the enhanced vulnerability of women to develop alcohol-related disease [Our results demonstrated that the association between self-harm and drinking behaviors differed between genders. Drinking behaviors in girls seemed to have stronger association with self-harm than boys. Some studies on the metabolism of alcohol in adults manifested that the ability to eliminate intracorporal ethanol was limited in women compared with men. The alcohol dehydrogenase (ADH), which was the enzyme catalyzing the phase I ethanol metabolism reaction, was less active in women than men . Also, t disease . Some ge disease . Ness et disease . Moreove disease . This neChina is a country where drinking is regarded as a kind of traditional culture. People drink when it comes to essential events from traditional festivals to commercial negotiations. For most adolescents, drinking alcohol was sometimes encouraged by their parents for its function of social communication in Chinese culture. Among those who were high school students, the prevalence of alcohol use (at least once) was 51.1% . Gender feeling down, or habit were the two groups of people committed the highest prevalence of self-harm .Additional file 3: Supplementary Table 3. AORs for students in different school types by gender.


Hospital acquired infections (HAI) are the most common complication found in the hospital environment. The aim of the study was to examine whether the use of an antimicrobial coating in high-touch areas in an orthopedic ward could reduce bacterial growth and HAI.Staphylococcus aureus and E. coli.From December 2017 to February 2018, HAI were registered on two orthopedic wards. A second registration was performed from December 2018 to February 2019. On the second occasion, an antimicrobial organosilane coating was applied just before the study period and thereafter weekly on one ward, while the other ward served as a control. Twenty defined high-touch areas on each ward were cultured before treatment and after 1, 2, 4, 8, 12, 14 and 16 weeks. Samples were cultured for aerobic colony counts, Staphylococcus aureus and E. coli were low on both wards. During the first registration period, the incidence of HAI was 22.7% and 20.0% on the non-treated and subsequently treated ward respectively. On the second occasion, after treatment, the incidence was 25.0% and 12.5% (treated ward) respectively (p = 0.0001).The total aerobic colony counts were 47% lower on the treated ward compared with the non-treated ward over the study period (p = 0.02). The colony counts for The use of a long-lasting antimicrobial organosilane coating appears to reduce the bioburden and reduce HAI. Since the incidence of HAI varies substantially over time, longer observation times are needed. Hospital acquired infections (HAI) are the most common complication found in the hospital environment and they result in significant patient morbidity and mortality. Despite careful hygiene routines and the more restrictive use of antibiotics, there is an increasing problem with serious infections and resistance to antibiotics.It has been proposed that an increased environmental bioburden on a ward could result in an increased HAI risk , 2. The The high-touch areas on a hospital ward are of special interest, as they could serve as a contamination source.The aim of the present study was to examine whether the use of an organosilane antimicrobial coating without a quaternary ammonium compound on an orthopedic ward could reduce bacterial growth and HAI. The hypothesis of the study was that, by adding an organosilane compound to the usual cleaning routines, the number of bacteria could be halved.The study was conducted on two 26-bed orthopedic wards in a community hospital in Western Sweden. The wards were each other’s mirror images, with a similar staff and patient mix. The treated ward was an acute orthopedic geriatric (AOG) ward, while an acute orthopedic (AO) ward served as a control. The patients were mainly suffering from fractures, pain problems, infections and threatening ischemic conditions.https://novalent.com/technology/products/). The actual durability of the surface coating depends on type of substrate used for wiping and the level of abrasion the surface would see under normal use between wipings. For high touch surfaces in hospital environments, the manufacturer expects it to last one week at a minimum, and begin to degrade over the following two weeks. High touch areas cleaned with alcohol are therefore recommended for Bioshield® 75 touch up on a weekly basis .The antimicrobial surface coating, Bioshield® 75, that was used is manufactured by Novalent, Greensboro, NC, USA. Bioshield® 75 is an aqueous organosilane. According to the manufacturer, it is a long-acting antimicrobial biostatic surface protectant and it has a mechanical and galvanic mode of action, resulting in the disruption of the cellular function and subsequent cellular death , mostly high-touch areas (18/20), while 2/20 were from floors . The loc2. The bacteria which were cultured were one quantitative culture (skin flora), followed by specific agents, staphylococcus aureus, enterococci and gram negative rods. The samples were grown on blood plates, incubated in a thermostatically controlled room at 36 °C and read after 1 to 2 days, depending on the type of bacteria. The grading was given as no growth (0), sparse growth, 1–10 colonies cfu (colony forming units) (I), moderate growth, 10–100 cfu (II), abundant growth, > 100 cfu (III), or pathogen growth (III). Environmental cultures were repeated after 8, 12, 14 and 16 weeks as a quality control and as a complement to the Petrifilm™ plates.A bacterial environmental culture was taken unannounced on both wards one month before the start of treatment to obtain an idea of the type of bacteria that could be expected. Depending partly on the result of the unannounced environmental culture before treatment and an ocular inspection of the wards, the hospital’s hygiene section decided that both wards would undergo so-called deep cleaning. It was performed the week before the start of treatment on the treated ward and during week 2 on the untreated ward. The environmental cultures were analyzed by the microbiologic laboratory at the hospital. The cultures were obtained using eSwab™ (pink cork) and covered an area of approximately 5 cmE. coli and coliform count plate and the staph express count system, for the enumeration of Staphylococcus aureus. The 3M™ Quick Swab Method and 4 mL of Letheen broth were used to neutralize any residual disinfectant. The area which was sampled was approximately 5 cm2. Using a pipette, 1 mL was drawn from the tube and dispensed onto the Petrifilm for the different plates. The plates were incubated in a heating cabinet at 34–35 °C and read after 1 to 2 days, depending on the type of bacteria, according to the manufacturer’s instructions. The results were given as the number of colonies on each plate. All the cultures were read and calculated by the same biomedical analyst. To obtain the number of cfu/cm2, the number of colonies must be recalculated with respect to surface area and dilution. In this study, the tested area was 5 cm2 and a 4 mL 3M Swab Sampler was used. As an example, if the number of colonies on the plate after incubation was 100, the result would be: 100 CFU × 4 mL = 400 CFU/5 cm2 or 80 CFU/cm2.Based on the results of the bacterial environmental cultures, three different Petrifilm plates were used, the aerobic count plate for the enumeration of aerobic flora, the 2 and < 1 CFU/cm2 for hospital pathogens (e.g. staph aureus) have been suggested as microbiologic benchmarks [Although not generally accepted, limit values have been proposed for a good cleaning standard in healthcare environments. For hand-touch sites, total aerobic colony counts (ACC) of < 2.5 to 5 CFU (colony forming units) per cmnchmarks . The breThe primary variable in the study was the total amount of ACC in CFU. In the power analysis, it was estimated that the total aerobic colony counts would be 50% lower on the treated ward compared with the non-treated ward over the study period. To achieve a power of 80%, 15 cultures are required on each occasion from each ward, if the p-value is set at 0.05. To increase power, 2 × 20 cultures from the two wards were obtained together on every occasion. The total ACC is given as the total amount of CFUs and the number of HAIs is given in percent. The unpaired Student’s t-test was used for the comparison of CFUs between the wards and the non-parametric Mann–Whitney U test was used for the comparison of HAIs. More specifically the percentage of patients with an HAI in each ward was registered every day and a comparison between wards was calculated after the whole study period. In the results the mean percentage of HAI, range and median are reported.E. coli it was 0 and 146 in the treated and untreated ward respectively.The numbers of ACC before treatment and up to 16 weeks are reported in Fig. The first registration of HAI was performed during a three-month period between 1st of December 2017 and 28th of February 2018. The frequency of patients with HAI at the first registration on the AOG ward was 20.0% (0–50.0%), and the corresponding figures for the AO ward were 22.7% (4.5–43.8%), p = 0.5. The second registration of HAI after treatment was made between 3rd of December 2018 and 28th of February 2019. During that period, the frequency of HAI in the AOG was12.5% (0–30%), and the corresponding figures for the AO were 25.0% (4.0–47.6%), p = 0.0001, Table The results of the environmental cultures taken unannounced one month before treatment and in weeks 8, 12, 14 and 16 are reported in Fig. Hygiene failures based on ACC were 69% in treated ward and 81% in non-treated ward.The principal finding in this study was that, by using a long-lasting organosilane coating, the total aerobic colony counts could be reduced and the number of hospital acquired infections decreased.There are a few people who question that there is a link between poor hygiene and the risk of infections –13. TotaSome factors causing the variation in the effect of the long-lasting organosilane are probably cleaning procedures, standard hygiene routines among staff, patient mix and patient overcrowding during the study period. There are no regulatory requirements for checking hygienic standards on hospital wards and reference material is therefore missing. Unfortunately, more systematic bacterial environmental surveys are only performed in cases of serious outbreaks of infections to control disease transmission paths, but normal hygiene standards are only checked by ocular inspections.Benchmarks for cleanliness in high-touch areas have been proposed, but they are not generally accepted , 16. UsiWhite et al. reported that 25% of the surfaces in a five-bed intensive care unit did not meet the hygiene standard . Dancer The question of how to further improve and reduce the bioburden is important. The initial and repeated treatments with the long-lasting organosilane in the high-touch areas were not coordinated with alcohol swiping. Theoretically at least, it could be an advantage to spray organosilane onto a clean surface without remaining biofilm, after which the effect might improve.During the study period, the standard cleaning procedures were followed. Today, the effect of cleaning is not routinely controlled by bacterial cultures or by adenosine triphosphate (ATP) bioluminescence assays. Paying more attention to the work of the cleaning staff, emphasizing the importance of good cleaning procedures and creating an opportunity to give positive and negative feedback could also have a favorable effect , 19.The frequency of HAI in the present study was fairly high, but, when it came to total ACC, it varied substantially on both wards during the study period. The Swedish Association of Local Authorities and Regions (SALAR) is an employers’ organisation and represents and advocates for local governments in Sweden. It performs a point prevalence measurement for HAI every year. In 2019, 9.2% of the patients had an HAI based on a survey of 13,633 patients . The reaOne of the reasons for conducting the study was to investigate whether organosilane treatment could prevent or reduce a calicivirus outbreak. Historically, the hospital has had yearly outbreaks of calicivirus infections during the winter season, which was the reason why the period between December and February was chosen to conduct the present study. However, during both registration periods, for unknown reasons, no such outbreaks were seen.Due to the large variation in both total ACC and HAI during the study period, the promising results of the present study must be interpreted cautiously. Although the number of total ACC decreased significantly, most contact surfaces remained as possible sources of contamination. The property of an ideal future antimicrobial coating must be that treated high-touch areas remain non-contaminated over a longer time period than is possible to achieve using alcohol or peroxide products. Furthermore, they should be non-toxic for humans and not result in the development of resistance among microbes.The initial environmental bacterial culture brought about a need for deep cleaning. For capacity reasons, it could only be implemented on one of the wards before the start of the study and it was followed on the other ward during week two. The deep cleaning probably had a bacteristatic effect for at least a few days . The stuThe use of a long-lasting antimicrobial organosilane coating appears to reduce the bioburden and reduce HAI. Since the incidence of HAI varies substantially over time, longer observation times are needed.Additional file 1. Raw data to Figs.


Neonates often develop transition problems after low-risk birth, precise assessment of which is difficult at primary birth centres. The aim of this study was to assess whether a video triage system can be established without a specially designed communication system between local birth centres and a tertiary neonatal intensive care unit in a region with a population of 700,000. 761 neonates who were referred to a tertiary neonatal intensive care unit were examined. During period 1 (April 2011-August 2015), only a voice call was available for consultations, whereas, during period 2 (September 2015-December 2017), a video call was additionally available. The respiratory condition was assessed based on an established visual assessment tool. A video consultation system was established by connecting personal smartphones at local birth centres with a host computer at a tertiary neonatal intensive care centre. During period 2, video-based triage was performed for 42.4% of 236 consultations at 30 birth centres. Sensitivity and specificity for predicting newborns with critical respiratory dysfunction changed from 0.758 to 0.898 and 0.684 to 0.661, respectively. A video consultation system for ill neonates was established without major instalment costs. Our strategy might improve the transportation system in both high- and low-resource settings. To improve the outcomes of high-risk foetuses, antenatal diagnoses and maternal transportation to higher-level birth centres have been encouraged2. However, for newborns born near term and at term, who require advanced care because of transition failure, abnormal clinical signs are often unnoticed until much later after birth3. Dissemination of an evidence-based program of neonatal cardiopulmonary resuscitation (NCPR) led to improved support for ill newborns worldwide5. However, newborns who cannot establish spontaneous breathing need to be transferred to neonatal intensive care units (NICUs) for advanced care support. Indeed, a large-scale survey in Japan conducted in 2012 showed that 20.5% of 55,331 newborns admitted to NICUs were transferred from primary/secondary birth centres after birth6. Although careful assessments are essential for precise triage decisions, currently, there is no established system for evaluating the conditions of newborns before transportation, potentially leading to diagnostic discordance between the reason for transport and final diagnosis, as reported in paediatric transport7. Our group has previously developed a visual assessment scale that can objectively predict which ill newborns have low respiratory compliance8. Implementing such a scale with a video call–based consultation system might improve the safety of newborns who would require additional support during transportation.Approximately 10% of newborns require some form of special care before spontaneous breathing is established10, expert diagnosis of radiographic images12 and consultations for advanced treatments15. Even in the perinatal field, live images, such as fundoscopy and cardiac ultrasound, are shared between remote institutions to involve local physicians and experts in the field19. Fang and colleagues successfully developed a telemedicine-based consultation system for neonatal resuscitation to improve patient access to expertise in neonatology and reduce unnecessary transfers of newborns to a higher level of care20. While these reports are encouraging, other studies suggested that further improvements are required for the security and reliability of the application and network used22. In addition, few of these systems survived beyond the test phase, presumably because of the maintenance cost and incompatibility with other communication tools/networks23. Given that video calls can now be easily performed using mobile phones, a flexible video call-based consultation network might be established without major installation costs.For adults, telemedicine using a video call has been proposed for better control of chronic diseasesThe aim of this study was to assess whether a consultation system for ill newborns, which incorporated video calls, can be established in primary/secondary birth centres and a tertiary NICU in a region with a population of 700,000 and to determine if this system can increase true-positive triage of clinically unstable newborns without increasing the use of medical resources required for the transportation.Values are shown as mean (SD) unless otherwise specified. The distance of one-way transportation was 17.4 (16.9) km. Twenty-seven (90%) units used the video call within the first 12 months of period 2. Background variables of the 761 newborns were; gestational age, 38.5 (2.1) weeks; birth weight, 2,800 (536) g; and postnatal age at referral, 16.5 (18.1) h. One hundred seventy-five newborns (23.0%) were born via induced delivery . Three hundred eighty-seven newborns (50.9%) were referred during the weekday daytime. Primary clinical problems at referral were respiratory problems (36.9%), gastrointestinal problems (13.5%), preterm birth and/or low birth weight (13.5%), cardiac problems (8.3%), congenital anomalies (5.0%), jaundice (4.7%), hypothermia and signs of being unwell (4.6%), fever and/or infection (4.1%), birth asphyxia (3.4%), hypoglycaemia (3.2%), neurological problems (2.5%) and other disorders .At the time of referral, 319 newborns (41.9%) were estimated to be clinically unstable based on the voice/video call. Subsequently, IPPV and NIPPV were required for 19.7%  and 5.9%  of newborns, respectively, during or <6 h after transportation.All newborns survived and were discharged home. Of 761 newborns, 525 were referred during period 1  in Japan; this accelerated our move to deploy relatively more secure applications. By the end of 2016, the use of video applications with unsecure registration and authentication systems  was terminated, and the system was operated using FaceTime and Zoom. Because a large volume of personal information can be shared on video calls, continuous effort is required to protect the privacy of newborns and their families. Although dissemination of NCPR contributes to the improvement of resuscitation at birth centres, following the initial treatment, difficult decisions remain regarding the handling of unstable newborns. Objective explanation of newborns’ condition to NICU is also difficult, occasionally leading to insufficient/excessive triage of newborns20. Future studies need to assess the benefit of using video calls for all newborns regardless of the type and severity of the primary clinical problem.Even during period 2 of our study, video calls were not mandatory for newborns, whose clinical condition was evident from the voice call. This policy might be relevant considering that, at small birth centres, obstetricians/midwives are able to make video calls only after the clinical condition of the newborn is stabilised. However, with additional hands to assist with video calls during resuscitation, neonatologists at a remote centre may provide a real-time feedback to the birth centre regarding the assessment, intervention and other management of the newbornFirst, findings from the current historical observational study are susceptible to uncontrolled bias. For example, from period 1 to 2, the number of outborn admissions reduced from 9.7 to 8.4 per month, whereas newborns who required IPPV or NIPPV increased from 23.2% to 30.9%. Given that no major change was introduced to the strategy of respiratory support, and that the occupancy rate of intensive cots remained high throughout the study period, it is likely that the intensive cot was predominantly occupied by relatively more unstable newborns, leaving fewer cots for their less critical peers. Our triage system assessed only respiratory disorders, assuming that non-respiratory conditions may be followed by abnormal respiratory patterns when the newborn’s condition deteriorates. Indeed, approximately 20% of newborns, whose primary symptom at referral was non-respiratory problems, required IPPV or NIPPV. Nevertheless, future studies need to investigate whether inclusion of non-respiratory symptoms within the triage system might improve the quality of assessment. Long-term outcomes were not assessed, which needs to be addressed to confirm the benefits of using video call–based triage. The accuracy could not be reviewed because of the difficulty in recording the video call. For the safety reason, we did not use the feedback from video calls to reduce the number of transportations. Therefore, we were unable to assess whether our strategy or video-call itself helped reduce unnecessary transportation and subsequent separation of the mother and newborn.A video call-based consultation system for newborns was successfully developed and operated in a mixed area with urban, rural and remote regions using personal smartphones, which provided obstetricians and midwives at local birth centres with the access to specialists in neonatal medicine. With further improvement of the triage system and video communication tool, our strategy might provide a method of ensuring the safety of ill newborns that involves minimum expense for the installation and maintenance of the hardware, software, network and human resources. Future studies need to assess whether the video consultation system improves the prediction and management of clinically unstable newborns.This retrospective observational study was conducted in compliance with the Declaration of Helsinki under the approval of the Ethics Committee of St. Mary’s Hospital. The Ethics Committee advised that informed consent was unnecessary because only anonymised data obtained for the clinical reason were used in the study. However, informed consent to publish the image in an online open-access publication was obtained from a parent of a newborn infant, who appears in Fig. Between April 2011 and December 2017, 3,097 newborns were admitted to a tertiary NICU at St. Mary’s Hospital . St. Mary’s Hospital includes one of two tertiary NICUs in the area, which comprises a population of 700,000 in the southern half of Fukuoka Prefecture and boundary parts of Saga, Nagasaki, Kumamoto and Ohita Prefectures. Transportation teams are formed in response to the consultation from birth centres according to the estimated severity of newborns .2O/kg)8. Newborns with a respiratory rate >50/min and at least one of the following were considered to be clinically unstable: nasal flaring, see-saw respiration and suprasternal/intercostal retraction. We did not consider non-respiratory symptoms, because respiratory dysfunction is a major reason for neonatal referral and non-respiratory conditions may ultimately show abnormal respiratory patterns when the systemic condition deteriorates.Of 911 newborns transferred to St. Mary’s Hospital during the study period, newborns who were referred 72 h after birth (n = 136), those for whom consultation was performed before birth (n = 9) and those who were unexpectedly delivered at home or in the ambulance (n = 5) were excluded from the analysis, leaving 761 newborns available as the study population  and applications . Step-by-step instructions for each device and application were also provided. For approximately 20% of the heads of birth centres whose mobile phones were incompatible with the aforementioned applications, we advised one of the staff members at the birth centre who owns a personal smartphone to make the video call.Clinical information from the electronic patient records including gestational age, birth weight, sex, delivery mode, Apgar scores, time of consultation, primary clinical problem, distance of transportation, postnatal age, estimation of clinical condition (stable/unstable) and requirement of respiratory support during or <6 h after transportation was collected. The time of initial consultations were categorised into two groups: weekday daytime and others . The primary clinical problem at referral was grouped as follows: respiratory problems ; gastrointestinal problems ; preterm birth and/or low birth weight; cardiac problems ; congenital anomalies; jaundice; hypothermia and signs of being unwell; fever and/or infection; birth asphyxia; hypoglycaemia; neurological problems such as seizures; and other disorders.Background clinical variables were compared between periods 1 and 2 and between the subcohorts of period 2  using the chi-square test, Fisher’s exact test or Student’s t-test with Bonferroni correction. Sensitivity, specificity, true-positive rate, true-negative rate, false-positive rate and false-negative rate of the risk estimation at the time of initial consultations compared to the subsequent requirement for invasive positive-pressure ventilation (IPPV) and non-invasive positive-pressure ventilation (NIPPV) during or <6 h after transportation were obtained for each cohort/subcohort. To assess whether the introduction of the video call system is associated with altered true-positive triage of clinically unstable newborns, univariate and multivariate logistic regression analyses were performed. Findings from the univariate logistic regression analysis were not corrected for multiple comparisons, however, p-values between 0.01 and 0.05 were regarded as chance level.


Malnutrition is extremely common in hospitalized patients. It can lead to various complications and increase mortality. However, it remains poorly recognized and many health care systems do not require nutritional assessment during the hospital stay. This most likely due to lack of awareness and inadequate coordination between health care workers. Physicians can utilize many different methods when performing malnutrition screening, and there is also a lack of global clear-cut recommendations on criteria used to diagnose malnutrition. This article aims to increase malnutrition awareness among health care providers, and provide a guide on screening, diagnosis, and management of malnutrition. There is no absolute agreement among societies on the definition of malnutrition, but frequently used elements in defining malnutrition are deficiencies of energy, protein, and a decrease in fat-free mass . MalnutrThe purpose of this review is to highlight the current literature available on the prevalence, impact on health outcomes, screening, and diagnosis of malnutrition, in addition to providing recommendations on the management of malnutrition and the benefit of nutritional supplements in malnourished patients.Prevalence of malnutrition on admission and the risk of nosocomial malnutritionMalnutrition is a common problem; it includes both undernutrition (underweight) and overnutrition (overweight and obesity). This public health epidemic targets all spectrums of the population; however, the most vulnerable groups are those with low-socioeconomic status, older people, those with acute or chronic illnesses, and expectant mothers .Lim et al. conducted a study to estimate the prevalence of malnutrition on admission in a tertiary hospital in Singapore involving 818 adults. Malnutrition was evident in 29% . In the Malnutrition is often present upon hospital admission. Additionally, 38% of well-nourished inpatients and 69% of malnourished inpatients either develop malnutrition or suffer further deterioration of nutritional status during hospitalization -12. NosoMalnutrition is associated with a significant increase in morbidity and mortality in the hospital settingMalnutrition was found to increase total complications in a study of 709 adults. The incidence of complications in the malnourished group was 27% compared to only 16.8% in the well-nourished group . The samIn addition to a prolonged hospital stay, a study of 837 patients over a 14-month period found that 25% of malnourished subjects required readmission to a healthcare facility after being discharged compared with 11% of the well-nourished group .Malnutrition is also associated with altered immune responses, as many studies showed that malnourished individuals are at a higher risk of developing nosocomial infections. They had a higher incidence of sepsis and intra‐abdominal abscess ,6,16. MaThe occurrence of pressure ulcers is also higher in patients with malnutrition. Studies showed that compared to well‐nourished patients, malnourished patients are 2.1 times more likely to develop decubitus ulcers .Malnutrition can exaggerate age‐related reduced muscle mass, which subsequently leads to deconditioning . In factMalnutrition was also associated with higher hospital costs. Braunschweig et al. conducted a study on 404 adults and found that patients who declined nutritionally, regardless of nutritional status at admission, had significantly higher hospital charges $45,762) compared to those who did not  . Similar,762 compInadequate malnutrition identification and diagnosisFailure to identify and subsequently refer to a dietitian lead to the persistently high prevalence of malnutrition. Several studies have been conducted to investigate malnutrition recognition and documentation in the hospital setting in an attempt to combat malnutrition.Among the studies conducted, Gout et al. reported that only 15% of malnourished patients were correctly identified and documented, and a dietitian was involved in only 45% of malnutrition cases . KellettNutrition screening for hospitalized patientsIn January 2016, the Global Leadership Initiative on Malnutrition (GLIM) reached a consensus to use a two‐step approach for the diagnosis of malnutrition - first screening to identify “at-risk” status, and second assessment for diagnosis and grading the severity of malnutrition [An important step in combating malnutrition is to increase screening in order to identify patients that are malnourished and/or at high risk of developing malnutrition during their hospital course. Usability is key in choosing a screening tool. The Nutrition Risk Screening 2002 (NRS-2002) and Mini Nutritional Assessment (MNA) rely on a few questions, do not require professional nutrition expertise, and do not take a long time to complete, thus, are the preferred screening tools in the healthcare setting and are recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). The following is an overview of both the tools in a healthcare setting .The Hospital: Nutrition Risk Screening 2002NRS-2002 is the preferred tool to detect undernutrition and the risk of developing undernutrition in the hospital setting ,22. It iNRS-2002 actual screening uses two main categories impairment of nutritional status and increases in requirements to identify patients at nutritional risk  is used to detect undernutrition and the risk of developing undernutrition among the older population living in nursing homes and hospitals . The MNAMalnutrition diagnosisGLIM reached a consensus on the criteria to be used when making the diagnosis of malnutrition. It includes three phenotypic criteria , and two etiologic criteria (reduced food intake or assimilation and disease burden). For the diagnosis of malnutrition, a combination of at least one phenotypic criterion and one etiologic criterion is required Table . BecauseManagement of malnutritionA diagnosis of malnutrition should be followed by a consultation with skilled nutrition practitioners like dietitians for comprehensive nutritional assessments if possible. After a complete assessment is performed, nutritional requirements can be calculated and a plan to meet those requirements is initiated.Oral nutritional supplements (ONS) can be used if improvements in energy, protein, and micronutrient intakes are required. An overview of 13 systematic reviews and meta-analyses by Stratton and Elia found that ONS were associated with significant clinical benefits. In the study, the daily intake of ONS was between 250 and 600 kcal/day, the duration of supplementation varied from a short period in hospital (one week) to a prolonged period in the community (up to two years) [The reviews by Stratton and Elia suggest that ONS consistently improved total nutritional intake, with little suppression of food intake . Thus, iMalnutrition is an exceedingly common medical problem with significant effects on morbidity and mortality. Despite its significance, it is underdiagnosed in healthcare systems. In this review, we recommend nutrition screening by either NRS-2002 for hospitalized patients or MNA for the older population living in nursing homes. Positive screening should be followed by GLIM criteria evaluation for diagnosis and severity grading. Consultation of skilled nutrition practitioners is needed when the diagnosis is made for full nutritional evaluation and calorie count. ONS has a positive effect on body weight and decreases mortality and should be considered in the management of malnutrition.