Facial expressions are complex and subtle signals, central for communication and emotion in social mammals. Traditionally, facial expressions have been classified as a whole, disregarding small but relevant differences in displays. Even with the same morphological configuration different information can be conveyed depending on the species. Due to a hardwired processing of faces in the human brain, humans are quick to attribute emotion, but have difficulty in registering facial movement units. The well-known human FACS  is the gold standard for objectively measuring facial expressions, and can be adapted through anatomical investigation and functional homologies for cross-species systematic comparisons. Here we aimed at developing a FACS for Japanese macaques, following established FACS methodology: first, we considered the species’ muscular facial plan; second, we ascertained functional homologies with other primate species; and finally, we categorised each independent facial movement into Action Units (AUs). Due to similarities in the rhesus and Japanese macaques’ facial musculature, the MaqFACS (previously developed for rhesus macaques) was used as a basis to extend the FACS tool to Japanese macaques, while highlighting the morphological and appearance changes differences between the two species. We documented 19 AUs, 15 Action Descriptors (ADs) and 3 Ear Action Units (EAUs) in Japanese macaques, with all movements of MaqFACS found in Japanese macaques. New movements were also observed, indicating a slightly larger repertoire than in rhesus or Barbary macaques. Our work reported here of the MaqFACS extension for Japanese macaques, when used together with the MaqFACS, comprises a valuable objective tool for the systematic and standardised analysis of facial expressions in Japanese macaques. The MaqFACS extension for Japanese macaques will now allow the investigation of the evolution of communication and emotion in primates, as well as contribute to improving the welfare of individuals, particularly in captivity and laboratory settings. Thorbidden .In the last decade, researchers have been adapting FACS to several species, including non-human primates: chimpanzees , orangutMacaca and other non-human primates. In particular, the genus Macaca has been extensively studied due to their wide variation of morphology and behaviour between and within the four monophyletic taxa [Macaca communication.Extending FACS to Japanese macaques will allow for expansion of research into this species’ expression and communicative abilities, as well as facilitating comparative studies within the genus tic taxa , 31. Othtic taxa , 33 repotic taxa  have higMacaca genus, it is important to consider differences and similarities between species in order to create a new FACS, and in particular, how the target species (Macaca fuscata) differs from the other species. A rhesus macaque-like population ancestral to the Japanese macaque migrated between 0.43–0.63 Ma ago from the Korean peninsula to the Japanese islands [Due to the wide morphological variation in the  islands –36, adapDespite their differences, rhesus and Japanese macaques display a similar group size , 38 and Regarding facial expressions in Japanese macaques, only a limited number of studies have been published. An experimental study  used onlAdapting FACS for Japanese macaques will not only allow a more detailed analysis of individual facial movements, but will be particularly important for their welfare assessment . All work undertaken for this manuscript was purely observational.Macaca fuscata fuscata) at two locations in Japan: in two outdoor enclosures at the Primate Research Institute, Kyoto University (KUPRI), housing 89 Japanese macaques , and at Koshima deserted island, which is inhabited by two troops of approximately 160 Japanese macaques. The individuals at the KUPRI outdoor areas (729–960 m2) were grouped by their region of origin (37 from Wakasa and 52 from Takahama). Each enclosure had access to indoor heated quarters, and featured varied climbing structures and environmental enrichment objects, such as platforms, ropes, swings, wooden toys, and feeders. Individuals had visual, olfactory and auditory contact between the two groups, as well with other animal species from the surrounding area (e.g. crows). Macaques were fed twice daily (once in the weekends) during the morning and afternoon with monkey chow, wheat and sweet potatoes, and occasional fresh tree branches. Water was supplied ad libitum. Please see [For the purpose of adapting FACS for Japanese macaques, we recorded spontaneous behaviour from Japanese macaques . The collection of videos used here totalled 21h and over 250 individuals from five distinct populations, which was enough to identify at least two examples of each facial movement  produced by each muscle of the Japanese macaque face .We recorded approximately 7h of video at KUPRI and 13h at Koshima, including ad libitum behaviour and opportunistic focals featuring any behaviour , and during varied observational field experiments .Normally, in es (e.g. ) and/or es (e.g. ). This ies  developmacaques , we instmacaques  for JapaStep 2 of FACS adaptations, intra-muscular electrical stimulation is usually employed to verify the link between muscle contractions and appearance changes [M. mulatta, combined with ethical concerns, this step was not performed for the Japanese macaque. The omission of this step has been done in most animal FACS adaptations for similar reasons , 17Step Step 3 usually comprises of frame-by-frame video observation of spontaneous facial behaviours to identify independent facial movements, along with a list of appearance changes based on facial landmarks  and crested macaques (M. nigra), which are phylogenetically more distant from rhesus macaques than Japanese macaques [Importantly, the information here reported for Japanese macaques must be used as an additional resource to the MaqFACS, and does not replace training and certification in MaqFACS. This work thus aims at being used as a  studies , 16, whe studies  could bemacaques , 62.We tested inter-observer reliability  by coding an additional seven clips totalling 24min (x̄ = 3.43min) of pre-existent footage with different individuals from the ones described in "Subjects and data collection". This footage had been collected beforehand for another research project during feeding and training tasks, focusing on the face of 21 Japanese macaques , living indoors in pairs/trios at KUPRI. The inter-reliability coding had a three-fold aim: 1) to verify which MaqFACS movements could be applied to Japanese macaques and if the new movements found in Japanese macaques could be coded consistently; 2) to check if both coders were able to reliably identify the MaqFACS movements in Japanese macaques while accounting for potential morphological differences between rhesus and Japanese macaques, 3) if agreement was low for particular AUs, modify appearance changes descriptions to improve identification of AUs between coders, followed by further rounds of coding, alternated with improvement in appearance changes description.The coder’s overall reliability  for a particular region (e.g. Upper face), as it can impact coding of the dynamic states of the face.The following sections report the differences between what was described for rhesus macaques in the MaqFACS and what we observed for Japanese macaques in each AU, and may include the following points: 1) comparative muscular basis ; 2) main appearance changes description , 3) important differences to consider during coding between Japanese macaques and other primate species . As such, this MaqFACS extension is to be used While the Japanese macaques’ browridge is not as pronounced as in apes (e.g. chimpanzee), it is more salient than in humans, presenting cranio-caudal movement. The superior surface of the browridge is usually covered in hair similar to the body and head hair, but slightly longer . In someBrow movements have been reported to be associated to some extent to eye movements, as when individuals look up, down or even left/right, the frontalis and depressor supercilii muscles are often activated , raisingIndividuals’ browridges were regularly moving, often coupled with eye movements, which may make it challenging to determine the neutral position of the browridge for each individual, particularly due to individual variation in, for example, hair covering the skin or protuberance of this region. The angle of recording or head movements can also influence judgement on the position of the browridge, and therefore it is advisable to code these movements in video only, after determining first the neutral brow position for each individual, and account for the position of the camera relative to the individual’s face, while avoiding coding stills on their own (except for higher intensity AU1+2 or AU41 where appearance changes are easier to identify).We identified 5 independent movements in the upper face of Japanese macaques, AU1+2, AU41, AU43, AU45 and AU6, which are described below and differences noted with humans and rhesus macaques.1) Comparative muscular basis: In humans, AU1 (Inner brow raiser) and AU2 (Outer brow raiser) are independently produced by the contraction of the medial frontalis and the lateral frontalis, respectively. In rhesus macaques, the medial and lateral frontalis muscles also contract independently when stimulated .2) Main appearance changes: despite independent muscle contraction in rhesus macaques, AU1 and AU2 were not observed in isolation in spontaneous behaviour, and therefore AU1+2 is coded when the browridge is raised. In Japanese macaques, we found the same merged movement, so AU1+2 is coded . In stro3) Differences: Additionally, we found a unilateral AU1+2 (AU1+2U), identical to what Julle-Daniere et al.  describe1) Comparative muscular basis: In humans, the brows are lowered and brought together by the action of three muscles , resulting in the AU4—Brow lowerer. These muscles have also been identified in all the other macaque species here referred.2) Main appearance changes: Despite the presence of the necessary muscles for AU4 in macaques, AU4 is not observed in Japanese macaques (nor in rhesus or Barbary macaques). In Japanese macaques, only AU41 was observed, where the browridge is brought downwards by the procerus muscle, but there is no corrugation on the glabella  Videos.3) Differences: Thus, AU4 seems to be observed exclusively in humans, since it brings the eyebrows closer together through the corrugator supercilii m. action, while AU41 only lowers the brows. This movement was described in Japanese macaques [1) Comparative muscular basis and 2) Main appearance changes: The eye closure and blink in Japanese macaques seems to recruit to some extent the lower portion of the orbicularis oculi m. often, with the lower eyelid raising slightly or twitching, even in a low intensity blink, where the eyelid does not close completely . Low intensity movement is visible in the corner of the eyes as well, where the skin both superiorly and inferiorly is slightly pulled towards the eye, and wrinkles slightly or deepens existing wrinkles. The pars palpebralis portion of the orbicularis oculi m. thus must extend slightly outside the eyelids, but this is not however enough to code an AU6—Cheek raiser (see below).3) Differences: Unlike in humans, where the sclera is very visible and aids in these AUs identification, the sclera in macaques is not visible in neutral forward eyeball position, but when there are eyeball movements, a small portion of white sclera appears laterally. Japanese macaques have a few short black eyelashes on both eyelids and the upper eyelid has a lighter colour in some individuals, sometimes with a white/blue coloration, contrasting with the surrounding darker red/pink of the face. The iris is coloured brown and the pupil is black, visible at close range. There is some morphological variation around the lower eyelid furrow and the infraorbital triangle, with some individuals presenting no wrinkles under the eye, while others present some wrinkles in neutral face, particularly in infants . To note3) Differences: AU6 in humans is easily identified due to the fat deposit on the cheek area. In Japanese macaques  Videos, 1) Comparative muscular basis: This orbicularis oris m. movement is described in humans as the vertical movement of the lips, with the upper lip being pulled towards the lower lip, and/or the lower lip pulled towards the upper lip, after mouth/jaw opening (AU26 or AU27), and without any inwards curvature of the lips.3) Differences: While in humans, AU8 can happen with narrowing of the lips and together with AU18—Lip pucker (see below), in rhesus macaques AU18 and AU8 are described as mutually exclusive. However, in Japanese macaques, we observed AU8 on its own , but als1) Comparative muscular basis: In humans, AU9 and AU10 are observed clearly independently, with distinctive appearance changes produced by distinct muscles . Despite the same independent muscles being identified in rhesus macaques, AU9 has not been observed without AU10, and therefore AU9+10 is usually coded.2) Main appearance changes: Nonetheless, appearance changes for AU9 and AU10 are presented separately in the MaqFACS, and so AU10 can still be coded on its own. In Japanese macaques, some of the appearance changes are similar to rhesus macaques, but we found some differences as well (see below). Importantly, we observed AU9 and AU10 on its own a few times in different individuals, although AU9+10 was more often observed. Both AU9 and AU10 were observed unilaterally frequently (see examples below), but they can happen bilaterally as well.2) Main appearance changes: During AU9 , the mai2) Main appearance changes: In Japanese macaques, low or medium intensity AU10 was often raising the upper lip unilaterally , Fig 8 o2) Main appearance changes: The main differences between AU9 and AU10 are the position of wrinkles and direction of pulling movement. While in AU9 the oblique wrinkles appear on the infraorbital triangle and sometimes extend to the nose, with a pulling movement towards the inner eye corner, in AU10 the wrinkles are almost perpendicular to the nose and appear on the lower edge of the infraorbital triangle, with a pulling movement more towards the outer corner of the eye . If appe1) Comparative muscular basis: This movement was not described in the MaqFACS nor for Barbary macaques, but the nasalis m. movement was validated in rhesus macaques before .2) Main appearance changes: Here, we found an identical movement to what is seen in Waller et al (2008), with both nostrils being pulled outwards, appearing inflated .1) Comparative muscular basis: In humans, the zygomaticus major m. pulls the corners of the lips back and upwards towards the ears, creating an upturned half-circle shape to the mouth. In rhesus macaques, the zygomaticus major m. is interrupted by the depressor anguli oris m., which is related to the opposite facial movement .2) Main appearance changes: Furthermore, in a neutral state, the lip corners of macaques are straight or slightly downwards. Thus, when AU12 acts, no upwards movements are seen. This anatomical feature was suggested to be shared by Japanese macaques . And ind1) Comparative muscular basis: In humans and macaques, this movement is caused by the depressor labii inferioris m.2) Main appearance changes: In the MaqFACS, AU16 is identified mainly by a change in the curvature of the lower lip, accompanied by a decrease in the distance between lower lip and mental region edge, and increase in lower teeth exposure. These appearance changes are also found in Japanese macaques .3) Differences: However, in Japanese macaques we also observed some frequent orbital action added, with the lower lip being pushed away from the teeth protruding forward, forming a "V" shape in frontal view, like if it was inflated . In huma1) Comparative muscular basis: In humans, the chin raiser is produced by the action of the mentalis m. that pushes the lower lip upwards, protrudes the chin boss and wrinkles the chin. The bony chin boss is an anatomical feature unique to humans and its function is still highly debated . Therefo2) Main appearance changes: The lack of chin boss impacts the appearance changes of AU17 in macaques, making it harder to detect. In the MaqFACS, it was only observed with other movements, but we observed it in isolation in Japanese macaques , Fig 11.1) Comparative muscular basis: In humans, AU18 brings the lip corners medially, creating wrinkles and protrusion of the everted lips. In rhesus macaques, due to differences in the protrusion of the lips and action of the orbicularis oris and incisivii labii muscles, two movements were described AU18i - True Pucker, equivalent to the human AU18, and AU18ii—Outer Pucker.2) Main appearance changes: Similarly to rhesus macaques, Japanese macaques produce both AU18i –14 and ACentre) and grooming (3) Differences: For AU18i in Japanese macaques, we observed one difference to rhesus macaques: AU18i was both observed with and without protrusion/inflation of the lips. When there was no protrusion/inflation of the lips, the appearance changes were: 1) lip corners drawn medially, and/or 2) vertical wrinkles formed on both/either lips Figs –14; thergrooming , but alsgrooming .1) Comparative muscular basis: In humans, the orbicularis oris m. pushes the upper and lower lip against each other when the mouth is closed, creating wrinkles.2) Main appearance changes: This movement was not described for rhesus or Barbary macaques, but it was observed for Japanese macaques . Here, t1) Comparative muscular basis: Due to the eversion and contrasting coloration of the lips in humans, AU28 is easier to identify, where in the main appearance change, the lip(s) are sucked or introduced into the mouth by the orbicularis oris m., after mouth opening (AU26).2) Main appearance changes: This movement is not mentioned in the MaqFACS, but we observed it for Japanese macaques. Thus, the lips are introduced into the mouth folding around the teeth, stretching the skin above and below the lips . It can 1) Comparative muscular basis: Humans and macaques have three identical extrinsic ear muscles . The ear movements in humans are very limited or non-existent , while i2) Main appearance changes: The ear movements observed in Japanese macaques were the same as in rhesus macaques, EAU1—Ears forward, EAU2—Ears elevator, and EAU3—Ears flattener (see MaqFACS for list of appearance changes).3) Differences: Ear visibility is more limited in Japanese macaques in frontal view, which might also vary depending on the length and density of the individual’s hair. The ears might be more visible from a 3/4, side or back view, and even when the hair is covering the ears, EAUs can be ascertained by movement of the hair attached to the pinna, which in some individuals is of a lighter coloration than the rest of the head hair. Movement of the hair surrounding the ears is part of the appearance changes to code ear movements in rhesus macaques, and is even more important in Japanese macaques .We observed several ADs (broader movements or movements from non-mimetic muscles) in Japanese macaques . We brieM. fuscata (but not in M. mulatta), the occipitalis m. can be added to the frontalis action [1) Comparative muscular basis: The occipitalis m., one of the scalp muscles, is located between the galea aponeurotica (connective tissue covering top of the cranium) and the nuchal region, although in humans, it presents some variation between individuals regarding its length and insertion . Functios action  to pull M. fuscata pulled back the ears before lifting the browridge and ears strongly, which indicates that at least in high intensities, these movements might tend to act simultaneously. However, we did observe independent movements of brow raising (AU1+2) and ears (EAU3), and so the muscular activity reported in Seiler [2) Main appearance changes: In Japanese macaques, we observed AD101—Scalp retraction frequently, but not independently from ear (EAU3) or brow (AU1+2) movements. Individuals might not be able or have difficulty in using these muscles independently in naturalistic behaviour (similar to what is seen in the human glabella muscles ) or it mn Seiler  might non Seiler ).M. nigra: [M. tonkeana: [M. nigra with the code AD101, with the following description: "The hair on the top of the head, including the crest, flattens as the skin is pulled backward. Skin on the forehead and temples appears stretched.’ [M. fuscata, we here apply this code for Japanese macaques as well since the movement does not appear to be an independent action (i.e. likely not an AU for M. fuscata).3) Differences: Scalp retraction was not described in the MaqFACS nor in other detailed studies of rhesus macaques’ facial expressions (e.g. ). Howeve. nigra:  and M. tonkeana: ) with veetched.’ . DespiteLipsmacking—AD181 in varied contexts [Several macaque species display contexts , 78, 80,contexts , main apcontexts ), it wascontexts , lipsmaccontexts , additioAD19—Tongue Show, was often seen in Japanese macaques, either on its own or accompanying other movements. This movement is coded whenever the tongue is shown beyond the teeth, where the mouth is open (AU26) and the lips parted (AU25). Another movement we observed with the tongue was AD36—Bulge, where the tongue is pushed against the cheek or lip, causing the skin to stretch on that area and to bulge.AD29—Jaw Thrust and AD30—Jaw Sideways, where AD29 codes a forward displacement of the jaw protruding the mental region and lower lip, while AD30 codes the displacement of the jaw to one side of the face, creating a misaligned lower face with the upper face.Two jaw movements described for humans were also observed in Japanese macaques: AD34—Puff and AD35—Suck, and identical movements were found in Japanese macaques, with AD34 expanding the cheek skin as air is forced into the mouth with the lips closed, and AD35 sucks the cheeks into the mouth producing a depression anterior and caudally to the lip corners. We also observed individuals compressing the cheek pouches, raising the skin of the cheek and neck area by the contraction of the platysma m. [AD86—Cheek Pouch Compressor to code this movement. We observed movement of food from the cheek pouches to the cheeks and then disappearing caudally (i.e. by being swollen), which sometimes was accompanied by facial movements, such as AU18 , which MaqFACS Extension for Japanese macaques, future research can now objectively measure this species’ facial movements.The number of AUs described for Japanese macaques was similar to what was described for other macaques (rhesus and Barbary) as well as other primates , suggesting that Japanese macaques, as other primate species, have a wide range of facial movements that can potentially be used to compose a variety of facial expressions. However, it is important to note that our study did not measure the actual use or co-occurrence of these movements in this species, but by applying the For example, in future studies accounting for the socio-ecological factors of Japanese macaques and other macaque species, it might be interesting to look at the relationship between facial movement complexity (i.e. with more AUs/higher co-occurrence of AUs) and social styles (i.e. despotic-tolerant), as well as other factors  in order to understand how evolutionary pressures might have shaped communication in each species. All mammals have well conserved facial musculature  and therHence, although Darwin’s initial idea of emotional continuity between species  is fittisensu [sensu [Macaca), it is more likely that this species’ facial expressions are simply poorly studied, and so the MaqFACS Extension will be a valuable resource from now on.Another explanation for this diversity of facial movements, might be that in Japanese macaques (as with probably other macaques), facial expressions are not exclusively used for communicative  purposeu [sensu ) expressu [sensu ). Japaneu [sensu . For exau [sensu , 55 faciAlthough this has not yet been measured with FACS in primates, the human FACS has been used to code asymmetric AUs that might potentially be associated with emotional states due to the lateralised brain processes . This was noted before for other species (e.g. ), where curately , 91. Humcurately , 93; ConMaqFACS Extension for Japanese macaques, it is now possible to objectively and systematically quantify a variety of facial behaviour variables  in order to better understand Japanese macaques’ expressions as a species. Furthermore, it is a powerful comparative tool that will allow comparisons to other species using the same tools, in order to further explore the evolutionary pathways of communication and emotion processes in animals and humans.Animal FACS have been used to investigate a range of both applied and fundamental questions, ranging from applying DogFACS to investigate emotion in dogs , 94 as wS1 Text(DOCX)Click here for additional data file.S1 Videoa. Video example of AU1+2 in real time. b. Video example of AU1+2 in slow motion.(ZIP)Click here for additional data file.S2 Videoa. Video example of AU1+2 in real time. b. Video example of AU1+2 in slow motion.(ZIP)Click here for additional data file.S3 Videoa. Video example of AU1+2 in real time. b. Video example of AU1+2 in slow motion.(ZIP)Click here for additional data file.S4 Video(AVI)Click here for additional data file.S5 Videoa. Video example of unilateral AU1+2 in real time. b. Video example of unilateral AU1+2 in slow motion.(ZIP)Click here for additional data file.S6 Video(MP4)Click here for additional data file.S7 Videoa. Video example of AU41 in real time. b. Video example of AU41 in slow motion.(ZIP)Click here for additional data file.S8 Video(AVI)Click here for additional data file.S9 Video(AVI)Click here for additional data file.S10 Videoa. Video example of AU43 and AU6 in real time. b. Video example of AU43 and AU6 in slow motion.(ZIP)Click here for additional data file.S11 Videoa. Video example of AU6 during a yawn in real time. b. Video example of AU6 during a yawn in slow motion.(ZIP)Click here for additional data file.S12 Videoa. Video example of AU8 in real time. b. Video example of AU8 in slow motion.(ZIP)Click here for additional data file.S13 Videoa. Video example of AU8 and AU18 in real time. b. Video example of AU8 and AU18 in slow motion.(ZIP)Click here for additional data file.S14 Videoa. Video example of AU9 in real time. b. Video example of AU9 in slow motion.(ZIP)Click here for additional data file.S15 Videoa. Video example of AU10 in real time. b. Video example of AU10 in slow motion.(ZIP)Click here for additional data file.S16 Videoa. Video example of AU10 in real time. b. Video example of AU10 in slow motion.(ZIP)Click here for additional data file.S17 Videoa. Video example of AU10 in real time. b. Video example of AU10 in slow motion.(ZIP)Click here for additional data file.S18 Videoa. Video example of AU9+10 in real time. b. Video example of AU9+10 in slow motion.(ZIP)Click here for additional data file.S19 Videoa. Video example of AU9+10 in real time. b. Video example of AU9+10 in slow motion.(ZIP)Click here for additional data file.S20 Videoa. Video example of AU38 in real time. b. Video example of AU38 in slow motion.(ZIP)Click here for additional data file.S21 Videoa. Video example of AU12 in real time. b. Video example of AU12 in slow motion.(ZIP)Click here for additional data file.S22 Videoa. Video example of AU12 in real time. b. Video example of AU12 in slow motion.(ZIP)Click here for additional data file.S23 Videoa Video example of AU12 in real time. b. Video example of AU12 in slow motion.(ZIP)Click here for additional data file.S24 Videoa. Video example of AU16 in real time. b. Video example of AU16 in slow motion.(ZIP)Click here for additional data file.S25 Videoa. Video example of AU16 in real time. b. Video example of AU16 in slow motion.(ZIP)Click here for additional data file.S26 Videoa. Video example of AU17 in real time. b. Video example of AU17 in slow motion.(ZIP)Click here for additional data file.S27 Videoa. Video example of AU18i in real time. b. Video example of AU18i in slow motion.(ZIP)Click here for additional data file.S28 Video(AVI)Click here for additional data file.S29 Videoa. Video example of AU24 in real time. b. Video example of AU24 in slow time.(ZIP)Click here for additional data file.S30 Videoa. Video example of AU28 followed by AD32 in real time. b. Video example of AU28 followed by AD32 in slow motion.(ZIP)Click here for additional data file.S31 Video(MP4)Click here for additional data file.S32 Videoa. Video example of EAU1 and AD51 in real time. b. Video example of EAU1 and AD51 in slow motion.(ZIP)Click here for additional data file.S33 Videoa. Video example of AU100 during a yawn in real time. b. Video example of AU100 during a yawn in slow motion.(ZIP)Click here for additional data file.S34 Videoa. Video example of AU100 accompanied by AU1+2 and EAU3 from back view in real time. b. Video example of AU100 accompanied by AU1+2 and EAU3 from back view in slow motion.(ZIP)Click here for additional data file.S35 Videoa. Video example of AD86 in real time. b. Video example of AD86 in slow motion.(ZIP)Click here for additional data file.S36 Videoa. Video example of AD86 in real time. b. Video example of AD86 in slow motion.(ZIP)Click here for additional data file.S37 Video(MP4)Click here for additional data file.


Recently, many video steganography algorithms based on the intra-prediction mode (IPM) have been adaptive steganography algorithms. These algorithms usually focus on the research about mapping rules and distortion functions while ignoring the fact that adaptive steganography may not be suitable for video steganography based on the intra-prediction mode; this is because the adaptive steganography algorithm must first calculate the loss of all cover before the first secret message is embedded. However, the modification of an IPM may change the pixel values of the current block and adjacent blocks, which will lead to the change of the loss of the following blocks. In order to avoid this problem, a new secure video steganography based on a novel embedding strategy is proposed in this paper. Video steganography is combined with video encoding. Firstly, the frame is encoded by an original encoder and all the relevant information is saved. The candidate block is found according to the relevant information and mapping rules. Then every qualified block is analyzed, and a one-bit message is embedded during intra-prediction encoding. At last, if the IPM of this block is changed, the values of the residual are modified in order to keep the optimality of the modified IPM. Experimental results indicate that our algorithm has good security performance and little impact on video quality. Information hiding is the method to keep information secure, and because of its great performance, information hiding has become more and more popular all over the world ,2,3. As Steganography is widely used in digital media, such as image, audio and video ,8,9. In In the beginning, adaptive steganography was proposed for image information hiding; many years later, because of its great performance, adaptive steganography has become the most important image steganography technology ,18. MoreThe first video steganography algorithm was proposed by Hu et al. . The secThe review above shows that the existing video steganography based on IPM is mainly the adaptive steganography algorithm. Most of them focus on the mapping rule and distortion function for the Syndrome-Trellis Code while ignoring the fact that adaptive steganography may not be suitable for video steganography based on the intra-prediction mode. In order to avoid this problem, a secure video steganography based on the intra-prediction mode is proposed in this paper. Firstly, the frame is encoded by the original encoder and all the relevant information is saved. Then, every qualified block is analyzed, and embedded in a one-bit message during intra-encoding. At last, if the IPM of this block is changed, all the values of the residual are modified to zero in order to keep the optimality of the modified IPM. In this way, we can ensure the modified IPM will keep its optimality after embedding. Hence, this algorithm can effectively resist the steganalysis algorithm. The modification of an IPM may change the pixel values of the current block and adjacent blocks, which will lead to a change in the cost of the following blocks; in order to avoid this problem, a new secure video steganography based on a novel embedding strategy is proposed in this paper.Because not all the blocks are appropriated for embedding messages, cover selection rules are proposed in this paper; all the blocks are analyzed and only the qualified block is embedded during the intra-prediction encoding.In order to avoid detection by steganalysis, after modifying the IPM of the selected block, all the residual values of the same block are modified to maintain the optimality of the modified IPM.In summary, this paper makes three novel contributions: The rest of this paper is organized as follows. The process of intra-prediction is briefly introduced in As an open video coding standard, H264/AVC was developed by the ISO/IEC MPEG and the ITUT VCEG standards committees . High daIn order to transmit and store easily, uncompressed video can effectively compress into a smaller video file by using video-coding techniques. For the uncompressed video sequence, there is temporal redundancy between the adjacent frames and special redundancy in a single frame. Spatial redundancy indicates that the values of the adjacent pixels are similar in the same frame, in other words, the adjacent regions usually have a high correlation. Therefore, decreasing the spatial redundancy is an effective method to obtain a high compression rate in the intra-prediction technique. There are four kinds of IPM in AVC, intra 4 × 4, intra 16 × 16, intra chroma and I_PCM. The intra 4 × 4 blocks are widely used in video steganography based on intra-prediction modes. Because the detail areas are usually encoded in intra 4 × 4 blocks, embedding messages in intra 4 × 4 blocks will have less influence on the video quality.The basic procedure of the intra-prediction scheme in AVC is proposed as follows:Firstly, the most probable mode (MPM) is calculated based on the IPMs of the adjacent blocks in Formula (1). R is the number of bits to encode the block. Since the computation complexity of RDcost is high, SATD is another choice to select the optimal IPM. The formula of SATD is shown in Formula (3). H represents Hadamard Transform. The intra-prediction mode with minimum cost will be chosen as the optimal IPM of the current block.Then, all the rate distortion (RD) costs of the candidate IPMs are calculated by using Formula (2). Parameter x, y).x, y).Finally, the identifier pre is calculated based on the optimal IPM and MPM of the current block. If the IPM and the MPM of the current block are the same, the pre will be set to 1, and then the optimal IPM will not be stored in order to save the bits of the coding stream. If the IPM and the MPM of the current block are different, the pre will be set to 0, and then optimal IPM will be stored in the coding stream. So, it will have great influence on the number of bits, if the IPM is changed in the block with the pre equaling 1.In this section, firstly, we analyze the influence of different embedding orders to the performance of steganography based on the intra-prediction mode. Then, the influence of optimality on the performance of the steganography based on the intra-prediction mode is analyzed. Recently, adaptive steganography has been widely used in video steganography based on the intra-prediction mode because of its great performance. There are many adaptive steganography algorithms based on both the intra-prediction mode and motion vector. Some of them have great security and little influence on the video quality, so adaptive steganography technology become more and more popular in information hiding area. Although adaptive steganography technology may suit for image steganography and video steganography based on motion vector, but adaptive steganography technology is not the perfect match for video steganography based on the intra-prediction mode.Because that adaptive steganography must calculate the cost of modifying every cover in order to choose the appropriate covers to modify. In all of the adaptive steganography algorithms, the definition of the distortion function is the most important part. Each author tries to define the distortion function in different ways. However, those facts exist with one condition: the changing of one cover has little influence on the rest of the covers. Otherwise, the loss of the rest of the covers may change after the first cover is modified. In addition, this distortion may accumulate after more covers are modified. There are some adaptive steganography algorithms based on the intra-prediction mode that exist, all of them must calculate the cost of modifying every cover before embedding the first secret message to the cover. However, in AVC intra-prediction, every block is encoded based on several pixel values of its adjacent blocks, which means the best intra-prediction mode of the same block may change if some pixel values of its adjacent blocks have a little variation. If some bits of a secret message are embedded into the cover blocks, the distortion of the rest of the cover blocks may have a few differences from the distortion they calculate before. In addition, this distortion may accumulate after more covers are modified just like the intra-frame distortion drift. In summary, adaptive steganography technology is not the perfect choice for video steganography based on the intra-prediction mode because of its embedding strategy. As a typical adaptive video steganography based on the intra-prediction mode, this paper selects Nie et al.’s algorithm to verify the above viewpoint. As shown in Ten video sequences were tested in different quantization parameters (QPs). The ratio of the optimal IPM changing is shown in In video steganography based on IPM, the IPMs of the selected blocks are modified in order to embed a secret message, which means the optimal IPM of the cover block is modified to a suboptimal IPM. So, the optimality of these IPMs will be destroyed. This is also the main idea for steganalysis to decide whether the video is embedded with a secret message or not. In order to avoid detection by steganalysis, the IPM of the cover blocks should try to maintain its optimality while embedding a secret message. To achieve this purpose, after modifying the IPM of a selected block, all the residual values of the same block are modified to zero. Since all the residual values are modified to 0, the values of the reconstruction pixels and the values of the prediction pixels with the current IPM are the same. In other words, the current IPM will be the optimal IPM for the cover block in view of the steganalysis algorithm. So, the information-hiding algorithm has great performance against the steganalysis.In order to make our algorithm more secure, an appropriate embedding strategy was chosen. Because the pixel values of the current block are predicted by pixel values of the adjacent blocks in the intra-prediction encoding scheme, the modification of the IPM must processed immediately before the intra-prediction of the next block. Otherwise, the statistical information may change after the modification of the IPMs. In addition, keeping the optimality of the IPMs can improve the security of the steganography algorithm. In this paper, the residual values of the current block will be modified after the message is embedded in the current block. Besides, the mapping rule and cover selection is important to the performance of our algorithm; the procedure of the mapping rule and cover selection is proposed in In order to embed the secret message to the IPM of every selected cover, all nine IPMs are divided into two groups. These two groups represent two different kinds of secret messages, 0 and 1. If the secret message is 0, the IPM of this cover should modify to the IPM in Group 0. If the secret message is 1, the IPM of this cover should modify to the IPM in Group 1. In AVC intra-encoding, there are nine IPMs that exist, and a similar direction means a similar prediction method. Because the cover IPM will not be modified to the IPM in the same group, the similar prediction method should not exist in the same group. Based on this, all nine IPMs are divided into these two groups in Formula (4). If the secret message of 0 is embedded into the blocks, the IPM of this block will modify to IPM that has the minimum cost in Group 0.As we all know, there are two different blocks that exist in AVC intra-macroblock. In this paper, only intra 4 × 4 blocks are chosen to embed the messages while the IPMs of the intra 16 × 16 blocks are not modified; this is because there are nine available IPMs in the intra 4 × 4 block while only four available IPMs in the intra 16 × 16 block. The more available the IPMs, the more difficult for the steganalysis to detect the video cover accurately. Furthermore, a smooth area is usually encoded in the intra 16 × 16 blocks while the detail area is encoded in intra 4 × 4 blocks. So, embedding messages in intra 4 × 4 blocks will have less influence on the video quality. The secret messages are only embedded into the intra 4 × 4 blocks.Not all the intra 4 × 4 blocks are appropriated for embedding messages in this paper. There are some blocks whose residual values are almost zero. These blocks are appropriated to embed the secret messages naturally; but, there are some blocks whose residual values are quite complicated and large. Embedding message in these blocks will have great influence on the video quality. In order to keep a balance between security and video quality, there is another cover selection rule. Firstly, assuming the coding of the intra 4 × 4 blocks are going to embed a one-bit message, the modified IPM can be decided based on the cost order and mapping rule. Then, the sum of all absolute values of the inverse transform residual matrix with the modified IPM are calculated before the modification, given as S. If S is greater than the threshold T, this block will embed a one-bit message, and all the residual values are modified to 0. If S is smaller than the threshold T, this block will not embed any message. Hence, the messages will embed into the blocks with little influence on the video quality. The modified IPM will still be the optimal IPM after encoding since the residual values are modified to zero.According to One frame of the original video is read.Read one intra 4 × 4 block from the encoding frame.Firstly, assuming the coded intra 4 × 4 blocks are going to be embedded as one-bit messages, the modified IPM can be decided based on the cost information and mapping rule.Then, the sum of all absolute values of the inverse DCT transform residual matrix with the modified IPM is calculated before the modification.Decide whether this block is going to be embedded as a one-bit secret message or not. The embedding position is recorded and encrypted by a private key. If the block can meet the cover selection rule, then the IPM will be modified and all the residual values are modified.Repeat Step 2 until all the intra 4 × 4 blocks are processed.One frame of the original video is read.Read one intra 4 × 4 block from the encoding frame.The position of the embedding blocks is generated by private key, the message is extracted by mapping rule.Repeat Step 2 until all the secret messages are extracted.The process of message extraction is presented as follow:In this section, in order to measure the performance of the proposed video steganography algorithm, experimental results are presented as follow. A video database ,26,27,28In our algorithm, the threshold T was used in cover selection, which has a great influence on the performance of the algorithm. When T becomes larger, more blocks will participate in the information embedding, thus the embedding capability of our algorithm will increase. However, since the values of the residual matrix will be modified after the message is embedded in the current block, the video quality will decrease if T becomes larger. In order to test the influence of different thresholds, experiments are carried out for different thresholds. In this experiment, video quality is evaluated by power signal-to-noise ratio (PSNR). PSNR is measured by Formulas (5) and (6). As shown in In order to evaluate the performance of the steganography algorithm, PSNR is used to measure the video quality with a different bit rate. PSNRs are widely used to evaluate video quality in the steganography algorithms.Different encoding standards have great influence on the video quality; so, Wang et al.’s algorithm does not participate in this experiment because this algorithm is based on the HEVC encoding standard while the other algorithms are based on the AVC encoding standard. In this experiment, several video sequences were compressed by different steganography algorithms. The result is shown in Security is the most important issue for all video steganography algorithms. In order to measure the security of the steganography, a state-of-the-art steganalysis was processed. Because of its great detection performance against video steganography based on IPM, Zhao et al.’s algorithm  was chosThe true positive rate is given as TP, and the true negative rate as TN.In this experiment, 118 video sequences were randomly selected for SVM training, and the remaining 60 video sequences were used for classification. Different SVM kernels were processed in this experiment. The experiment was executed 10 times to calculate the average accuracy rate. As shown is Since the security of the steganography must be compared with a similar capability, the payload of Nie et al.’s algorithm and Bouchama et al.’s algorithm was set to 0.375 and 0.5, respectively, so the capability of all the algorithms can be kept close. As shown in Furthermore, Wang et al.’s algorithm was also compared with our algorithm. Although Wang et al.’s algorithm is based on the HEVC encoding standard, in the security experiment of Wang et al.’s algorithm, Zhao et al.’s algorithm was also chosen as the steganalysis method. Since the encoding standard is different, the experiment is processed with different QPs, which is the same with Wang et al.’s paper. As shown in A secure video steganography based on intra-prediction modes is proposed in this paper. In order to improve the performance of our algorithm, a novel embedding strategy is proposed. Different from adaptive steganography, the modification of the current block is processed immediately before the intra-prediction of the next block, so the modification of the current block will not affect the following blocks. In addition, after the modification of the IPM, the residual values will be modified to keep the optimality of the modified IPM. Finally, in order to keep the balance between the capability and video quality, a cover selection rule is proposed in this paper, where only the qualified blocks are embedded with a secret message. The experimental results show that this algorithm has great security performance and the security of our algorithm can basically maintain stabilization during different quantization parameters.In the future work, we will improve the modification to the residual matrix, so the video quality will be better. The embedding method also will be improved to enhance the coding capability and security. In addition, the proposed algorithm will be implemented in HEVC since the HEVC encoding standard has become more and more popular all over the world.


Clinical outcomes among adolescents living with HIV (ALHIV) might be improved by interventions aimed at addressing limited health literacy. We developed a Spanish-language rap video on HIV concepts and examined its acceptability and feasibility as a learning tool among ALHIV in Lima, Peru. Twenty-eight ALHIV receiving care at an urban pediatric hospital and ten stakeholders engaged in the care of adolescents watched the video. Adolescents completed a pre- and post-video questionnaire. We conducted focus groups with ALHIV and in-depth interviews with stakeholders and analyzed transcripts to identify themes. ALHIV described concepts of CD4 cell count and viral load as they were portrayed. Participants reported the video was relatable, accessible, and provided hope that ALHIV could lead healthy lives and advocated for future videos to address topics such as transmission and sexual health. Questionnaires indicated some improvement in viral load knowledge. An HIV health literacy music video intervention was feasible to implement and accepted by ALHIV and their healthcare providers. Communicating HIV knowledge via music videos may be promising; further study is needed to optimize implementation. Declines in HIV virologic suppression and adherence to combination antiretroviral therapy (cART) are common during adolescence –3, a timDespite a disproportionate burden of new HIV infections in Latin America and the Caribbean among 15–24 year olds , 16–19, To inform adolescent-friendly interventions addressing health literacy, we developed a Spanish-language rap video and assessed its acceptability and feasibility as a learning tool among ALHIV in Lima, Peru.Our prior work among ALHIV in Lima identified that unsuppressed viral load, CD4 count decline, and nonadherence increase throughout adolescence , 21. We In May and June 2018, we enrolled 28 ALHIV (10–18 years) receiving HIV care at a large urban pediatric hospital in Lima, Peru and ten health care providers who routinely cared for adolescents, including pediatricians, infectious disease specialists, nurses, peer counselors, and the director of a non-profit organization providing community-based HIV services. Nearly all ALHIV were perinatally-infected. No adolescents or stakeholders refused participation; however, one adolescent who consented was unavailable on the day of the focus groups. Adolescent participants and an accompanying guardian were provided with lunch on the day of the session and reimbursed for travel (approximately 8 USD); stakeholders were remunerated approximately 10 USD for interviews.Adolescents and their caregivers were approached to participate during routinely scheduled visits at the pediatric hospital. Participants were asked to watch the rap video. Adolescents completed a pre- and post-video questionnaire and participated in a focus group to share their opinions about the video. Key stakeholders completed in-depth interviews to discuss their opinions on video acceptability and utility, implementation strategies, and topics for future music videos. We defined acceptability as how well the intervention was received by ALHIV and how the intervention met the needs of ALHIV . We follThe pre- and post-video questionnaire was designed to assess comprehension of the video’s key HIV messages, including CD4 cell count, viral load and cART adherence. While the pre- and post-video questionnaire can be used as a preliminary assessment of the intervention’s effectiveness of improving health literacy, the study was not powered to detect within-person differences in responses. We purposefully sampled questions from validated tools to align with key themes. These included questions from The Brief Estimate of Health Knowledge and Action—HIV version (BEHKA-HIV) and HIV Treatment Knowledge Scale, a validated tool for youth living with HIV , 27. AddA trained qualitative researcher led four focus groups with adolescents and conducted in-depth individual interviews with key stakeholders, which were audio-recorded. Semi-structured guides were developed for focus groups and interviews separately. To assess acceptability, focus group guides questioned adolescents on what they liked and disliked about the video and the perceived importance and applicability of video content to adolescents’ lives. Feasibility of the video primarily focused on if and how adolescents would watch or share the video. In-depth interview guides with key stakeholders focused on assessing acceptability via questions on the relevance and value of video content for ALHIV. We probed stakeholders on the feasibility of the intervention with questions on how the video could be shared with ALHIV or implemented in the future.Guides were designed to assess acceptability, effective communication of key messages, importance of content, potential uses, and themes for future videos , 25. AllWe assessed HIV knowledge acquisition by categorizing participants’ responses as correct or incorrect in the pre- and post-video questionnaire administration, resulting in four categories: incorrect at both time points, correct at both time points, correct in the pre-period but incorrect in the post-period, and incorrect in the pre-period but correct in the post-period.Audio recordings were transcribed verbatim, translated by a bilingual study team member, and analyzed. One researcher read the transcriptions and grouped the data into main themes based on focus group guides  and subgroup themes. Another researcher performed a secondary review to confirm findings. Discrepancies between researchers were resolved by discussion.Study materials were reviewed and approved by the ethics committee at the National Institute of Child Health , Lima, Peru and the institutional review board of Harvard Medical School, Boston, USA. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.th–75th percentile: 13–16)  completed both the pre- and post-video questionnaire. Most adolescents were female (63%) and the median age was 15 years  participated in the focus groups; ten stakeholders, including seven pediatricians or infectious disease doctors, one nurse, one peer counselor, and one director of a non-profit organization, participated in in-depth interviews.Adolescents and stakeholders described how three aspects of the video enhanced its acceptability: relatable content, an adolescent-friendly medium, and ease-of-access.I think that it approaches their reality because there are images of Peru, a place they recognize. In other words [the setting] is not a foreign place where [the adolescents] say, ‘well maybe there yes, but here, no.’ Or that in those places, yes you are going to live, but here you are not. It’s saying that here, yes, there is a solution to the problem, this problem.Adolescents enthusiastically responded to seeing places they recognized. One adolescent commented: “[I like that] they chose places from here, from our country… the north, it’s all really good”, while another adolescent expressed her joy seeing one of her favorite places and mentioned “I loved [the video] because it is at my favorite beach.”Participants explained how the familiar backdrop of the video and the diversity of the people featured in the video fostered a perception of personal relevance. One health provider commented on how the recognizable backdrop was significant to adolescents:They have included a diverse group, diverse races, men and women together, everyone singing together. I think this is good because anyone can feel identified.” Another health provider commented on the effectiveness of peers  as communicators of information because “even though they are already familiar with the illness, and they know what we tell them every day at their appointments, it’s always necessary for them to be reminded of something in their own language.”Others appreciated the diversity of the artists in the video. A health provider described how the diversity of people helped adolescents feel like they were more relatable: “[I like the video format] because it teaches me and I am going to learn through listening and it is not as boring as a brochure or a talk.[The video is] interesting because they have used new music … a genre called trap. And they seem to have copied that song, a song that mostly young people listen to.Health providers described how music was relevant to adolescents and effective in capturing their attention:…this type of video clip is what usually attracts attention. I mean, unfortunately, I do not know if this is true in all countries, but the custom of reading things is very much lost. That is one thing that for me is wrong, but, well, that's our reality. If you give me something to read and something to watch that has music, I prefer [the latter]. That is very clear.It gives them another medium that corresponds to their age and music that they know. And this is important, right? Hearing it from a peer that speaks to them, sings to them. They probably think they are alone with this illness.Adolescents and stakeholders identified the audio and visual components of the video as attractive to the target population. Adolescents expressed their preference to listen to music and watch videos and described how the music engaged them:Well, they have YouTube… they can look for it, if we tell them, ‘look at this link or that one.’ And most of the kids now use the internet, no? I think if we say to them ‘if you want, you can watch it at home or you can repeat it and watch at the internet cafe’, then that would also be a reinforcement so that they know and that they watch it.They could look for the video in many ways [including] internet cafes. They go to the places where there is Wi-Fi, with tablets, computers, laptops. Ay, right now most of them have access to the internet, they have a link.A key consideration related to acceptability was whether adolescents were able to access the video. Health providers expressed that a web-based video would be broadly accessible to adolescents:Two key themes emerged in this area: (1) adolescents reported improved understanding of key concepts in HIV, as they were portrayed in the video, and (2) health providers highlighted aspects of the video facilitating this effective communication.…That we have to take care of our health and that our CD4 must increase and that our … viral loads will go down and our defenses will win and put the virus to sleep in the body.Another common takeaway was the importance of cART adherence for viral load suppression and overall health. One adolescent explained that, for her, the importance of adherence was a key take-away:We have to take the pills or the [antiretrovirals] so that everything goes well, and that is the truth. If we take the medication, we are not going to get sick and we will be able to control our viral load too. If we take the medication, the viral load is controlled and there won’t be any problems.Adolescents juxtaposed their knowledge of CD4 count and viral load before and after watching the video. These two adolescents reported the video corrected misconceptions and offered new information:Before the video, I thought that CD4 was for example, the virus that was in our body and the viral load was something good.Adolescent: And now in the video, what are you understanding?Study worker: That the CD4 is our cells that protect our body.Adolescent: And the viral load?Study worker: : Our virus that is acting.AdolescentIt’s interesting.Adolescent: Interesting…did you learn something about the topic?Study worker: Yes, about CD4, what CD4 is.Adolescent: And what is it?Study worker: One’s defensesAdolescent: And was there another idea that you captured from the video…?Study worker: …That one has to conquer HIV.Adolescent: That one has to conquer HIV, and how are you going to conquer HIV?Study worker: Taking our medicines and paying attention to the doctor.Adolescent: Both qualitative data and quantitative data suggest adolescents improved their understanding of the role the CD4 count, viral load, and cART adherence. When asked what he understood from the video, this adolescent responded by using a metaphor from the video:…They repeat [the message] several times and that is good. The more you repeat the message the more you will internalize it. It is also not good to put many messages in the song, two or three main ideas is what I noted. They are about the CD4 [count], that you are going to be okay… and that if you want to be undetectable you have to take all your pills—that's a good message to improve adherence.It’s the way they express [the message] no? They express it always motivating the youth, the adolescents. And they feel motivated. The [rap] emphasizes a lot taking medications…and that if they take the medication everything will be all right and [the disease] will be controlled.Health providers described aspects of the video facilitating effective messaging, including repetition, a succinct message, and a motivating tone:Everything depends on us; taking care of ourselves and improving our health, it all depends on us.It talks about the medicines, about taking all of the medicines that we have, and it's good because it teaches us not to neglect ourselves, how to treat ourselves, and all of that.Health providers and adolescents noted the video reinforced that it is possible to live a healthy life with HIV, a message they felt could be especially important during disclosure:I think it’s perfect. The topic is very interesting because it’s really going to help a lot. I would like to see it … in Ministry of Health materials, something that penetrates, no? Because we would avoid so much. I mean, we would avoid that children [on antiretrovirals] don’t know about these topics…It would help a lot with retention and above all for them to know that there is an incentive …that you are going to be okay, so that is very important. There are many children who get depressed here because of the diagnosis and during the disclosure process they do not accept their diagnosis. …Because when you receive this news [of the HIV diagnosis], you think that the world suddenly ends, you don't want to live, but with information like this, our emotional state changes, improves, makes you want to continue living. (Adolescent)It gives hope. It tells you that you are going to be okay. If you take the pills, you will live better, and if you listen to the doctor. So, these messages are positive and so they lift the spirits of the person living with HIV. Adolescents affirmed the importance of the content in the video, particularly messaging that self-care is imperative to a healthy life and that adolescents are responsible for their decisions. Adolescents reported information in the video was important because it encouraged autonomy:“when we feel bad or down… so that it gives me strength”, while another mentioned it would have been useful to see the video prior to disclosure: “for [the sake of] our emotional state, no? So that when they give us our diagnosis it doesn’t shock us as much.” Other adolescents suggested the video could be used in schools for health education or a student-led presentation, as a way to initiate discussion.Adolescents reported diverse potential uses of the video. Several mentioned they would watch it to improve their HIV knowledge or lift their spirits. One adolescent explained he would watch the video Adolescents expressed mixed opinions about sharing the video with friends and family. Proponents of sharing felt it would help their network understand what it was like to live with HIV. Others felt like the sentiment and message of the video would only be understood and appreciated by those living with HIV.“we should give them the video so they see that there are young people talking about this topic, who are saying that with treatment they can be okay.” While both providers and adolescents recommended the video be shown in health facility waiting rooms, some providers emphasized the video should be accompanied by dialogue: “… it is not the same for them to see the video alone as it would be to see it here [in the hospital]. …Perhaps in the hospital with someone from the psychology team or during clinical consultations…”Providers suggested the video could be used to teach ALHIV that it is possible to live a healthy life if adherence to cART is maintained. For example, one pediatrician suggested: When asked about potential themes for future videos, adolescents expressed interest in self-esteem, mental health and emotional wellbeing, basic concepts in HIV/AIDS, HIV prevention, self-care, advances in HIV science, and HIV-related discrimination. Sexual health was also raised as a topic by providers and adolescents. One of the most commonly suggested changes was to vary the music genre. Some participants suggested the repetition of reggaetón music would lend itself to learning lyrics, which for some adolescents were too fast in the current video. Others expressed a preference for slower ballads or bachata music.In both pre- and post-video periods, the majority of participants correctly endorsed that cART improved the body’s immune system by increasing CD4 count 24/27, 89%) and missing doses of cART increased HIV in the body  (Table 4/27, 89%Through questionnaires, focus groups, and in-depth interviews, we found an HIV health literacy music video intervention was widely accepted by ALHIV and their healthcare providers. Qualitative data revealed adolescents felt the video was relatable and familiar due to the selection of actors and filming locations. Adolescents described the video as empowering and provided them with hope they could lead healthy lives. Additionally, some adolescents who were unable to positively identify the role of viral load before the video were able to do so in the post-video questionnaire. These findings demonstrate the need to investigate the impact of delivering health education through music videos on outcomes at the individual and population levels.acceptable, one of the primary aims of our study. Participants described their willingness to re-watch the video to absorb the content or make themselves feel better about their diagnosis, demonstrating acceptability. The World Health Organization emphasizes interventions should also be equitably available and appropriate for adolescents’ needs [effective at making positive contributions to adolescent health. Our findings indicate the intervention was both acceptable and feasible, two key components used to determine whether future effectiveness studies should be pursued.We used a rap music video as a medium to deliver HIV-related information to ALHIV. The use of a music video—as opposed to conventional communication like brochures or verbal instruction from providers—fulfills criteria for being an “adolescent-friendly” intervention according to four factors defined by the World Health Organization . First, s’ needs . Online s’ needs , primaris’ needs . These us’ needs . Lastly,During focus groups, adolescents advocated for the use of the video as a teaching tool in schools. While messages in the study video primarily were targeted at ALHIV, future videos on topics such as HIV prevention and sexual health may be an opportunity to disseminate important health messages to adolescents without HIV. Resources for sexual health information may be particularly valuable in Peru and other settings where a compulsory sexual health education in primary and secondary schools is either not available or not enforced . With reA potential limitation in our study is that adolescents received care at the same children’s hospital and were largely perinatally-infected. Because the hospital is the largest pediatric facility in metropolitan Lima, we expect our results are broadly generalizable to other urban Latin American settings and likely extend to all ALHIV, regardless of mode of transmission.There is a substantial dearth of evidence on interventions tailored to ALHIV from diverse settings, especially related to improving health literacy. Adolescence is a crucial period to intervene on health literacy as ALHIV gain autonomy and eventually transition from pediatric to adult HIV care, a period marked by poor clinical outcomes and loss to follow up . We foun


In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients.A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines.Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7–62.5% were malnourished at admission and 35.6–60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life.Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.The online version of this article (10.1007/s00068-020-01304-5) contains supplementary material, which is available to authorized users. Malnutrition is an underestimated problem in the general hospitalized population. Estimations up to a 50% prevalence of this condition have been reported, with probably even higher numbers in the critically ill –4. MalnuIn severely injured patients, the relationship between nutritional status and clinical outcome is complicated by the systemic pathophysiological responses to trauma, which may affect, as well as may be affected by, the patient’s nutritional status –11. The This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement . A systeArticles about the pathophysiology and metabolic effects of malnutrition in severely injured trauma patients were considered eligible for inclusion, as well as clinical studies in which the prevalence and/or outcomes of malnutrition in severely injured trauma patients were reported. We did not use a specific definition of malnutrition and severely injured patients because different criteria and assessments tools for both malnutrition and severely injured patients were used in the literature. We selected publications in Dutch, English, French, and German without restriction on publication year. Identified articles were first screened for relevance based on title and abstract. Articles without full-text were not included; the majority (56%) of these were outdated (> 20 years old). The full-text of potentially eligible articles were read before inclusion in the review. The reference lists of the included articles were screened for additional literature. Expert opinions, conference papers and letters to the editor were excluded. Selected articles were grouped by topic: (1) articles describing the metabolic response of malnutrition in severely injured trauma patients, and (2) clinical cohort studies describing the prevalence of malnutrition and its association with clinical outcomes in severely injured trauma patients during hospital admission.All selected articles about the pathophysiology and metabolic effects of malnutrition in severely injured trauma patients were review articles. Data on pathophysiology and metabolic effects of malnutrition in these articles were summarized and combined in a model. The methodological quality of the included review articles could not be assessed according to the AMSTAR tool or equivalent as suggested by the PRISMA-guidelines , 15, becPatients’ age and gender, reported prevalence of malnutrition, type of nutritional assessment tool, and reported clinical outcomes were extracted from the selected cohort studies. Authors were contacted for more detailed information on the severely injured and geriatric patients groups in their studies, however none of the contacted authors responded to our query. Due to the inconsistent and different assessment tools and reported outcomes, the extracted data of these studies could not be pooled.The risk of different types of bias of the included cohort studies was assessed using the ‘Methodological index for non-randomized studies’ (MINORS criteria) on a 3-point scale ranging from 2 (reported and adequate) to 0 (not reported) .Article selection, data extraction and assessment of methodological quality were performed independently by the first two authors. Disagreement was resolved by discussion.The search yielded 3689 articles. After removing 418 duplicates, 3271 articles were screened for eligibility. Seventy-three articles were excluded because no full-text was available. Twenty articles fulfilled the inclusion criteria and were included in this review. Two more studies were included based on hand search of the reference lists  together with post-injury released hormones , act as catabolic stimulants , 18, 23.The combination of this acute phase response and increased energy expenditure after trauma leads to a hypermetabolic state  tool, Nutritional Risk Screening (NRS 2002) tool and serum biomarkers  , 35, 36.Ten studies reported on clinical outcomes, such as mortality, hospital length of stay, quality of life, and complications associated with malnutrition, six in the general trauma population , 33–35 aGeriatric patients at risk for malnutrition or suffering from malnutrition had more often cognitive impairments, infectious complications, depressive symptoms, comorbidity, less amelioration of their nutritional status, a higher prevalence of frailty and suspected sarcopenia than well-nourished patients , 29, 36.It is universally recognized that baseline “malnutrition” is a risk factor for worse clinical outcomes and that nutritional adequacy is important in component of the complex multidisciplinary care of severely injured patients. Yet, our comprehensive review of the published literature reveals that the evidence-base for these commonly held tenets is surprisingly sparse, outdated, and frequently of low-quality. The practice of critical care is rapidly changing, and many of the “landmark” studies in metabolism have been performed prior to recent treatment paradigm shifts in blood transfusion, fluid administration, sedation interruption, and ventilator management, to name but a few. Very few actual scientific studies have been conducted in the modern era of critical care and the literature is marked by heterogeneity in assessment tools, assessment times, interventions, and outcomes. It is thus impossible to quantitatively synthesize the literature. As such, we attempt to qualitatively synthesize the literature and offer suggestions to improve future studies in the field of nutrition in polytrauma patients.The metabolic changes after trauma are distinctive and complex and make trauma patients more susceptible for developing malnutrition. Second, in these patients a vicious circle is set in motion by malnutrition, leading to further deterioration of the nutritional- and health status. The results of the review also underline the importance of early malnutrition recognition and intervention to prevent further deterioration.The prevalence of malnutrition varied widely in the selected studies and depends upon the way in which malnutrition was defined and measured. Malnutrition has been defined in various ways , 38, dueThe detection of malnutrition in an early phase provides the clinician with the opportunity to intervene and attempt to prevent further deterioration of the nutritional status. The literature suggests that only a fraction of malnourished hospitalized patients receive timely nutritional support to prevent nutritional status decline . KondrupAlthough it seems intuitively obvious that the problem can be easily solved by providing the patients with the appropriate amount of calories and proteins, there is no strong evidence that increasing nutrient delivery improves clinical outcomes , 50. RecA limitation of our systematic review on pathophysiological processes and metabolic changes after severe trauma is that this part was based on reviews (some published more than two decades ago) and mostly not performed according to the currently applied systematic review guidelines. We do consider this knowledge to be important, although we do acknowledge that there are currently new insights being developed. The clinical studies on prevalence and outcomes of malnutrition were small cohort studies, with ill-defined patient populations and great variation in outcomes. Other limitations are that our review was incomplete as the full-texts of 73 identified articles could not be retrieved, and that we imposed language restrictions.Based on the overall findings uncovered by this systematic review, we believe that future research on nutrition-related research in severely injured trauma patients should incorporate the following: First, as already mentioned, we recommend the widespread use of a uniform, simple, and validated risk stratification score for which we would recommend the NUTRIC-score. Second, recognizing that traditional biomarkers for monitoring nutritional status  are strongly influenced by the acute phase response, we recommend that a C-reactive protein be measured concomitantly to give information about the inflammation status to show that albumin and prealbumin are more related to the acute phase response than nutritional status , 58. In Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, low-quality, and outdated. Nutritional assessment and ongoing monitoring is hampered by low prioritization and heterogeneous, unvalidated tools. However, based on the malnutrition-associated adverse outcomes, the nutritional status of severely injured trauma patients should be routinely and carefully monitored. This review shows that the combination of a prolonged and/or disturbed metabolic response following severe traumatic injuries that negatively influences the nutritional status and the negative influence of malnutrition upon this response, leads to a vicious circle of further deterioration of the nutritional- and health status. Additional trials are required to better define the optimal nutritional treatment of severely injured patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results.Supplementary file1 (DOCX 16 kb)Below is the link to the electronic supplementary material.


M = 20.29, SD = 2.70) took part in an online survey. The results suggested higher moral reasoning for participants who described themselves as gamers and those which do not play, compared those who play but do not identify as gamers. It was suggested that males had higher moral scores and more mature reasoning than females. The results of a regression analysis suggested that there were no significant predictors for moral development from either game play or the demographic variables. The findings suggest that moral development could be less influenced by sex, age, and video game play factors such as video game content and amount of game play, than was previously thought for this age group.Previous research with video game play and moral development with adolescents, found both positive and negative relationships. This study aimed to extend this research to explore moral development and video game play with university students. One hundred and thirty-five undergraduate students ( Gaming is a popular pastime among adults; with an average of 4.8 hours spent a week playing online and those aged 18–34  making up about 40% of gamers, with the industry worth reported (from transactions in 2019) to be $43.4 billion . FurtherLongitudinal research has been carried out to explore the long term role of aggression with violent video games. In one study with children, a risk factor for pro-social behavior was found with those who played competitive games for 8 h or more a week, but there was no association found with violent video games . FurtherSince then research has started to explore other psychological factors that could be related to video game play such as, morality . JoeckelPrevious research on video games and morality with university samples have found that participants (age range 18–29) demonstrated moral sensitivity, through feelings of guilt when playing as terrorists . FurtherFull ethical approval was obtained through the Universities ethics committee. Undergraduate University participants were recruited through opportunity sampling and with (49%) recruited from the SONA system for psychology students to gain course credits. All participants gave written informed consent in accordance with the Declaration of Helsinki. A total of 135 participants were sampled.The study was an online study as a follow-up to r = 0.69 and test retest reliability of r = 0.88  was included to measure the level of engagement and how participants usually feel when playing video games. The measures consisted of 19 questions and scored; Yes = 2 Maybe = 1 and No = 0. The maximum score on the measure is 38 α = 0.85 .The data for the SRM were analyzed through matching and identifying participants’ response to Criterion Justification (CJ) within a stage of moral development and moral type for each of the 11 questions. The eleven questions consisted of five themes: contract and truth, affiliation, life, property and law, and legal justice. All scorable responses would have yielded a type A moral score which was an average stage of moral development. Those that did yield a score could have also demonstrated Moral type B which was identified if participants referred to two of three components  in their responses. M = 20.29, SD = 2.70), just under half were male (42%) and the majority of the sample had a White  background (85%). Free school meals were taken as a measure of social economic status (SES) with 25% receiving free school meals at some point during schooling. One participant aged 41 years was subsequently removed as an outlier on the basis of their age being much higher than the next oldest participant and they would be classed as a different generation of gamer GEN X . There were no significant differences for SES  and ethnicity  with SRM scores and were not included in further analysis.This study aims to explore the relationship between moral development (SRM scores) and video game play for university students . Of the er GEN X . The samF 3.05, p = 0.051, but these differences were not significant and post hoc tests were not carried out.A multiple linear regression was carried out on moral development scores and video game play. As recommended by This study explored the relationship between moral development (SRM scores) and video game play for university students. The results suggested no predictors of moral development for either video game play or demographic variables (age and sex). This suggests that moral development and reasoning may not be related to video game play, as often presumed. Although moral development was not predicted by video games there were some differences and trends between participants. Males had higher moral scores than females, and there were significant differences between males and females game play with most of the gaming variables; except playing COD and gaming status (playing the video games). The video game play variables suggested that there were different sub-groups of video game play style emerging; those that did not play (non-players), those that did play but did not identify as gamers (non-gamers) and those that identified as gamers. When the sub-groups are compared, gamers and non-players had higher moral score than the non-gamers.The results of moral development and sex differences between males and females in university age students was similar to Overall the results of moral development suggested a gradual progression for the university sample. This gradual development could be due to the small variability in the age range of the sample; university samples tend to recruit from 2 to 3 year groups . Interestingly, recent debates have suggested that adolescence should be extended into the early 20s . Sawyer M = 19.61) selected the utilitarian option (to save more lives), as opposed to deontological (not sacrificing a life)  . The des a life) . It coul a life) .This lack of relationship between moral development and video game play is an interesting finding when compared to previous research which has suggested a moral presence for in-game morality e.g.,  as it coSimilar to previous research with video game play i.e., , the resAlthough the research reported null findings, these findings suggest some important implications for age, development, and the interaction with media. In line with previous longitudinal research, which found no relationship between aggression and video game play for adults . The impAn alternative explanation for the higher moral scores in this research could be related to those who play more video games, in this case suggested by the data to be males and gamers, engaging more positively with the research and thus creating a bias. Cross-sectional designs have limitations, participants are compared to other participants rather than their own development over time in longitudinal studies. Exploring morality within a virtual context gives the opportunity to explore moral processes in a different context but can also develop further understanding of real-life moral development. Future research could consider the role of moral development in video game play, as moral development could act as both a mediating  and moderating variable . There is also scope for future research to explore further how moral development could be supported for adults, particularly how university students could have moral learning and development supported through their studies at university. There could potentially be a development shift where young people will develop into higher stage 3/stage 4, which future research could explore with a larger age range of adult samples. There are also implications for how morality should be measured virtually, including if measures are appropriate  and sensitivity  and the differences between exploring long-term and short-term effects/relationships. In conclusion, we suggest that moral development does not have a significant relationship with any of video game play and demographic variables for the university sample.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by the Bournemouth University – Science, Technology & Health Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study.SH contributed to the conception, design, data collection, and analysis. All authors contributed to the manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


An important consideration when developing a deep neural network (DNN) for the prediction of molecular properties is the representation of the chemical space. Herein we explore the effect of the representation on the performance of our DNN engineered to predict Fe K-edge X-ray absorption near-edge structure (XANES) spectra, and address the question: How important is the choice of representation for the local environment around an arbitrary Fe absorption site? Using two popular representations of chemical space—the Coulomb matrix (CM) and pair-distribution/radial distribution curve (RDC)—we investigate the effect that the choice of representation has on the performance of our DNN. While CM and RDC featurisation are demonstrably robust descriptors, it is possible to obtain a smaller mean squared error (MSE) between the target and estimated XANES spectra when using RDC featurisation, and converge to this state a) faster and b) using fewer data samples. This is advantageous for future extension of our DNN to other X-ray absorption edges, and for reoptimisation of our DNN to reproduce results from higher levels of theory. In the latter case, dataset sizes will be limited more strongly by the resource-intensive nature of the underlying theoretical calculations. The proliferation of high-brilliance light sources such as 3atalysts ,2 and shatalysts .Besides providing element- and site-specific information on geometric structure, X-ray absorption spectroscopy (XAS) is also able to provide direct information on the electronic structure around the absorption site ,6. IndeeExtracting this information via analysis of the XAS spectrum demands detailed theoretical treatments ,8. The rTo address this, a number of recent works have explored supervised machine learning/deep learning algorithms with a view towards mapping the relationship between XANES spectra and the underlying electronic and geometric structure of materials ,29,30,31An important consideration when engineering a DNN for this task is the representation, or ‘featurisation’, of the input data: How should the local environment—the ‘chemical space’—around an arbitrary Fe absorption site be best represented to maximise the performance of the DNN? In this contribution, we explore the effect of representation on the performance of our DNN . Using tn hidden layers, and an output layer. The dimensions of the input layer in our DNN are determined by the representation used (see the “Representation” section). The first hidden layer comprises 1200 neurons and every subsequent layer is reduced in size by 30% relative to the preceding hidden layer; our DNN uses four hidden layers. The output layer comprises X neurons, defined by the discretization of our target XANES spectra.A schematic of our DNN is shown in k, is connected to every neuron in the preceding layer, The layers are all fully connected, or ‘dense’, i.e., each neuron in an arbitrary layer, The derivatives of Our DNN optimizes c.a. three million internal weights via sequential feed-forward and back propagation cycles. Gradients of the MSE cost function with respect to the internal weights are updated iteratively according to the Adaptive Moment Estimation (ADAM) algorithm. Gradients are estimated over minibatches of 100 samples. The learning rate for the ADAM algorithm, K folds with K evaluations are made such that every data sample appears in the out-of-sample testing set once, and in the in-sample training set K-fold partitions. The repeated evaluations of performance can be used to estimate an error. We mitigate the risk of overfitting our DNN to the training set by assessing the performance of each K-fold on the out-of-sample data only. We use five-fold cross-validation, i.e., an 80:20 in-sample/out-of-sample split, with five repetitions.The performance of our DNN is assessed via K-fold cross validation . The datOur DNN also utilises dropout ; dropoutOur DNN is programmed in Python 3 with the TensorFlow/Keras ,43 API. We trial two alternative representations of chemical space: The CM and RDC.The CM representation (MIJ) ,34,35 isZ is the nuclear charge of an atom and N is the upper limit on the number of atoms designated for inclusion in the CM. The off-diagonal elements of I and J and the on-diagonal elements of N atoms, the closest N atoms to the absorbing atom are used to construct the CM and the rest are discarded; if the system contains less than N atoms, the remaining rows and columns of the CM are zero-filled. The sorted CM representation is unique, invariant with respect to atomic indexing, translations, and rotations of the chemical space that it describes, and its construction requires no explicit information on chemical bonding [The upper triangle of  bonding ,34,35.Where CM featurisation is used in this work, R, where the intensity is defined:The RDC representation ,37,38,39I and J, respectively. I and J, and Like the CM representation, the RDC representation is invariant with respect to atomic indexing, translations, and rotations of the chemical space that it describes, and its construction requires no explicit information on chemical bonding . It doess, ect.) ,47 to enAn additional advantage of the RDC is that t length ,46,47 reWhere RDC featurisation is used in this work, The CM and RDC representations are useful descriptors on account of their simplicity; both require very little space in memory, and the requisite operations for their construction are easily vectorisable; large datasets can be featurised quickly, and can typically fit in the memory in their entirety.Our dataset comprises 9040 unique Fe-containing structures harvested from the Materials Project Library via the Materials Project API. Fe K-edge XANES spectra for one arbitrary absorption site per structure have been calculated using multiple scattering theory as implemented in the FDMNES package . The Fe  package .The arctangent convolution is only applied as a post-processing step on XANES spectra estimated by our DNN; our dataset comprises only unconvoluted cross-sections, and our DNN learns from these unconvoluted cross-sections.ETarget and EEst.) and intensity (Target and Est.) scales. The upper  has on the performance of our DNN  engineerN that are large enough to capture the necessary structural information, but not so large as to increase the propensity for overfitting. The maximum radius around an absorption site encoded into a CM of dimensions At this point, it is important to highlight an important difference between the CM and RDC representations. Throughout this work we have limited the dimensions of In summary, the performance of our DNN demonstrates that it is possible to develop a highly generalisable neural network for the prediction of XANES spectra at a specific absorption edge for an arbitrary absorption site, and that the RDC is a robust local descriptor for this purpose. This represents a highly encouraging starting point for our proof-of-principle demonstration which can be developed in a number of ways. Firstly, our theoretical XANES spectra (from which our DNN learns) are calculated under the muffin-tin approximation, and although this represents a computationally cost-effective choice for developing the underlying method, it is clear that the usefulness of our DNN can be considerably improved by moving beyond this. Secondly, the training set from which our DNN learns is composed of perfectly-ordered, homogeneous crystalline systems. While we have previously demonstrated  that it