Background: Childhood malnutrition contributes to nearly half (45%) of all deaths among children under 5 globally. The United Nations’ Sustainable Development Goals (SDGs) aims to end all forms of malnutrition by 2030; however, measuring progress towards these goals is challenging, particularly in countries with emerging economies where nationally-representative data are limited. The primary objective of this study was to estimate the overall burden of childhood malnutrition in Ghana at national and regional levels using 3 data sources.Methods: Using data from the long-standing Ghana Demographic and Health Surveys (GDHS), Ghana Multiple Indicator Cluster Survey (GMICS), and the emerging Ghana Socioeconomic Panel Survey (GSPS), we compared the prevalence of malnutrition using the extended composite index of anthropometric failure (eCIAF) for the period 2008- 2011. This study included data for children aged 6-59 months and calculated all anthropometric z-scores based on the World Health Organization (WHO) Growth Standards. We tested for differences in malnutrition subtypes using two-group configural frequency analysis (CFA). Results: Of the 10 281 children  included in the study, the only demographic difference observed was the children included in the GSPS were slightly older than those included in the GDHS and GMICS . Based on the eCIAF, the overall prevalence of malnutrition at the national level was higher among children in the GSPS , followed by the GDHS , and then those in the GMICS . The two-group CFA showed that the 3 data sources also estimated different prevalence rates for most of the malnutrition subtypes included in the eCIAF. Conclusion: Depending on the data source adopted, our estimates of eCIAF showed that between one-third and half of all Ghanaian children aged 6-59 months had at least one form of malnutrition over the period 2008-2011. These eCIAF estimates should complement the commonly reported measures such as stunting and wasting when interpreting the severity of malnutrition in the country to inform policy decisions. Implications for policy makersThe conventional measures of early childhood malnutrition, such as stunting and wasting show that Ghana is making good progress in meeting the United Nations’ Sustainable Development Goals (SDGs) for malnutrition by 2030. However, the extended composite index of anthropometric failure (eCIAF), a broader alternative to the conventional measures of malnutrition, shows that the country still has very high prevalence rates of early childhood malnutrition. By using multiple nationally-representative data sources, our study identified regions with the highest malnutrition prevalence rates to be prioritized for reducing early childhood malnutrition.  Implications for the public Children with multiple anthropometric failures are more likely to experience ill-health and face a higher mortality risk, and should be prioritized for interventions. Our study identifies high risk children who suffer from multiple subtypes of malnutrition for targeted interventions.2 continues to be a major determinant of child survival in countries with emerging economies,3 and contributes to almost half (45%) of all deaths among children under the age of 5 years globally.4 For the children who survive, early childhood malnutrition increases the risk of developing health conditions such as diabetes and cardiovascular diseases, impaired cognitive development, reduced school achievement, and lower economic productivity in adulthood.6 Early childhood malnutrition has enduring negative socioeconomic and health consequences into late adulthood,7 and are deficiency diseases caused by poor nutrition.8 Early childhood under-nutrition may manifest in stunting , wasting , underweight , or their combinations,7 while over-nutrition may manifest in overweight or obesity. Current worldwide estimates indicate that in 2018, significant numbers of children under the age of 5 years were affected by stunting (149 million), wasting (49 million), and overweight (40 million), with Asia and Africa continuing to bear the greatest share of the global burden of early childhood malnutrition.9 Early childhood malnutrition comprises both over- and under-nutrition, 2 pandemics which seriously threaten human health10 on Ghana’s performance on the Millennium Development Goals (MDGs), between 1993 and 2014, the country had successfully cut in half the proportion of children who were underweight and presented with wasting, as targeted in the MDGs, but failed to meet the target for stunting . In spite of the progress at the national level, there have been significant inequalities across the country. Particularly, the prevalence of stunting among children under 5 is alarming in rural and economically deprived areas.11 Although the conventional measures of malnutrition  reflect distinct biological processes, none of them are designed to give an overall estimate of malnutrition in a given population due to the overlapping nature of these measures.13 To enable an overall estimate of undernutrition in a population, Svedberg14 and Nandy et al15 developed the composite index of anthropometric failure (CIAF); which has further been expanded by other authors17 to account for over-nutrition and called extended composite index of anthropometric failure (eCIAF). Compared to the conventional measures, the CIAF and eCIAF are better in guiding policy interventions because they allow for distinguishing children who are experiencing single versus multiple anthropometric failures. Children with multiple anthropometric failures are more likely to experience ill-health and face a higher mortality risk,18 thus, should be prioritized for interventions. Regardless of the improvements made as indicated by the conventional measures of malnutrition, early childhood malnutrition remains a significant public health issue in Ghana and tracking the overall estimate of malnutrition in the population using indices such as the CIAF and eCIAF would be invaluable for developing evidence-informed policy interventions. Compared to other African countries, Ghana has made significant strides in reducing childhood malnutrition. According to the 2015 final report19 For example, SDG 2.2 targets an end to all forms of malnutrition by 2030, including achieving the internationally agreed targets on stunting (40% reduction) wasting , and overweight  in children under 5 years of age by 2025.20 However, the reliable data sources needed to track progress towards achieving these specific goals of early childhood malnutrition in sub-Saharan Africa are scarce.21 In Ghana for instance, 2 nationally representative cross-sectional household surveys, the Ghana Demographic and Health Surveys (GDHS) and the Ghana Multiple Indicator Cluster Survey (GMICS) have been the major data sources for tracking child and maternal health indicators, since the 1980s and 1990s, respectively. In 2009, the Ghana Socioeconomic Panel Survey (GSPS) was launched, with the first wave of data collection concluding in 2010. The GSPS was designed to provide a scientific framework for tracking and studying changes in the country’s developmental process.22 One of the main challenges of meeting the targets set for early childhood malnutrition in the Sustainable Development Goals (SDGs) is the lack of comprehensive and consistent data to enable tracking of progress.10 on Ghana’s performance on childhood malnutrition indicators in the MDGs only relied on data from the GDHS. Given that the GDHS, GMICS, and GSPS are conducted on different time schedules, the 3 data sources could provide complementary and therefore comprehensive insights on the burden of early childhood malnutrition in the country. For example, GDHS alone can only track childhood malnutrition in 5-year intervals, whereas the combination of the GDHS and GMICS reduces this interval to 3 years; since each survey is conducted in the intervening period of the other. Clearly, monitoring the progress towards SDG 2.2 using the combination of these 3 data sources provides information to policy-makers within shorter time intervals and allows for timely implementation of interventions. Studies that provide comparisons of baseline estimates of early childhood malnutrition across these data sources can encourage the triangulation of the 3 data sources for monitoring childhood malnutrition in Ghana. The GDHS, GMICS and GSPS use similar survey methodology and have significant overlap in the range of indicators they cover, including education, health, livelihood, and social protection. Like other countries aiming to achieve SDG 2.2, Ghana could benefit from consistently using these nationally representative data sources to track progress. However, important reports such as the 2015 report23 assessed the factors affecting the uptake of intervention programs to prevent malnutrition,24 or focused on only deprived areas such as the Northern region of Ghana.25 To the best of our knowledge, estimates of the overall burden of childhood malnutrition at both national and regional levels have not been previously reported in Ghana. Therefore, the primary objective of this study was to use the CIAF and eCIAF indices to estimate the overall prevalence of early childhood malnutrition in Ghana at both national and regional levels, and compare these estimates across the GMICS, GDHS, and GSPS data sources. A secondary goal of the study was to compare the magnitude of change in the conventional measures of malnutrition over 2 survey cycles for each of the data sources; an analysis useful for providing further context to the country’s progress towards achieving SDG 2.2. This study contributes to the literature by measuring the overall burden of malnutrition not only at the national level but also at the regional levels to capture spatial variations in malnutrition across the country. Insights from this paper will be useful for targeted policy initiatives, especially in high-risk areas, to reduce the prevalence of childhood malnutrition and improve child health in general. Previous studies on childhood malnutrition in Ghana have examined the correlates of malnutrition in a nationally representative sample,26 The 2009-2010 GSPS was conducted and managed by the Economic Growth Center at Yale University and the Institute of Statistical, Social, and Economic Research at the University of Ghana.27 The 2011 GMICS was carried out by the Ghana Statistical Service, with technical support from the United Nations Children’s Fund (UNICEF) and other international organizations.28 This study relied on data obtained from 3 nationally representative surveys in Ghana, namely the 2008 GDHS, the 2009-2010 GSPS, and the 2011 GMICS. The 3 surveys were selected because they were the closest in years to one another between the 3 data sources . Secondl30 we excluded children aged less than 6 months because of the possibility of a significant decrease in adiposity during this period. We also excluded children based on the World Health Organization (WHO) flagging criteria32 for unusual or biologically implausible anthropometric measurements, as these height and/or weight values and their z-score derivatives are usually considered to be errors in measurement and/or recording. We used the children sub-sample from each of the data sources, focusing on those aged 6-59 months who had their anthropometric  measurements recorded. Similar to previous studies,26 For the 2009-2010 GSPS, 5041 occupied households selected and 5009 were successfully interviewed, resulting in a household response rate of over 99%.22 The household response rate was close to 100% in the 2011 GMICS, given that 11 925 households were successfully interviewed out of a total of 11 970 occupied households selected.28 The 3 surveys conducted face-to-face interviews with all participants. The 2008 GDHS, 2009-2010 GSPS, and 2011 GMICS all used a 2-stage stratified sample design. At the first stage, 411, 334, and 810 clusters were selected for the 2008 GDHS, 2009-2010 GSPS, and 2011 GMICS, respectively. These clusters were selected using a simple random sampling technique from an updated master sampling frame constructed from the 2000 Ghana Population and Housing Census. For the second stage, 30 households were selected from each cluster selected at the first stage for the 2008 GDHS whereas 15 households were selected for both the 2009-2010 GSPS and 2011 GMICS. In total, 11 913 occupied households were selected in the 2008 GDHS, out of which 11 778 were successfully interviewed, yielding a household response rate of about 99%.https://dhsprogram.com/. The 2009-2010 GSPS data is publicly available, but its usage is subject to terms and conditions of the data custodians. The data can be accessed from The World Bank Microdata Library website at the address https://microdata.worldbank.org/index.php/catalog/2534. Similar to the GDHS, the GMICS requires an authorization from the data custodians before the data can be accessed. The authorization for access and access to the whole MICS database can be completed through the MICS program website at the address https://mics.unicef.org/surveys. The 3 surveys fulfilled all ethical requirements and participants’ records in the databases were anonymized, fully concealing the identities of all participants. No further approvals are required for the retrospective use of these data. The GDHS requires an authorization from the custodians before the data can be accessed. The authorization for access and access to the whole DHS database can be completed through the DHS program website at the address 33 The following standard case-definitions were applied to each record to classify children as: wasted: WHZ <-2.0, stunted: HAZ <-2.0, underweight: WAZ <-2.0, or overweight: WAZ >2.0. We also used the CIAF and eCIAF to measure the overall prevalence of malnutrition . The CIAF identifies 7 mutually exclusive subtypes of undernutrition, including: (a) no failure: normal WAZ, HAZ, and WHZ, (b) wasting only: WAZ <-2.0 but normal HAZ and WHZ, (c) wasting and underweight: WAZ and WHZ <-2.0 but normal HAZ, (d) stunting, wasting, and underweight: HAZ, WAZ, and WHZ <-2.0, (e) stunting and underweight: HAZ and WHZ <-2.0 but normal WAZ, (f) stunting only: HAZ <-2.0 but normal WAZ and WHZ, and (y) underweight only: WHZ <-2.0 but normal HAZ and WAZ. The CIAF sums all the subtypes (b) to (y) of undernutrition to estimate the overall prevalence of early childhood undernutrition in a population. The eCIAF accounts for over-nutrition by adding 2 more groups to the CIAF, namely (g) stunting and overweight, and (h) overweight only. Thus, the eCIAF can estimate the overall prevalence of early childhood malnutrition in a population. The study variables included age (in months), sex , region of residence , height (in cm) and weight (in kg). Except for region of residence, the other variables were used to calculate a range of z-scores, including HAZ, WAZ, WHZ, and BMI-for-age (BMIZ) using the 2006 WHO growth standards. We compared the distributions of sex, age, height, weight, HAZ, WAZ, WHZ, BMIZ, stunting, wasting, underweight, and overweight between the 3 data sources; using the chi-square test or analysis of variance, as appropriate.34 Similar to Seirs et al,35 we generated quantile regression fits for every 2.5th percentile from the 0.05th to 0.95th quantiles of the 4 z-score values for each sex and age group. Estimates for each quantile were connected with lines and polygons were used to represent the 95% confidence intervals for the estimates, with non-overlapping confidence polygons indicating statistically significant differences. Further, we used quantile regression models to make sex- and age-specific comparisons of the entire distributions of HAZ, WAZ, WHZ, and BMIZ between the GDHS, GMICS, and GSPS data sources. Quantile regression allows the estimation and inference on quantiles of a distribution without assumptions of normality and equality of variance required for standard regressions on mean values.svydesign of the R survey package. We used the eCIAF to calculate and plot the overall prevalence of early childhood malnutrition for each of the 10 regions in the country. These prevalence estimates were weighted to be regionally representative and reflect the regional variations in malnutrition across the country. We applied the appropriate weights  for each of the surveys. Given the 2-stage stratified sample design of the survey, we included information on both the primary and secondary sampling units, as well as using the region of residence as strata in specifying the survey design effects in the function 36 In our two-group CFA, the observed frequencies were compared with expected frequencies in order to identify the “discrimination types” . We made comparisons between the GSPS and GDHS, the GSPS and GMICS, and the GDHS and GMICS. We used 2 methods to test for differences between the GDHS, GMICS, and GSPS for each of the subtypes of malnutrition captured in the CIAF and eCIAF. First, we calculated the prevalence of each of the subtypes of malnutrition in the eCIAF with their 95% confidence intervals, with non-overlapping confidence intervals indicating statistically significant differences. Similar to the weighting procedure explained above, these prevalence estimates were weighted to be nationally representative. Second, we used a two-group configural frequency analysis (CFA) to identify the subtypes of CIAF that are significantly different between the GDHS, GMICS, and GSPS. Unlike using confidence intervals to ascertain statistical significance, the CFA is a nonparametric method useful for analyzing the frequencies in multi-way contingency tables.37 For the GMICS, we compared our estimates from the 2011 survey to the latest prevalence estimates from the 2017-2018 survey.28 Although the second wave of data collection for the GSPS took place in 2014-2015, the data are currently not publicly available, thus we were unable to report on the changes in prevalence estimates from this data source. With regards to the secondary objective of the study, we compared the changes in the prevalence of stunting, wasting, and overweight across the data sources. For the GDHS, we compared our estimates from the 2008 survey to the latest prevalence estimates from the 2014 survey.38 Specifically, we used the R-packages data.table39 for data preparation, confreq40 for the CFA, quantreg41 for the quantile regression, ggmap42 for mapping regional malnutrition prevalence rates, survey43 for weighting prevalence estimates to be nationally representative, zscorer44 for calculating anthropometric z-scores in the GSPS data, and ggplot245 for plotting the anthropometric z-scores. For all tests conducted in this study, statistical significance was set at 0.05 alpha level. All data restructuring and analyses were conducted in R version 3.6.0.P < .001). All the anthropometric measures were marginally higher in the GSPS compared to the GMICS and GDHS. Furthermore, except for underweight, the prevalence estimates were higher in the GSPS followed by the GDHS and then the GMICS for stunting , wasting , and overweight . After applying the exclusion criteria , a total of 6532 children were included in the GMICS. Using the same exclusion criteria , a total of 2141 children were included in the GDHS. Similarly, applying the same exclusion criteria  yielded a total of 1608 children to be included in the GSPS.  For the comparison of younger (6-23 months) and older (24-59 month) children , the qua Based on the eCIAF, the overall prevalence estimate of malnutrition at the national level was higher among children in the GSPS , followed by those in the GDHS , and then those in the GMICS  . The pre Comparing prevalence estimates of the malnutrition subtypes in the CIAF between the data sources , we foun Further, we used a two-group CFA, which is a non-parametric statistical approach, to cross-check the differences in the prevalence estimates of the anthropometric failure subtypes identified in  The prevalence of malnutrition calculated at the regional level using the eCIAF is shown in  Based on the GDHS, over a 6-year period of 2008-2014, Ghana had a 37% reduction in the prevalence of stunting, 47% reduction in the prevalence of wasting, and 53% reduction in the prevalence of overweight . Over a 46 created 5 prevalence thresholds  for describing the severity of malnutrition in a population, with very low and low classifications matching the targets for SDG 2.2. These thresholds are expected to facilitate prioritization and trigger action for targeted interventions. Based on these thresholds, each data source classified the prevalence of early childhood malnutrition differently. For example, whilst the GMICS identifies overweight to be very low in the country, the GDHS and GSPS classifies the country as having medium and very high prevalence levels of overweight, respectively. Although there are no prevalence thresholds available to describe the overall level of childhood malnutrition based on indices such as CIAF and eCIAF, our estimates of eCIAF showed that between nearly one-third  and half  of Ghanaian children aged 6-59 months had at least one form of malnutrition over the study period. Thus, it is likely that the eCIAF estimates from the 3 data sources may inform different prioritization schemes for children requiring urgent interventions. The use of the CIAF and eCIAF allows for distinguishing children who are experiencing single versus multiple anthropometric failures. This distinction is especially important because children with multiple anthropometric failures are more likely than those with only one to experience ill-health and face a higher mortality risk,18 and thus, should be prioritized for interventions. This study sought to estimate the overall prevalence of early childhood malnutrition in Ghana at both national and regional levels, while comparing these estimates across 3 data sources. The results showed that the prevalence estimates for stunting (29.1% to 35.4%), wasting (6.9% to 19.4%), and overweight (6.4% to 20.1%) varied considerably across data sources. Recently, de Onis et al10 To this end, Ghana has since been moving towards decentralized policy-making and program development to tackle early childhood malnutrition from the regional, municipal and district levels. Similar to the national level estimates, our results showed that the prevalence estimates of childhood malnutrition varied across the regions, and among the 3 data sources. For example, although the GDHS estimated higher prevalence rates for the Central, Eastern and Upper East regions, the GSPS estimated lower prevalence rates for the Eastern and Upper East regions, and the GMICS estimated lower prevalence rates for the Central and Eastern regions. Some of the observed variations may be due to the differences in the time periods during which the surveys were undertaken and potentially sampling issues, where the GSPS reported that clusters in the Upper East and Upper West regions were over sampled to allow for a reasonable number of households to be interviewed. It is also possible that the 3 data sources captured different but real variations in early childhood malnutrition in the country. Thus, using multiple data sources as national surveillance tools could provide a broader and more comprehensive assessment of the extent of early childhood malnutrition at sub-national levels, which may be instrumental for prioritizing and designing interventions. With these comprehensive assessments at their disposal, policy-makers could be more empowered to make informed decisions. For example, based on the totality of evidence from the 3 data sources, targeted interventions to mitigate malnutrition, especially in the regions with the highest prevalence rates , could reduce the level of inequities across the country. One of the key lessons the country has learned in the implementation of the MDGs on childhood malnutrition was the need to decentralize intervention programs development.17 where there is the co-occurrence of high prevalence of under- and over-nutrition among children. Both under- and over-nutrition can lead to significant co-morbidities which can, if unaddressed, result in mortality. Finding ways to ensure that health systems respond to both of these categories and that health promotion plans are in place for diverse regions and populations is essential for successful interventions to reduce child malnutrition. In our study, the GMICS and GDHS, being the major data sources used to track childhood indicators, revealed low to medium overweight prevalence rates of 2.0% and 6.4%, respectively, while the GSPS showed a much higher rate of 20.1%. Other studies over similar time frames as ours conducted among school-aged children  mainly in urban sectors have reported overweight prevalence rates in excess of 10%; including overweight prevalence of 26.7% reported by Mahammed and Vuvor,47 18.1% reported by Aryeetey et al,48 and 16.4% reported by Adom et al.49 Although the overweight prevalence rates reported in these studies were conducted in slightly older children and mainly in urban settings, it is worth monitoring the overweight prevalence rates in the 0-59 months group to avert the possibility of the country being taken by surprise with the double burden of malnutrition in this age group. This is particularly important given that the estimates from the GSPS are hinting the possibility of a co-occurrence of under- and over-nutrition leading to a double burden of malnutrition in the country. Many countries like Ghana whose economies are in transition are experiencing the dual burden of malnutrition,20 To provide some context for Ghana’s progress towards meeting the 2025 targets, we compared the latest prevalence estimates from the 2014 GDHS and the 2017-2018 GMICS with our estimates  were to one another; and in turn provided an assessment of how their complementary usage  could serve as national surveillance tools to monitor childhood malnutrition in the country. We found that the GSPS prevalence estimates of malnutrition were consistently higher than the estimates from the GDHS and GMICS. To better understand why that was the case, we plotted the entire distributions of the anthropometric z-scores using quantile regressions. These plots compared estimates between the GSPS, GDHS, and GMICS separately for boys and girls, as well as for the younger (6-23 months) and older (24-59 month) children . Yet still, 2 of the data sources were 3 years apart, and the results of the study should be interpreted with this consideration. However, we did not find any clear trend in the prevalence estimates based on the year in which the surveys were conducted. Overall, malnutrition prevalence estimates were higher in 2009-2010 GSPS than estimates in the 2008 GDHS and 2011 GMICS. A major strength of the study is the use of nationally representative data sets, which provided robust prevalence estimates of early childhood malnutrition. Although some of the data for child age may be based on mother’s or caretaker’s reports, the anthropometric indicators  were objectively measured by well-trained technicians, To the best of our knowledge, this study is the first to reveal the variations in the overall prevalence estimates of early childhood malnutrition using indices such as the CIAF and eCIAF at the national and regional levels in Ghana across 3 nationally representative data sources. Depending on the data source adopted, our estimates of eCIAF showed that between one-third and half of all Ghanaian children aged 6-59 months had at least one form of malnutrition over the study period. These estimates are quite alarming and should play a complementary role to the usually reported measures of stunting, wasting, and overweight when interpreting the level and severity of malnutrition in the country to inform policy decisions. We have also found regions with the highest prevalence rates to guide policy-makers design targeted interventions. By comparing estimates across the 3 data sources, our study has demonstrated that triangulating multiple data sources as national surveillance tools to monitor early childhood malnutrition would enrich the evidence base for effective policy-making. In designing effective interventions, policy-makers need estimates of both incidence and prevalence of malnutrition. Although the MICS and DHS are popular data sources in Ghana and around the world for estimating prevalence of malnutrition, the GSPS being a panel survey provides a promising opportunity to measure incidence of malnutrition at a nationally representative level; an indicator virtually non-existent in the developing world. We are grateful to all the families who participated in the 2008 GDHS, 2009-10 GSPS, and 2011 GMICS surveys. Also, we are grateful to the DHS and MICS programs for kindly providing access to their respective datasets. Lastly, the 2009-10 GSPS data used in this study is a joint effort undertaken by the Institute of Statistical, Social and Economic Research (ISSER) at the University of Ghana, and the Economic Growth Centre (EGC) at Yale University. At the same time, ISSER and the EGC are not responsible for the estimations reported by the authors. This study is based on data from 3 surveys which fulfilled all ethical requirements and participants’ records were anonymized in the respective databases, fully concealing the identities of all participants. Since the data are publicly available, no further approvals are required for the retrospective use of these data. Authors declare that they have no competing interests. JPK led the conceptualization of the study, design and acquisition of the data, statistical analysis, drafting the manuscript, and interpretation of the results. JA, TM, EJC, ED, and AN supported drafting of the manuscript, data analysis, and critically reviewed the manuscript.


One-hundred and sixteen participants  assessed the videos by scoring, on a self-reported 9-point scale, three dimensions of emotion: valence, arousal, and dominance. The content was attributed a specific valence  if more than 60% of the participants identified it with an emotion category. Results: In total, 242 short videos, including 112 positive videos, 47 neutral videos, and 83 negative videos, were retained in the video stimuli database. In the three-dimensional degree of emotion, the distribution relationship between them conformed to the fundamental characteristics of emotion. The internal consistency reliability coefficient for valence, arousal, and dominance was 0.968, 0.984, and 0.970. The internal consistency reliability of the emotional dimensions for people and faces, animals, objects, and scenes ranged between 0.799 and 0.968. Conclusions: The emotion short-video system contains multi-scene dynamic stimuli with good reliability and scoring distribution and is applicable in emotion and emotion-related research.Two hundred and ninety-nine videos representing four categories  were standardized using Adobe Premiere Pro CC 2018, with a unified duration of 3 s, a resolution of 1080 pixels/inch, and a size of 1920 × 1080 mm Emotion has a significant impact on individuals’ survival and adaptation. Emotions can influence the cognitive processes of humans by exerting an effect on subjective feeling, conflict handling, and decision making ,2,3. ForGenerally, emotional stimulus databases include visual, auditory, olfactory, and tactile materials. Visual stimuli are the most commonly used materials in psychological research because they are intuitive to feel, easy to use, and accurate when measuring the start and the end of stimuli. The International Affective Picture System (IAPS) is the world’s most widely used database . In the Previous studies pointed out that the emotional intensity caused by dynamic expressions is higher than that of static ones . PresentIn real life, the generation of emotion mainly relates to dynamic simulation. Dynamic emotion videos  and emotIn this study, emotions were rated according to three dimensions , and the short videos were classified into four categories . The sample size was calculated by referring to the method specified in exploratory factor analysis and is generally 5–10 times the number of items on the scale used . Therefop = 0.912). This study was reviewed and approved by the Medical Ethics Committee of Peking University (IRB00001052-21046). All participants were voluntary and signed an informed consent before the study. After completing all the experiments, the participants obtained a fee.We used the convenience sampling method to recruit participants. One hundred and seventy-seven college students took part in the study, and four dropped out midway. Of the 173 participants who completed the questionnaires and video assessments, after removing 57 participants who had scores ≥14 on the Baker Depression Scale  or ≥10 o2.The authors took the videos in various places and locations with iPhone or Huawei mobile phones in the resolution of 4K frames per second, and a total of 575 clips were obtained. Among them, 299 clips with explicit content and precise emotional expressions were selected through preliminary screening by four researchers. Those excluded were mainly because of their vague meaning or because they were unclear images or shaky camera shots. Using Adobe Premiere Pro CC 2018, the 299 videos were processed into 3 s videos with a resolution of 1080 pixels per inch and a size of 1920 × 1080 mmAfter the selection procedure, the image classification method proposed by Colden et al.  was emplThe biological sex of female vs. male was coded as 1 vs. 0. Education level was categorized into two subgroups . Marital status was defined as married (coded as 1) or unmarried (coded as 0). Recent life events were investigated by the following self-made questions: 1. Have you lost important relatives or friends in the last month? 2. Have you divorced or felt lovelorn in the last month? Have you encountered any unacceptable setbacks in your studies or career in the last month? Have you experienced any events other than the above problems in the last month that have significantly affected your mood? If the answer to the above question was yes, the score was 1; if the answer was no, the score was 0.The Beck Depression Inventory  was usedThe GAD-7  was usedBefore the experiment, the participants were instructed to practice rating the videos. After watching the videos, the participants were asked to score their emotional responses  on a 9-point scale. On the valence scale, 1 represents very negative emotions or feelings , 5 means no emotional change , and 9 indicates very positive  emotions. On the arousal scale, 1 point indicates high passivity ; 5 points mean no emotional change ; 9 points indicate high activity . On the dominance scale, 1 point indicates a controlled state , 5 points mean no emotional change , and 9 points indicate being in control of the situation .This study was conducted in the spring of 2020. Due to the global COVID-19 pandemic at that time, we chose to perform our research online. We developed a website using JavaScript (version 2018) and nodeJS (version 4.4.3) for this experiment and stored visual clips on the cloud server. A user could log into the website with a unique assigned username and password to start the experiment. Participants were instructed to watch each video only once and score the three emotional dimensions in the slider at the bottom of the web page after each display. Only after watching a video could the participants rate it. The rating scales remained available to the participant until they completed valence, arousal, and dominance ratings. The individual scoring time of each video was up to the participant, accounting for 1.5 to 2 h in total. The participants were told not to think and to rate according to their feelings at that moment. After each rating, by clicking “Next,” the following video appeared. The playing order was random for each participant.t-tests to compare the mean differences of variables between gender groups, and finally scatter charts and correlation analyses to show the distribution characteristics between two of the three dimensions  of emotion under various conditions.The statistical analyses were performed using the software SPSS 22.0. We first used descriptive statistics to show the sample characteristics under various conditions within-group or between-group, then independent sample On the valence dimension, a video was determined to induce a negative emotion when it scored less than 5, a neutral emotion when its score was equal to 5, and a positive emotion when its score was over 5. When videos are categorized according to the valence dimension, the recognition rate is expected to be higher than 60.0% ,37, thatThe internal consistency reliability coefficient (Cronbach’s Alpha) of 116 participants for the evaluation of 242 videos by of participants for the dimensions of valence, arousal, and dominance was 0.968, 0.984, and 0.970, respectively, and the internal consistency was higher than 0.92 across the positive, neutral, and negative categories . For eacp values > 0.1).The scores in the valence and dominance dimensions were widely distributed, with larger range values ; in the arousal dimension, the scores tended to converge and meet at more than 4.5, with a narrow standard deviation. There were no significant sex differences in the three emotional dimensions. Compared to the male participants, the female participants did not show any sensitivity in recognizing negative, positive, or neutral videos . There were no sex differences in the distribution. When the videos were divided into the four categories of humans, animals, objects, and scenes, the inequality of the distribution became apparent. In the people and animal categories, a dense concentration of ratings was in the positive or negative emotion area; in the object category, the ratings were uniformly distributed; in the scene category, the rating scores were mainly in the neutral or positive areas. In the middle panel of p < 0.001). The rating of valence increased as that of the dominance dimension. The human and animal categories were mainly in the high and low dominant areas, objects were uniformly distributed, and scenes were in the highly controlled area. The distribution pattern in the bottom panel of p < 0.001; negative videos: r = −0.753, p < 0.001).The scatter plot shown in the upper panel of This study established an emotional stimulus material system composed of dynamic short videos drawn from real life with events and scenes. The valence of the videos was positive, neutral, or negative. The obtained rating patterns from the valence, arousal, and dominance dimensions corresponded with the distribution of basic emotions and were similar to the distribution of the IAPS, indicating a high validity of the video stimuli system. The reliability coefficients for valence, arousal, and dominance were 0.968, 0.984, and 0.970. The internal consistency of the videos in different categories ranged from 0.799 to 0.968.The short videos in this study have two advantages, i.e., they can facilitate future research and expand researchers’ options. Each stimulus of the emotional stimulus material system expresses a precise and dynamic meaning of emotions and appeared closer to the actual situation of emotion generation. Another advantage is that we included four categories of videos from diverse sources, i.e., people (including human faces), animals, objects, and scenes. Positive stimuli contained natural sceneries, artificial landscapes, lovely animals, attractive food, smiling faces, interacting family scenes, and playing children. Neutral videos covered everyday objects, buildings, ordinary natural sceneries, and everyday facilities. Negative videos included those with bloody scenes (shot on props), ghosts (played by researchers), crying faces, disasters , garbage-related scenes , insects, etc.The scatter plots showed that arousal and dominance increased as pleasantness grew, rosed up and decreased as the unpleasantness increased, and remained neutral when valence was near the neutral area. These findings are consistent with those of the IAPS and CAPS , indicatThe present stimulus system obtained similar maximum values in the three dimensions of valence, arousal, and dominance as those of the CAPS , with raIn this study, gender differences were not significant for the three emotional dimensions. However, Yi et al. study  found thThe strengths of this study include: (1) the videos extended standard tools like CAPS by adding the dynamic dimension, (2) the exclusion of individuals with possible clinical depression or anxiety avoided the impact of these two conditions on the emotion rating of the videos; (3) randomizing the order of video playing and balancing the participants’ gender ensured the standardization of the research; (4) from the perspective of the application prospect of the video library, future studies may assess the application of the video library in other age groups and patient populations. Further, emotion videos have been used in recent social cognition studies, such as in the areas of visually mediated empathy and somatosensory vicariousness and their interaction with neural activities ,43. DynaThis study also has some limitations. First, the total number and categories of the short-video stimuli should be expanded, especially those in the high arousal/valence areas. Second, in the video evaluation, there was no test for the classification of complex emotions represented in the video, such as to judge whether the positive emotions reflected in a video were joy or amusement and whether the negative emotions reflected in a video were sadness, anger, or fear. Future research can further improve this aspect and supplement videos as needed. Third, some social and natural scenes in the videos may have Oriental cultural characteristics, such as garden sceneries and group dance, so their cross-cultural applicability needs to be further verified.This study established an emotion short-video system containing dynamic stimuli with diverse scenes in multiple categories and demonstrated its high reliability and validity. The corpus can supplement other emotional visual materials in related research areas.


Heavy drinking has increased among older adults in recent years. Research suggests romantic partners influence each other’s alcohol use, but this influence may vary by partnership type and relationship quality. Heavy drinkers are more likely to form cohabiting versus marital unions and, relative to marriage, cohabitation is linked with a higher risk of heavy episodic drinking. Although some studies have explored older married couples’ alcohol consumption, we lack research on older cohabitors despite the substantial growth in this form of partnership during later life. We use data from the 2014-2018 waves of the Health and Retirement Study to examine drinking behavior among a sample of older married and cohabiting couples  using Actor-Partner Interdependence Models (APIM). Heavy drinking is measured as consuming more than 3 drinks on a given day or 7 drinks per week for women, or 4 drinks on a given day or 14 per week for men . Compared to first marriages, being in a cohabiting union is associated with significantly higher odds of one (OR=5.22) or both (OR=3.82) partners becoming heavy drinkers over the observation period, but there are no significant differences between those in first marriages and remarriages. Relationship quality is also a significant correlate of heavy drinking risk, with male partners’ negative relationship quality and female partners’ positive relationship quality associated with a higher risk of heavy drinking over time. Results suggest the importance of accounting for partnership type and relationship quality in understanding partners’ drinking behavior.


A total of 517 valid data were collected, including 222 (42.9%) were male students and 295 (57.1%) were female students. The collected questionnaires were analyzed for reliability and validity after removing incomplete data, followed by structural equation modeling for model verification. The findings showed that: (1) short video flow experience had a positive effect on short video addiction; (2) short video addiction had a negative effect on intrinsic and extrinsic learning motivation; (3) intrinsic and extrinsic learning motivation had a positive effect on learning well-being; (4) short video flow experience had an indirect negative effect on intrinsic and extrinsic learning motivation; (5) short video flow and short video addiction had indirect negative effects on learning well-being. According to the results, it is clear that addiction to short videos has a negative impact on learners' learning motivation and positive psychology of learning, so parents and teachers should effectively guide students to use short video apps in a self-controlled way.While media use can be beneficial in some ways, excessive use of media has led to growing concerns about its potential negative consequences. With the popularity of Chinese video applications (apps) such as DouYin, TikTok, Kwai, and other short video apps sweeping through schools around the world. Due to the diversity and immersion principle of short videos, their popularity continues to grow, and the phenomenon of students being addicted to short videos also brings many hidden dangers to the learning effect. Among other things, the problem of excessive use of the Internet among Chinese youth has led the government to propose a series of control policies to strengthen the monitoring of harmful habits of youth in the use of online applications. In addition, the problem of youth addiction to short videos has become a major concern for education experts and the general public, thus demonstrating that short video addiction is indeed an ongoing research issue. Therefore, this study aimed to understand the causes of short-form video addiction and its impact on the psychology of learning, and to investigate the relationship between short-form video flow experience, short-form video addiction, intrinsic and extrinsic learning motivation, and learning well-being from the perspectives of flow experience theory and micro ecological systems. The questionnaire was sent  In the past two decades, new technologies and the Internet have undoubtedly changed our lives; this includes how we deal with the many great advantages brought by the Internet and the dangers that may be caused by abuse of the Internet . The useInternet addiction can be divided into two types of definitions, broad Internet addiction, which encompasses general and multidimensional Internet overuse behaviors, and specific Internet addiction, which has similar characteristics to general Internet addiction, which refers to things like smartphone addiction, social media addiction, etc. . The shoIn the field of Internet addiction research, short videos are an independent and emerging Research Topic with a clear definition of terms, unlike social media, which is such a large border area. Short videos are videos that are <15 min in length, mostly between 1 and 5 min, and have a clear theme type. Because short videos are characterized by a clear style, concise content, and fast rhythm, most of the video content will attract users' attention within seconds and make them keep watching , which aAlthough there are still few studies on short video addiction, Internet addiction is a new form of dependence on connected devices, and such addictive behaviors can cause psychological problems and leave many negative effects. For example, Chen et al.  study foPrevious research has demonstrated that Internet addiction can have a negative impact on the psychological and emotional development of adolescents , which mIn order to systematically understand the causes of short video addiction and its effects on learners, this study was conducted based on the micro ecological system to consider the trend of youth mental health education from an ecosystem perspective . BrofenbIn summary, although short video addiction has received much attention and heated discussion from the public, there is still a lack of related study on the topic of short video addiction. Therefore, this study used the ecosystem theory to construct a research model to investigate the relationship between short video flow, addiction, intrinsic and extrinsic learning motivation, and learning well-being among Chinese vocational school students, in the hope of shedding light on the prevention and education of addictive behaviors at home or on campus.Bronfenbrenner  proposedThis study considers “person” as the perception of flow experience when watching short videos, “content” as the addictive nature of interaction with the cell phone, and “process” as the learner's motivation to learn, and the perceived subjective well-being in their learning life. That is, when learners often experience high levels of immersion in the process of watching short videos, they will begin to develop video dependency, which will weaken their motivation to learn and affect their perceived positive feelings about their learning lives. Accordingly, it is worth exploring whether there is a relationship between short video flow and the control of cell phone addiction among technical high school students. Therefore, Therefore, this study explored from the perspective of integrating flow experience and ecosystem theories to understand the relationship between short video flow, short video addiction, intrinsic and extrinsic learning motivation, and learning well-being, as shown in Flow is defined as the experiences that a person immerses him/herself in to be fully involved in the process of an activity . In receH1: Short video flow has a positive effect on short video addiction.Internet has brought easy access to short videos, which are potentially easy for individuals to become addicted to. Short video addiction is defined as the excessive and irrational use of short videos to a point where it influences one's daily life , 21. SevH2: Short video addiction has a negative effect on intrinsic learning motivation.H3: Short video addiction has a negative effect on extrinsic learning motivation.Motivation is an important determinant of students' learning success rate . TherefoFurthermore, a recent study provided evidence that motivation is important for student well-being , while oH4: Intrinsic learning motivation for learning has a positive effect on learning well-being.H5: Extrinsic learning motivation has a positive effect on learning well-being.Students' learning motivation to enjoy and continue learning is a critical reason for academic success. Motivation can be defined as intrinsic and extrinsic, where intrinsic motivation means being able to enjoy or engage in an activity without any reinforcement, whereas extrinsic motivation requires outcomes such as achievement incentives . HoweverH6: Short video flow has an indirect negative effect on intrinsic learning motivation.H7: Short video flow has an indirect negative effect on extrinsic learning motivation.Although there is a great deal of research on Internet flow, the impact of short video flow on learning is still unknown. However, some clues can be deduced from other studies. For example, from the perspective of psychological symptoms, it has been observed that when playing games, addicts present a highly entertaining state where they cannot stop their activities, desire more time to play games, and feel empty, depressed, and irritable when they are not playing, with all the harmful consequences that these symptoms have on the individual's life . AccordiH8: Short video flow has an indirect negative effect on learning well-being.Well-being also refers to an individual's quality of life, is an important factor that predicts individuals' natural and social environments , and canH9: Short video addiction has an indirect negative effect on learning well-being.This study used a descriptive and relevant cross-sectional method, and the snowball sampling method when issuing the questionnaire. This way, the questionnaire link is sent to the communication group of university students in vocational schools in China in instant messaging software such as QQ and WeChat. After inviting them to fill out the questionnaire and forward it to their peers, the questionnaire was collected from October 20, 2020. The collection of data was closed after receiving 600 questionnaires. In this study, it was ensured that all processes conducted in the study comprising humans were in accordance with the ethical principles of the American Psychological Association and in compliance with Chinese regulatory requirements. Informed consent was provided in the survey, so that all participants were aware that they were participating in this study and that the data they provided were presented anonymously.In this study, 600 questionnaires were collected, and 83 invalid questionnaires with incomplete answers or that took <3 min to complete were deleted, resulting in 517 valid questionnaires, with a valid recovery rate of 86.2%. Among them, 222 (42.9%) were male students and 295 (57.1%) were female students; 56 (10.8%) watched short videos for 1–3 days per week, 130 (25.1%) watched for 4–6 days per week, and 331 (64%) watched every day. The average viewing time per day was <1 h for 61 participants (11.8%), between 1 and 3 h for 266 participants (51.4%), and more than 3 h for 190 participants (36.8%); the average age of participants was 19.19 years old (the standard deviation was 1.12 years).strongly disagree to 5 indicating strongly agree. The greater the assessment score, the greater the tendency to have a high level of that construct.This was a quantitative study in which data were collected through a questionnaire. The content of the questionnaire was adapted from past research instruments and associated theories. Three revisions were made for the fluency and comprehensibility of the text description of the item, and the completeness of the connotation of the aspect was reviewed by three educational experts for content validity. The content of the questionnaire was rated on a 5-point Likert scale, with 1 indicating Csikszentmihalyi  defined Media addiction, as a mental disorder and a complex biopsychosocial phenomenon, is defined as a user's inability to control media use and the adverse effects it has on the user's daily life . AccordiAccording to Deci and Ryan , an indiIn well-being research, one of the definitions of well-being is based on subjective evaluations of the quality of life, including positive and negative effects and cognitive evaluations of life satisfaction, which are related to the attainment of happiness . Based oIn this study, the internal consistency of the test scale was confirmed by Cronbach's α, and composite reliability (CR) was conducted to retest the reliability. Among the standards that have been commonly used in the past the Cronbach's α value and CR value should be >0.70 so that it is regarded as the acceptable standard, and the Cronbach's α value and CR value in this study were between 0.93 and 0.96, which meets the suggested standard, as shown in In this study, average variance extracted (AVE) and factor loading (FL) were used to determine the convergent validity. In confirmatory research, the FL value should be higher than 0.50 and if it is lower than this value the items should be deleted, while all the questions retained in this study met the criteria suggested by the scholars, where the mean FL values of the configurations ranged from 0.71 to 0.93, as shown in The confirmatory indicated that each construct has construct discriminant validity if its AVE root number value is larger than the Pearson correlation coefficient value of other constructs. The results of the analysis indicated that each of the constructs in this study had discriminant validity, as shown in The goal of social sciences is not only to perform basic statistical descriptions and identify individual factors and behaviors , but also to identify causal relationships between scientific domains of interest . This requires complex statistical data analysis methods and techniques due to the complexity of social reality, that is, the underlying characteristics of many social phenomena . Survey 2/df should be smaller than 5; the root mean square error of approximation (RMSEA) should be smaller than 0.10; goodness-of-fit index (GFI) and adjusted goodness-of-fit index (AGFI) should be >0.80; and items with factor loadings (FL) not higher than 0.50 must be removed from the original questionnaire. As shown in First-order confirmatory factor analysis (First-order CFA) was conducted to confirm the fit of a single dimension; the statistical threshold value of χM value of short video flow was 2.30, SD value was 1.16; the M value of short video addiction was 2.18, SD value was 1.13; the M value of intrinsic learning motivation was 3.65, SD value was 0.95; the M value of extrinsic learning motivation is 3.77, SD value is 0.92; the M value of learning well-being was 3.47, SD value was.98 as shown in The descriptive analysis results of the construct showed that the 2/df for the proposed indicators should be <5; RMSEA values should be <0.10; GFI, AGFI, normed fit index (NFI), non-normed fit index (NNFI), comparative fit index (CFI), incremental fit index (IFI), and relative fit index (RFI) values should be larger than 0.80 ; short video addiction had a negative effect on intrinsic learning motivation ; short video addiction had a negative effect on extrinsic learning motivation ; intrinsic learning motivation had a positive effect on learning well-being ; and extrinsic learning motivation had a positive effect on learning well-being , as shown in This study proposes five research hypotheses based on the theory of flow and ecosystem theory and constructed a theoretical model, and validates it through a structural equation modeling. Model verification results showed that short video flow had a positive effect on short video addiction ; short video flow had an indirect negative effect on extrinsic learning motivation (β = −0.36**); short video flow had an indirect negative effect on learning well-being (β = −0.30**); and short video addiction had an indirect negative effect on learning well-being (β = −0.40**), as shown in In this study, Bootstrapping was used to find the confidence interval of the indirect effect and to test the hypothesis of the mediated effect simultaneously. The results of the indirect effects analysis showed that short video flow had an indirect negative effect on intrinsic learning motivation . The confidence limit of CI does not cross 0 to represent the statistical significance of the results of the validation analysis, meaning that the upper and lower bound values, whether positive or negative, should be in the same direction. As shown in M = 2.30, SD = 1.16). Media addiction, as a mental disorder and a complex biopsychosocial phenomenon, is defined as a user's inability to control media use and its adverse effects on the user's daily life . Intrinsic motivation refers to people's spontaneous curiosity and interest, their tendency to pursue challenges, and to train and advance their knowledge and skills to engage in tasks even in the absence of actionable rewards . Extrinsic motivation comes from the external goals of the activity itself and involves being driven by externally imposed incentives and punishments to make oneself willing to participate in the task . Well-being is a core expressive indicator of optimal human functioning and is a state experienced by a person that emphasizes material success, comfort, and pleasure as a subjective feeling and an individual's awareness of inner satisfaction and pleasure .Flow experience is defined as an optimal experience in which an individual is completely immersed in an activity due to being energized, attentive, and successful during the activity , while t rewards ; particithe task ; participleasure , 51; parThe reason for the low overall mean of short video flow and short video addiction presented in this study can be explained by the argument of Kassas and Palma , who sugPeople with high flow are fully immersed in the process of activity that they are doing . With thThe results of this study showed that short video addiction had a negative effect on intrinsic and extrinsic motivation to learn. This result signifies that short video addiction had a negative influence on their daily life , 21, sucSeveral studies have indicated that motivation is an important factor for students' learning success rate  and is aHow short video flow affects students' learning motivation may be a critical reason to failure in academic. The results of the present study showed that short video flow had an indirect negative effect on intrinsic and extrinsic learning motivation. However, when in flow, people are highly focused and concentrate on what they are doing at a given moment . In lineThe results of this study indicated that short video flow had a negative effect on well-being, which indicates that the learning well-being of these participants who are highly enjoying short video flow experiences  is negatChen et al.  and ChenGaraigordobil  suggesteIn addition, Leung and Chen  suggest This study aims to understand the causes of short video addiction and its impact on the psychology of learning, and to develop a research model that combines the perspectives of mind flow theory and ecosystem theory to investigate the relationship between short video flow, short video addiction, intrinsic and extrinsic learning motivation, and learning well-being. The results of the study showed that: (1) short video flow has a positive effect on short video addiction; (2) short video addiction has a negative effect on intrinsic and extrinsic learning motivation; (3) intrinsic and extrinsic learning motivation have positive effects on learning well-being; (4) short video flow has an indirect negative effect on intrinsic and extrinsic learning motivation; and (5) short video flow and short video addiction have indirect negative effects on learning well-being.In addition, although the participants in this study reported low levels of addictive behaviors, the descriptive analysis showed that most used short videos frequently and for a long period of time, which may be due to the idea that they would choose to conform to social norms, as suggested by scholars, but also due to a cognitive gap and that they did not consider their use behavior as an addiction. Therefore, it is also recommended that parents, college teachers, and counselors can communicate to students the concept of behavioral addiction and the possible harm that short videos can cause to learning and mental health.From the above results, it is clear that addiction to short videos has a negative impact on learners' motivation and positive psychology of learning, but according to the software characteristics of short videos, it is inevitable that users will have a high level of flow experience, so it is difficult to eliminate this enjoyment experience. Therefore, according to the viewpoint of PPC theory, parents, college teachers, and counselors should cultivate college students' self-monitoring ability, effectively guide them to use short-video apps in a self-controlled manner, and watch short videos for a reasonable amount of time, so as to enhance their intrinsic and extrinsic learning motivation, and further enable them to feel a positive subjective sense of well-being in their learning experience, and at the same time reduce their dependence on short videos.In addition, due to the negative impact of the addiction on students, this study also suggests that governments should set appropriate regulations on the use of online media for different student groups. For example, for underage students, they should be restricted from logging in and using their short video accounts late at night to ensure that they get enough rest time. For adult students, it is recommended to use the short video time every day as a reminder, and the short video software will be temporarily stopped when the accumulation exceeds a certain time on the same day to avoid excessive use of it. At the same time, the government can also sponsor schools and educational organizations to promote education on proper Internet use so that students can understand the dangers of problematic Internet use.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.J-HY, Y-TW, Y-FW, and M-YC: concept and design and drafting of the manuscript. J-HY, Y-TW, Y-FW, and M-YC: acquisition of data and statistical analysis. M-YC and J-NY: critical revision of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Escherichia coli (DEC) is an important bacterial agent for diarrhea in infants, children, and international travelers, and accounts for more than 30% of diarrheal cases in children less than 5 years old. However, the choices of antimicrobial agents are now being limited by the ineffectiveness of many first-line drugs, in relation to the emergence of antimicrobial-resistant E. coli strains. The aim of this systematic review and meta-analysis was to provide an updated prevalence of antimicrobial-resistant DEC in Asia. A comprehensive systematic search was conducted on three electronic databases , where 40 eligible studies published between 2010 and 2022 were identified. Using meta-analysis of proportions and a random-effects model, the pooled prevalence of DEC in Asian diarrheal patients was 22.8% (95% CI: 16.5–29.2). The overall prevalence of multidrug-resistant (MDR) and extended-spectrum beta-lactamase (ESBL)-producing DEC strains was estimated to be 66.3% (95% CI: 58.9–73.7) and 48.6% (95% CI: 35.1–62.1), respectively. Considering antimicrobial drugs for DEC, the resistance prevalence was highest for the penicillin class of antibiotics, where 80.9% of the DEC isolates were resistant to amoxicillin and 73.5% were resistant to ampicillin. In contrast, resistance to carbapenems such as imipenem (0.1%), ertapenem (2.6%), and meropenem (7.9%) was the lowest. The relatively high prevalence estimation signifies that the multidrug-resistant DEC is a public health threat. Effective antibiotic treatment strategies, which may lead to better outcomes for the control of E. coli infections in Asia, are necessary.Diarrhea is one of the leading causes of morbidity and mortality in developing countries. Diarrheagenic  Escherichia coli is a commensal bacterium that colonizes the intestinal tract and rarely causes disease in healthy individuals. However, some E. coli strains have evolved by acquiring virulence determinants via horizontal gene transfer [E. coli strains involved in diarrheal diseases are known as diarrheagenic E. coli (DEC). DEC strains are classified into six pathotypes based on microbiological and epidemiological characteristics [E. coli (ETEC), (ii) enteropathogenic E. coli (EPEC), (iii) enteroinvasive E. coli (EIEC), (iv) enterohemorrhagic E. coli (EHEC)—which is also known as Shiga-toxin-producing E. coli (STEC) or, less commonly, verotoxin-producing E. coli (VTEC)—(v) enteroaggregative E. coli (EAEC), and (vi) diffusely adherent E. coli (DAEC) [transfer ,2. Theseeristics , as welleristics . These si (DAEC) ,5,6.DEC infections are typically associated with watery, mucous, or bloody diarrhea, and abdominal cramps, with or without fever ,7. OtherE. coli over the years is alarming and underlines the need for proper interventions to prevent transmission. Moreover, the emergence of multidrug-resistant (MDR) and extended-spectrum beta-lactamase (ESBL)-producing DEC strains has become a serious threat to public health, as the existing antibiotics are increasingly ineffective [bla) genes reported in the ESBL-producing DEC isolates include blaTEM, blaSHV, and blaCTX-M, with the highest frequency of ESBL producers found in the EAEC pathotype [The global incidence of antimicrobial resistance in ffective . MDR andffective . The mosathotype ,16,17. Tathotype . In the n = 1592) from 10 different studies, although the majority of studies were conducted in Iran (n = 11). The second highest number of cases of DEC was in Bangladesh, which recorded 1180 cases from only three studies. Overall, a total of 5208 DEC cases were identified and subjected to antimicrobial susceptibility testing using 46 different antibiotics  . The minn = 2178), followed by EPEC , EAEC , STEC , and EIEC   a. Only 4 n = 73) . In the 40 included studies, the antimicrobial susceptibility of the isolated DEC was tested against various antibiotics . The pooI2 = 97%, p < 0.01). The minimum and maximum prevalence of MDR-DEC was 18.5% [p = 0.0310).In this study, MDR was defined as resistance to three or more antimicrobial agents. The prevalence of MDR in DEC isolates was relatively high across individual studies, with 80.8% (21 out of 26) of the included studies reporting resistance rates higher than 50.0% of the total DEC isolates . The metas 18.5%  and 97.1as 18.5% , respectI2 = 98%, p < 0.01). As shown in Of the 40 eligible studies, 16 studies with a total sample size of 1432 reported ESBL-producing DEC in Asian diarrheal patients. After pooling the results of these studies, the overall prevalence of ESBL-producing DEC in Asia was estimated to be 48.6% (95% CI: 35.1–62.1), with significant heterogeneity between studies  [The pooled estimate revealed that 22.8% (95% CI: 16.5–29.2) of all diarrheal cases in Asia in the last two decades were caused by DEC , where t< 0.001) . Differe< 0.001) . DespiteConversely, the pooled estimate of DEC in China was 11.1% (95% CI: 4.5–17.7)—lower than the prevalence of DEC in Asia in general . The majConcerning the antimicrobial drugs for the treatment of DEC, the Centers for Disease Control and Prevention (CDC) Yellow Book 2020 recommends that antibiotics used to treat non-STEC DEC include fluoroquinolones such as ciprofloxacin, macrolides such as azithromycin, and rifaximin , although they are not recommended for the treatment of STEC due to the possible risk of hemolytic uremic syndrome . In thisE. coli against a wide array of antimicrobials was also reported by a recent comprehensive study in Ethiopia, where 78.0%, 76.9%, and 67.0% of E. coli isolates were resistant to ampicillin, tetracycline, and sulfamethoxazole/trimethoprim, respectively [E. coli isolates [High proportions of DEC isolates were also resistant against fluoroquinolones such as ciprofloxacin , levofloxacin , norfloxacin , and ofloxacin , as well as the synthetic quinolone antibiotic nalidixic acid , in spite of their importance as first-line treatments for diarrhea. Additionally, high resistance against macrolides such as azithromycin  and erythromycin , rifampicin , tetracycline , and sulfamethoxazole/trimethoprim  was alarming, as choices of antimicrobial agents are now limited by the ineffectiveness of many antibiotics. Resistance of ectively . In anotisolates . NeverthCampylobacter recorded 80.8% prevalence, while the pooled estimates of MDR Shigella and Salmonella were 79.0% and 59.5%, respectively [Klebsiella pneumoniae was recorded at 32.5%, whereas the prevalence of MDR Acinetobacter baumannii and Pseudomonas aeruginosa was 10.0% and 5.0%, respectively [Moreover, the high resistance burden of many first-line drugs has resulted in relatively high rates of MDR in DEC isolates. The pooled estimate of MDR-DEC in Asia was 66.3% (95% CI: 58.9–73.7) —substantectively . In Spaiectively . AlthougE. coli strains may not endanger health in healthy individuals; however, non-pathogenic strains that have acquired virulence genes may induce disease that may not be easily treated. They could also act as a reserve for the acquisition of virulence determinants for other bacterial species [E. coli showed a significantly increasing trend, reported at 7.8% and 18.3% in 2010 and 2014, respectively [E. coli have been shown to have good susceptibility to carbapenems and amikacin [Resistance in non-pathogenic  species . Moreoveectively . In a coectively . ESBL-pramikacin ,73,74; tn = 40) did not incorporate all of the countries in Asia; thus, the calculated prevalence might not fully represent the true proportions of antimicrobial-resistant DEC in Asia. However, a significant number of studies were included from 10 Asian countries; thus, data from a large number of participants  were analyzed. Second, although it is common in meta-analyses of prevalence estimation [Our SRMA is the first to provide a comprehensive estimation of antimicrobial-resistant DEC in Asia. Nonetheless, our analysis has several limitations. The first and most important limitation is that the included studies  in Asia that were available in the PubMed, ScienceDirect, and Scopus databases  and Nik Mohd Noor Nik Zuraina (N.M.N.N.Z.) independently evaluated the eligibility of all articles using predetermined inclusion criteria. The selected articles were then coded, and data were extracted in a table in Microsoft Excel, consisting of the author’s name, title, year of publication, study period, study region, study design, sample population, sample size, sample type, age, isolated bacterial species, resistance patterns of the isolates, and prevalence of MDR and ESBL-producing DEC.I2) [I2 > 75% and a significance level < 0.05  were deemed to represent substantial heterogeneity. In addition, publication bias was calculated by evaluating a funnel plot, which was tested for significance with Egger’s test only for the included studies of more than 10 subjects.The meta-analysis was performed using metaprop codes in the meta (version 5.2-0) and metafor (version 3.4-0) packages of R (version 4.2.1), as implemented in RStudio (version 2022.02.2+485) . The pooI2) , where IE. coli infections in Asia as well as in different parts of the world.Our SRMA provides evidence of a substantial distribution of antimicrobial-resistant DEC in Asia. The pooled estimates demonstrated a significantly high prevalence of DEC in Asia, posing a major new problem for public health. Our analysis revealed that the pooled prevalence of MDR and ESBL-producing DEC in Asia was 66.3% and 48.6%, respectively. While the prevalence varied across different countries in Asia, the evidence signifies that multidrug resistance is a public health threat worthy of careful consideration. It is therefore crucial to continuously monitor drug-resistant DEC by performing robust drug susceptibility tests as well as establishing an antimicrobial surveillance system so that reliable antibiotic strategies can be implemented, which may lead to better outcomes for the control and treatment of


This is the case of a ruptured Spetzler-Martin grade II arteriovenous malformation (AVM) located in the cerebellopontine angle and draining into the transverse sinus. The AVM was initially treated with staged embolization using Onyx (ev3 Neurovascular). However, recurrence was noted and treatment with microsurgical resection was undertaken. The authors present technical nuances of the approach and strategies for microsurgical resection of a previously embolized recurrent AVM with the aid of intraoperative indocyanine green angiography. Follow-up after endovascular treatment is critical, and curative treatment with microsurgical resection can be achieved with low morbidity in such AVMs as demonstrated by this case.https://youtu.be/LMpz_YTFC0gThe video can be found here:  This is a case of a previously ruptured recurrent cerebellopontine angle AVM that was initially treated with endovascular embolization.0:29 Patient History and Exam. The patient is a 66-year-old male who presented to an outside institution after sudden headache, right-sided numbness, and dizziness.On exam, he awakened to voice and was oriented times three. His pupils were equal and reactive. He had a right abducens palsy and right facial droop. He had mild paresis in the right upper and lower extremities and numbness to light touch on the right side.0:52 Preoperative Imaging. Patient underwent a CT head that showed a 5 × 3.5–cm right cerebellar hemorrhage with extension into the ventricles causing obstructive hydrocephalus. CTA head showed a suspected AVM with a draining vein toward the right transverse-sigmoid junction.1:09 Surgical Treatment. In the setting of symptomatic posterior fossa hemorrhage, patient underwent emergent external ventricular drain placement and suboccipital decompression with hematoma evacuation.1:19 Diagnostic Angiogram. Subsequently, the patient underwent a diagnostic cerebral angiogram shown here to better characterize the AVM. This demonstrated a Spetzler-Martin grade II AVM due to eloquent location. The nidus measured 18 × 18 mm, fed by the superior cerebellar artery and anterior inferior cerebellar artery on the right. It contained flow-related perinidal aneurysms, which are known to be associated more with posterior circulation AVMs. It drained through a dilated cerebellar vein into the right transverse sinus. Patient underwent endovascular treatment at the originating institution.1:57 Embolization Stage 1. Stage 1 of endovascular treatment occurred with embolization of two branches of the superior cerebellar artery feeding the AVM. This occluded about 80% of the AVM with 1.6 ml of Onyx-34 (ev3 Neurovascular).2:12 Embolization Stage 2. Stage 2 took place the following day with embolization of the anterior inferior cerebellar artery branches and associated perinidal aneurysm. Notably on postembolization injections, embolic material did not penetrate the AVM nidus completely, making recurrence a possibility.2:33 Postembolization Course. Patient recovered from his hemorrhage and was discharged to rehab. His neurological exam was significant for dysarthria, stable right abducens palsy, right facial droop, and left hemiparesis as a complication of nontarget embolization of a lateral pontine artery.Patient was referred to our institution afterwards and seen for a follow-up angiogram at 4½ months.2:58 Follow-Up Angiogram and Imaging. Follow-up angiogram showed that most of the AVM nidus remained occluded. However, as shown in these oblique views of right vertebral artery injection, recurrence of arteriovenous shunting was present with supply from the right superior cerebellar artery draining into the right transverse sinus. Notably, there was now also some supply through the right tentorial artery making this a pial AVM with additional dural supply.A preoperative MRI was obtained with T2 axial sequences shown here noting the encephalomalacia from prior hemorrhage and the nidus with Onyx-casted arteries. A CTA obtained showed these embolized vessels; however, recurrent feeding arteries were not well appreciated given the artifact.Given the recurrence, treatment options were discussed, including observation, repeat embolization, radiosurgery, or microsurgical resection. The decision was made to proceed with microsurgical resection for its ability to provide the most definitive and immediate treatment for this low-grade previously ruptured AVM.4:02 Retrosigmoid Approach. We chose a retrosigmoid approach to access the CP angle AVM. Patient was positioned three-quarter prone with the head affixed to a rigid 3-point Mayfield head holder. The head is rotated away from the side of the lesion and the neck is flexed. A lazy S–shaped incision is marked out behind the ear away from his prior midline incision and 2 cm behind the pinna. The incision is made through the subcutaneous tissue and subperiosteal dissection of the soft tissue and muscle is undertaken to expose the subocciput and asterion.A retrosigmoid craniotomy is performed at the transverse-sigmoid junction and the dura is opened in a cruciate fashion as shown. This allows exposure to the CP angle fissure for release of CSF, which allows optimal visualization lateral to the brainstem under the tentorium.After the craniotomy is done and connected with the prior craniectomy defect, the microscope is brought in for improved visualization and illumination. The dural opening is completed and the dural leaflets are tacked up with 4-0 Nurolon sutures.5:05 Exposure of the CPA. The right CPA fissure is followed and opened sharply, freeing arachnoid from the tentorium, as well as thickened adhesions formed from the prior hemorrhage. This allows for the cerebellum to relax away from the tentorium.Starting inferiorly, the cerebellomedullary fissure is opened, separating the arachnoid from the right posterior inferior cerebellar artery and lower cranial nerves. A combination of microforceps and microscissors are used to lyse the adhesions. Dissection is moved superiorly toward the trigeminal nerve. Feeding vessels infiltrated with Onyx become visible, and they are followed toward the nidus. The superior cerebellar artery is identified superior deep to the nidus along with an embolized branch.5:53 Resection of AVM. The AVM nidus is seen in the right CP angle posterior to the trigeminal root exit zone. Onyx embolic material was present throughout much of the nidus as well as in various feeding vessels seen here. The upper aspect of the AVM nidus remained patent and arterialized. The arterialized draining vein entering the tentorium and draining into the right transverse sinus is identified. Intraoperative indocyanine green angiography is performed to visualize the AVM and its draining vein.6:19 Using gentle spreading of the microforceps and bimanual technique, feeding arteries of the AVM are identified and dissected. Using bipolar cautery and sharp dissection, a plane is cleared around the AVM nidus and away from the cerebellar parenchyma. We coagulate and divide small arterial feeders to the AVM.6:41 Predominantly, these feeders were from branches of the superior cerebellar artery. Feeding arteries containing Onyx were also coagulated and sharply divided at a point adjacent to the nidus to allow release from surrounding structures. Here, an embolized perinidal aneurysm is seen as we dissect adjacent to the trigeminal nerve.7:03 Starting superficial to deep, feeding arteries both contributing to the nidus and previously embolized are disconnected in systematic fashion, while preserving other vessels and critical structures of the CP angle. After circumferential dissection around the AVM nidus, the draining vein remains arterialized. We inspect around the nidus, noting that embolized arteries may be left behind as they are no longer feeding the AVM. Another indocyanine green intraoperative video angiogram is performed and compared with the one just prior to resection.7:41 The remaining arterial supply to the arterialized vein now originated within the tentorium. A clip is placed and the infratentorial portion of the AVM is removed and sent as specimen to pathology. Next, the tentorium surrounding the vein is coagulated and divided. After this, the vein appears bluish in color and is no longer arterialized. A final fluorescence video angiogram confirms no residual nidus with no arterial blood flow in the vein present. A 7-mm straight Yaşargil clip is then placed across the draining vein at the tentorium.8:16 Closure. Hemostasis is achieved and copious irrigation is applied to the resection bed. The dura is closed in a watertight fashion with a synthetic dural patch graft. The bone flap was reaffixed with titanium plates and screws, and the muscles and scalp were closed in a standard multilayered fashion.8:34 Postoperative Imaging. Immediate postoperative angiogram showed complete resolution of the AVM, as shown in this AP and lateral injection of the right vertebral artery.Postoperative CT head showed expected postsurgical changes.8:49 Postoperative Course. Postoperatively, the patient remained neurologically stable and discharged home on POD 5. He recovered well and remained without new symptoms at 3-month and 6-month follow-up. Final pathology confirmed an arteriovenous malformation.9:04 Conclusion. In summary, follow-up is important in endovascularly treated AVMs, particularly those of the brainstem and CP angle. Microsurgical resection of previously embolized recurrent AVMs is safe and effective and is the optimal treatment of choice after recurrence of low-grade AVMs in the posterior fossa, providing definitive treatment.Primary surgeon: Nayar. Assistant surgeon: Dowlati. Editing and drafting the video and abstract: Dowlati, Chesney. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Dowlati. Supervision: Nayar.


The single-antenna technique proposed in this paper was developed for measuring the radar cross-section at near-field distances in a real environment, from reflection coefficient measurements on the antenna. The near-field radar cross-section is corrected with an analytical factor calculated as a ratio between the radar cross-section computed at far-field and near-field. The analytical correction factor takes into account the effects of the diffraction at the edges of the target at incidence angles higher than 20°. An improved, distance averaging technique is proposed to reduce the multipath propagation effects. A time-gating procedure is additionally used in order to better isolate the reflection from the target and to remove the real environment contributions. The method was successfully tested on a rectangular metallic plate as a target over a wide frequency band, at normal and oblique incidence angles; however, it might also work for arbitrarily shaped targets, because they can actually be divided into small rectangular patches. Generally, the radar cross-section (RCS) is measured in anechoic chambers (AC) at near-field distances. Large targets, such as aircraft, ships, or terrestrial vehicles require large anechoic chambers and, therefore, the cost of such a measurement would be prohibitive. In this case, the RCS measurements in a real environment at near-field distances could be a strong alternative to the anechoic chamber measurements ,2,3.The RCS evaluation is usually performed by measuring the scattering parameters in monostatic, quasi-monostatic, or complex bistatic configurations with two antennas often exhibiting a strong mutual coupling, and therefore not suitable for measurements at oblique incidence angles . In orderget. In , the autA representative approach to evaluate the RCS at near-field distances consists of performing near-field to far-field transformations by using mathematical relations between the scattered field and the current density on the target ,15,16,17All aforementioned methods have a rather high computational efficiency but a quite poor extrapolation accuracy due to the surface current approximation.In this paper, we propose a single-antenna method for measuring the RCS of a target in the near-field and in a real, multipath environment. The multipath propagation effects are reduced by applying an improved distance averaging technique combined with a time-gating procedure following a specific strategy for an optimal choice of the post-processing technique. A correction factor made it possible to validate our method at near-field distances and at oblique incidence angles where the diffraction effects are strong. The diffraction effects are calculated by defining equivalent edge currents on the side of the target and by using the diffraction coefficients developed by Kouyoumjian in . The mear is the radar-to-target distance, and The RCS in the far-field zone is defined as effects .a by b , , 1), in In , λ is thr is in the near-field range, for most practical antenna sizes and measuring ranges, When the distance By using  in 3), , 3), thea by b becomesAt far-field distances, the RCS of a rectangular target of sizes The diffraction term in  can be cThe electric field diffracted by a wedge when the incident field is of a soft-type polarization  is(6)EdThe magnetic field diffracted by a wedge when the incident field is of a hard-type polarization isz axis, the far magnetic field radiated by the equivalent electric line source of a length b can be written asWhen assessing the diffraction on a plate edge along the a along the x-axisA similar form can be derived for the magnetic field originating from a magnetic finite line source of a length Finally, the diffracted-to-incident magnetic field ratio can be expressed as follows:F between near- and far-field zones as follows:By using es as in , one canIn a single-antenna radar configuration, the far-field zone radar equation yields (12)σff=When measuring the RCS in a real site, in order to reduce the environment impact, we subtracted the reflection coefficient measured without the target Sno from rIn , d0 is aThe distance-averaging technique proposed in  is a newIn order to validate the method, simulations and measurements were performed at frequencies between 3 and 11 GHz. We choose as a target a rectangular, metallic plate of 22 cm by 35 cm, and we used a horn antenna with an aperture size of 20 cm by 20 cm.The antenna was a standard ridged horn (model PowerLog 70180 by Aaronia), operating in the frequency range from 700 MHz to 18 GHz. The gain variation in the main direction of radiation over the frequency range of interest is given in Most radars for discovering targets hidden by vegetation use low frequencies, typically in the VHF and UHF bands. Outdoor tests in a real scenario would require long ranges and high power levels. We therefore tested our technique by using a scale-reduction approach. As a multipath environment we chose an indoor site i.e., a regular office room. In that case, distances and typical target sizes can be reduced by a factor of ten, whereas the frequencies are multiplied by the same factor. The power level delivered by the VNA internal generator is enough for a good signal-to-noise ratio.The eld zone .When measuring the reflection coefficients on a planar target in a real environment, as the angle of incidence increases, the magnitude of the scattered field from the target becomes comparable to the that of the scattered field from other objects. In addition, the application of the distance averaging technique (DA) would reduce the effects of the diffraction not only on the environing objects, but also on the target edges . In thatF at F factor , and the far-field simulations is displayed in The absolute error between the RCS measured at near-field distances corrected with the F , by taking as reference the simulations of the RCS in the far-field zone  was calculated. The RME in  was calceld zone :(15)ϵRMEAs expected, the RCS obtained after the utilization of the DA at oblique incidence is very far from far-field simulated RCS. Instead, by utilizing a combination between the DA and TG, the absolute error between the measurements and the far-field RCS rarely exceeds 5 dB over the entire 3–11 GHz band. Thus, when measuring the RCS at near-field distances an adaptive choice between the post-processing methods (DA or DA+TG) is needed, depending on the frequency and angle of incidence.We proposed a novel single-antenna method and strategy of post-processing for RCS measuring in the near-field-zone. The simulated, far-field RCS is in good agreement with the RCS measured in the near-field region at normal incidence and in a real environment, by applying DA. Conversely, at oblique incidence a combination between DA and TG as post-processing techniques would lead to more accurate results than the DA alone. In any case, the relative mean error over the frequency range of interest, compared to the far-field simulation is less than 15%. The technique proposed in this paper may reduce the cost of the RCS measurements by using either smaller anechoic chambers, or by performing real site measurement. Future research will focus on optimizing the method to measure the RCS of simplified models consisting of rectangular patches and slots; the far-field RCS of such a model can further be evaluated analytically for comparison purposes. In order to extend the method to dielectric targets, the


PurposeThis paper examines the changes in the representation of women and racial minorities in academic medicine, compares the proportion of minorities in medicine and the general United States (US) population, and discusses potential explanations for observed trends.MethodsA retrospective cross-sectional analysis of the Association of American Medical Colleges (AAMC) database was done and used to collect data on the gender and race of physicians in academic medicine. Data was collected for instructors, assistant professors, associate professors, full professors, and chairpersons from 2007 to 2018, and trends were presented.ResultsWhite physicians represented most academic physicians at every academic level, peaking in proportion at 82.74% of chairpersons and were lowest at the level of instructor at 59.30%. A similar distribution existed when gender was compared, with men comprising 84.67% of chairpersons and forming the majority at levels of full, associate, and assistant professors. However, most physicians at the level of instructors are women at 55.44%.ConclusionsThough women and racial minorities have gained greater representation in academic medicine over the past decade, high-level academic positions are not as accessible to them. Existing efforts of advocacy for women and minority races have proven fruitful over the past decade, but much more work needs to be done. Gender and racial diversity in medicine improves workforce morale, reduces burnout, enhances patient care, and leads to a higher quality of scientific advancement , 2. IncrGiven the high value of greater representation in medicine, trend analyses have been conducted for various trainee and physician groups in medicine. These analyses provide insights into the efficacy of representation advocacy and guide the goals of future advocacy efforts. Yu et al. showed that from 1998 to 2007, the greatest representation of women in academic medicine occurred at the lowest levels of the academic ladder, with “instructors” being almost 50% women, whereas only 14.7% of professors were women, with just 9.2% being chairpersons [Since 2007, many advocacy initiatives and social movements in America have been put into action to increase gender and racial representation in medicine, such as the efforts of the black lives matter movement. However, based on our literature review, to date, no study has analyzed trends in gender and racial representation in academic medicine since 2007. This paper examines recent trends in career advancement for women and racial minorities in academic medical from 2007 to 2018 to capture the effects of advocacy efforts in the past decade and a half. This study also aims to provide insights into current diversity gaps in American academics and therefore, guide future advocacy efforts.This was a retrospective data analysis study that was exempt from the Research Ethics Board review. It was based on publicly available data, and the dissemination of results did not identify any individual or generate new forms of identifiable information. The methodology of this study has been validated in recent publications , 16. TheAnalysis of dataPercentages were used to report trends in gender and race in academic medicine. The percentage of faculty members was averaged over 12 years for each academic position . The absolute change in the number of physicians from 2007 to 2018 was calculated for each gender and racial group.Between the years 2007 and 2018, over 46,258 academic medicine positions were added in the United States (US) . Representation of other genders  was not studied. Future studies should assess the representation of all genders as well. There is a limited amount of research on the role that gender and race play in the selection of a career in academic medicine by under-represented groups. This is a relevant area for future research, particularly on the identification of perceived and real barriers to entry and progress in academic medicine, such as access to grant money, resources, and supports needed to publish or the ability to participate in clinical trials. The data did not include indicators of academic productivity such as h-index, number of citations, and the total number of publications. Furthermore, this study did not explore any additive effects of being both a gender and racial minority, which may place them at a further disadvantage.Analysis of the AAMC data examining the past 12 years revealed that at higher ranks of academia, there is gender and racial disparity, with a disproportionately high representation of males and Whites. However, between the years 2007 and 2018, under-represented minorities have made large strides at all levels of academia, and the proportions of gender and race in academic medicine are trending towards greater diversity and representation, matching their proportions in the general population. While the causes of the disparities in representation are likely multifactorial, several compelling arguments seek to explain these differences. These results demonstrate a cohort of academic physicians that is increasing in both gender and racial diversity at all levels of academic medicine.