To examine changes in drinking patterns and to assess factors associated with reported increases in frequency of drinking, units consumed and frequency of heavy episodic drinking (HED) during the UK lockdown.Online cross‐sectional survey of 2777 self‐selected UK adults.Thirty percent of participants reported drinking more frequently in lockdown, 16% reported drinking more units per drinking occasion and 14% reported more frequent HED. For men and women, increased frequency of drinking was associated with being less likely to believe alcohol drinking would lead to greater chance of catching COVID‐19  and deterioration in psychological wellbeing ; increased unit consumption was associated with deterioration in financial situation  and physical health . Finally, increases in the frequency of HED were associated with deterioration in psychological wellbeing  and being furloughed . Other gender differences were detected, for example, living with children was associated with an increase in units consumed  and the frequency of HED  for men, but not women.In this self‐selected UK sample, a significant proportion of individuals reported drinking more frequently in lockdown, drinking more units per drinking occasion and more frequent HED. There were consistent predictors of increased consumption across men and women, but other gender differences were detected. This study identifies groups that may require targeted support in future lockdowns. COVID‐19 is a respiratory disease that was declared a global pandemic in March 2020. Many countries introduced social distancing measures in order to control the spread of the virus. In the UK, a national ‘lockdown’ was introduced on 24 March 2020, requiring significant disruption to people's lives. Lockdown had a polarising impact on drinking patterns in the UK , 4, withEarly data have identified some characteristics associated with increases in alcohol consumption in lockdown. Increases in consumption are more likely amongst heavier drinkers , this isIt is important to consider increases in alcohol consumption in relation to drinking patterns as different patterns are associated with different harm profiles , 14, 16.It is particularly important to examine the socio‐demographic characteristics associated with each of these factors as we may expect to see socio‐demographic differences in patterns of consumption and subsequent alcohol‐related harms. Being male , 18 and Lockdown has also caused stress about work, health, finances and caring responsibilities . Stress Previous research has outlined interactions between alcohol consumption and other behaviours, specifically smoking  and exerIn order to inform public health messaging and the provision of support for alcohol reduction during future waves of COVID‐19 in the UK, we examine which socio‐demographic, environmental, health factors and other behaviours are associated with increases in the frequency of drinking occasions, increases in units consumed on drinking occasions and the frequency of HED occasions. As we know that there is a divergence in changes to drinking in lockdown between men and women  and diffWhat proportion of adult drinkers have increased, maintained and decreased the frequency of their alcohol consumption, units consumed per drinking occasion and the frequency of heavy drinking occasions during the lockdown in the UK?increases in the frequency of drinking in lockdown?increases in units consumed per drinking occasion in lockdown?increases in the frequency of HED in lockdown?What socio‐demographic, environmental, health factors and other behaviours are associated with:This study aims to answer the following research questions among adult men and women in the UK who drink separately:https://osf.io/vmc5u/. We analyse cross‐sectional data from the baseline wave of an ongoing retrospective longitudinal online survey of UK adults—the HEalth BEhaviours during the COVID‐19 pandemic (HEBECO) study. The eligibility criteria were that participants be aged 18 or older, be fluent in English and be willing to complete follow‐up surveys online. More information about the survey and an overview of the questions is available online (https://osf.io/sbgru/).The analysis plan was pre‐registered and is available at https://osf.io/sbgru/.Our self‐selected sample of UK‐based adults (18+) completed the baseline survey of the HEBECO study between 30 April 2020 (initiation of recruitment) and 14 June 2020 (inclusive), when the strictest lockdown policies were relaxed . Recruitment was online and through a number of channels, including unpaid posts and paid advertisements on Facebook, Google and Reddit and through relevant mailing lists of UK universities, charities, local government, as well as through the networks of Cancer Research UK and Public Health England. To account for the non‐random nature of the sample, all data are weighted to the proportions of sex, age, ethnicity, education and country of living obtained from the Office for National Statistics . For fulA summary of the measures is provided below, but please see Rather than relying on potentially arbitrary dates for the start of the COVID‐19 pandemic, participants were asked to identify the moment when COVID‐19 started to impact on their lives, and use that moment as an anchor for ‘before’ and ‘since’ COVID‐19 throughout the survey (referred to as ‘pre’/‘post’‐COVID‐19 throughout). Those who reported that COVID‐19 had not impacted them were asked to consider 21 March 2020 as the time since COVID‐19, in line with the UK government's introduction of strict social distancing measures and the closure of pubs.All outcome variables are derived from the Alcohol Use Disorders Identification Test‐Concise (AUDIT‐C), a three‐item questionnaire asking about the frequency of drinking, average units consumed on a drinking occasion and frequency of HED. As outlined above, participants responded to two sets of the AUDIT‐C questions, one in reference to the 12 months pre COVID‐19 and the second asking the same information for the period following the self‐assigned date where they believed COVID‐19 started to affect them. The three outcome variables were increase in the frequency of drinking , increase in units consumed per drinking occasion  and increase in the frequency of HED . An increase was defined as a higher score on the relevant AUDIT‐C item post‐COVID‐19.The following socio‐demographic characteristics were assessed: age (continuous in years 18–110+), ethnicity  and education . Two measures of baseline drinking characteristics were included: alcohol reduction attempts in the last 12 months (continuous between 0 and 14+) and pre‐COVID‐19 AUDIT‐C score (continuous between 0 and 12). Six variables were focused on lockdown living situation: living alone , living with children , keyworker , furloughed , working from home  and overall experience of social distancing (continuous 0–100). Changes to lifestyle as a result of COVID‐19 were examined over six domains: living conditions, financial situation, psychological wellbeing, social relationships, family relationships and physical health. Participants rated each of these areas of their life pre‐ and post‐COVID‐19 on a scale of ‘1 (poor)’ to ‘5 (excellent)’. Change scores were calculated where negative score indicated an improvement. Variance Inflation Factors (VIF) were checked for multicollinearity, and no issues detected (VIFs <1.7). Health concerns were measured by two variables: number of existing health conditions (continuous between 0 and 11) and perceived alcohol risk, which measured participants beliefs that alcohol would put them at greater risk of catching or having worse outcomes from COVID‐19 (continuous 1–100); finally, smoking status  and change in the frequency of physical activity .https://osf.io/pnrhq/).The protocol and analysis plan were pre‐registered on Open Science Framework (spss on full cases (missing data described in the results). All analyses were stratified by gender. All data were weighted to the proportions of sex, age, ethnicity, education and country of living obtained from the Office for National Statistics [Analyses were conducted using atistics  to accouDescriptive statistics were calculated to characterise the sample in terms of socio‐demographic characteristics. The proportions of those who reported increases, decreases and no change in the frequency of drinking occasions, units consumed and the frequency of HED were calculated.Logistic regression models were conducted to examine associations of: (i) drinking more frequently post‐lockdown (vs. drinking less or the same); (ii) drinking more units per occasion post‐lockdown (vs. less or the same); and (iii) more frequent HED post‐lockdown (vs. less or the same) with: socio‐demographic factors, pre‐COVID‐19 drinking characteristics, lockdown living situation, changes to lifestyle, health concerns and other behaviours.https://projectredcap.org/) is a secure, web‐based software platform designed to support data capture for research studies, providing: (i) an intuitive interface for validated data capture; (ii) audit trails for tracking data manipulation and export procedures; (iii) automated export procedures for seamless data downloads to common statistical packages; and (iv) procedures for data integration and interoperability with external sources.HEBECO study data were collected and managed using REDCap electronic data capture tools hosted at University College London , 35. REDn = 2777, weighted %: 52% female, 48% male). Table A total of 2994 participants responded to this survey, 10 participants reporting that they were non‐binary and seven who preferred not to say are excluded from this analysis due to the gender stratification and low numbers in these categories. This leaves a sample of 2977 participants . Men were more likely than women to drink both more units (19% vs. 14%) and less units (25% vs. 20%). Deterioration in financial circumstances and physical health were associated with increased unit consumption for both men and women. Amongst women, increases in units consumed per drinking occasion were associated with having more alcohol reduction attempts in the last year. Whereas, amongst men, increases in units consumed per drinking occasion were associated with living with children, deterioration in psychological wellbeing and believing that alcohol was unlikely to put them at greater risk of getting or not recovering from COVID‐19.Finally, the majority (61%) reported no change in the frequency of HED occasions pre‐ and post‐COVID‐19. For both women and men, being furloughed and deterioration in psychological wellbeing were associated with increases in the frequency of HED. Amongst women, increases in the frequency of HED were also associated with being younger, last‐year alcohol reduction attempts and living alone. Amongst men, increases in the frequency of HED were associated with living with children, having a more negative experience of social distancing, deterioration in financial circumstances, improvements in social relationships and being a current smoker.This study has important implications in terms of highlighting groups that may need targeted support for alcohol reduction to counteract an increase in drinking during future COVID‐19‐related lockdowns in the UK. There were some consistencies in correlates of increased drinking amongst men and women. Deterioration in psychological wellbeing was one of the most consistent predictors of increases in the frequency of drinking and HED for both men and women. Being furloughed was also a consistent predictor of increases in HED across men and women. This is in line with other literature showing that alcohol consumption increases in economic downturns where unemployment is higher, partly due to increases in leisure time, amongst those who are unemployed . These fIn line with other studies , there iDeterioration in financial circumstances was consistently associated with increases in all of the drinking measures for men, but only with units consumed for women. Previous research examining the relationships between economic downturns and alcohol consumption also found men were more likely to drink heavily in response to recessions and increased unemployment . This maA key strength of this study was the variety of measures collected, permitting a detailed analysis of a broad range of potential factors predicting drinking patterns during the start of COVID‐19‐related lockdown in the UK. Furthermore, this survey allowed participants to select the date that they felt COVID‐19 started to affect them, this offers a strength over other studies that rely on using the date lockdown began to signal ‘before’ and ‘after’, in a period of ongoing change. Although the full lockdown began on 24 March, there was advice and knowledge of the virus and its effects in the months before this which may have affected drinking behaviour. For example, pubs in England were closed on 20 March and people were encouraged to work from home or socially distance from 16 March. Furthermore, the collection of data while lockdown was ongoing limits the potential for recall bias, which might be present in retrospective studies. However, this study was not without limitations. As pre‐COVID‐19 drinking is only measured post‐COVID‐19, it may be susceptible to recall bias. The sample was self rather than randomly selected, which reduces the generalisability of these results. Specifically, the results may be more reflective of people who complete online surveys about health than the general population in the UK. Black, Asian and Minority Ethnic people in particular were underrepresented in the study sample, this means that ethnicity was treated as white versus minority ethnic groups. Grouping all Black, Asian and Minority Ethnic participants together in this way does not allow examination of differences between different ethnicities and cultures, which limits the generalisability of these conclusions further. Finally, here we use a non‐validated measure of self‐assessed changes in psychological wellbeing, which may have been interpreted differently by participants.Thirty percent of participants reported drinking more frequently in lockdown, 16% reported drinking more units per drinking occasion and 14% reported more frequent heavy episodic drinking. Men were more likely than women to drink both more and fewer units per drinking occasion, whereas shifts in other drinking patterns were roughly equivalent. There were some correlates of increased drinking patterns that were consistent across men and women; being less likely to believe alcohol drinking would lead to greater chance of catching COVID‐19 or worse outcomes, and deterioration in psychological wellbeing was consistently associated with increased frequency of drinking. Deterioration in financial situation and physical health were associated with increased unit consumption and deterioration in psychological wellbeing and being furloughed consistently predicted increases in heavy episodic drinking. Other gender differences were detected in the correlates of increased drinking. This study identifies groups that may require targeted support in the event of future lockdowns. However, this sample was predominantly white and further research examining the effect of lockdown on drinking amongst a more representative sample of UK drinkers would be of value.MO, CG, JB, DK, AH and LS declare no conflicts of interest. JB and LS have received unrestricted research grants from Pfizer related to smoking cessation.The study has been approved by UCL Research Ethics Committee at the UCL Division of Psychology and Language Sciences (CEHP/2020/579) as part of the larger program ‘The optimisation and implementation of interventions to change behaviours related to health and the environment’. All participants provided fully informed consent. The study is General Data Protection Regulation compliant.Appendix S1. Full description of measures.Appendix S2. Unweighted associations.Click here for additional data file.


Demand for virtual visits  is increasing due to the COVID-19 pandemic. There may be additional benefits of virtual visits as they appear to be convenient and potentially cost-saving to patients. People receiving maintenance hemodialysis require ongoing care from their nephrologist and may benefit from virtual visits; however, the optimal model for a virtual kidney clinic is unknown.To codesign and assess the feasibility of a virtual (video) kidney clinic model with clinic staff, nephrologists, and patients receiving maintenance hemodialysis, to be used for routine follow-up visits.Mixed-methods study.Two main kidney clinics in central Calgary, Alberta.Adults with kidney failure receiving maintenance hemodialysis, nephrologists, and clinic staff.First, we individually interviewed clinic staff and nephrologists to assess the needs of the clinic to deliver virtual visits. Then, we used participant observation with patients and nephrologists to codesign the virtual visit model. Finally, we used structured surveys to evaluate the patients’ and nephrologists’ experiences when using the virtual model.Eight video visits  were scheduled between October 2019 and February 2020 and 7 were successfully completed. Among completed visits, all participants reported high satisfaction with the service, were willing to use it again, and would recommend it to others. Three main themes were identified with respect to factors influencing visit success: IT infrastructure, administration, and process.Patients received training on how to use the videoconference platform by the PhD student, whom also set up the technical components of the visit for the nephrologist. This may have overestimated the feasibility of virtual visits if this level of support is not available in future. Second, interviews were not audio-recorded and thematic analysis relied on field notes.Video visits for routine follow-up care between people receiving hemodialysis and nephrologists were acceptable to patients and nephrologists. Video visits appear to be feasible if clinics are equipped with appropriate equipment and IT infrastructure, physicians are remunerated appropriately, and patients receive training on how to use software as needed. While video visit technology today is fairly straightforward, integrating video visits into existing health care systems is challenging. Ensuring the technology is easy to use and functional3 is a prerequisite for successful implementation of video visits; however, implementation into a clinical setting presents other challenges. Video visit adoption in practices requires significant change management and ongoing guidance, training, troubleshooting, and support,4 that accounts for the unique aspects of each practice setting.5The adoption of virtual care is expanding due to the COVID-19 pandemic. There are many forms and applications of virtual care. Video visits are clinical appointments occurring between a patient and health care provider by video, an alternative to in-person or telephone. While video visits are not appropriate in every circumstance, early reports suggest that overall, they may offer some benefits6 However, in addition to their potential benefits, video visits also have potential risks, such as those related to a limited physical assessment or potential disruption to the patient-provider relationhip,7 particularly if technology is a barrier to effective communication.8 Therefore, broad implementation of video visits will require thorough evaluation of benefits and risks to prevent unintended consequences.People that receive maintenance hemodialysis frequently meet with a nephrologist for routine follow-up visits. Virtual visits may be appropriate for many of these encounters, as physical assessments are not always required. Our earlier work found that patients, nurses, and nephrologists were interested in trying video visits and reported several theoretical benefits that this mode of care delivery may offer.We did this present study to (1) design and test a virtual (video) kidney clinic model for routine visits between patients on hemodialysis and their nephrologist and (2) identify the barriers and facilitators of video visits that may guide future implementation.We focused our study at two major kidney clinics in central Calgary, Canada, which is operated by the provincial health authority, Alberta Health Services (AHS). In addition to meeting with nephrologists during dialysis rounds, patients have routine visits 3 to 4 times a year with their primary nephrologist at the kidney clinic. These visits are typically offered in person and occasionally through the provincial Telehealth platform, which still requires patients to travel to a registered health facility to attend the visit. At the time of this study, interest in offering video visits where patients attend from their own homes through simple videoconferencing software was increasing. The Microsoft Skype for Business platform was available through AHS as a video visit platform allowing patients to visit from their own homes, which was scheduled through the AHS Outlook personal information manager. We planned to use Skype for Business software for this study.Table S1) to identify the logistical requirements needed for video visits in this particular context (readiness assessment). Second, we assessed the feasibility of video visits and iteratively redesigned the virtual visit model through observing actual clinical encounters and a structured survey completed by nephrologists and patients (feasibility pilot study). The intention of this work was to iteratively trial and redesign the virtual visit model until no new feasibility considerations were identified. Therefore, we did not formally calculate a sample size, but recruited until participant and feedback saturation was met. We did not audio record interviews or code transcripts; however, saturation was determined through comprehensive field notes. The University of Calgary research ethics board approved this study, and the study was in adherence to the Declaration of Helsinki. All participants provided informed consent.We iteratively designed a video visit model using a mixed methods approach. The main objective was to assess patient and nephrologist readiness and identify process considerations through trial and error and observation . Full meFigure S1). Two staff members from the clinic were purposively sampled to participate due to their role in managing clinical workflow.Nephrologists holding clinics for maintenance hemodialysis patients at the kidney clinic were approached to participate in the readiness interview  if permission was granted.We invited nephrologists that participated in the readiness assessment to participate in the pilot study. We supplemented this sample with additional nephrologists to increase the diversity of the study sample. Patients that had previously been interviewedSupplemental Item S1 and presented in 10 Comprehensive field notes were collected during each encounter  to capture what factors facilitated or hindered video visits. These field notes were classified into different themes and any new themes identified through subsequent visits were added. Patient-provider pairs were recruited until no new themes were found.Full details of the video visit intervention are described in Supplemental Item S1 and Figure S1 for recruitment details). Four (57%) were female, and the median number of years in practice was 14. Six of the 7 nephrologists were remunerated by way of salary and 1 by fee-for-service. Two members of the booking team were purposively recruited to participate in the study. Both agreed to participate; 1 was female and 1 was male.Seven nephrologists participated in the readiness assessment . Seven visits involving 7 patients and 6 nephrologists were successfully completed using the Zoom for Healthcare platform.Supplemental Tables S2 and S3). Overall, participants reported similar quality between video and in-person visits across most domains. All nephrologists agreed that in-person visits allowed for a better physical assessment but indicated that such assessments are not always required. Some patients noted that if training had not been available, they might have had difficulty using the technology. Patients and nephrologists agreed a video visit was more personal than a telephone call, and some nephrologists additionally noted that some degree of physical assessment was possible through video. All participants would recommend video visits to their peers, under appropriate circumstances. While video visits were convenient and cost-effective for patients, all agreed that in-person visits would still be needed on occasion either for a physical assessment or simply to maintain the patient-provider relationship.All of the nephrologists (n = 6) and patients (n = 7) that participated in a successful video visit were interviewed about their experience and asked to complete a survey  integration; among others may help prepare clinics for implementation. Provincial and national administration and policies are unclear. A national virtual care taskforce in Canada has proposed 19 recommendations to move forward with virtual care,21 which include national standards, safety and quality framework, remuneration, education and curriculum for providers, and licensing, among others. To ensure consistent, safe, and high-quality virtual care, future efforts that focus on the administration, governance, and health information systems of virtual care are needed.To move forward with virtual care, clinics need to determine the changes needed to implement virtual care, which will be specific to each setting. ChecklistsThe findings from our study provide practical considerations for the future implementation of video visits in Alberta. In brief, clinics should be equipped with sufficient IT infrastructure that enables high-quality video visits. Patients should receive training on an as-needed basis and have an option to borrow a tablet if they do not have access to 1 of their own. Clinic processes will need to be adapted to allow for the integration of video visits in practice, such as scheduling, greeting patient upon arrival, and collecting information to prepare the chart for the nephrologist for the visit. Where clinical data are not available during the visit (such as in an EMR system), designing a process for dialysis nurses and clinic staff to communicate and share information before the visit will be helpful, particularly for home dialysis patients that often bring hard copy material to the appointment.These findings should be interpreted within the limitations of the study. First, our work focused on the episodic success of video visits and did not follow up patients to explore efficacy outcomes. It is possible that even though virtual visits often save patients’ travel-related time and costs, they may not be clinically appropriate in all circumstances and could lead to negative effects. Second, the PhD student (M.L.) was involved in the intervention delivery. She trained patients on how to use the platform and participated in visit activities the day of the appointment . While this offered important insight through participant observation, involving clinic staff in this process may have yielded helpful information to better understand how the clinic process needs to adapt to accommodate for these new duties. Third, our work aimed to identify clinic readiness for video visit implementation and factors influencing the success of virtual visits. Both these parameters are context specific, and our findings may not apply to other settings. Finally, the pilot study occurred before the COVID-19 pandemic and it is possible that several of the recommendations based on our findings have been already addressed.Video visits for follow-up routine encounters between nephrologists and people on hemodialysis are feasible and acceptable, given sufficient technology and patient training are available. Virtual visits should be integrated into the health care system and used to complement in-person care when appropriate. Scheduling processes in the clinic will need to be updated to accommodate video visits. Ownership of duties related to video visit setup, patient training, and supporting nephrologists with any technical issues needs to be clarified, as does governance and medical-legal policies. Leveraging the EMR and increasing communication between dialysis site staff and nephrologists may help improve the effectiveness of video visits.Click here for additional data file.Supplemental material, sj-pdf-1-cjk-10.1177_20543581211008698 for Video Visits Using the Zoom for Healthcare Platform for People Receiving Maintenance Hemodialysis and Nephrologists: A Feasibility Study in Alberta, Canada by Meaghan Lunney, Chandra Thomas, Doreen Rabi, Aminu K. Bello and Marcello Tonelli in Canadian Journal of Kidney Health and Disease


Digital video forensics plays a vital role in judicial forensics, media reports, e-commerce, finance, and public security. Although many methods have been developed, there is currently no efficient solution to real-life videos with illumination noises and jitter noises. To solve this issue, we propose a detection method that adapts to brightness and jitter for video inter-frame forgery. For videos with severe brightness changes, we relax the brightness constancy constraint and adopt intensity normalization to propose a new optical flow algorithm. For videos with large jitter noises, we introduce motion entropy to detect the jitter and extract the stable feature of texture changes fraction for double-checking. Experimental results show that, compared with previous algorithms, the proposed method is more accurate and robust for videos with significant brightness variance or videos with heavy jitter on public benchmark datasets. The rapid development and spread of low-cost and easy-to-use video editing software, such as Adobe Premiere, Photoshop, and Lightworks, makes it easier to tamper with digital video without efforts. Inter-frame forgery happens quite often. It includes inserting frames into a video sequence or removing frames from a video sequence . These tA considerable amount of effort has been devoted to inter-frame forgery detection. Most of these approaches are based on the successful extraction of some characteristics of the video. For example, some recent works detected tampered video by calculating the optical flow between frames ,3,4,5,6.For the forgery detection of the videos with noises, a few methods have been developed, including low-rank theory for video with blur noise , the coaWe propose a novel framework that not only takes into account both brightness and jitter noises, but also considers the lowest motion video. To deal with considerable illumination noise, we introduce the relaxing brightness constancy assumption  and deveThe rest of this paper is organized as follows. In Most of the prior works detected forgeries based on the analysis of correlations between frames, which relies on features extracted from videos. As noises in videos could significantly affect feature extraction and correlation analysis, we classify the existing methods into two categories: methods without considering noises and methods considering noises.In terms of the type of features, previous methods could be divided into two categories: image-features-based and video-features-based. Methods in the first category usually extracted image features of each frame, such as texture features , color cAlthough these methods have been validated on videos from public data sets, they generally did not consider noises. They could probably generate incorrect results on real-life videos containing various noises. For example, the performance of methods ,4,19 decTo address the issue of feature extraction in the blurry video, Lin et al.  adopted Illumination noises and jitter noises have side effects on the detection result. However, few works take both brightness and jitter noises into account at the same time. Although  has consWhen a moving object in the three-dimensional world is projected onto a two-dimensional plane, optical flow (OF) is the relative displacement of the pixels of the image pairs . Specifit-th frame is dt, then Equation (1) can be expanded by the first-order Taylor seriesHorn and Schunck (H&S) method  is a clax, y, and t directions, respectively. Combining Equations (1) and (2), we can get the EquationLet According to the definition of speed Equation u and v. An equation cannot determine a unique solution, so a new condition Equation (4) is the re image , which iE is relatively small, so the corresponding values of the grayscale change of The H&S algorithm converts the The above classical umptions .Gennert et al.  relaxed Combining Equations (2) and (8), we can obtainLet The enhanced We propose a novel framework to overcome the brightness and jitter noises in video inter-frame tampering detection. As illustrated in The consistency of the of video ,5,6. BasStep 1: Due to the brightness variations, the intensity of images should be normalized  before an filter .i-th video frame, which is calculated by Equation (13)N is the video frames number.Step 2: Based on the enhanced w is the width of the sliding window, The average ME to perceive the consistency of video motion direction, which can sense video jitter.Step 3: Jitter frame pixels have small amplitude movements in the same motion direction , which hME can be calculated as follows: 1. Use the frame difference method [Shi-Tomasi corner calculation method [e method  to calcun method  to obtaiC is the variable counter for peak point. Algorithm 1: Reduce the impact of illumination changesS.Output: store position of suspicious tampering point in C = 0 //C is the variable counter for peak pointthenend if7:  end for8: 11:   (a) return FORGED VIDEOelse run Algorithm 214:  end if15:  else return ORIGINAL VIDEO16:end if17:Step 4: We judge whether the video is tampered with based on the continuity of the video frame feature sequence. Video jitter refers to a small motion in the same motion direction of the video frame. Since the enhanced x-direction, y-direction, and Step 1: We compute the gradient structure information of the Step 2: We perform morphological operations on the binary mask Step 3: We calculate the texture changes fraction Algorithm 2: Detection algorithm based on video texture changes fractionend if7:    end for8: 10:   (a) return FORGED VIDEOelse return ORIGINAL VIDEO12:end if13:Due to the picture continuity of video frames, the content similarity between adjacent frames is substantial, and the value Algorithm 3: judgment of video tamperInput:suspicious tampering point set in S, the variable counter for peak point Celse:6:      end if10:         end if11:      end for12:   end for13: The exiting common video tamper operation can cause different tampering point on the extracted video feature sequence. More concretely, the deletion forgery causes a sudden peak in the feature sequence, and the insertion forgery causes two pikes. When I is multiplied by a factor M, and a constant To evaluate the enhanced  dataset . The datWe estimate the or (AAE)  and the or (AAE) . The AAEThe test results of different The evaluation result of the HS+IN  algorithm is shown in The evaluation result of the HS+BR (brightness relaxing factor) algorithm is shown in Combining IN and BR, we propose the enhanced We conduct extensive experiments in diverse and realistic forensic setups to evaluate the performance of the proposed detection framework in this section. The experimental data is introduced first. Then the setup of parameters and evaluation standards are suggested. Finally, we present the experimental results and comparison analysis with four existing state-of-art algorithms to detect accuracy and robustness.To evaluate the detection effect of the proposed method, we performed experiments on three public datasets, namely the SULFA Video Library  , the CDN(1) The video library includes videos of different motion levels, including slow motion, medium motion, and high motion.(2) The video library contains videos of different brightness intensities and different scenes (indoors and outdoors).(3) The video library includes a variety of mobile phone videos, as well as camera videos, which were taken with or without a tripod.THR_E respectively. Based on the results of We download 150 videos with noticeable brightness changes from the video website and adopt the metrics of ACE forensics  to deteraptively , and theTo evaluate the performance of the detection algorithm, we use the error metrics of Based on the detection result of r between frame 50th and 94th is 1.0046, which shows frame pair  is very similar. Therefore, the peak pair  is the location of video insertion forgery.r has prominent peaks at frame deletion point 56. Because the motion entropy r between frame 44th and 58th is 0.9844. Therefore, the peak pair  is the location of video insertion forgery.According to the performance evaluation criteria of the proposed algorithm, a comparison is made between the proposed algorithm in the paper and the state-of-the-art different video tamper detection algorithms ,6,9,37. As compared to methods reported in ,6,9,37, For ,6, the dood. For , the detood. For , the tesPrior video tampering detection methods are not suitable for videos with dynamic brightness changes and jittery videos. The detection method  based onTo reduce the effect of illumination noises and jitter noises, we utilize a robust optical flow detection method based on relaxing brightness consistency assumption and intensity normalization, which can reduce the influence of significant brightness change and small brightness change, respectively. At the same time, we use motion entropy In this paper, we have proposed a novel detection framework for inter-frame forgery in real-life video with illumination noises and jitter noises. Firstly, for videos with severe brightness changes, we relax brightness constancy constraint and adopt intensity normalization to propose a new optical flow algorithm in Algorithm 1. Secondly, for videos with large jitter noises, we introduce motion entropy to detect the jitter and extract the stable feature of texture changes fraction for double-checking in Algorithm 2. Finally, we make the judgment of video tamper in Algorithm 3. The proposed method was validated by extensive experimentation in diverse and realistic forensic setups. The obtained results indicate that the proposed method is entirely accurate and robust. It can detect video single-forgery or multi-forgeries with an average accuracy of 89%, including frame deletion, frame insertion, frame replacement, and frame copy-move. Furthermore, the proposed method is not sensitive to the jitter noises, illumination noises, or the motion level of the video. In the future, it would be beneficial to explore the suitability of some other real-life video scenes, such as blurred video and still video.


This work considers the design and practical implementation of JSCC-Cast, a comprehensive analog video encoding and transmission system requiring a reduced amount of digital metadata. Suitable applications for JSCC-Cast are multicast transmissions over time-varying channels and Internet of Things wireless connectivity of end devices having severe constraints on their computational capabilities. The proposed system exhibits a similar image quality compared to existing analog and hybrid encoding alternatives such as Softcast. Its design is based on the use of linear transforms that exploit the spatial and temporal redundancy and the analog encoding of the transformed coefficients with different protection levels depending on their relevance. JSCC-Cast is compared to Softcast, which is considered the benchmark for analog and hybrid video coding, and with an all-digital H.265-based encoder. The results show that, depending on the scenario and considering image quality metrics such as the structural similarity index measure, the peak signal-to-noise ratio, and the perceived quality of the video, JSCC-Cast exhibits a performance close to that of Softcast but with less metadata and not requiring a feedback channel in order to track channel variations. Moreover, in some circumstances, the JSCC-Cast obtains a perceived quality for the frames comparable to those displayed by the digital one. Analog encoding and transmission systems are capable of adapting to the channel conditions without any prior knowledge. By contrast, all-digital video systems require either certain channel information provided by a feedback channel or the transmission of a large amount of redundancy in order to ensure successful reception regardless of the channel conditions.All-digital video systems guarantee error-free transmissions above a certain channel quality, keeping fixed the received video quality, hence, wasting bandwidth due to redundancy. In case the channel quality is not sufficient to guarantee an error-free transmission, the video quality will be significantly degraded, and even temporal drops in the video sequence will occur due to the loss of complete video frames.In a wireless-multicast scenario, an all-digital system has to target the worst of the receivers or broadcast several video layers simultaneously. The required redundancy to combat low-quality channels will penalize those receivers with high-quality channels. Notice that in the case of multiple video layers, the bandwidth will also be reduced. By contrast, analog encoding and transmission video systems send exactly the same information to all the receivers regardless of their channel status. The quality of the image received will depend on the channel quality experienced by each receiver.Video visualization on different types of fixed and mobile devices is growing every year . This maVideo system research and developmental studies are currently focused on digital systems due to their great adaptability, although there are a number of situations in which analog encoding and transmission video systems can outperform their all-digital equivalents:In summary, analog encoding and transmission video systems are simpler than their all-digital equivalents since the transmission is the same for all receivers, and no feedback channel is required.This paper investigates a functional scheme in order to reduce the bandwidth required by raw video transmission over channels with limited capacity while keeping an acceptable video quality level. In order to address this objective, JSCC-Cast is proposed, which is a low-complexity scheme for encoding analog video with negligible digital metadata and with special emphasis on its suitability for Internet of things (IoT) systems.JSCC-Cast extends our previous work on coding and transmission of still images based on analog joint source channel coding (AJSCC) techniques . In ordeJSCC-Cast, a comprehensive analog video encoding and transmission system, is proposed which requires a minimum amount of metadata to reconstruct the video. Since the corruption of metadata during the transmission makes video decoding impossible, it is crucial to properly protect such metadata, resulting in a reduction in the available bandwidth for video data. JSCC-Cast is also designed to provide a video quality comparable to other similar alternatives with high compression levels and minimum computational cost and delay.A detailed analysis and design of the different components of JSCC-Cast is performed. This analysis allows us to evaluate the impact of several design parameters on the system performance and the quality of the resulting decoded video.The contributions of this work can be summarized as follows:The following is a review of the main existing approaches relative to video encoding and transmission.Although all-digital video systems usually offer the best transmission characteristics for any media due to the great research progress over the last decades, the analog encoding and transmission of video in certain scenarios offers important advantages.One such scenario is wireless multicast transmission in which the receivers have different channel quality levels. In this case, digital systems adapt their transmission rate to the worst receiver, thus penalizing the receivers that could obtain higher quality. Video transmission over time-variant channels is also problematic for all-digital systems since they have to constantly adapt their transmission rates. This imposes severe requirements on the video encoder, especially if it has to operate in real time. Notice that wireless digital transmission systems rely on strategies such as adaptive modulation and coding to match the transmission rate relative to the channel capacity. This requires a feedback link to inform the transmitter about the channel quality observed at the receiver. Although this approach performs well in quasi-static scenarios, video transmission over highly time-variant channels still remains a challenge since the throughput noticeably deviates from the channel capacity .There are proposals in the literature that seek to mitigate this problem by transmitting digital video sequences with different bandwidth ratios and encoding them in several video layers ,7: A basHybrid video systems combine both analog and digital strategies in order to obtain simpler schemes. Hybrid approaches benefit from the advantages of the analog systems in which the transmitted symbols are always received, although they are distorted with noise. Therefore, in multi-cast transmission, the receivers decode the video with a quality inversely proportional to the channel noise level.The hybrid video system of reference in the literature is the so-called Softcast , which mApart from Softcast, many other hybrid video systems have been also proposed. Most of them make use of the DCT or the wavelet transform in some of the video processing steps. They all have in common the need for a large amount of metadata, which is critical for video decoding. The following is a review of the hybrid systems that exist in the literature at present, classified according to the used transform and sorted by chronological order.DCAST  exploitsThe system proposed in  uses higSparseCast  uses comCG-Cast  is a SofParCast  is a vidThe work in  is a SofSharpCast  is a hybWireless Cooperative Video Coding (WCVC)  is basedThe system described in  improvesThe system described in  is anothMCast  is a verWaveCast  employs The work in  describeAdaptive hybrid digital–analog video transmission (A-HDAVT)  is a fadJSCC-Cast aims at encoding and transmitting video with low complexity, low delay, and minimum metadata information. The system is also suitable for the transmission over time-varying channels thanks to the intrinsic characteristics of the analog encoding of the video information. In addition, the objective is to obtain a comprehensive system that is competitive with hybrid alternatives and even with all-digital schemes traditionally employed in video compression. The components of the analog transmitter and receiver are described below.The sequence of frames corresponding to the video to be transmitted is the input to our system. We focus on grayscale frames for simplicity. The information processing can be generalized in order to color videos since similar operations are applied individually to each color component.B is the number of pixels per spatial dimension and F is the number of frames in the temporal dimension. Therefore, the total number of pixels per 3D array is In the next step, the system applies a domain transform to the 3D arrays in order to compact the signal energy into a smaller number of relevant coefficients. In the transformed domain, non-relevant information can be easily removed with a negligible impact on the video representation. Indeed, the coefficients after the transform are ordered according to their importance and then discarded or decimated from less to most important until selecting the number of coefficients required to achieve the target compression level.The use of domain transforms and the removal of dispensable coefficients are essential for the exploitation of the spatial and temporal video redundancy for compressing video representation. As shown in ,8, the dj-th vector of transform coefficients after this reorganization. The subindex The coefficients at the output of the transform operation are organized next into two different data streams due to its different impact on the visual quality, namely direct current (DC) and alternate current (AC) coefficients. Let j-th data stream, respectively. These parameters must be included as digital metadata because they are needed at the receiver to undo normalization.Since the analog JSCC mappings employed for the encoding operation perform better with normalized inputs, the vectors j-th data stream. Note that, in general, the continuous mappings can expand the dimension of the symbols to be transmitted; hence, the expansion factor is defined as follows.The next step is the encoding of the transformed coefficients. This operation is carried out in the analog domain. The real-valued coefficients In the limiting case Following our previous work in , we consIn the first case, a linear mapping is considered where the input symbols are simply scaled before transmission by a linear factor, i.e., we have the following:i-th entry of the the normalized input vector In the second case, we considered orthogonal spherical codes based on the exponential chirp modulation , which iAs observed, the nonlinear mapping given by  consistserved in , performNote that a different analog mapping could be applied to each coefficient stream F frames of the input video sequence, stacking all the resulting encoded symbols into a single vector This same procedure is repeated for all the An important issue is that the transmit power is not uniformly distributed among the encoded symbols; therefore, the channel noise can distort differently the distinct parts of the video frames during the reconstruction procedure. This same problem was identified when designing the Softcast system  and solvP represents the available transmit power and The FHT is then applied to the encoded symbols as follows:Note that, for each 3D array, the system requires the knowledge of the two pairs of mean and variance values for the AC and DC symbols, respectively. This metadata is assumed to be transmitted digitally. It is first compressed by means of Huffman coding and next encoded with a convolutional code of rate The real-valued analog-encoded symbols generated at the transmitter are assumed to be sent over an additive white Gaussian noise (AWGN) channel. Hence, the received symbols can be expressed as follows:The operations at reception to recover the transmitted video sequence are shown in n. Note that the estimates of the vectors When considering linear mappings, all transformations at transmission are linear. Hence, the reception operations can be implemented jointly with a linear minimum mean square error (MMSE) estimation of the received symbols under the assumption of a Gaussian source distribution. In this case, the transmitted symbols estimating tor λ in .When the vectors Equation . For thir that minimizes the Euclidean distance between the vector of encoded symbols As observed, the above equation simply chooses the symbol j-th data stream normalized symbols, the next step is to undo the power normalization and mean removal carried out in Equation   and the MSE=1NMF∑x and y are two image signals, L being the dynamic range of the image pixel value, and The SSIM is an image metric that evaluates the distortion of luminance, contrast, and image structure. The SSIM is defined as follows:The SSIM is fairer than the PSNR because it aims at approximating the perceptual quality of images by modeling some of the characteristics of the human visual system. Since the SSIM is a metric designed for images, it must be applied frame by frame. In order to handle a representative single value, an arithmetic mean is applied to the set of individual SSIM values obtained for the different frames.This section details and justifies the design decisions for JSCC-Cast analog video encoding and transmission for which its main signal processing tasks are shown in Domain transforms are intended to concentrate most of the energy present in a video frame and relevant to the human perception into a few coefficients. Therefore, these transforms facilitate the elimination of the coefficients less significant to the human eye and allow for low-bandwidth ratios while preserving perceived quality.There is a wide variety of transforms for the compression of video frames and sequences which are employed in both digital and analog systems. The most well known, due to their properties and characteristics, are the discrete Fourier transform (DFT), the DCT, the Walsh–Hadamard transform (WHT), and the DWT. Each of them presents a different response to compression and also on the robustness against noise . The DCTIn our previous work , we analThe transforms can be applied to the whole image or to regions of it. Hence, one of the main issues is the selection of the size of the region or block for which the transform will be applied to. In , there iSource video is a temporal sequence of frames. Therefore, video compression is possible by individually applying a 2D-DCT to each video frame, in which case only the spatial correlation is exploited. It is possible to increase the compression level by considering the temporal correlation between contiguous frames. In the particular case of the DCT, this results in the 3D-DCT, which is mathematically defined as the following :(23)S=K a constant and This method of rearranging the symbols at the output of the 3D-DCT is an improvement over the isoplane-based approach ,43. The As mentioned in In this section we present the results obtained from different computer experiments carried out in order to evaluate the performance of JSCC-Cast. As a benchmark, we consider Softcast , an analAs stated above, the proposed JSCC-Cast system will be compared with an all-digital system based on the H.265 standard, one of the most advanced digital video codecs. However, the comparison methodology is not trivial because of the different characteristics of both schemes, but we can say that the proposed system is simpler to implement than H.265 for several reasons such as the number of signal processing tasks required by H.265 . AdditioThe design philosophy of the H.265 is significantly different than that of JSCC-Cast because JSCC-Cast aims at providing an acceptable video quality for a wide range of situations requiring a negligible amount of critical metadata, whereas the all-digital system focuses on providing as much quality as possible for a particular bandwidth ratio, which needs to be adapted depending on the channel conditions. In this sense, the all-digital implementation should be interpreted as an upper bound where most of the limitations considered for the design of the analog scheme are relaxed.As an implementation of the H.265 codec, we have used the x265 library  by meansAnother issue is the practical implementation of the digital H.265-based system. JSCC-Cast was designed to operate on small blocks of frames, but the all-digital system requires exploiting greater temporal redundancy in order to perform correctly. Therefore, in the all-digital system, video sequences are processed in blocks of 25 frames.We consider two different types of video sequences depending on their resolution: common intermediate format (CIF) and full high-definition (HD). We have also considered two particular bandwidth ratios: 0.05 and 0.1 for CIF videos, and 0.005 and 0.01 for full HD videos. This decision is because of the fact that similar average SSIM values were obtained for both resolutions with these rates; hence, it is sensible to compare their behaviour. The performance obtained with JSCC-Cast is compared to that provided by Softcast and with the all-digital system described in ted from  transmitAccording to the results shown in Regardless of the comparison with the all-digital system, the H.265 encoder always outperforms its analog counterparts, especially for low SNR values. Such a performance difference becomes smaller as the channel SNR increases. This behavior was expected since the quality of the received videos with analog transmissions directly depends on the channel quality, whereas the digital transmission shows a floor effect. As mentioned, this behavior of the analog video schemes is particularly attractive for multicast scenarios.A feedback link between the receiver and the transmitter is required to inform the transmitter about the channel quality. According to this information, the transmitter adapts its modulation and coding scheme, resulting in slower transmissions when the channel quality drops, hence reducing the overall system performance.In the case of deep channel fading situations, it is very likely that the digital system transmits above the channel capacity, especially if the channel fluctuates fast over time. This results in a situation where the receiver cannot recover the transmitted data, hence requiring additional strategies such as retransmissions, which severely penalize the throughput.Although the all-digital scheme provides the best performance, it is important to emphasize that the comparison between the analog-based approaches and the all-digital one is not utterly fair. On the one hand, JSCC-Cast is simpler than the all-digital one since it requires less signal processing tasks and no feedback. For this reason, this encoding scheme is specially suitable for devices with restricted computational resources such as, for example, IoT devices where power consumption is a fundamental issue. On the other hand, real-world wireless channels, contrarily to simulated AWGN channels, exhibit fluctuations  that penalize all-digital systems:In contrast to all-digital systems, JSCC-Cast does not need to track channel variations. This greatly simplifies the design of the encoding-transmission operations and reduces the overall complexity. In view of the results and considering the general characteristics of the analog-domain processing, we can conclude that there will be certain scenarios in which the performance of the proposed JSCC-Cast is reasonably good and is a better choice than all-digital systems.Another interesting comparison between the proposed JSCC-Cast and Softcast consists in analyzing their performance with respect to the compression level applied to the source videos for a given channel noise level. Another remarkable result from the previous experiment is the flat behavior exhibited by the JSCC-Cast regardless of the bandwidth ratio for a channel SNR of 5 dB. This indicates that the quality of the transmitted videos in the low SNR regime is essentially dominated by the particular encoding of the DC coefficients. Thus, increasing the number of AC coefficients has a minimum impact on the quality of the reconstructed videos because they are received with too much noise. As a consequence, they do not contribute in refining the frame’s details.In this section, we illustrate the performance of the two considered analog schemes (the proposed one and Softcast) by means of a visual comparison with some video frames extracted from the computer experiments. This visual analysis aims at illustrating that the perceptual quality of the videos transmitted with both systems is eventually similar in spite of the SSIM or PSNR differences presented in the previous figures.The considered original frames are shown in Regarding full HD videos, An important issue to assess the feasibility of video coding systems is the amount of metadata required to decode the transmitted video sequences. JSCC-Cast requires the following parameters to be transmitted as metadata: a bit indicating if the block is from a 2D or 3D-DCT, the polynomial expansion parameter of the analog JSCC, and the variance and the mean from each block. Such information is critical in the decoding operation because its corruption renders the received bitstream useless. Therefore, metadata must be transmitted with an adequate level of protection to ensure an error-free transmission regardless of the channel conditions. Considering that large amounts of metadata also produce a big overhead in the transmission of the video stream, which can result in significant performance reductions, According to It is worth remarking that the metadata is not included in the computation of the bandwidth ratio. This simplification is usually assumed for the evaluation of hybrid/analog schemes such as Softcast or its variations when their performance is compared to other digital alternatives. Although the volume of metadata is relatively low with respect to the volume of transmitted analog symbols, the impact of sending this information is ignored. In the case of JSCC-Cast, this simplification is actually justified, as the amount of metadata is practically negligible.In this work we have proposed JSCC-Cast, an analog video encoding and transmission system that is competitive with similar contemporary hybrid systems such as Softcast and even surpassing them under certain circumstances. The paper focuses on presenting the design and optimization of JSCC-CAst for which its minimal computational cost renders it very suitable for the encoding of videos with a high resolution and a very low requirement of digital metadata. Due to its simplicity, the use of this system is oriented towards IoT devices with low power consumption and limited computational capacity.JSCC-Cast presents a behavior similar to Softcast when considering conventional video quality metrics, such as PSNR or SSIM, for both reasonable compression levels and practical ranges of channel SNR. Indeed, the proposed analog scheme is able to outperform Softcast for low bandwidth ratios so that it is very attractive for video transmission on networks with severe bandwidth requirements. In addition, although Softcast provides slight gains in terms of the objective quality metrics, the perceived quality of the reconstructed frames is very similar. Finally, the division of the video sequences in 3D blocks allows for the application of either the 2D or 3D-DCT relative to each block, which limits the propagation of certain visual patterns on the reconstructed frames, while requiring also a minimum increase in the amount of metadata to be transmitted.JSCC-Cast has also been compared to an all-digital system based on the H.265 standard. Under certain circumstances, such as devices with limited computational resources, time-varying wireless channels, and/or receivers with dissimilar channel conditions in multicast scenarios, the analog coding of video information is more suitable to ensure its correct visualization and reception since it achieves an acceptable performance for all considered channel SNR values.Finally, we will analyze the improvements that could be made to the system to increase its performance.Although JSCC-Cast exhibits blocking effects in some situations, they can be mitigated at the decoder by means of smooth filtering, hence increasing the quality of video at reception.The performance of JSCC-Cast is relatively far from that of H.265, the state-of-the-art digital system, for a specific SNR in channels with high noise. This problem could be mitigated by applying more complex analog coding techniques in order to protect the transmitted information at the cost of increasing the computational cost of the system, without significantly increasing the amount of transmitted information.In analog systems the image quality is directly proportional to the noise level of the channel. In this work, we have evaluated simulated channels with AWGN noise, but it would be very interesting to deal with real channels in order to evaluate how it affects the video quality.


The association between the presence of a diagonal earlobe crease (DEC) and coronary artery disease has been prescribed earlier. However, it is unclear whether patients with acute myocardial infarction (AMI) and DEC have a higher risk of dying.Study participants were persons with AMI who were included in the KORA Myocardial Infarction Registry Augsburg from August 2015 to December 2016. After taking pictures of both earlobes, two employees independently assessed the severity of DEC in 4°. For analysis, the expression of the DEC was dichotomized. Information on risk factors, severity and therapy of the AMI was collected by interview and from the medical record. Vital status post AMI was obtained by population registries in 2019. The relationship between DEC and survival time was determined using Cox proportional hazards models.p = 0.0037). In the fully adjusted model, patients with DEC grade 2/3 had a 1.48-fold increased risk of death compared to the DEC grade 0/1 patient group . The fully adjusted model applied for 1-year survival revealed a significant, 2.57-fold hazard ratio of death  for the patients with DEC grade 2/3.Out of 655 participants, 442 (67.5%) showed DEC grade 2/3 and 213 (32.5%) DEC grade 0/1. Median observation period was 3.06 years (5–1577 days). During this period, 26 patients (12.2%) with DEC grade 0/1 and 92 patients (20.8%) with grade 2/3 died  1.23–2.96, Our results indicate that DEC is independently associated with 1-year AMI survival.The online version contains supplementary material available at 10.1186/s12872-021-02425-4. Coronary artery disease (CAD) is the most common disease in Europe and in the US. In the US, CAD accounts for 1 in 7 deaths, killing over 366,800 people a year . For decThe pathogenesis of Frank's sign is based on several theories. One concept considers primarily a microvascular disorder in the earlobe with elastic fiber tears and thickening of the arteries . Others Although previous studies have shown that DEC is an independent indicator of CAD, its association with the prognosis after AMI is not investigated so far. Thus, the objective of the present study was to prospectively examine the association of Frank's sign on long-term survival in patients with AMI.The study was conducted in accordance to the Declaration of Helsinki and approved by the ethics commission of the Bavarian Medical Association . From all participants written informed consent was obtained.The study population consisted of patients with AMI who were admitted to a hospital in the study region of the KORA Myocardial Infarction Registry. Figure In the present study, patients who were registered at the KORA Myocardial Infarction Registry between 1 August 2015 and 31 December 2016 were contacted by a study nurse during their hospital stay after transfer from the intensive care unit. They received information about the study and were asked to participate.Photos of both ear lobes were taken in sitting position by a study nurse. All photos were rated for the presence of a DEC by two trained study nurses independently. The raters were blind towards the rated patients and their clinical characteristics. The results of the two raters were compared and in case of disagreement an third person discussed the findings with the raters and a common decision was made. The assessment was based on the classification published by Patel et al. : grade 0From the KORA Myocardial Infarction Registry, socio-demographic and clinical data collected by patient interview and chart review was used. Clinical information which was not routinely collected for the KORA Myocardial Infarction Registry, was extracted from the medical charts. Information on current vital status and date of death was obtained from the population registries in 2019.2-test was used to test the differences in frequencies, t-Test or Wilcoxon test for differences in continuous variables, respectively.Continuous data were expressed as median values with interquartile ranges (IQR) or means with standard deviation and categorical variables as percentages. The ChiAgreement between the raters was determined by weighted Kappa coefficients and related 95% confidence intervals.p value < 0.05 were taken to be statistically significant.To investigate the association between DEC and mortality, relative risks were computed by Cox proportional hazards models. The proportional hazards assumption was valid for all factors used in the Cox models shown by parallel lines of log(− log(event)) versus log of event times. An unadjusted model, a model adjusted for age and sex as well as a model adjusted for all meaningful potential confounding variables was calculated. Potential confounding factors were sex , age (continuous), history of reinfarction (yes/no), history of diabetes mellitus (yes/no), history of stroke (yes/no), chronic kidney disease (yes/no), peripheral arterial occlusive disease (yes/no), any recanalization therapy (yes/no), number of affected vessels (1/2/3/others), c-reactive protein level (≤ 3 vs. > 3 mg/dl), left ventricular ejection fraction < 50% versus ≥ 50%. Variables with a For the main analysis, the DEC variable was dichotomized by collapsing grades 0 and 1, and grades 2a, 2b and 3. The ear with the highest grade was considered. Sensitivity analyses were performed with different combinations of gradings: grades 0, 1, 2 (2a and 2b) and 3, sum of grades of both ears, grad 3 versus grades 2–0.We included 655 patients with AMI in our study (mean age 68.0 ± 10.8 years) . Also, higher age, hypertension, smoking, hyperlipidemia, history of ischemic heart disease, heart and renal failure, and higher levels of c-reactive protein were significantly associated the presence of DEC. Patients with DEC 2/3 had more often a reduced LV ejection fraction after PCI (p = 0.0243) and had a higher 1 year mortality (p < 0.0031). STEMI was more often seen with DEC 2/3, whereas NSTEMI with DEC 1/2 (p = 0.0049).DEC 2/3 was significantly more often detected in men (No frequency differences were seen between right and left ear (see Table p = 0.0037) within a median follow-up time of 3 years compared to patients with DEC grade 0/1   1.23–2.96, p = 0.0897)  compared to patients with DEC grade 0/1. After adjusting for age and sex, the hazard ratio decreased to 2.14 . In the fully adjusted Cox regression model, patients with DEC grade 2/3 had a 2.57-fold increased risk of death compared to the patients with DEC grade 0/1   with DEC grade 0/1 and 42 patients (9.5%) with grade 2/3 died. In the unadjusted Cox regression model patients with DEC grade 2/3 had a 3.52-fold higher risk of death  for the sum of grades of both ears and 1.97  for the highest grade of both ears (3 vs. 0). After adjusting for other covariables, the hazard ratios decreased and were not statistically significant.Sensitivity analyses using other categorizations of DEC  overall confirmed these results , and in-patient rehabilitation of AMI patients with DEC.Additional file 1. Angiographic findings within the study population with (grade 2/3) and without (grade 0/1) diagonal earlobe crease (DEC) (n = 655).Additional file 2. Association between diagonal earlobe crease (DEC) and 3-year all cause mortality in patients with AMI (n = 651).