Mycobacterium ulcerans, an environmental opportunistic pathogen, causes necrotic cutaneous and subcutaneous lesions, named Buruli ulcers, in tropical countries. PCR-derived tests used to detect M. ulcerans in environmental and clinical samples do not allow one-shot detection, identification, and typing of M. ulcerans among closely related Mycobacterium marinum complex mycobacteria. We established a 385-member M. marinum/M. ulcerans complex whole-genome sequence database by assembling and annotating 341 M. marinum/M. ulcerans complex genomes and added 44 M. marinum/M. ulcerans complex whole-genome sequences already deposited in the NCBI database. Pangenome, core genome, and single-nucleotide polymorphism (SNP) distance-based comparisons sorted the 385 strains into 10 M. ulcerans taxa and 13 M. marinum taxa, correlating with the geographic origin of strains. Aligning conserved genes identified one PPE (proline-proline-glutamate) gene sequence to be species and intraspecies specific, thereby genotyping the 23 M. marinum/M. ulcerans complex taxa. PCR sequencing of the PPE gene correctly genotyped nine M. marinum/M. ulcerans complex isolates among one M. marinum taxon and three M. ulcerans taxa in the African taxon (T2.4). Further, successful PPE gene PCR sequencing in 15/21 (71.4%) swabs collected from suspected Buruli ulcer lesions in Côte d’Ivoire exhibited positive M. ulceransIS2404 real-time PCR and identified the M. ulcerans T2.4.1 genotype in eight swabs and M. ulcerans T2.4.1/T2.4.2 mixed genotypes in seven swabs. PPE gene sequencing could be used as a proxy for whole-genome sequencing for the one-shot detection, identification, and typing of clinical M. ulcerans strains, offering an unprecedented tool for identifying M. ulcerans mixed infections.IMPORTANCE We describe a new targeted sequencing approach that characterizes the PPE gene to disclose the simultaneous presence of different variants of a single pathogenic microorganism. This approach has direct implications on the understanding of pathogen diversity and natural history and potential therapeutic implications when dealing with obligate and opportunistic pathogens, such as Mycobacterium ulcerans presented here as a prototype. Mycobacterium ulcerans, a nontuberculous mycobacterium aggregated in a so-called Mycobacterium marinum/M. ulcerans complex, is responsible for Buruli ulcer, a neglected tropical infection that occurs in rural populations in 36 countries and 4 continents  and two insertion sequences IS2404 and IS2606  in the context of taxonomic and phylogenetic investigations of this pathogen (M. ulcerans complex members (including different taxa). We further analyzed this hot spot and are now reporting that investigating this hot spot by using an appropriate PCR sequencing system described here could add a convenient laboratory tool for diagnosing genomic diversity of M. ulcerans in clinical materials.Here, investigating a large collection of pathogen , we obseM. marinum complex genomic sequences. In detail, 355 M. ulcerans genomes were isolated from humans and animals from Angola, Benin, Cameroon, Côte d'Ivoire, Democratic Republic of the Congo, Gabon, Ghana, Nigeria, Papua New Guinea, Republic of the Congo, Togo, Uganda, Australia , the United States, Japan, and French Guiana, 3 M. pseudoshottsii genomes were isolated from the United States and China, 3 M. liflandii genomes were isolated from Israel, and 24 M. marinum genomes were isolated from France, Thailand, Israel, the United States, Japan, and the United Kingdom.We investigated a database containing a total of 385 M. ulcerans taxa and 13 M. marinum taxa comprising 24 isolates, as previously reported (M. marinum taxa (1) was composed of M. marinum taxon 1.1, which includes 8 isolates with between 5 and 767 SNPs, M. marinum taxon 1.2, which includes 2 isolates with 13 SNPs, M. marinum taxon 1.3, which includes 1 isolate, M. marinum taxon 1.4, which includes 2 isolates with 18 SNPs, M. marinum taxon 1.5, which includes 1 isolate, M. marinum taxon 1.6, which includes 1 isolate, M. marinum taxon 1.7, which includes 1 isolate, M. marinum taxon 1.8, which includes 1 isolate, M. marinum taxon 1.9, which includes 1 isolate, M. marinum taxon 1.10, which includes 1 isolate, M. marinum taxon 1.11, which includes 2 isolates with 2 SNPs, M. marinum taxon 1.12, which includes 1 isolate, and M. marinum taxon 1.13, which includes 2 isolates with 88 SNPs  was composed of 165 isolates all from Southern Australia, with SNPs varying between 1 and 618 , and 6 animal isolates  originating from four counties . The M. ulcerans taxon 2.2 was comprised of 10 isolates exclusively from North Australia, with SNPs varying between 1 and 395 . M. ulcerans taxon 2.3 was detected in Africa and North Australia; Papua New Guinea included 12 isolates with SNPs varying between 7 and 489 . M. ulcerans taxon 2.4 (specific for Africa) included 160 isolates with SNPs varying between 1 and 955 . Taxon 2.4 was divided into subtaxon 2.4.1, which included 139 isolates with SNPs varying between 1 and 655, and subtaxon 2.4.2, which included 21 isolates with SNPs varying between 4 and 598. M. ulcerans taxon 2.5 included 6 isolates, with SNPs varying between 9 and 256 . M. ulcerans taxon 2.6 (specific for French Guiana) included one isolate (M. ulcerans P7741 isolated from French Guiana). Taxon 2.7 included M. liflandii 128FXT isolated in Africa. Taxon 2.8 included M. marinum strain BB170200 isolated in Israel. Taxon 2.9 included 3 isolates with SNPs varying between 254 and 509 . Taxon 2.10 included Mycobacterium sp. 012931. Interestingly, we found the M. ulcerans strain Harvey (JAOL01000001.1) with 1,363 SNPs within taxon 2.1. This strain has remained unclassified and is waiting for genome sequence confirmation to ensure the correct classification of this atypical strain  yielded a total of 54,211 genes comprising 2,804 core genes (99% ≤ strains ≤ 100%), 783 soft core genes (95% ≤ strains < 99%), 2,155 shell genes (15% ≤ strains < 95%), and 48,469 cloud genes (0% ≤ strains < 15%). Core genome tree and single-nucleotide polymorphism (SNP) distance based on core genome sequence data  yielded 10 different M. ulcerans and M. marinum isolates from different areas, we searched for a specific marker gene whose sequence would detect and discriminate between the announced taxa. Using the Seaview application, we observed that one PPE gene sequence was variable enough to discriminate between the M. ulcerans and M. marinum taxa, acting as a hot spot sequence proxy for the complete genome sequence, as detailed above. M. ulcerans strain SRR6346343 in taxon 2.1, isolated from T. vulpecula in Gippsland, completely lacked the PPE gene. A phylogenetic tree drawn from 384 extracted PPE gene sequences in the assembled genomes of M. marinum and M. ulcerans showed coherent clustering of taxa with the core genome phylogenetic tree (PPE gene was annotated as a PPE family protein (CP003899.1) in the M. liflandii strain 128FXT used as the reference (GenBank accession number NC_020133.1). The PPE protein was predicted to be an alpha helical transmembrane protein with a 0.934205 probability. We further observed deletions in the 5′ extremity of the PPE gene detected specifically in M. ulcerans taxa 2.1, 2.2, 2.3, 2.4.1, and 2.4.2 and the M. ulcerans strain Harvey (JAOL01000001.1), resulting in a PPE gene size varying between 335 bp and 562 bp, correlating with the clustering of taxa in the core genome tree  in the common region compared to all the other isolates , two taxa specific for Africa (T2.4.1/T2.4.2), one taxon (T2.5) specific for Asia, and one taxon (T2.3) shared between Africa and Papua New Guinea.Based on output conserved alignment genes from the pangenome analysis of 385 different tic tree . This 1,ome tree . In M. u and 1.8 . Alignin and 1.8  and 4. APPE gene in nine cultured M. ulcerans and M. marinum isolates belonging to four taxa retrieved an experimental sequence identical to the one derived in silico from the whole-genome sequence of the same strain (PPE gene for each strain (Table S3). As for DNA extracted from 24 swabs collected for the diagnosis of Buruli ulcers, the insertion sequence IS2404 real-time PCR found 21 positive samples exhibiting cycling threshold (TC) values of <32 (PPE gene further detected 15/21 (71.4%) positive samples, which all exhibited real-time PCR IS2404 TC values of <39.9  as well as reads deposited for 174 M. ulcerans and 167 M. ulcerans isolates from two large epidemic areas in Australia and Africa  (–https://github.com/s-andrews/FastQC). These 341 M. ulcerans sequencing reads were assembled using SPAdes version 3.14.0 and annotated using Prokka version 1.14.6  . Moreover, one PCR primer pair specifically targeting a 390-bp region in the PPE gene of interest was designed using primer BLAST (https://www.ncbi.nlm.nih.gov/tools/primer-blast/).We retrieved WGS data for 44 assembled genomes of aterial) –8. FastQn 1.14.6 , 11. To M. ulcerans isolates and one M. marinum isolate maintained in the IHU Méditerranée Infection Mycobacteriology Laboratory collection and firmly identified by WGS were incubated for 6 weeks at 30°C on solid Löwenstein-Jensen medium . DNA was extracted from colonies using the InstaGene matrix following the manufacturer’s instructions (Bio-Rad). In addition, 24 leftover swab samples taken from suspected Buruli ulcer cutaneous lesions in 24 different patients as part of routine medical management in Côte d'Ivoire were tentatively diagnosed as M. ulcerans infections at the Institut Pasteur Laboratory, Abidjan, Côte d’Ivoire  in 50-μL reaction mixtures containing 5 μL of genomic DNA template, 25 μL of AmpliTaq Gold 360 master mix (Thermo Fisher Scientific), 1.5 μL of each primer , and 17 μL of deionized water. The PCR program included an initial denaturation at 95°C for 15 min, then 35 cycles of 95°C for 30 s, 64°C for 30 s, and 72°C for 1 min 30 s, followed by a final extension at 72°C for 10 min. DNA from a Mycobacterium bovis BCG strain treated under the same conditions was used as a negative control. Amplification products, confirmed by 1.5% agarose gel electrophoresis, were purified using the Millipore NucleoFast 96 PCR kit according to the manufacturer’s recommendations  and sequenced using the BigDye terminator cycle sequencing kit (Applied Biosystems) with an ABI automated sequencer (Applied Biosystems). Sequences were assembled using the Chromas Pro 1.7 software .Eight d’Ivoire . Swabs wNo clinical specimen was sampled specifically for this study, which only incorporated anonymized, leftovers of samples routinely collected for the diagnosis of Buruli ulcers in consulting patients.The data supporting the findings of this study are available within the article and its supplemental material. Raw data that support the findings of this study are available from the corresponding author upon reasonable request.


The aging society posits new socioeconomic challenges to which a potential solution is active and assisted living (AAL) technologies. Visual-based sensing systems are technologically among the most advantageous forms of AAL technologies in providing health and social care; however, they come at the risk of violating rights to privacy. With the immersion of video-based technologies, privacy-preserving smart solutions are being developed; however, the user acceptance research about these developments is not yet being systematized.With this scoping review, we aimed to gain an overview of existing studies examining the viewpoints of older adults and/or their caregivers on technology acceptance and privacy perceptions, specifically toward video-based AAL technology.A total of 22 studies were identified with a primary focus on user acceptance and privacy attitudes during a literature search of major databases. Methodological quality assessment and thematic analysis of the selected studies were executed and principal findings are summarized. The PRISMA-ScR  guidelines were followed at every step of this scoping review.Acceptance attitudes toward video-based AAL technologies are rather conditional, and are summarized into five main themes seen from the two end-user perspectives: caregiver and care receiver. With privacy being a major barrier to video-based AAL technologies, security and medical safety were identified as the major benefits across the studies.This review reveals a very low methodological quality of the empirical studies assessing user acceptance of video-based AAL technologies. We propose that more specific and more end user– and real life–targeting research is needed to assess the acceptance of proposed solutions. As a response to the health care challenges related to an aging society  and lackWhile AAL is mainly perceived as helpful and beneficial when it comes to assisting older individuals -13, the Traditionally, technology acceptance has been measured with the Technology Acceptance Model (TAM)  as well With a focus on privacy, Lorenzen-Huber and colleagues  developeDepending on the unfolding of these relevant factors in this mental tradeoff, positive aspects of technology may even override privacy concerns . HoweveOverall, the role privacy plays in the acceptance of AAL technologies is complex, can be seen as a tradeoff between barriers and benefits or a multidimensional phenomenon, and its evaluation is dependent on a specific point in time and on the way it is examined. It is therefore timely to review and map the existing literature in this field. Therefore, a scoping review method was applied with the aim of gaining an overview of existing studies examining the viewpoints of older adults (aged≥50 years) and/or their caregivers on technology acceptance and privacy perceptions, specifically toward video-based AAL technology.The more specific objectives of this review were to (1) scope the body of literature about acceptance and privacy perceptions toward video-based AAL technologies; (2) identify methodologies used to measure acceptance and privacy perceptions toward video-based AAL technology; and (3) identify major knowledge gaps and synthesize the knowledge about perceptions toward video-based AAL technology as a guideline for future research.This review concentrates on AAL technology that is camera/video-based. The reasons for specifically targeting camera/video are two-fold: on the one hand, visual sensors have high potential to provide quality care -9, whereThis review was based on a methodological framework developed by Arksey and O’Malley  that wasThe final search took place on August 23, 2021 (and a rerun of databases was performed again in September 2022), and was not restricted by publication date. The reproducible full electronic search strategy of all databases searched is provided in Studies published in English, Spanish, German, French, Portuguese, Italian, Russian, and Georgian languages were considered, although English search terms were used. The following databases were searched: Web of Science (includes Medline), PsycINFO and CINAHL (by EbscoHost), Scopus, Sociology Abstracts by ProQuest, Google Scholar, and ArXives. Articles were included for this review if they dealt with privacy perceptions and acceptance attitudes of potential or current users of video-based AAL technology, such as older adults (50+ years) or disabled people (of any age) and their caregivers, family members, nurses, medical staff, and bystanders (of any age). The full table of inclusion and exclusion criteria can be accessed in In the next stage, full texts of the 136 articles were retrieved in Mendeley software and were assessed for eligibility on a full-text level by the two researchers independently. Disagreements were resolved by a third researcher and a total of 18 articles were identified for inclusion from the databases searched. Three additional articles were preidentified through personal registers. Reference lists from these publications were manually searched for any reports missed by database searches and personal registers, and one more article was found to be eligible for inclusion in the scoping review, resulting in a total of 22 articles .Data extraction was executed by two researchers independently and was charted in a spreadsheet. The extracted data included author, year, title, place of publication, country, purpose, technology and context of use, methods, and main outcomes. In some cases, the authors of the articles were contacted to obtain and confirm the data. Disagreements and questions during the data extraction process were addressed by the third investigator and interrater agreement was reached through their help. The final table of data extraction is given in In line with the research objective of understanding the various methods used for assessing acceptance and privacy attitudes toward video-based AAL, the characteristics and methodological quality of the single studies were explored using critical appraisal. An adapted version of the Scale to Assess the Methodological Quality of Studies Assessing Usability of Electronic Health Products and Services  was usedThe articles were read several times to identify key values and areas in which acceptance and privacy perceptions related to video-based AAL technology appear in the care of people in need. Data were analyzed with thematic analysis  using thThe 22 included articles were published between 2006 and 2021, with a rather even distribution over the years. Articles were developed from work conducted in 6 countries, with the most publications coming from the United States  and Canada , followed by Germany  and the United Kingdom . Most studies were in published in English , with the remaining two selected articles published in French.The characteristics of the 22 included studies are summarized in More publications based their research on study participants having direct contact with technology  than no direct contact with technology . Regarding the former, participants either got to experience the relevant assistive technology in a living lab  or the technology was installed in a specific environment . Where direct contact with technology was not provided, participants were either shown videos , introduced to a scenario , or the technology was presented to them through a presentation .Only 4 of the 22 studies obtained a score of 10 or more out of 13  in the critical appraisal assessment. The main questions that failed to fulfill the criteria were related to the triangulation of methods, training and externality of the researcher, as well as the number of participants. The full details of the critical appraisal tool and detailed results are provided in Based on previously proposed models of technology acceptance ,17,19 anPrivacy: Informational privacy attitudes and handling and access to the video materialIntrusivenessType of obtained informationLocation of a video-based active and assisted living systemDuration of use (control over it)Privacy concern mitigationNecessity: medical necessitySocial environment and its influenceNegative effects on caregiversBystanderPositive effect on caregivers and family membersBenefitsSecurity and medical safetyBeing independentRemain at homeBarriersDignity and confidentialityInterference with normal routineCyber dependencyDecreased human contactRegarding the overall acceptance of video-based AAL, the results from the selected 22 studies show that acceptance attitudes toward video-based AAL technologies are rather conditional. Few studies reported more concerns over the use of monitoring systems than advantages ,49; howeMost of the studies reported much higher levels of trust in health care providers than in insurance companies and the government. Selected studies also show that participants agree that relatives, family members, and health care providers can have access to the video material, although there is slight interstudy variation in this regard. For example, Bourbonnais et al  demonstrInvading physical as well as emotional privacy was reported as worrisome across the studies by the participants. Ziefle et al  reportedThe privacy-by-design paradigm in technology allows data protection through inherent technology design . Six of Most studies showed that bathrooms and bedrooms are the areas where the installation of video-based AAL systems is accepted the least by individuals. Demiris and colleagues  suggesteMost of the selected studies conveyed the idea that it is very important for individuals to have control over the duration of use of a video-based AAL system; in particular, they wish to turn it on and off whenever they like. Participants believed that this ability of a system was an advantage that also maintains privacy. Likewise, most of the studies showed that participants were not happy with the idea of a permanent installation of a monitoring system without them having control over the duration of its use.Participants across the studies identified several positive aspects that helped prevent privacy concerns, including privacy filters that guaranteed anonymity of the filmed subjects; having control over the system in terms of choosing its location and time for recording; and in the case of wearable cameras, the egocentric point of view of the camera, which did not show the user’s face alleviated participants’ worries. Moreover, studies showed that the greater the perceived need for help, the more privacy one may be willing to give up.Medical necessity was reported as one of the greatest predictors and modulators of acceptance attitudes toward video-based AAL technologies across all included studies. The perceived benefit-to-cost ratio appeared to increase with the level of medical necessity, which also included more readiness to share information or accept potential privacy threats.Some studies mainly identified possible negative effects on formal caregivers, such as feeling threatened by being under constant surveillance ,36,49. TMost participants across the studies expressed concerns about the presence of household members, visitors, roommates, or facility staff in the video. Some of them felt uncomfortable receiving visitors, coupled with the fear of explaining the installed system to them. The need for consent from the bystanders was raised. Interestingly, two studies using a wearable camera ,50 reporHalf of the selected studies integrated caregivers, including formal caregivers from institutions or family members. The thematic analysis demonstrated that a video-based AAL system could alleviate anxiety in caregivers by detecting medical emergencies, could give them more peace of mind, and increase their well-being in general. Caregivers from the facilities also noted that their workload could be greatly alleviated using these technologies, which would also result in better care practices. However, caregivers also noted the possible negative effects of video-based AAL technologies, which are described in further detail in the Barriers section below.All selected studies agreed that the biggest benefit of video-based AAL technology was detecting medical emergencies, which then leads to feelings of security and peace of mind. People are willing to accept surveillance, and even the loss of privacy it entails, when the result is greater security of person and property and/or faster response to emergency situations. Apart from detecting emergencies, some studies also reported a great benefit in the documentation of emergencies or explanation of falls, such as checking where the resident is hit in the falling accident ,49. ImpoParticipants across the studies agreed that proposed video-based AAL technologies promoted more autonomy and the ability to live more independently whether in their own home or a residential facility. In the case of living independently in their own homes, proposed technologies reduced their fear of being alone at home and promoted a sense of confidence and security.The ability to be autonomous and independent led participants to appreciate the possibility to remain in their own homes and feel safe.With privacy being the main threat in the video-based AAL technologies, we here present some other barriers identified through the thematic analysis. Besides the two main barriers presented below, two other less prominent barriers identified were the potential of cyber dependency and decreased human contact.The risk to confidentiality and concern over dignity was often raised across the studies in relation to the video-based AAL technology. Feelings of vulnerability, embarrassment, “feeling stupid,” or the potential of monitoring technologies to demoralize them and arouse negative emotions were also reported among participants of the selected studies.Participants changing their behaviors because of the technology in question was detected across the studies. Caine et al  executedVideo-based AAL technology acceptance research still has a long way to go. This scoping review managed to grasp some important points of this process. We synthesized existing knowledge about the benefit-barrier tradeoff of video-based AAL technologies, and further identified knowledge gaps and directions for future research.interference with the normal routine. This subcategory, identified as a barrier, might be specific for video-based AAL. In fact, behavior changes and discomfort due to video surveillance are reported. Indeed, a camera, analogous to the human eye, can “see” and report data that are easily interpretable by humans compared to numerical data. Therefore, the fear of the risk to perhaps accidentally reveal personal and intimate details is particularly high.To synthesize existing knowledge on attitudes and perceptions of technology acceptance and privacy, a thematic analysis across the 22 selected studies was performed. Five main categories emerged in this process: Privacy, Medical Necessity, Social Environment and its influence, as well as separately grouped Benefits and Barriers. The latter two themes are usually weighted off against each other and hence play a crucial role when it comes to the decision of accepting or rejecting assistive technology . While minformational privacy attitudes and handling and access to the video material that emerged in our review highlighted the importance of controlling the data as well as the data flow. Data access is viewed as critical depending on the person with access to the data . Efforts to preserve (data) privacy are being developed as part of the so-called privacy-by-design paradigm, as described under the subcategory type of obtained information. The subcategory location of video-based AAL system states that typically sensitive activities occurring in the bedroom and bathroom particularly evoke privacy concerns. Lorenzen-Huber et al [Privacy, as the main emerging category, presented not only as a notion of threat or concern, but further branched into six identified subcategories depicting multiple aspects of the construct and demonstrating that privacy attitudes are rather conditional and tradeable. Similarly, in the model of preimplementation acceptance , privacyer et al  reportedsocial environment and its influence emerging in this study is not entirely based on this notion, but highlights the dynamics within the social environment that can have an influence on acceptance. There are two potential identified subcategories that illustrate these dynamics. First, negative effects on caregivers unfolds the fear that video-based AAL technology may contribute to a culture of mistrust, whereas positive effect on caregivers and family members explains how video-based AAL may alleviate anxiety in caregivers and provide more peace of mind. Another emerging topic, concerns regarding bystanders, seems to considerably influence participants’ perceptions of video-based AAL. This concern might be particularly relevant when it comes to camera technology due to pervasive monitoring and the visibility of the system.Previous models ,19,57 haWith so many factors playing a role in the acceptance of video-based AAL systems, specific questions based on real-life practice need to be addressed in future studies to obtain an accurate picture of user acceptance. During our literature search, tens of general technology acceptance studies were identified; however, only 22 of them focused specifically on video-based AAL acceptance. This is important to note, as each technological solution has its own specifications and it is very difficult to talk about general technology acceptance. This is particularly evident since even when considering only video-based AAL technologies, acceptance depends on numerous variables. Hence, more specific, end user–focused, and real life–targeting research needs to be done, where the type of technology, obtained data thresholds, control over the system, and user specificities such as context and needs are taken into account. This is particularly evident given that in 9 of the selected 22 studies, the participants did not even have any direct contact with the proposed technology when answering questions about its acceptance. This point can be taken to another level by observing an interesting tendency across the studies: even when participants rated the proposed system as favorable, this would not always translate into their willingness to use it. This discrepancy between attitudes and behaviors has been well-documented for a long time  and the Overall, it is very important to note that the panorama of published studies reveals a tremendous methodological weakness, as they fail to consider and report relevant methodological aspects. Research in this area still seems to be in an exploratory stage; hence, more effort is needed to take off from this phase. Taking all this information into account, studies of higher methodological quality targeted at specific technologies are needed to answer the questions of user acceptance and privacy in video-based AAL.


Science misinformation on topics ranging from climate change to vaccines have significant public policy repercussions. Artificial intelligence-based methods of altering videos and photos (deepfakes) lower the barriers to the mass creation and dissemination of realistic, manipulated digital content. The risk of exposure to deepfakes among education stakeholders has increased as learners and educators rely on videos to obtain and share information. We field the first study to understand the vulnerabilities of education stakeholders to science deepfakes and the characteristics that moderate vulnerability. We ground our study in climate change and survey individuals from five populations spanning students, educators, and the adult public. Our sample is nationally representative of three populations. We found that 27–50% of individuals cannot distinguish authentic videos from deepfakes. All populations exhibit vulnerability to deepfakes which increases with age and trust in information sources but has a mixed relationship with political orientation. Adults and educators exhibit greater vulnerability compared to students, indicating that those providing education are especially susceptible. Vulnerability increases with exposure to potential deepfakes, suggesting that deepfakes become more pernicious without interventions. Our results suggest that focusing on the social context in which deepfakes reside is one promising strategy for combatting deepfakes. The COVID-19 pandemic further solidified digital communication as a primary medium for information exchange among educators and learners2. Indeed, K-12 students are digital natives who use various online platforms such as YouTube to complete academic assignments3, with varying degrees of judgement for the reliability of the sources4. The amount of time children eight years old or less spent on YouTube has doubled between 2017 and 2020, portending an increased reliance on online media for even the youngest learners5. Social media and other online information sources have also facilitated lifelong education for continued professional and personal development6. However, the proliferation of misinformation on social media and other platforms raises the risk of exposure to deliberately misleading educational content8.Widespread use of the internet by learners of all ages has democratized the development and accessibility of educational materials9. While many types of misinformation exist outside of the mainstream10, misinformation on science, technology, engineering, and math (STEM) related topics such as climate change and vaccines have had major public policy repercussions14. Social media and modern communication methods facilitate the rapid dissemination of misinformation, amplifying these impacts16. Misinformation campaigns tend to rely on undermining the consensus, highlighting uncertainty, undermining the credibility of leading figures and institutions, and disseminating pseudoscientific alternatives17.The consequences of exposure to online misinformation range in severity and scale, often depending on context20. Generative neural networks (GNNs) are a class of deep neural network models that represent the state-of-the-art technique that can be leveraged to democratize the mass synthesis of manipulated digital content22. They have been used to fabricate images by training them to encode human features23, to manipulate images via replacing specific components of a digital image or video24, and to create videos via animation of a still image with the characteristics of a source video25.The availability of open-source artificial intelligence (AI) algorithms has significantly lowered the barriers to altering videos and images in order to produce highly realistic, manipulated digital content 37. However, these algorithms exhibit low rates of successful detection and are not robust across deepfake types, content format, content characteristics, and datasets38. Parallel efforts to advance user-focused solutions are nascent and characterized by high failure rates39. Recent work indicates that human–machine teams show promise for overcoming these challenges to identifying deepfakes42; these studies, however, don’t account for the social and individual characteristics that modulate individuals’ vulnerabilities to deepfakes. The successful design, development, and deployment of human–machine teams for deepfake detection and other mitigation strategies requires a comprehensive understanding of individuals’ abilities to successfully detect deepfakes, personal characteristics that moderate individuals’ vulnerability to deepfakes, and digital content characteristics that influence successful detection44. The enabling data, however, have not yet been made available.In this study, we investigate the vulnerabilities of K-12 students, higher education students, teachers, principals, and general adult learners to deepfakes related to climate change and investigate potential population and video characteristics that can be leveraged in mitigation approaches. To date, the anticipated prevalence of deepfakes across societal contexts has motivated a large body of work seeking to develop algorithmic techniques to detect deepfakes45. To date, work investigating the vulnerabilities of K-12 students to STEM misinformation has tended to focus on deliberately falsified text-based content and media literacy50. A limited number of studies have investigated adults’ vulnerability to deepfakes, but these have been limited to deepfakes depicting politicians, how it impacts voters’ attitudes toward politicians depicted in the videos, and how vulnerability can be moderated by personal characteristics , as well as attempted inoculations within these contexts52  related to climate change has been much more challenging55. However, the emergence of AI algorithms—particularly to create deepfakes—increases the risk of exposure to convincing climate change misinformation57. Additionally, it’s currently unknown if deepfakes present novel threat vectors that can take advantage of similar vulnerabilities as mainstream climate change misinformation or if deepfakes expand the misinformation attack surface.Climate change is a particularly compelling aspect of STEM to explore because the polarized nature of climate change has left this domain vulnerable to digital misinformation. Climate change misinformation outside of deepfakes is pervasive and typically relies on recipients’ motivated cognition to protect against ideologically or economically threatening scientific evidenceregardless of whether the video was authentic or a deepfake. In aggregate, U.S. adults and educators were less likely to correctly identify deepfake videos than authentic videos, while middle school and higher education students were more likely to identify deepfake videos than authentic videos. However, vulnerability fluctuates across individual deepfake videos and can be quite severe. Heterogeneity analyses indicated that an individual’s susceptibility varies as a function of age, political orientation, and trust in information sources. Further, vulnerabilities increased dramatically as individuals were exposed to more potential deepfakes, suggesting that deepfakes can become more pernicious without educational interventions. An analysis of video characteristics that respondents reported drove their decisions indicated that the social context in which deepfakes are embedded could provide a promising approach for educational mitigation strategies. We conclude by discussing the implications of these results on the development of technical and social mitigation strategies for combatting STEM-focused deepfakes.To investigate the vulnerabilities of the education system climate change deepfakes, we fielded a survey that embedded a series of randomly assigned authentic or deepfake videos on climate change. We then asked respondents to identify the video as authentic or manipulated and gathered information regarding respondents’ demographics, background knowledge of climate change, learning habits, and perspectives on deepfakes. We found that between 27 percent to over half of survey responses were unable to correctly identify the authenticity of videos We fielded our survey to five key populations: nationally representative samples of (1) adults in the U.S. 18 years of age and older, (2) U.S. K-12 teachers, and (3) U.S. K-12 principals, (4) a large sample of middle school students from three states across the U.S., and (5) a sample of undergraduate and graduate students at Carnegie Mellon University (CMU). See methods section for more detail on these samples.What is the effect of receiving a deepfake video on an individual’s ability to correctly identify a video’s authenticity and how does that effect vary by population?Our secondary research questions, which leverage the contextual questions in the surveys to uncover drivers of vulnerabilities and potential avenues for deepfake mitigation, were as follows:What characteristics of the video do respondents analyze to determine the authenticity of the video and how are they related to the probability of correctly identifying the video’s authenticity?How does the effect of a deepfake video on an individual’s ability to correctly identify a video’s authenticity vary by respondent background characteristics and beliefs?Our main research question, which sought to understand the vulnerability of each population to the deepfake videos, is:The survey instrument took about ten minutes to complete and was divided into two portions. One portion presented the respondent with four videos, each about 10–15 s in length. Each video featured one of four speakers: (1) Timothy Gallaudet, an oceanographer and former Acting Administrator of the National Oceanic and Atmospheric Administration; (2) Richard Lindzen, Professor Emeritus of Meteorology at the Massachusetts Institute of Technology; (3) Greta Thunberg, noted climate change activist; and (4) Naomi Seibt, anti-climate change activist. These speakers were chosen to expose respondents to a variety of views and types of speakers on climate change that youth and adult learners are likely to encounter. Gallaudet and Lindzen are credentialed speakers with positions of scientific authority with opposing views on climate change. While Gallaudet is a climate change believer, Lindzen is a climate change skeptic. Greta Thunberg and Naomi Seibt are both younger activists and represent the climate change and anti-climate change perspective, respectively.41, we did not tell participants the probability of being exposed to a deepfake because stakeholders would not be privy to such information when encountering deepfakes in real-life. We randomized the order of the speakers for each respondent to avoid any effects of being exposed to prior authentic or deepfake videos.The four videos were drawn from a bank of eight possible videos. For each speaker, the bank contained an authentic video in which the speaker espoused their view of climate change and an AI generated deepfake video where the speaker is made to espouse their opposite view of climate change. Thus, climate change believers are made to be climate change skeptics and vice versa. Each respondent received one video from each speaker and was randomly assigned to receive an authentic or deepfake video of each speaker. A participant could view an authentic video of one speaker, but a deepfake of another speaker. In contrast to prior studiesThe second portion of the survey elicited the views of the respondents on a variety of dimensions including: personal climate change beliefs, perceptions of the scientific consensus on the causes of climate change, knowledge of climate change, political affiliation (asked only of adults), information sources respondents use to learn about climate change, trust in those information sources, internet use habits, use of social media platforms, perceptions of the risks associated with and the prevalence of deepfakes, and demographic questions.or authentic videos  to 11 percentage points (adults) compared to when they received an authentic video. Based on the percentage of respondents that correctly identified authentic videos, these estimates represent a 10 percent  to 19 percent (adults) decrease in correct responses. In contrast, student populations were better able to detect deepfake videos (compared to authentic videos) with an 8 percentage point increase in correct responses among middle school students and a 14 percentage point increase in correct responses from CMU students. This translated to a 16 and 21 percent increase in correct responses, respectively. Regression models presented in Table These overall results, however, hide important heterogeneity as respondents’ accuracy in correctly identifying deepfake and authentic videos varied across individual videos  use of technical aspects of the video such as facial features or overall quality, then respondents are making decisions in part based on overall or specific flaws in the video. Similarly, if receiving a fake video resulted in a greater (or less) use of social aspects of the video such a familiarity with the speaker’s views or overall credibility of the content, then respondents are using contextual knowledge in their decision-making process. We then explore whether leveraging these aspects of videos are associated with the correct identification of authentic and manipulated videos.The results in Table 59. Indeed, recent work has indicated that cognitive processing of faces is a helpful technique towards assessing the authenticity of visual media41.The results in Table p < 0.10 for adults and p < 0.05 for teachers). Using the credibility of the content also helped adults and teachers accurately identify authentic videos. Respondents who reported that they were familiar with the speaker’s views were also statistically significantly more likely to correctly identify authentic videos in every population and with estimates that range from 38 to 48 percentage points. Educating information consumers to assess the social context that surround deepfakes such as content credibility and the speaker identity therefore present new focal points for strategies that may be more robust than a focus on technical aspects. This finding aligns with recent developments in the science of communication/misinformation fields, as higher levels of a priori knowledge has been found to increase cognitive reflection and decrease susceptibility to misinformation60. Indeed, over the long term the value of assessing the technical aspects of deepfake videos is likely to decline as deepfake generation technologies are expected to continue their rapid advancement towards producing content that is indistinguishable from authentic videos61.However, Table The design of the survey instruments fielded in this work enabled an understanding of how respondent characteristics and beliefs moderated their vulnerabilities to deepfakes. Table 64. The digital misinformation in these studies did not include deepfakes, which indicates that deepfakes present a distinct modality of misinformation that affects information consumers differently than other misinformation pathways. While further work is required to better understand the mechanisms driving the higher susceptibility of older individuals, related work indicates that this increased vulnerability may be due to higher degrees of trust and greater difficulty detecting lies, in addition to a lower familiarity with social media65. These results suggest that older populations should be prioritized as target audiences for deepfake mitigation strategies. This is the first study identifying higher levels of vulnerability to deepfakes among older information consumers.In both the general adult population and the teacher population, the ability to detect deepfake videos declined with age. We found that each year of age was associated with a 0.6 percentage point reduction in likelihood of correctly identifying deepfakes  influenced their vulnerability to deepfakes. Panel C of Table 56, may be a promising mitigation strategy to reduce vulnerability to deepfakes.However, similar to other modalities of STEM misinformationOur results also indicate that other mitigation strategies, such as training information consumers to identify deepfakes via repeated exposure, are unlikely to succeed and may worsen vulnerabilities  for at least two of four speakers. This gap between correctly identifying deepfake videos versus authentic videos was seen to be as large as 39 percentage points. These results have severe implications for the vulnerability of the U.S. education system. Vulnerabilities of K-12 students open the possibility that students take science misinformation as fact and develop a flawed view of science, the scientific process, and the policy implications of science. If these flawed views go unchallenged, they can solidify as students mature and enter positions in society where they can more directly influence policy. The more severe vulnerability of adults, and particularly of teachers and principals, is perhaps more alarming. Teachers and principals must synthesize and communicate contemporary issues in science to students and vulnerabilities to misinformation can translate to inadvertent teaching of information to students. Further, educators are even less equipped to debunk any misinformation students bring into the classroom as students increasingly become exposed to and rely on online information. The vulnerability of adults means that parents may not be able to debunk misinformation their children are exposed to and may play a role in spreading it.and authentic videos. Thus, while prior studies focused on the more technical aspects of videos and the interplay between human and algorithmic detections, our results show that the social context of videos is also critical to consider. Educating information consumers to assess social characteristics of digital content may therefore present new focal points for strategies to mitigate vulnerabilities to deepfakes that may be more robust than a focus on technical aspects. Over the long term, deepfake generation technologies are expected to continue their rapid advancement towards producing content that is indistinguishable from authentic videos, eroding the utility of visually assessing technical aspects of deepfake videos.Second, we found that focusing on technical aspects such as overall video quality or facial features can help respondents more accurately detect deepfakes but analyzing the social aspects such as knowledge of the speaker or the credibility of the content can help more accurately identify both deepfake Finally, we found several personal-level characteristics of individuals can guide the development and implementation of mitigation strategies. First, older individuals tended to exhibit higher levels of vulnerability and specific educational interventions should be tailored for this population. Second, higher trust in information sources, including in print, peer, and online sources, was found to raise respondents’ vulnerability to deepfakes, indicating that traditional media literacy approaches may also be effective in combatting deepfakes. Our results also suggest that other types of mitigation strategies, such as those that rely on repeated exposure, are unlikely to succeed and may worsen vulnerabilities. These latter results further highlight the need for education on deepfake detection, as repeated exposure to potential deepfakes can increase confusion and allow deepfakes to become a more potent medium by which to spread misinformation.Though this study advances our knowledge of education stakeholders’ societal vulnerabilities to deepfake videos, including several nationally representative samples, this study also has some important limitations. First, the characteristics of videos between speakers were not varied in systematic ways, preventing us from understanding the discrete characteristics of deepfake videos that drive the heterogeneity in responses and vulnerabilities observed. Further research is needed to understand how specific features of deepfakes drive individuals’ vulnerability. Second, self-reported information on sensitive questions such as climate change, political ideology, and deepfakes can suffer from social desirability bias and may not always reflect the true view of the respondent. Though randomization meant that our main vulnerability results were not affected by this bias, the relationships between deepfake vulnerability and these aspects may have been affected. Third, the analysis of the relationships between video aspects and the probability of respondents correctly identifying deepfake and authentic videos are the only correlational analyses in this study. Though these results point to promising avenues for deepfake mitigation, more research is needed to establish causal connections. Finally, this study analyzed the specific type of misinformation where people’s views on climate change were manipulated. We chose our speakers to ensure variation in an array of salient characteristics including gender, age, professional positions, credentials, and notoriety. Nevertheless, we do not capture the full array of climate change speakers  nor do they represent other types of possible deepfakes on climate change . The results may also not generalize to misinformation on other topics such as vaccinations and it may not generalize to deepfakes that manipulate content in other ways.55.The survey consisted of two parts. In one part, respondents were asked to watch four videos. After each video, respondents were asked about the authenticity of the video and which aspects of the video helped them make their decision. The respondent could have identified the video as “Definitely Fake,” “Probably Fake,” “Cannot Tell,” “Probably Real,” or “Definitely Real.” These options allowed respondents to express a view on the authenticity of the video while providing an option (cannot tell) that suggests confusion in the respondent. Options regarding the aspects of the video that helped respondents make their decision include technical aspects  as well as social aspects (familiarity of the respondent with the speaker’s view and credibility of the content of the video). These characteristics were chosen based on the literature on the creation of deepfakes and the social science literature on misinformation66. Where possible, we used or modified questions and scales that have been used in previous misinformation studies. Where no questions could be found, we created our own items. Appendix B contains the survey instrument and lists the sources of questions used from previous studies.The second part of the survey elicited the views of the respondents on a variety of dimensions. The constructs were chosen based on research that showed a relationship between these constructs and vulnerability to misinformationTheoretically, viewing the climate change associated videos prior to answering questions eliciting views on climate and deepfake videos could affect a respondent’s answer on those questions and vice versa. To guard against this possibility, we randomized whether the individual received the video or contextual questions first.69, a technique that generates artificial video content by transforming another video. The backbone of our video-to-video synthesis tool was the First Order Motion (FOM) model25, a machine learning model that takes two inputs, a driving video and a reference image, and yields a synthesized video that is an animation of the reference image according to the motion of objects in the driving video. To produce deepfakes related to climate change, we selected driving videos of individuals speaking in front of a camera about climate change and reference images of distinct individuals speaking in front of a camera. The audio component of the driving video was then added to the synthesized video. Following this procedure, we created four deepfake videos for our survey.The AI generated deepfake videos used in the survey were created via video-to-video synthesis70. The ASLP and ATP are weighted based on distributions of characteristics from the National Center for Education Statistics’ Common Core of Data71. All three panels leverage probabilistic sampling and account for non-random non-response. The study sample included 761 unique individuals from the ALP, 740 from the ASLP, and 642 from the ATP.This survey leveraged three standing, nationally representative panels at the RAND Corporation: (1) The American Life Panel (ALP), a sample of adults 18 years of age or older; (2) the American School Leader Panel (ASLP), a sample of U.S. K-12 public school principals; and (3) American Teacher Panel (ATP), a sample of U.S. K-12 public school teachers. The ALP is weighted to be nationally representative on distributions of characteristics from the Current Population Survey Annual Social and Economic SupplementThe Challenger Center, a non-profit organization that provides experiential STEM education programs to students throughout the United States, recruited a sample of 805 middle school students in grades six through eight. Three Challenger Learning Centers recruited students from Kentucky, Maine, and Missouri. CMU recruited 87 graduate and undergraduate students from across the university. As these two samples were convenience samples, no weights were assigned to respondents.In total, the analytical sample contained 3,035 respondents and 12,140 respondent-video observations. Table Randomization of deepfake videos to respondents means that the background characteristics and beliefs of respondents were uncorrelated with the receipt of authentic or deepfake videos. Table Yisr was respondent, i’s, response to the video of speaker, s, randomized to be shown in the rth position . We analyzed three outcomes of interest: correctly identifying the authenticity of the video, incorrectly doing so, and responding “Cannot Tell.” The respondent was coded as correct if they selected “Definitely Fake” or “Probably Fake” when receiving a deepfake video, or “Definitely Real” or “Probably Real” when receiving an authentic video. Deepfakeisr was an indicator for whether the video is a deepfake video, while ai, gs, and tr were respondent, speaker, and order fixed effects, respectively. No fixed effects were needed for identification, but were included to increase the precision of estimates. Finally, eisr was a stochastic individual-level error term. Regressions using the ALP, ASLP, and ATP were weighted to retain national representativeness and all models used clustered standard errors at the respondent level to account for the correlation between each respondent’s response to the videos. We used linear probability models to ease the interpretation of the results and analyzed each population separately.We analyzed the data at the respondent-video level to obtain an overall estimate of the vulnerability of populations to STEM deepfakes and answer research question 1. We leveraged models of the following form separately on each population:Recall that after each video we asked the respondents to indicate which of six video aspects helped them decide the video’s authenticity. To answer research question 2, we first investigated whether viewing a deepfake caused respondents to differentially use aspects of the video in their decision-making process. We leveraged models of the following form:Aisr was now one of the six video aspects. The coefficient of interest is β1, which indicated the extent to which respondents noted a particular video aspect was used to make their decision when receiving a deepfake. If β1 is small in magnitude and statistically insignificant, respondents are equally likely to have considered that video aspect in their decision-making progress, regardless of the authenticity of the video they are viewing. If β1 is positive (negative) and statistically significant, respondents are more (less) likely to have considered that aspect of a video when receiving a deepfake video.Equation  is identWe then investigate whether considering a video aspect leads to a higher likelihood of correctly detecting the video’s authenticity. We leveraged models of the following form:Aisr. We estimated results separately for the subsamples of authentic and deepfake videos. The vector of coefficients of interest is β1, which estimated the relationship between analyzing each video aspect and the probability of correctly, incorrectly, or being unable to identify the video’s authenticity. Because video aspects were not randomly assigned, these results were correlational.Equation  is the sFinally, we explore which subsets of populations are more vulnerable to deepfake videos to answer research question 3. We leveraged models of the following form:Xi. The coefficient of interest is b2, which provides the differential effect of receiving the deepfake video for the subgroup of interest compared to the reference group. We test the constructs previously detailed in the Survey Instrument section and the effect of the order of seeing the video. The larger number of individual and video characteristics could have presented a multiple hypothesis comparison problem. We did not formally correct for multiple hypotheses due to the exploratory nature of the analyses, but we guarded against it by only presenting results that showed a pattern of statistical significance across populations. In addition, we explored results from models that removed respondent fixed effects and include a vector of covariates of the characteristics in Table Equation  was idenThe potential potency of deepfakes in spreading misinformation and the inclusion of vulnerable populations in the study, such as middle school children, raise important ethical considerations. On one hand these types of studies are essential because understanding how individuals react to deepfakes necessitate the controlled exposure to deepfakes. On the other hand, exposing individuals to deepfakes under any circumstances can have unintended effects. For example, our results indicate that repeated exposure to deepfakes can make individuals more susceptible to future deepfakes.To balance the need for rigorous evidence with the safety of participants, the study team took several steps to minimize any harm the repeated exposure to potential deepfakes could cause. Prior to data collection, the study was approved by the Institutional Review Boards of RAND  and the study was performed in accordance with all relevant guidelines and regulations including the declaration of Helsinki. As part of the procedures that were approved of the IRB, all participants provided informed consent before taking the survey. All adults provided informed consent directly. Schools opted into the study after an explanation of the procedures and secured parental informed consent before fielding the survey to middle school students. Respondents could also decline to take the survey in its entirety, answer any question, or stop taking the survey at any time with no penalty. Most importantly, each respondent was made aware of the authenticity of each video at the end the of the survey. For adult populations, the final page of the survey contained a screenshot of each video the respondent was exposed to and a clear indication of whether each video was authentic or a deepfake. For middle school students, the Challenger Center prepared a mini-lesson for teachers that clearly indicated the authenticity of each video and structured a discussion around deepfakes. The study team thought this more robust debrief was needed for middle school students because children are considered a vulnerable population.These precautions ensured that no respondent left the study with a misinformed view of each speaker’s climate change belief. Whether these strategies were effective in mitigating future vulnerabilities to deepfakes is unknown. However, one important contribution of the study was to highlight the need for dedicated research to understand effective educational mitigation strategies, which our results indicate should include the social context of deepfakes.Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.


To determine whether smoking and drinking moderate the correlation between biological rhythm and mental health and the role of gender differences in these moderating effects.Adolescents from three cities, all twelve middle schools , named Shenzhen, Nanchang and Shenyang in China, were asked to complete a standardized questionnaire including the details of biological rhythm, psychological health, and the status of smoking and drinking. The PROCESS program was used to analyze whether smoking and drinking moderated the relationship between biological rhythm and psychological health.P < 0.001). Specifically, smoking and drinking accelerated the relationship between biological rhythm and psychological health in the total sample  and only the subgroup of girls , respectively.The analyses revealed poorer psychological health and greater likelihood of smoking and drinking in participants with higher scores for biological rhythm disorder (As the findings suggest, attention should be given to smoking, drinking and gender-specific approaches employed to alleviate the psychological disorders of adolescents with biological rhythm disorders.The online version contains supplementary material available at 10.1186/s12888-023-05253-2. Psychological disorders have been a global epidemic that affects the population all over the world . The conBiological rhythm is defined as biological changes with repeated daily and regular cycles, comprising hormone secretion, the sleep-wake cycle, body temperature, regular eating habits, etc. . A growiIn addition, people with biological rhythm disorder were more likely to have engaged in alcohol and cigarette use . FurtherMoreover, cigarette smoking and alcohol drinking, which start in or are observed throughout adolescence , affect Reportedly, a larger social jetlag , more seThree cities, including Shenzhen, Nanchang and Shenyang in China were chosen conveniently for this study. A cluster sampling method was conducted to select the study sample. First, we respectively extracted four large middle schools including junior and senior high schools and all participants were from grades 7 to 12, from each of the above three cities. Second, we randomly choose five classes for each grade in each chosen school and all students in selected classes were included in the survey, and about 2 700 students were chosen in each targeted region. Individuals with a family history of mental illness and being unwilling to participate in the survey were not included in the investigation. Finally, a total of 8,082 middle school students completed anonymous questionnaires in a classroom setting. Ninety-six incomplete questionnaires were excluded. The effective response rate was 98.8%. After excluding invalid questionnaires, including that the students were not at school on the investigation day, the students or their parents/caregivers were not reluctant to fill out the investigation questionnaire, and the students responded the questionnaires with an incomplete manner or dishonestly answered questionnaires or with logical errors, 7,986 adolescents, the range of the age from 8 to 23 years old, completed a standardized questionnaire finally, including 3,866 (48.4%) boys and 4,120 (51.6%) girls. In the study, only 0.1% of participants were less than 10-year-old who may have skipped a grade because of superior grades. Our study was approved and reviewed by the Ethics Committee of Anhui Medical University . Our survey data were collected from October to December 2019, and all participants, parents and surveyed schools signed informed consent for inclusion before the administration of the survey.In the present study, sociodemographic data for each participant were collected, including gender (boys/girls), age, registered residence , only child (yes/no), paternal and maternal education (< 12 years/≥ 12 years), and self-reported family economy . In China, less than 12 years of schooling means no high school graduation.Mental health was evaluated using the Chinese version of the fifteen-item Brief Instrument on Psychological Health of Youths (BIOPHY-15) . The queBiological rhythm status was assessed using the Self-Rating of Biological Rhythm Disorder for Adolescents (SBRDA) . The SBRSmoking among adolescents was evaluated based on the Youth Risk Behavior Survey System (YRBSS) . The oneDrinking was assessed based on the Youth Risk Behavior Survey System (YRBSS) . “DuringThe validity of self-reported data on behaviors in adolescence that are relevant to smoking and drinking has been assessed , 32.R2 and F increased due to interaction). We adjusted the effects of sociodemographic characteristics  in the moderation models and compared the moderating effects between boys and girls, and the bootstrapping analysis with 5000 replicates was performed to determine the significance of the moderation effects. All P values were 2 tailed, and P < 0.05 implied that the moderating effects were statistically significant.All statistical analyses in this study were conducted by SPSS version 23.0 . We assessed the sociodemographic characteristics of the sample using descriptive statistics. We conducted a chi-square test to compare the gender differences among different sociodemographic characteristics. Spearman correlation analysis was performed to test the correlations between smoking, drinking, biological rhythm, and mental health among Chinese adolescents and to examine gender differences. In SPSS PROCESS, the interacting effects  were calculated automatically on the software to explore whether smoking and drinking moderated the associations between biological rhythm and mental health among adolescents. and they also produced the proportions of the variances explained by the moderating effects of smoking and drinking . The self-reported family economic status fell into the following groups: 12.9% were bad economy families, 66.2% were general economy families, and 20.9% were good economy families. Compared with girls, boys had significantly higher child trauma scores, a lower level of biological rhythm and fewer suicidal behaviors  (P < 0.001). The details of gender differences can be found in Table Of the 7,986 adolescents, the mean age was 14.7 ± 2.0 years, the average age of the boys was 14.7 ± 2.0, and that of the girls was 14.7 ± 1.9. In total, 31.9% of the participants’ registered residences were rural, 34.7% of the participants were only children, and all there were gender differences , emotional disorder , behavior problems , social adaptation , smoking , and drinking . Spearman correlation analyses also revealed a marked link between psychological health and smoking  and drinking   and drinking  separately negatively predicted psychological health status, while the above negative prediction effects were significant in boys  and girls . Additionally, smoking  and drinking  respectively accelerated the association between biological rhythm and psychological health in the total sample. Classified by genders, among girls, smoking accelerated the association between biological rhythm and psychological health , and drinking also accelerated the association between biological rhythm and psychological health . Among boys, smoking  and drinking  did not accelerated respectively the association between biological rhythm and psychological health.In Tables The present study explored the correlations among biological rhythm, smoking, drinking and psychological health and assessed the moderating effects of smoking and drinking on the correlation between biological rhythm and psychological health while gender differences were taken into account. The study showed that significant associations existed between biological rhythm, smoking, drinking and psychological health in adolescents. Additionally, smoking and drinking aggravated the negative influences of biological rhythm disorder on psychological health, which varied by gender. In the total sample and the girls, smoking will accelerate the effect of biological rhythm disorder on psychological health, such as drinking. However, there were no moderating effects of smoking or drinking in boys.Biological rhythm disorder was observed to be negatively associated with psychological health, which was similarly reported in other studies , 34. PreAs has been acknowledged in recent studies, we found a positive correlation between substance abuse and psychological health. A self-reported investigation focusing on college students in Spain also showed that students with substance use were more likely to suffer from depression and anxiety symptoms . If giviThe present study shows that smoking and drinking worsen the correlations between biological rhythm disorder and psychological health in adolescents. Tobacco users exhibit depression, agitation and anxiety, which are attributed to the promoting effects of tobacco on neuroadaptations in nicotinic pathways in the brain, which causes poor psychological health . PsycholPeople suffering from biological rhythm disorders smoke and drink more than normal persons . AdditioAnother notable finding is that smoking and drinking, as moderating variables, have gender-specific effects on the relationship between biological rhythm disorder and psychological disorder. These moderating roles significantly accelerate the effect of biological rhythm disorder on psychological health only in girls, and stronger associations between biological rhythm, smoking, drinking and psychological health among girls are displayed. The reasons for these differences may be the narrowing gender gap in the prevalence of substance abuse, which is characterized by an increasing representation of girls . MoreoveThere are several limitations in the present study. First, owing to the cross-sectional study design, the converse associations and causal associations between biological rhythm disorder and psychological health cannot be inferred. Second, data were based on self-report, which was prone to recall bias. Third, smoking and drinking, classified only in a binary way in the study, did not take more detailed characteristics or joint effects into account. Both smoking and drinking had very small but statistically significant moderating effects on biological rhythm disorder and psychological health. The adverse effects of smoking and drinking have been thoroughly established in previous research, but the attention may be more played to reduce the prevalence of smoking and drinking among girls with biological rhythm disorder to promote psychological health in the future. Psychological health, affected by complicated factors, may also be influenced by health care resources and utilization, which may lead to the small moderating effects of substance use on biological rhythm disorder and psychological health. Therefore, further research is needed to clarify the moderating effects. Nevertheless, to our knowledge, this is the first study to detect the moderating roles of smoking and drinking on the correlation between biological rhythm disorder and psychological health and gender differences in Chinese adolescents, which covers urban and rural areas.The present research explores the potential relationships between biological rhythm disorder, smoking, drinking, and psychological health. In formulating the primary preventive measures concentrating on the psychological health of adolescents, especially girls, reducing tobacco and alcohol use or cessation treatment need to be taken into consideration by health care professionals to improve psychological symptoms with biological rhythm disorder. More longitudinal studies are needed to confirm these findings in the future. More efforts are needed to explore why smoking and drinking effects accelerate the relationships between biological rhythm disorder and psychological health problems. Further research should consider the joint effect of smoking and drinking and the dose responses of tobacco and alcohol consumption to obtain a fuller picture of the impacts of smoking and drinking on the relationship.This study filled a gap in knowledge regarding the effects of smoking and drinking on the correlation between biological rhythm disorder and psychological health among adolescents. Remarkable moderating effects of smoking and drinking on the correlation were observed. However, we only observed moderating effects in girls but not in boys. Further rigorous studies are needed to explore the mechanism of gender differences in moderating effects.Below is the link to the electronic supplementary material.Supplementary material 1: Supplement Figure 1 and Supplement Table 1


Thymus atlanticus (Lamiaceae) is a plant endemic to the Mediterranean basin that is found in significant quantities in the arid regions of Morocco. Thymus atlanticus is used in traditional medicine to treat infectious and non-infectious diseases. It is also used for the isolation of essential oils and for the seasoning of many dishes in the Mediterranean diet. The major constituents of Thymus atlanticus are saponins, flavonoids, tannins, alkaloids, various simple and hydroxycinnamic phenolic compounds, and terpene compounds. Several of these compounds act on signaling pathways of oxidative stress, inflammation, and blood sugar, which are parameters often dysregulated during aging. Due to its physiochemical characteristics and biological activities, Thymus atlanticus could be used for the prevention and/or treatment of age-related diseases. These different aspects are treated in the present review, and we focused on phytochemistry and major age-related diseases: dyslipidemia, cardiovascular diseases, and type 2 diabetes. Thymus citriodorus), caraway thyme (Thymus herba-barona), and creeping thyme (Thymus serpyllum). Common thyme (Thymus vulgaris) has been considered the most usable. There is also a Spanish variety (Thymus zygis), also known as white thyme. Furthermore, diluted thyme oil rubbed into the scalp removes dandruff, stimulates circulation, improves hair condition, and accelerates its growth. It also has a relaxing effect. Thyme is also an ornamental plant with significant decorative values. It is also used as an additive in preparations used in the tanning process of leather.Nowadays, Thymus species are versatile herbs that are cultivated and encountered worldwide. The genus Thymus contains about 350 species of aromatic perennial herbaceous plants. Thymus possibly derives from the Greek word “thyo”, which means to perfume, cleanse, or fumigate, or refers to the Greek word “thymon”, which signifies bravery or a cure . The ancThymus atlanticus  Roussine is locally known by its vernacular name: in Amazigh as Azukni, Tazuknite, and in Arabic as Ziitra. In infusion or decoction, its leafy stems are used against headaches, influenza, fever, and chills, as well as against digestive disorders and menstrual pain in women. Its fumigation is used to treat respiratory ailments. It is important to note that while thyme has a long history of traditional use, scientific research is ongoing to fully understand its potential health benefits and any associated risks.The Moroccan endemic species The genus Thymus belongs to the Lamiaceae family, which is one of the largest families in the plant kingdom and one of the eight most important genera in terms of the number of species included . AccordiThymus atlanticus  Roussine [In Morocco, the Lamiaceae family has more than 225 species, characterized by great wealth and biodiversity. The genus Thymus is represented by about twenty species, of which 12 are endemic . MoroccaRoussine ,11, whicThymus atlanticus  Roussine, which is the smallest of the Moroccan thymes. Indeed, it is a calcifuge, hemicryptophyte, perennial herbaceous plant with overwintering buds at ground level, specific to the Oro-Mediterranean floor of the Maghreb, with very small white or pale pink flowers, in low carpet, prostrate, very polymorphic, especially calcifuge, from 1700 to 3400 m , the best-known of which has indeed six chemotypes [Thymus atlanticus in different phenological stages showed carvacrol as the main constituent, except for essential oil from leaves in the post-flowering stage, where the main constituent was thymol [Apart from thymol and carvacrol, the main constituents of thyme essential oils include p-cymene, linalool, terpinene, pinene, myrcene, and limonene. The occurrence of different chemotypes has been described in several species of Thymus plants. The Moroccan thyme essential oils are characterized by the chemotypes camphor, carvacrol, borneol, thymol, and geranyl acetate ,14. Althemotypes . The twos thymol ,27,28. Ts thymol .Thymus atlanticus metabolites is very sparse, with the exception of its essential oils and a few reported polyphenols. The essential oil of Thymus atlanticus was characterized by 21 volatile constituents, the main ones being carvacrol (47.1%), p-cymene (7.5%), and α-pinene (3.7%). Thymus atlanticus variety on a non-polar TG-5MS column [Up to date, the chemistry of S column .The other key phytoconstituents of the thyme genus include saponins, flavonoids, tannins, alkaloids, and various simple and hydroxycinnamic phenolic compounds . More paThyme also contains vitamins, especially A and C. Its leaves are an excellent source of potassium, calcium, iron, manganese, magnesium, and selenium . It is iThymus atlanticus may be a rich source of biologically active components. Indeed, Kouya et al. [Thymus atlanticus, notably rosmarinic acid, rutin, hyperoside, quercetin, apigetrin, and caffeic acid. High-performance liquid chromatography (HPLC) was and is still the main technique applied in the analysis of plant phenolics since it allows rapid, cost-effective qualitative and quantitative screening. This technique has also been combined with spectral information gathered by the photodiode array detector and, more particularly, by mass spectrometry analysis, which has been mainly carried out in the negative ion mode due to its high sensitivity in detecting distinct classes of phenolic compounds. By using these techniques, more studies will help to isolate new active compounds, allowing the identification of their exact mechanisms of action.Together, a et al.  have desThymus atlanticus on human health. The data obtained with essential oils is convincing for a lot of microorganisms. The therapeutic effects of Thymus atlanticus on age-related diseases could be mediated, at least in part, by major plant compounds such as rosmarinic acid, apigenin, and quercetin. In this context, the individual effects of these different molecules on different in vitro and in vivo models are well documented. However, no data is currently available on the cocktail effects of these molecules, which could permit the development of new treatments and the use of Thymus atlanticus extracts in optimal conditions for various diseases.There are currently a lot of arguments about the benefits of T. riatarum, T. maroccanus, and T. broussonetii, such as essential oils, were found to exert high antimicrobial efficacy in combination with standard antibiotics; the effect on Gram-positive bacteria was more important than on Gram-negative bacteria [E. coli, Salmonella sp., Ent. Cloacae, K. pneumonia, V. cholerae, B. subtilus, B. cereus, M. luteus, and S. aureus, except for Pseudomonas aeruginosa [Thymus atlanticus essential oils possess strong antimicrobial activity, notably against Escherichia coli [Thymus atlanticus essential oils exert synergic antimicrobial activity with ciprofloxacin against Pseudomonas aeruginosa and Bacillus subtilis. The maximum synergistic effect was observed for Klebsiella pneumonia [Previous investigations have reported that Moroccan endemic thymes exhibit important biological properties, including antifungal, antimicrobial, and antiviral activities ,36,37. Ibacteria ,36,37,38ruginosa . In vitrhia coli . Moreoveneumonia . Moreoveneumonia . TherefoThymus atlanticus ameliorated Triton-induced acute hyperlipidemia in rats, hamsters, and mice [Thymus atlanticus polyphenol-rich extracts were also found to be efficacious in reducing hyperlipidemia, notably total cholesterol and LDL-cholesterol levels, in chronically high-fat diet-treated hamsters [Thymus atlanticus polyphenol-rich extract was partially explained by its ability to inhibit cholesterol biosynthesis, as reflected by the reduction in the hepatic expression of HMG-CoA reductase observed in chronically high-fat diet-treated hamsters [Thymus atlanticus significantly decreased total cholesterol content (p < 0.05) and HMG-CoA reductase expression (p < 0.05) but did not affect fecal cholesterol, bile acid contents, or CYP7A1 and ABCG5/G8 expression (p > 0.05) in high-fat diet-treated hamsters [Thymus atlanticus polyphenolic compound, was found to attenuate the high cholesterol-feeding-induced hypercholesterolemia in hamsters [Studies have shown that polyphenol-rich extracts of and mice ,42,43. Thamsters . The anthamsters . The samhamsters . Intereshamsters .Thymus atlanticus inhibited inflammation caused by local application of croton oil or xylene and injection of carrageenan or arachidonic acid in animal models [Thymus atlanticus was found to inhibit the production of monocyte chemoattractant protein 1 (MCP-1) by macrophage cultures activated by lipopolysaccharides in a dose-dependent manner [Thymus atlanticus combined with fat-diet-treated hamsters [Atherosclerosis is a major histological modification of the arteries that promotes the development of cardiovascular diseases and is also involved in vascular dementia ,48. The l models ,43. Moret manner . Interest manner , was fouhamsters . These ehamsters . Rosmarihamsters ,52. Morehamsters , as wellhamsters . In addihamsters ,56.Thymus atlanticus on myocardial infarction. However, rosmarinic acid, its principal compound, was found to exert potent cardioprotective effects against acute myocardial infarction induced by isoproterenol in a rat model [2+ homeostasis of the sarcoplasmic reticulum Ca2+ ATPase (SERCA2) and ryanodine receptor (RyR2) [Thymus atlanticus flavonoid compound, has been associated with improved cardiovascular health [To date, no research has been undertaken to examine the possible effect of at model ,58. The r (RyR2) . More rer (RyR2)  have sugr (RyR2) . Moreover health . In randr health . In addir health .Studies have demonstrated that rosmarinic acid treatment improved blood pressure in fructose-fed  and angiThymus atlanticus and its compounds could offer an alternative tool for the prevention and treatment of stroke.Previous studies have shown that rosmarinic acid alleviates neurological deficits and reduces cerebral infarct volumes in association with the attenuation of decreased superoxide dismutase, catalase activities, and GSH (reduced glutathione) levels in rats suffering from ischemic stroke and post-stroke depression . Animal Thymus Atlanticus prevented the development of hyperglycemia and hyperinsulinemia in 63-day-old high-fat-fed hamsters [Thymus atlanticus leaves had no effects on blood glucose levels but effectively prevented hyperinsulinemia in Triton-induced hyperlipidemia hamsters. The failure to obtain a significant decrease in blood glucose levels could be explained, at least in part, by the short duration of treatment with Thymus atlanticus, since 24 h was not enough to exert its beneficial effects on hyperinsulinemia as well as on hyperglycemia. Interestingly, studies have demonstrated that rosmarinic acid, one of the main polyphenols found in Thymus atlanticus [Thymus atlanticus and its compounds exert their beneficial effects on insulin action by decreasing oxidative stress.Previous investigations have shown that supplementation with a polyphenol extract of hamsters . The mechamsters . Ramchouhamsters  have replanticus , resultelanticus . Moreovelanticus ,77. Morelanticus . Moreovelanticus . The samlanticus . Rutin wlanticus . Thus, oThymus atlanticus (Lamiaceae) is widely present in Morocco and constitutes an important source of bioactive molecules, which can be used for the treatment of infectious and non-infectious diseases, especially age-related diseases. The ease of cultivating Thymus atlanticus, which produces many bioactive molecules with significant therapeutic capacities, makes it possible to envisage a valuation that could, like argan oil, which is emblematic of Morocco, have positive economic repercussions at several levels.Thymus atlanticus extracts as well as mixtures of compounds from Thymus atlanticus that may have therapeutic potential, such as antimicrobial, anti-inflammatory, or antioxidant properties. Moreover, safety and toxicology should be assessed, especially when used as dietary supplements, in phytomedicine, or in traditional medicine, to determine eventual side effects and establish safe dosage levels. Finally, yet importantly, to help conduct clinical trials on new Thymus atlanticus metabolites in well-designed clinical trials for specific health conditions and metabolomics, the latter may entail a deeper understanding of the metabolic changes induced by Thymus atlanticus extracts in living organisms.The future direction must emphasize the characterization of novel bioactive compounds in


Real-time MRI (rt-MRI) in children is a new imaging technique that combines the advantages of US — at frame rates of up to 50 images per second — with the quality and features of MRI. Although still subject of research, it has become a standard tool in the diagnostic portfolio of two pediatric radiology departments in Germany. Based on ultrashort acquisition times, any detrimental effects of macroscopic movements of the child and the physiological movements of the organs are negligible. Especially in pediatric brain imaging, rt-MRI has already proven its value. With suitable indications, rt-MRI can reduce anesthesia and sedation examinations in children below 6 years of age by 40% due to its very short examination time and its robustness to motion. There is a high level of acceptance among parents and referrers when diagnostic possibilities and limitations are communicated correctly. Conclusion: Completely new diagnostic possibilities arise in the imaging of the moving lung, the beating heart, joint movements, and speaking and swallowing, as demonstrated in this video-backed review.The online version contains supplementary material available at 10.1007/s00431-023-04996-0. Real-time MRI (rt-MRI) with ultrafast image acquisitions of down to 20 ms (50 images per second) is an entirely new approach in pediatric radiology. Although the technique was described 13 years ago , 1312, 1The VC technique enables the scanning of a large volume, such as the brain, the lung, or the abdomen, within a few seconds. Herein, numerous 2D-slices are acquired, and each of these slices is free of motion artifacts due to a per-slice acquisition time of down to 20 ms . Thus, eIn VC, with every new image, a tiny slice shift is introduced. This results in a large number of slices with a high overlap of 50 to 90%. With typical parameters, the acquisition of 300 slices at 3 mm width and a slice shift of 0.3 mm takes about 15 s. Thus, the steady state of proton excitation is maintained, which results in favorable tissue contrasts. In addition, the overlapping slices create a harmonious, gliding image impression. Despite the minimal slice thickness of several millimeters needed in 2D MRI, the image impression equals that of a 3D sequence.For the radiographer, there is no change to his general workflow at the MR console. The rt-MRI sequences are planned and performed “out of the box” like any genuine, conventional MR sequence Fig. . After dAfter almost 3 years of routine use, we conclude that this new, fast type of MRI addresses an obvious need among our clinical colleagues. In brain imaging after fontanel closure, rt-MRI with VC is often needed for alterations of the cerebrospinal fluid (CSF) spaces and for the exclusion of gross pathology. However, apart from some specific situations such as minimal handling in very low birth weight preterm children, rt-MRI, when available, is often preferred over the US examination, even when the fontanel is still open, especially when surgical planning depends on imaging. Unlike US, rt-MRI does not require an US window such as the anterior fontanels and thus provides a complete overview of the entire brain, including the brain stem and the cerebellum. Additionally, rt-MRI is often faster and provides a superior soft tissue contrast than US.Regarding CSF spaces, VC has been proven to be equivalent to a conventional T2-fast spin-echo sequence in small children but with considerably fewer motion artifacts . Beyond With the example of three typical findings, hygroma, hemorrhage, and tumor Videos , and 4, Ultrafast acquisition in the same slice position enables the visualization of periodic or non-periodic motion in real-time . RegardiDue to the inflow effects of blood and CSF in gradient-recalled echo sequences, rt-MRI is well suited for the non-contrast imaging of medium to large blood vessels . In contThere is an obvious potential for real-time imaging of the lungs during free breathing. Periodic motion due to breathing and the heartbeat hinders conventional thorax diagnostics in MRI as it causes artifacts. Though periodic motion can be quite well compensated by respiratory gating, breath-hold maneuvers, and ECG-gating, those mechanisms prolong the examination time considerably. Furthermore, they are dependent on a consistent periodic pattern and fail in cases of irregular breathing or arrhythmia . This isThe visual impression of the lung rt-MRI resembles a CT scan. Often, VC sequences, as noted above, are employed. Coronal orientation for acquisition is preferred to preserve the steady state of the lesions during the predominantly head-feet motion during the breathing cycle. Although T2/T1 contrast should, in theory, result in a superior lesion-to-background contrast compared with T1 or PD-weighted imaging, this advantage is offset by the pronounced fluctuation of signal intensities caused by the loss of the steady state in through-plane motion. Therefore, both are often performed with the more stable proton-density weighting and the contrast-rich T2/T1 weighting. Even small lesions, such as metastases, can often be detected above a diameter of 4 mm Video , but onlThe movement of the tongue and soft palate are easily visualized with rt-MRI , 22. In Functional upper GI tract diagnostics, including swallowing, tests for gastroesophageal reflux, and gastroduodenal transport, can be evaluated in adults using rt-MRI –25. HoweImaging of joint movement with rt-MRI has previously been shown in adults, focusing on the temporomandibular joint and the knee , 27.Rt-MRI was used to dynamically assess the upper cervical spine, e.g., in children with suspected atlantoaxial instability Video . The chaIn addition to dynamic imaging of the spine, static images of the whole spine can also be generated in a few seconds using VC. Depending on the height of the spine and the available field of view, two to three stacks are needed. Thus, the entire scan takes 40 s, with positioning the patient taking a total of about 6 min. This examination time is in the same range as an X-ray image of the whole spine (unpublished data). The single image stacks are afterward combined to compose an image stack of the whole spine. In post-processing, curved multiplanar reconstructions generate an image impression of a conventional X-ray image in both the anterior–posterior projection and the coronal projection Fig. . The CobReal-time MRI is an option to evaluate highly dynamic structures such as the chest wall in patients with pectus excavatum . SpecifiThe third option of rt-MRI, interactive navigation, proves useful in abdominal imaging. It allows navigating orientation under permanent visualization. This enables, for example, imaging of bowel movements with and without endoluminal contrast medium, depiction of the ureter and its peristalsis, and defecography in status Video . Yet, thRt-MRI is a novel imaging modality that seems tailored for children. Due to the ultrafast frame rate, macro-movements, as well as physiological movements of children’s organs, are frozen. This renders rt-MRI a viable option for imaging awake infants and toddlers without sedation, regardless of a suitable US-window.Due to the different image appearance and the lower spatial resolution compared to conventional MRI, rt-MRI competes more with US diagnostics than with standard MRI in most indications. In departments with the possibility of rt-MRI, ultra-fast examinations of the brain in a few seconds without motion artifacts have become clinical standards and significantly reduced sedation rates. In addition, new indications are emerging, such as imaging of the lungs and the spine, as well as dynamic examinations of thoracic wall malformations or the soft palate before nasopharyngeal insufficiency.Video 1 (MP4 9543 KB)Video 2 (MP4 2947 KB)Video 3 (MP4 2390 KB)Video 4 (MP4 2987 KB)Video 5 (MP4 4718 KB)Video 6 (MP4 4188 KB)Video 7 (MP4 6923 KB)Video 8 (MP4 3842 KB)Video 9 (MP4 5799 KB)Video 10 (MP4 4486 KB)Video 11 (MP4 1790 KB)Video 12 (MP4 2585 KB)Video 13 (MP4 5541 KB)Video 14 (MP4 6819 KB)Below is the link to the electronic supplementary material.