Evaluating a Remotely Delivered Cardio-Oncology Rehabilitation Intervention for Patients With Breast Cancer (REMOTE-COR-B): Protocol for a Single-Arm Feasibility Trial.

BACKGROUND: Exercise rehabilitation is a promising strategy for reducing cardiovascular disease risk among patients with breast cancer. However, the evidence is primarily derived from programs based at exercise centers with in-person supervised delivery. Conversely, most patients report a preference for home-based rehabilitation. As such, there is a clear need to explore strategies that can provide real-time supervision and coaching while addressing consumer preferences. Evidence from cardiac rehabilitation has demonstrated the noninferiority of a smartphone-based telerehabilitation approach (REMOTE-CR) to improve cardiorespiratory fitness in people with cardiovascular disease compared to a center-based program. OBJECTIVE: This study aims to assess the feasibility, safety, and preliminary efficacy of the REMOTE-CR program adapted for patients with breast cancer at risk of cardiotoxicity (REMOTE-COR-B). We will also assess the satisfaction and usability of REMOTE-COR-B. METHODS: We will conduct a single-arm feasibility study of the REMOTE-COR-B program among patients with stage I-III breast cancer who are at risk of cardiotoxicity (taking treatment type and dose, as well as other common cardiovascular disease risk factors into account) and who are within 24 months of completing primary definitive treatment. Participants (target sample size of 40) will receive an 8-week smartphone-based telerehabilitation exercise program involving remotely delivered real-time supervision and behavior change support. The platform comprises a smartphone and wearable heart rate monitor, as well as a custom-built smartphone app and web application. Participants will be able to attend remotely monitored exercise sessions during set operating hours each week, scheduled in both the morning and evening. Adherence is the primary outcome of the trial, assessed through the number of remotely monitored exercise sessions attended compared to the trial target (ie, 3 sessions per week). Secondary outcomes include additional trial feasibility indicators (eg, recruitment and retention), safety, satisfaction, and usability, and objective and patient-reported efficacy outcomes (cardiovascular fitness, quality of life, fatigue, self-reported exercise, self-efficacy, habit strength, and motivation). Adherence, feasibility, and safety outcomes will be assessed during the intervention period; intervention satisfaction and usability will be assessed post intervention; and objective and patient-reported efficacy outcomes will be assessed at baseline, post intervention (2-month postbaseline assessment), and at follow-up (5-month postbaseline assessment). RESULTS: Recruitment for this trial commenced in March 2023, and 7 participants had been recruited as of the submission of the manuscript. The estimated completion date for the project is October 2024, with results expected to be published in mid-2025. CONCLUSIONS: The REMOTE-COR-B intervention is a novel and promising approach to providing exercise therapy to patients with breast cancer at risk of cardiotoxicity who have unique needs and heightened safety risks. This project will provide important information on the extent to which this approach is satisfactory to patients with breast cancer, safe, and potentially effective, which is necessary before larger-scale research or clinical projects. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12621001557820; www.anzctr.org.au/ACTRN12621001557820.aspx. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53301.

The promoting physical activity in regional and remote cancer survivors (PPARCS) trial: Physical activity maintenance.

INTRODUCTION: The study examined whether increased physical activity (PA) in nonmetropolitan cancer survivors was maintained 12 weeks following the PPARCS intervention. METHODS: PA outcomes were assessed using an accelerometer at baseline, end of the intervention, and at 24 weeks. Linear mixed models were used to examine between-group changes in PA outcomes. RESULTS: The increased moderate-to-vigorous PA (MVPA) following intervention was maintained with significantly higher MVPA in the intervention group at 24 weeks (vs. controls) compared to baseline nett change of 52.5 min/week (95% CI 11.0-94.0.4). CONCLUSIONS: Distance-based interventions using wearables and health coaching may produce MVPA maintenance amongst nonmetropolitan cancer survivors.

Visual digital data, ethical challenges, and psychological science.

Digital visual data afford psychologists with exciting research possibilities. It becomes possible to see real-life interactions in real time and to be able to analyze this behavior in a fine-grained and systematic manner. However, the fact that faces (and other personally identifying physical characteristics) are captured as part of these data sets means that this kind of data is at the highest level of sensitivity by default. When this is combined with the possibility of automatic collection and processing, then the sensitivity risks are compounded. Here we explore the ethical challenges that face psychologists wishing to take advantage of digital visual data. Specifically, we discuss ethical considerations around data acquisition, data analysis, data storage, and data sharing. We begin by considering the challenges of securing visual data from both public space security systems and social media sources. We then explore the dangers of bias and discrimination in automatic data processing, as well as the dangers to human analysts. We set out the ethical requirements for secure data storage, the dangers of "function creep," and the challenges of the right of the individual to withdraw from databases. Finally, we consider the tensions that exist between sensitive visual data that require extra protections and the recent open science movement, which advocates data transparency and sharing. We conclude by offering a practical route map for tackling these complex ethical issues in the form of a Privacy and Data Protection Impact Assessment template for researchers. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A randomized controlled trial of Promoting Physical Activity in Regional and Remote Cancer Survivors (PPARCS).

BACKGROUND: Physical activity (PA) is important for cancer survivors. Trials of remotely delivered interventions are needed to assist in reaching under-served non-metropolitan cancer survivors. The objective of this study was to ascertain whether wearable technology, coupled with health coaching was effective in increasing PA in breast and colorectal cancer survivors living in regional and remote areas in Australia. METHODS: Cancer survivors from 5 states were randomized to intervention and control arms. Intervention participants were given a Fitbit Charge 2TM and received up to 6 telephone health coaching sessions. Control participants received PA print materials. Accelerometer assessments at baseline and 12 weeks measured moderate-to-vigorous PA (MVPA), light PA, and sedentary behavior. RESULTS: Eighty-seven participants were recruited (age = 63 ± 11 years; 74 (85%) female). There was a significant net improvement in MVPA of 49.8 min/week, favoring the intervention group (95% confidence interval (95%CI): 13.6-86.1, p = 0.007). There was also a net increase in MVPA bouts of 39.5 min/week (95%CI: 11.9-67.1, p = 0.005), favoring the intervention group. Both groups improved light PA and sedentary behavior, but there were no between-group differences. CONCLUSION: This is the first study to demonstrate that, when compared to standard practice (i.e., PA education), a wearable technology intervention coupled with distance-based health coaching, improves MVPA in non-metropolitan cancer survivors. The results display promise for the use of scalable interventions using smart wearable technology in conjunction with phone-based health coaching to foster increased PA in geographically disadvantaged cancer survivors.

Exercise for the Prevention of Anthracycline-Induced Functional Disability and Cardiac Dysfunction: The BREXIT Study.

BACKGROUND: Breast cancer survivors treated with anthracycline-based chemotherapy (AC) have increased risk of functional limitation and cardiac dysfunction. We conducted a 12-month randomized controlled trial in 104 patients with early-stage breast cancer scheduled for AC to determine whether 12 months of exercise training (ExT) could attenuate functional disability (primary end point), improve cardiorespiratory fitness (VO2peak), and prevent cardiac dysfunction. METHODS: Women 40 to 75 years of age with stage I to III breast cancer scheduled for AC were randomized to 3 to 4 days per week aerobic and resistance ExT for 12 months (n=52) or usual care (UC; n=52). Functional measures were performed at baseline, at 4 weeks after AC (4 months), and at 12 months, comprising: (1) cardiopulmonary exercise testing to quantify VO2peak and functional disability (VO2peak ≤18.0 mL·kg-1·min-1); (2) cardiac reserve (response from rest to peak exercise), quantified with exercise cardiac magnetic resonance measures to determine changes in left and right ventricular ejection fraction, cardiac output, and stroke volume; (3) standard-of-care echocardiography-derived resting left ventricular ejection fraction and global longitudinal strain; and (4) biochemistry (troponin and BNP [B-type natriuretic peptide]). RESULTS: Among 104 participants randomized, greater study attrition was observed among UC participants (P=0.031), with 93 women assessed at 4 months (ExT, n=49; UC, n=44) and 87 women assessed at 12 months (ExT, n=49; UC, n=38). ExT attenuated functional disability at 4 months (odds ratio, 0.32 [95% CI, 0.11-0.94]; P=0.03) but not at 12 months (odds ratio, 0.27 [95% CI, 0.06-1.12]; P=0.07). In a per-protocol analysis, functional disability was prevented entirely at 12 months among participants adherent to ExT (ExT, 0% versus UC, 20%; P=0.005). Compared with UC at 12 months, ExT was associated with a net 3.5-mL·kg-1·min-1 improvement in VO2peak that coincided with greater cardiac output, stroke volume, and left and right ventricular ejection fraction reserve (P<0.001 for all). There was no effect of ExT on resting measures of left ventricular function. Postchemotherapy troponin increased less in ExT than in UC (8-fold versus 16-fold increase; P=0.002). There were no changes in BNP in either group. CONCLUSIONS: In women with early-stage breast cancer undergoing AC, 12 months of ExT did not attenuate functional disability, but provided large, clinically meaningful benefits on VO2peak and cardiac reserve. REGISTRATION: URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12617001408370.

Investigating age-related differences in ability to distinguish between original and manipulated images.

Manipulated images can have serious and persistent ramifications across many domains: They have undermined trust in political campaigns, incited fear and violence, and fostered dangerous global movements. Despite growing concern about the power of manipulated images to influence people's beliefs and behavior, few studies have examined whether people can detect manipulations and the psychological processes underpinning this task. We asked 5,291 older adults, 5,291 middle-aged adults, and 5,291 young adults to detect and locate manipulations within images of real-world scenes. To determine whether a simple intervention could improve people's ability to detect manipulations, some participants viewed a short video which described the five common manipulation techniques used in the present study. Overall, participants demonstrated a limited ability to distinguish between original and manipulated images. Older adults were less accurate in detecting and locating manipulations than younger and middle-aged adults, and the effect of age varied by manipulation type. The video intervention improved performance marginally. Participants were often overconfident in their decisions, despite having limited ability to detect manipulations. Older adults were more likely than younger and middle-aged adults to report checking for shadow/lighting inconsistencies, a strategy that was not associated with improved discriminability, and less likely to report using other strategies (e.g., photometric inconsistencies) that were associated with improved discriminability. Differences in strategy use might help to account for the age differences in accuracy. Further research is needed to advance our understanding of the psychological mechanisms underlying image manipulation detection and the myriad factors that may enhance or impair performance. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

AI-synthesized faces are indistinguishable from real faces and more trustworthy.

Artificial intelligence (AI)-synthesized text, audio, image, and video are being weaponized for the purposes of nonconsensual intimate imagery, financial fraud, and disinformation campaigns. Our evaluation of the photorealism of AI-synthesized faces indicates that synthesis engines have passed through the uncanny valley and are capable of creating faces that are indistinguishable-and more trustworthy-than real faces.

Perceptual and computational detection of face morphing.

A relatively new type of identity theft uses morphed facial images in identification documents in which images of two individuals are digitally blended to create an image that maintains a likeness to each of the original identities. We created a set of high-quality digital morphs from passport-style photos for a diverse set of people across gender, race, and age. We then examine people's ability to detect facial morphing both in terms of determining if two side-by-side faces are of the same individual or not and in terms of identifying if a face is the result of digital morphing. We show that human participants struggle at both tasks. Even modern machine-learning-based facial recognition struggles to distinguish between an individual and their morphed version. We conclude with a hopeful note, describing a computational technique that holds some promise in recognizing that one facial image is a morphed version of another.

"To be there for my family" and "Keep my independence": Metropolitan and Non-Metropolitan Cancer Survivors' Health Behaviour Motives.

PURPOSE: Cancer survivors are at risk of comorbidities and mortality, and those living outside of metropolitan areas are particularly susceptible given poorer socioeconomic, health and support resources. As engagement in health behaviours is affected by participants' autonomous motives, investigation of the motives of cancer survivors in metropolitan and non-metropolitan areas could elucidate the values and reasons for practising health behaviours, allowing programs to be tailored to these motives. METHODS: Metropolitan (n = 103) and non-metropolitan (n = 80) Australian cancer survivors completed a survey item by describing their motives for physical activity and healthy diet change. Inductive thematic analysis of responses was performed to establish themes across health behaviour motives. RESULTS: Analyses revealed four themes: to be able to, longevity, psychological health and appearance. Survivors primarily referred to being able to enjoy family, leisure activities, travel and staying independent, with these motives often linked to longevity. Motives were similar across locations; however, those in non-metropolitan locations reported continuation of work and pain relief more frequently. Female survivors more often reported weight loss. CONCLUSIONS: A predominant motive for health behaviour change in cancer survivors across geographical location was the ability to enjoy family and engage in leisure and work activities. Programs aiming to promote health behaviours in cancer survivors might consider framing interventions accordingly by emphasizing benefits of longevity and maintaining independence.

Psychological correlates of physical activity and exercise preferences in metropolitan and nonmetropolitan cancer survivors.

OBJECTIVE: Interventions to increase physical activity (PA) in cancer survivors have often adopted a "one-size-fits-all" approach and may benefit from being tailored to psychological constructs associated with behavior. The study objective was to investigate the exercise preferences and psychological constructs related to PA among cancer survivors. METHODS: Posttreatment colorectal, endometrial, and breast cancer survivors (n = 183) living in metropolitan and nonmetropolitan areas completed survey measures of PA, exercise preferences, attitudes, self-efficacy, perceived behavioral control (PBC), and intention toward PA. RESULTS: A structural equation model with adequate fit and quality indices revealed that instrumental attitude and self-efficacy were related to PA intention. Intention was related to behavior and mediated the relationship between self-efficacy and behavior. Preferred exercise intensity was related to self-efficacy, PBC, attitudes, and intention, while preferred exercise company was related to self-efficacy and PBC. Participants preferred moderate-intensity PA (71%), specifically self-paced (52%) walking (65%) in an outdoor environment (58%). CONCLUSIONS: Since instrumental attitude and self-efficacy were associated with PA, incorporating persuasive communications targeting attitudes in PA interventions may promote PA participation. As cancer survivors who prefer low-intensity exercise and exercising with others report lower self-efficacy and PBC, interventions targeting confidence and successful experience in this group may also be warranted.

Assessing the reliability of a clothing-based forensic identification.

A 2009 report by the National Academy of Sciences was highly critical of many forensic practices. This report concluded that significant changes and advances were required to ensure the reliability across the forensic sciences. We examine the reliability of one such forensic technique used for identification based on purported distinct patterns on the seams of denim pants. Although first proposed more than 20 years ago, no thorough analysis of reliability or reproducibility of this forensic technique has previously been reported. We performed a detailed analysis of this forensic technique to determine its reliability and efficacy.

Preoperative ß-Blockade with Propranolol Reduces Biomarkers of Metastasis in Breast Cancer: A Phase II Randomized Trial.

PURPOSE: The majority of deaths from breast cancer occur following the development of metastatic disease, a process inhibited by ß-blockers in preclinical studies. This phase II randomized controlled trial evaluated the effect of preoperative ß-blockade with propranolol on biomarkers of metastatic potential and the immune cell profile within the primary tumor of patients with breast cancer. PATIENTS AND METHODS: In this triple-blind placebo-controlled clinical trial, 60 patients were randomly assigned to receive an escalating dose of oral propranolol (n = 30; 80-160 mg daily) or placebo (n = 30) for 7 days prior to surgery. The primary endpoint investigated the effect of propranolol on prometastatic and proinflammatory gene expression within the primary tumor. RESULTS: Propranolol downregulated primary tumor expression of mesenchymal genes (P = 0.002) without affecting epithelial gene expression (P = 0.21). Bioinformatic analyses implicated downregulation of Snail/Slug (P = 0.03), NF-κB/Rel (P < 0.01), and AP-1 (P < 0.01) transcription factors in structuring the observed transcriptome alterations, and identified changes in intratumoral neutrophil, natural killer cell, and dendritic cell recruitment (all P < 0.01). Patients with clinical evidence of drug response (lowered heart rate and blood pressure) demonstrated elevated tumor infiltration of CD68+ macrophages and CD8+ T cells. CONCLUSIONS: One week of ß-blockade with propranolol reduced intratumoral mesenchymal polarization and promoted immune cell infiltration in early-stage surgically-resectable breast cancer. These results show that ß-blockade reduces biomarkers associated with metastatic potential, and support the need for larger phase III clinical trials powered to detect the impact of ß-blockade on cancer recurrence and survival.See related commentary by Blaes et al., p. 1781.

Walking the boundaries: using the 6-min walk test for accurate assessment of the level of fitness in breast clinic outpatients.

BACKGROUND: Healthy levels of physical activity and improved fitness have shown better quality of life outcomes and improved survival in women with breast cancer. There is a lack of baseline data for fitness levels in breast cancer outpatients in Australia. METHODS: A single centre cross-sectional study was performed to provide a snapshot of the fitness levels of women attending the Surgical and Oncology Breast Outpatient Clinic at Western Health, Melbourne. A total of 200 women (aged 18-85 years) were surveyed and the 6-min walk test (6MWT) was performed. Single and multiple linear regression analyses were performed. RESULTS: The mean 6-min walk distance (6MWD) was 486.6 m (95% CI ±12.8 m), which was comparable with reference ranges. The mean age of participants was 47.5 years. Ninety-seven (48.5%) participants had diagnosis of breast cancer. Breast cancer diagnosis had a negative effect on 6MWD of -33.6 m walked (P = 0.010). However, multiple regression analysis showed that only age (-2.6 m walked per year older; P < 0.001), body mass index (-4.2 m walked per unit of body mass index increase; P < 0.001) and presence of comorbidities (-56.9 m walked; P < 0.001) had statistically significant negative effects on 6MWD. Self-reported exercise tolerance correlated significantly with 6MWD (walking: P < 0.001 and stairs: P = 0.014). CONCLUSION: The 6MWT was easily performed within outpatient environment to accurately assess baseline level of fitness in breast cancer clinic outpatients. This indicates that 6MWT can be used as a valuable adjunctive tool to assess the level of fitness in breast cancer patients to make therapeutic recommendations in improving breast cancer outcomes.

Can people detect errors in shadows and reflections?

The increasing sophistication of photo-editing software means that even amateurs can create compelling doctored images. Yet recent research suggests that people's ability to detect image manipulations is limited. Given the prevalence of manipulated images in the media, on social networking sites, and in other domains, the implications of mistaking a fake image as real, or vice versa, can be serious. In seven experiments, we tested whether people can make use of errors in shadows and reflections to determine whether or not an image has been manipulated. Our results revealed that people's ability to identify authentic and manipulated scenes based on shadow and reflection information increased with the size of the manipulation, but overall, detection rates remained poor. Consistent with theories of incomplete visual representation, one possible reason for these findings could be that people rarely encode the details of scenes that provide useful cues as to the authenticity of images. Overall, our findings indicate that people do not readily make use of shadow and reflection cues to help determine the authenticity of images-yet it remains possible that people could make use of these cues, but they are simply unaware of how to do so.

Exercise as a diagnostic and therapeutic tool for the prevention of cardiovascular dysfunction in breast cancer patients.

BACKGROUND: Anthracycline chemotherapy may be associated with decreased cardiac function and functional capacity measured as the peak oxygen uptake during exercise ( V·O2 peak). We sought to determine (a) whether a structured exercise training program would attenuate reductions in V·O2 peak and (b) whether exercise cardiac imaging is a more sensitive marker of cardiac injury than the current standard of care resting left ventricular ejection fraction (LVEF). METHODS: Twenty-eight patients with early stage breast cancer undergoing anthracycline chemotherapy were able to choose between exercise training (mean ± SD age 47 ± 9 years, n = 14) or usual care (mean ± SD age 53 ± 9 years, n = 14). Measurements performed before and after anthracycline chemotherapy included cardiopulmonary exercise testing to determine V·O2 peak and functional disability ( V·O2 peak < 18 ml/min/kg), resting echocardiography (LVEF and global longitudinal strain), cardiac biomarkers (troponin and B-type natriuretic peptide) and exercise cardiac magnetic resonance imaging to determine stroke volume and peak cardiac output. The exercise training group completed 2 × 60 minute supervised exercise sessions per week. RESULTS: Decreases in V·O2 peak during chemotherapy were attenuated with exercise training (15 vs. 4% reduction, P = 0.010) and fewer participants in the exercise training group met the functional disability criteria after anthracycline chemotherapy compared with those in the usual care group (7 vs. 50%, P = 0.01). Compared with the baseline, the peak exercise heart rate was higher and the stroke volume was lower after chemotherapy ( P = 0.003 and P = 0.06, respectively). There was a reduction in resting LVEF (from 63 ± 5 to 60 ± 5%, P = 0.002) and an increase in troponin (from 2.9 ± 1.3 to 28.5 ± 22.4 ng/mL, P < 0.0001), but no difference was observed between the usual care and exercise training group. The baseline peak cardiac output was the strongest predictor of functional capacity after anthracycline chemotherapy in a model containing age and resting cardiac function (LVEF and global longitudinal strain). CONCLUSIONS: The peak exercise cardiac output can identify patients at risk of chemotherapy-induced functional disability, whereas current clinical standards are unhelpful. Functional disability can be prevented with exercise training.

Publisher Correction: Single-cell profiling of breast cancer T cells reveals a tissue-resident memory subset associated with improved prognosis.

In the version of this article originally published, the institution in affiliation 10 was missing. Affiliation 10 was originally listed as Department of Surgery, Royal Melbourne Hospital and Royal Womens' Hospital, Melbourne, Victoria, Australia. It should have been Department of Surgery, Royal Melbourne Hospital and Royal Womens' Hospital, University of Melbourne, Melbourne, Victoria, Australia. The error has been corrected in the HTML and PDF versions of this article.

Detecting morphed passport photos: a training and individual differences approach.

Our reliance on face photos for identity verification is at odds with extensive research which shows that matching pairs of unfamiliar faces is highly prone to error. This process can therefore be exploited by identity fraudsters seeking to deceive ID checkers (e.g., using a stolen passport which contains an image of a similar looking individual to deceive border control officials). In this study we build on previous work which sought to quantify the threat posed by a relatively new type of fraud: morphed passport photos. Participants were initially unaware of the presence of morphs in a series of face photo arrays and were simply asked to detect which images they thought had been digitally manipulated (i.e., "images that didn't look quite right"). All participants then received basic information on morph fraud and rudimentary guidance on how to detect such images, followed by a morph detection training task (Training Group, n = 40), or a non-face control task (Guidance Group, n = 40). Participants also completed a post-guidance/training morph detection task and the Models Face Matching Test (MFMT). Our findings show that baseline morph detection rates were poor, that morph detection training significantly improved the identification of these images over and above basic guidance, and that accuracy in the mismatch condition of the MFMT correlated with morph detection ability. The results are discussed in relation to potential countermeasures for morph-based identity fraud.

Single-cell profiling of breast cancer T cells reveals a tissue-resident memory subset associated with improved prognosis.

The quantity of tumor-infiltrating lymphocytes (TILs) in breast cancer (BC) is a robust prognostic factor for improved patient survival, particularly in triple-negative and HER2-overexpressing BC subtypes1. Although T cells are the predominant TIL population2, the relationship between quantitative and qualitative differences in T cell subpopulations and patient prognosis remains unknown. We performed single-cell RNA sequencing (scRNA-seq) of 6,311 T cells isolated from human BCs and show that significant heterogeneity exists in the infiltrating T cell population. We demonstrate that BCs with a high number of TILs contained CD8+ T cells with features of tissue-resident memory T (TRM) cell differentiation and that these CD8+ TRM cells expressed high levels of immune checkpoint molecules and effector proteins. A CD8+ TRM gene signature developed from the scRNA-seq data was significantly associated with improved patient survival in early-stage triple-negative breast cancer (TNBC) and provided better prognostication than CD8 expression alone. Our data suggest that CD8+ TRM cells contribute to BC immunosurveillance and are the key targets of modulation by immune checkpoint inhibition. Further understanding of the development, maintenance and regulation of TRM cells will be crucial for successful immunotherapeutic development in BC.

Can people identify original and manipulated photos of real-world scenes?

Advances in digital technology mean that the creation of visually compelling photographic fakes is growing at an incredible speed. The prevalence of manipulated photos in our everyday lives invites an important, yet largely unanswered, question: Can people detect photo forgeries? Previous research using simple computer-generated stimuli suggests people are poor at detecting geometrical inconsistencies within a scene. We do not know, however, whether such limitations also apply to real-world scenes that contain common properties that the human visual system is attuned to processing. In two experiments we asked people to detect and locate manipulations within images of real-world scenes. Subjects demonstrated a limited ability to detect original and manipulated images. Furthermore, across both experiments, even when subjects correctly detected manipulated images, they were often unable to locate the manipulation. People's ability to detect manipulated images was positively correlated with the extent of disruption to the underlying structure of the pixels in the photo. We also explored whether manipulation type and individual differences were associated with people's ability to identify manipulations. Taken together, our findings show, for the first time, that people have poor ability to identify whether a real-world image is original or has been manipulated. The results have implications for professionals working with digital images in legal, media, and other domains.