Ethical challenges in the use of digital technologies in psychological science: Introduction to the special issue.

Digital technologies are pervasive in every aspect of our daily lives. The proliferation of such technologies has also influenced the conduct of biomedical, behavioral, and social research. The articles in this special issue provide illustrative examples of the range of applications of digital technologies in psychological science research across a variety of populations. They highlight ethical, legal, and social issues that emerge when digital technologies are employed in psychological science research in the current era of rapid technological change, increasing prevalence of interdisciplinary team science, evolving understandings of ethical precepts and social norms, and promoting open science. This introduction to the special issue provides an overview of challenges to the Belmont principles of respect for persons, beneficence, and justice revealed in the 10 articles. The conclusions reached are that these ethical principles do not always adapt well to the digital environment and that practices cannot always be uniquely classified under one of these three headings. We recommend that conceptual work and practical guidance be undertaken to expand the interpretation of these principles in the light of evolving societal norms and emerging ethical issues. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Examining Public Awareness of Ageist Terms on Twitter: Content Analysis.

Background: The World Health Organization, the Centers for Disease Control and Prevention, and the Gerontological Society of America have made efforts to raise awareness on ageist language and propose appropriate terms to denote the older adult population. The COVID-19 pandemic and older adults' vulnerability to the disease have perpetuated hostile ageist discourse on social media. This is an opportune time to understand the prevalence and use of ageist language and discuss the ways forward. Objective: This study aimed to understand the prevalence and situated use of ageist terms on Twitter. Methods: We collected 60.32 million tweets between March and July 2020 containing terms related to COVID-19. We then conducted a mixed methods study comprising a content analysis and a descriptive quantitative analysis. Results: A total of 58,930 tweets contained the ageist terms "old people" or "elderly." The more appropriate term "older adult" was found in 11,328 tweets. Twitter users used ageist terms (eg, "old people" and "elderly") to criticize ageist messages (17/60, 28%), showing a lack of understanding of appropriate terms to describe older adults. Highly hostile ageist content against older adults came from tweets that contained the derogatory terms "old people" (22/30, 73%) or "elderly" (13/30, 43%). Conclusions: The public discourse observed on Twitter shows a continued lack of understanding of appropriate terms to use when referring to older adults. Effort is needed to eliminate the perpetuation of ageist messages that challenge healthy aging. Our study highlights the need to inform the public about appropriate language use and ageism.

Mobile Technologies for Supporting Mental Health in Youths: Scoping Review of Effectiveness, Limitations, and Inclusivity.

BACKGROUND: Over the past decade, there has been growing support for the use of mobile health (mHealth) technologies to improve the availability of mental health interventions. While mHealth is a promising tool for improving access to interventions, research on the effectiveness and efficacy of mHealth apps for youths is limited, particularly for underrepresented populations, including youths of color and economically marginalized youths. OBJECTIVE: This scoping review study sought to evaluate the following research questions: (1) What is the extent of the current literature on mHealth apps that provide intervention for mental health problems in children and adolescents? (2) What is known from the existing literature about the effectiveness or efficacy of delivering mental health services via mHealth apps? (3) What are the gaps in the knowledge base in the fields of technology and mental health? (4) Do the reviewed mHealth apps address issues of cultural sensitivity or have they been tested with underrepresented groups (ie, youths of color or economically marginalized groups)? METHODS: An electronic database search was conducted using relevant search terms. Seven independent reviewers screened identified studies, including title and abstract review to determine if studies met the following inclusion criteria: (1) targeted samples with mental health symptomology or disorders, (2) studied youth participants aged 6-17 years, and (3) examined the use of a mobile app-based platform for intervention. Relevant studies were subjected to full-text review to extract and chart relevant data based on a priori research questions. RESULTS: The initial database search yielded 304 papers published from 2010 to 2021. After screening and selection, the final review included 10 papers on the effectiveness and efficacy of mental health intervention apps for youths aged 8 to 17 years. Identified apps targeted a broad range of mental health challenges in youths (ie, depression, self-harm, autism spectrum disorder, anxiety, and obsessive-compulsive disorder). Results identified only a small number of studies suggesting that current effectiveness and efficacy research in this area are limited. While some studies provided general support for the effectiveness of mHealth apps in improving mental health outcomes in youths, several notable limitations were present across the literature, reducing the generalizability of findings. Additionally, considerations around racial, ethnic, and socioeconomic diversity were scarce across studies. CONCLUSIONS: Although some studies cited in this scoping review provide support for the effectiveness and efficacy of mHealth apps targeting mental health concerns in youths, the overall body of literature remains quite limited. Moreover, mHealth apps expressly developed to be culturally responsive are almost nonexistent. Further efforts are needed to recruit youths who are typically underrepresented in research and invite stakeholder participation and collaborative input in the early stages of the mHealth app development process.

Toward alert triage: scalable qualitative coding framework for analyzing alert notes from the Telehealth Intervention Program for Seniors (TIPS).

Objective: Combined with mobile monitoring devices, telehealth generates overwhelming data, which could cause clinician burnout and overlooking critical patient status. Developing novel and efficient ways to correctly triage such data will be critical to a successful telehealth adoption. We aim to develop an automated classification framework of existing nurses' notes for each alert that will serve as a training dataset for a future alert triage system for telehealth programs. Materials and Methods: We analyzed and developed a coding framework and a regular expression-based keyword match approach based on the information of 24 931 alert notes from a community-based telehealth program. We evaluated our automated alert triaging model for its scalability on a stratified sampling of 800 alert notes for precision and recall analysis. Results: We found 22 717 out of 24 579 alert notes (92%) belonging to at least one of the 17 codes. The evaluation of the automated alert note analysis using the regular expression-based information extraction approach resulted in an average precision of 0.86 (SD = 0.13) and recall 0.90 (SD = 0.13). Discussion: The high-performance results show the feasibility and the scalability potential of this approach in community-based, low-income older adult telehealth settings. The resulting coded alert notes can be combined with participants' health monitoring results to generate predictive models and to triage false alerts. The findings build steps toward developing an automated alert triaging model to improve the identification of alert types in remote health monitoring and telehealth systems.

A User-Centered Design Approach to Developing a Voice Monitoring System for Disorder Prevention.

BACKGROUND: Many individuals will experience a voice disorder in their lifetime, especially occupational voice users. While a number of voice monitoring systems have been developed, most were designed with the clinician/researcher as the end user. For a patient to use these systems, they need field experts to help them interpret data from the system to understand its meaning. Most of these systems would have challenges in being used in a preventative context with the occupational voice user as the sole system user. OBJECTIVE: The current study introduces a novel design approach: user-centered design (UCD) with paper prototypes in the creation of a voice monitoring system for voice disorder prevention (VDP). The goal of this design approach is to design systems that are engaging and intuitive for users so they will be interested in interacting with the system and be able to benefit from the system without the need of external support. METHODS: The current study was conducted in two phases: an iterative design phase and a test phase. In the iterative design phase, 15 participants gave their opinions on the measures and feedback designs they felt would be the most beneficial to users. In the test phase, the researchers collected real voice data over multiple sessions for 18 additional participants and provided this data using the final feedback displays from the design phase. RESULTS: By engaging in UCD, the researchers identified key design challenges for VDP: (1) educating the user, (2) balancing contextualization and granularity, and (3) addressing disconnection between user and system goals. CONCLUSION: UCD holds promise for designing VDP systems that are both engaging and intuitive for occupational voice users.

Experiences and Perceptions of Distinct Telehealth Delivery Models for Remote Patient Monitoring among Older Adults in the Community.

Three major telehealth delivery models-home-based, community-based, and telephone-based-have been adopted to enable remote patient monitoring of older adults to improve patient experience and reduce healthcare costs. Even though prior work has evaluated each of these delivery models, we know less about the perceptions and user experiences across these telehealth delivery models for older adults. In the present work, we addressed this research gap by interviewing 16 older adults who had experience using all these telehealth delivery models. We found that the community-based telehealth model with in-person interactions was perceived as the most preferred and useful program, followed by home-based and telephone-based models. Persistent needs reported by participants included ease of access to their historical physiological data, useful educational information for health self-management, and additional health status tracking. Our findings will inform the design and deployment of telehealth technology for vulnerable aging populations.

Design and Evaluation Challenges of Conversational Agents in Health Care and Well-being: Selective Review Study.

BACKGROUND: Health care and well-being are 2 main interconnected application areas of conversational agents (CAs). There is a significant increase in research, development, and commercial implementations in this area. In parallel to the increasing interest, new challenges in designing and evaluating CAs have emerged. OBJECTIVE: This study aims to identify key design, development, and evaluation challenges of CAs in health care and well-being research. The focus is on the very recent projects with their emerging challenges. METHODS: A review study was conducted with 17 invited studies, most of which were presented at the ACM (Association for Computing Machinery) CHI 2020 conference workshop on CAs for health and well-being. Eligibility criteria required the studies to involve a CA applied to a health or well-being project (ongoing or recently finished). The participating studies were asked to report on their projects' design and evaluation challenges. We used thematic analysis to review the studies. RESULTS: The findings include a range of topics from primary care to caring for older adults to health coaching. We identified 4 major themes: (1) Domain Information and Integration, (2) User-System Interaction and Partnership, (3) Evaluation, and (4) Conversational Competence. CONCLUSIONS: CAs proved their worth during the pandemic as health screening tools, and are expected to stay to further support various health care domains, especially personal health care. Growth in investment in CAs also shows the value as a personal assistant. Our study shows that while some challenges are shared with other CA application areas, safety and privacy remain the major challenges in the health care and well-being domains. An increased level of collaboration across different institutions and entities may be a promising direction to address some of the major challenges that otherwise would be too complex to be addressed by the projects with their limited scope and budget.

Motivational Interviewing Conversational Agent for Parents as Proxies for Their Children in Healthy Eating: Development and User Testing.

BACKGROUND: Increased adoption of off-the-shelf conversational agents (CAs) brings opportunities to integrate therapeutic interventions. Motivational Interviewing (MI) can then be integrated with CAs for cost-effective access to it. MI can be especially beneficial for parents who often have low motivation because of limited time and resources to eat healthy together with their children. OBJECTIVE: We developed a Motivational Interviewing Conversational Agent (MICA) to improve healthy eating in parents who serve as a proxy for health behavior change in their children. Proxy relationships involve a person serving as a catalyst for behavior change in another person. Parents, serving as proxies, can bring about behavior change in their children. METHODS: We conducted user test sessions of the MICA prototype to understand the perceived acceptability and usefulness of the MICA prototype by parents. A total of 24 parents of young children participated in 2 user test sessions with MICA, approximately 2 weeks apart. After parents' interaction with the MICA prototype in each user test session, we used qualitative interviews to understand parents' perceptions and suggestions for improvements in MICA. RESULTS: Findings showed participants' perceived usefulness of MICAs for helping them self-reflect and motivating them to adopt healthier eating habits together with their children. Participants further suggested various ways in which MICA can help them safely manage their children's eating behaviors and provide customized support for their proxy needs and goals. CONCLUSIONS: We have discussed how the user experience of CAs can be improved to uniquely offer support to parents who serve as proxies in changing the behavior of their children. We have concluded with implications for a larger context of designing MI-based CAs for supporting proxy relationships for health behavior change.

Older adults' perceptions of community-based telehealth wellness programs: a qualitative study.

As older adult populations rise in the United States, community-based telehealth programs are gaining momentum because of their ability to provide telehealth services for community-dwelling older adults at a lower cost compared to home-based telehealth services. The success of such community-based telehealth programs heavily depends on end-user engagement and acceptance; however, few studies to date have explored these issues. We conducted an interview study with 14 active and 3 inactive participants of a community-based Telehealth Intervention Program for Seniors (TIPS) to examine older individuals' perceived benefits and barriers to participating in community-based telehealth programs as well as strategies to improve those programs. We found that older adults had a positive experience toward the use of telehealth services in a community setting, including benefits like monitoring health status and enabling socialization. There were no perceived barriers about the telehealth program. Aspects that can be improved include facilitating the management and sharing of historical physiological data, providing additional assessments of cognitive and/or mental status, supporting self-education, and enabling more comprehensive health status tracking. We conclude this paper by discussing the implications of our results to the improvement of community-based telehealth programs for low-income, vulnerable aging populations.

Seeking Mental Health Support Among College Students in Video-Based Social Media: Content and Statistical Analysis of YouTube Videos.

BACKGROUND: Mental health is a highly stigmatized disease, especially for young people. Due to its free, accessible format, college students increasingly use video-based social media for many aspects of information needs, including how-to tips, career, or health-related needs. The accessibility of video-based social media brings potential in supporting stigmatized contexts, such as college students' mental health. Understanding which kinds of videos about college students' mental health have increased viewer engagement will help build a foundation for exploring this potential. Little research has been done to identify video types systematically, how they have changed over time, and their associations on viewer engagement both short term and long term. OBJECTIVE: This study aims to identify strategies for using video-based social media to combat stigmatized diseases, such as mental health, among college students. We identify who, with what perspective, purpose, and content, makes up the videos available on social media (ie, YouTube) about college students' mental health and how these factors associate with viewer engagement. We then identify effective strategies for designing video-based social media content for supporting college students' mental health. METHODS: We performed inductive content analysis to identify different types of YouTube videos concerning college students' mental health (N=452) according to video attributes, including poster, perspective, and purpose. Time analysis showed how video types have changed over time. Fisher's exact test was used to examine the relationships between video attributes. The Mann-Whitney U test was used to test the association between video types and viewer engagement. Lastly, we investigated the difference in viewer engagement across time between two major types of videos (ie, individuals' storytelling and organization's informational videos). RESULTS: Time trend analysis showed a notable increase in the number of (1) videos by individuals, (2) videos that represent students' perspectives, and (3) videos that share stories and experiential knowledge over the recent years. Fisher's exact test found all video attributes (ie, poster, perspective, and purpose) are significantly correlated with each other. In addition, the Mann-Whitney U test found that poster (individual vs organization) and purpose (storytelling vs sharing information) type has a significant association with viewer engagement (P<.001). Lastly, individuals' storytelling videos had a greater engagement in the short term and the long term. CONCLUSIONS: The study shows that YouTube videos on college students' mental health can be well differentiated by the types of posters and the purpose of the videos. Taken together, the videos where individuals share their personal stories, as well as experiential knowledge (ie, tips and advice), engaged more viewers in both the short term and long term. Individuals' videos on YouTube showed the potential to support college students' mental health in unique ways, such as providing social support, validating experience, and sharing the positive experience of help-seeking.

Identification of ortho catechol-containing isoflavone as a privileged scaffold that directly prevents the aggregation of both amyloid ß plaques and tau-mediated neurofibrillary tangles and its in vivo evaluation.

In this study, polyhydroxyisoflavones that directly prevent the aggregation of both amyloid ß (Aß) and tau were expediently synthesized via divergent Pd(0)-catalyzed Suzuki-Miyaura coupling and then biologically evaluated. By preliminary structure-activity relationship studies using thioflavin T (ThT) assays, an ortho-catechol containing isoflavone scaffold was proven to be crucial for preventing both Aß aggregation and tau-mediated neurofibrillary tangle formation. Additional TEM experiment confirmed that ortho-catechol containing isoflavone 4d significantly prevented the aggregation of both Aß and tau. To investigate the mode of action (MOA) of 4d, which possesses an ortho-catechol moiety, 1H-15N HSQC NMR analysis was thoroughly performed and the result indicated that 4d could directly inhibit both the formation of Aß42 fibrils and the formation of tau-derived neurofibrils, probably through the catechol-mediated nucleation of tau. Finally, 4d was demonstrated to alleviate cognitive impairment and pathologies related to Alzheimer's disease in a 5XFAD transgenic mouse model.

Predictors of Retention for Community-Based Telehealth Programs: A Study of the Telehealth Intervention Program for Seniors (TIPS).

Community-based telehealth programs (CTPs) allow patients to regularly monitor health at community-based facilities. Evidence from community-based telehealth programs is scarce. In this paper, we assess factors of retention-patients remaining active participants-in a CTP called the Telehealth Intervention Programs for Seniors (TIPS). We analyzed 5-years of data on social, demographic, and multiple chronic conditions among participants from 17 sites (N=1878). We modeled a stratified multivariable logistic regression to test the association between self-reported demographic factors, caregiver status, presence of multiple chronic conditions, and TIPS retention status by limited English proficient (LEP) status. Overall, 59.5% of participants (mean age: 75.8yrs, median 77yrs, SD 13.43) remained active. Significantly higher odds of retention were observed among LEP females, English-speaking diabetics, and English proficient (EP) participants without a caregiver. We discuss the impact of CTPs in the community, the role of caregiving, and recommendations for how to retain successfully recruited non-English speaking participants.

Improving Heart Disease Risk Through Quality-Focused Diet Logging: Pre-Post Study of a Diet Quality Tracking App.

BACKGROUND: Diet-tracking mobile apps have gained increased interest from both academic and clinical fields. However, quantity-focused diet tracking (eg, calorie counting) can be time-consuming and tedious, leading to unsustained adoption. Diet quality-focusing on high-quality dietary patterns rather than quantifying diet into calories-has shown effectiveness in improving heart disease risk. The Healthy Heart Score (HHS) predicts 20-year cardiovascular risks based on the consumption of foods from quality-focused food categories, rather than detailed serving sizes. No studies have examined how mobile health (mHealth) apps focusing on diet quality can bring promising results in health outcomes and ease of adoption. OBJECTIVE: This study aims to design a mobile app to support the HHS-informed quality-focused dietary approach by enabling users to log simplified diet quality and view its real-time impact on future heart disease risks. Users were asked to log food categories that are the main predictors of the HHS. We measured the app's feasibility and efficacy in improving individuals' clinical and behavioral factors that affect future heart disease risks and app use. METHODS: We recruited 38 participants who were overweight or obese with high heart disease risk and who used the app for 5 weeks and measured weight, blood sugar, blood pressure, HHS, and diet score (DS)-the measurement for diet quality-at baseline and week 5 of the intervention. RESULTS: Most participants (30/38, 79%) used the app every week and showed significant improvements in DS (baseline: mean 1.31, SD 1.14; week 5: mean 2.36, SD 2.48; 2-tailed t test t29=-2.85; P=.008) and HHS (baseline: mean 22.94, SD 18.86; week 4: mean 22.15, SD 18.58; t29=2.41; P=.02) at week 5, although only 10 participants (10/38, 26%) checked their HHS risk scores more than once. Other outcomes, including weight, blood sugar, and blood pressure, did not show significant changes. CONCLUSIONS: Our study showed that our logging tool significantly improved dietary choices. Participants were not interested in seeing the HHS and perceived logging diet categories irrelevant to improving the HHS as important. We discuss the complexities of addressing health risks and quantity- versus quality-based health monitoring and incorporating secondary behavior change goals that matter to users when designing mHealth apps.

Videoconferencing-Based Telemental Health: Important Questions for the COVID-19 Era From Clinical and Patient-Centered Perspectives.

The COVID-19 pandemic has intensified the search for digital approaches in mental health treatment, particularly due to patients and clinicians practicing social distancing. This has resulted in the dramatic growth of videoconferencing-based telemental health (V-TMH) services. It is critical for behavioral health providers and those in the mental health field to understand the implications of V-TMH expansion on the stakeholders who use such services, such as patients and clinicians, to provide the service that addresses both patient and clinical needs. Several key questions arise as a result, such as the following: (1) in what ways does V-TMH affect the practice of psychotherapy (ie, clinical needs), (2) to what extent are ethical and patient-centered concerns warranted in terms of V-TMH services (ie, patient needs), and (3) how do factors related to user experience affect treatment dynamics for both the patient and therapist (ie, patient and clinical needs)? We discuss how behavioral health providers can consider the future delivery of mental health care services based on these questions, which pose strong implications for technological innovation, the adaptation of treatments to new technologies, and training professionals in the delivery of V-TMH services and other digital health interventions.

Understanding Students' Mental Well-Being Challenges on a University Campus: Interview Study.

BACKGROUND: Research shows that emerging adults face numerous stressors as they transition from adolescence to adulthood. This paper investigates university students' lived experiences of maintaining mental well-being during major life events and challenges associated with this transitional period. As we continue to design health technology to support students' mental health needs, it is imperative to understand the fundamental needs and issues particular to this phase of their life to effectively engage and lower the barriers to seeking help. OBJECTIVE: This study first aimed to understand how university students currently seek and receive support to maintain their mental well-being while going through frequent life events during this period of emerging adulthood. The study then aimed to provide design requirements for how social and technical systems should support the students' mental well-being maintenance practice. METHODS: Semistructured interviews with 19 students, including graduate and undergraduate students, were conducted at a large university in the Midwest in the United States. RESULTS: This study's findings identified three key needs: students (1) need to receive help that aligns with the perceived severity of the problem caused by a life event, (2) have to continuously rebuild relationships with support givers because of frequent life events, and (3) negotiate tensions between the need to disclose and the stigma associated with disclosure. The study also identified three key factors related to maintaining mental well-being: time, audience, and disclosure. CONCLUSIONS: On the basis of this study's empirical findings, we discuss how and when help should be delivered through technology to better address university students' needs for maintaining their mental well-being, and we argue for reconceptualizing seeking and receiving help as a colearning process.

Medical Drama Viewing and Medical Trust: A Moderated Mediation Approach.

This study investigates the relationship between medical drama viewing and medical trust, applying the cultivation theory and using a moderated mediation approach. A multigroup Structural Equation Modeling analysis of survey data on 983 U.S. adults indicates that exposure to medical dramas is positively associated with perceived realism of medical dramas, which in turn is positively associated with trust in physicians in medical dramas, and this trust in physicians in medical dramas is positively associated with trust in physicians in the real world. The study suggests that perceived realism of and trust in physicians in medical dramas mediate the relationship between medical drama viewing and medical trust, with health literacy moderating this cultivation process. Implications and future research directions are discussed.

Understanding Patient Information Needs About Their Clinical Laboratory Results: A Study of Social Q&A Site.

Clinical data, such as laboratory test results, is increasingly being made available to patients through patient portals. However, patients often have difficulties understanding and acting upon the clinical data presented in portals. As such, many turn to online resources to fill their knowledge gaps and obtain actionable advice. In this work, we present a content analysis of the questions posted in a major social Q&A site to characterize lay people's general information needs concerning laboratory test results and to inform the design of patient portals for supporting patients' understanding of clinical data. We identified 15 information needs related to laboratory test results, and clustered them under four themes: understanding the results of lab test, interpreting doctor's diagnosis, learning about lab tests, and consulting the next steps. We draw on our findings to discuss design opportunities for supporting the understanding of laboratory results.

Change of Brain Functional Connectivity in Patients With Spinal Cord Injury: Graph Theory Based Approach.

OBJECTIVE: To investigate the global functional reorganization of the brain following spinal cord injury with graph theory based approach by creating whole brain functional connectivity networks from resting state-functional magnetic resonance imaging (rs-fMRI), characterizing the reorganization of these networks using graph theoretical metrics and to compare these metrics between patients with spinal cord injury (SCI) and age-matched controls. METHODS: Twenty patients with incomplete cervical SCI (14 males, 6 females; age, 55±14.1 years) and 20 healthy subjects (10 males, 10 females; age, 52.9±13.6 years) participated in this study. To analyze the characteristics of the whole brain network constructed with functional connectivity using rs-fMRI, graph theoretical measures were calculated including clustering coefficient, characteristic path length, global efficiency and small-worldness. RESULTS: Clustering coefficient, global efficiency and small-worldness did not show any difference between controls and SCIs in all density ranges. The normalized characteristic path length to random network was higher in SCI patients than in controls and reached statistical significance at 12%-13% of density (p<0.05, uncorrected). CONCLUSION: The graph theoretical approach in brain functional connectivity might be helpful to reveal the information processing after SCI. These findings imply that patients with SCI can build on preserved competent brain control. Further analyses, such as topological rearrangement and hub region identification, will be needed for better understanding of neuroplasticity in patients with SCI.

Validity of Quantitative Lymphoscintigraphy as a Lymphedema Assessment Tool for Patients With Breast Cancer.

OBJECTIVE: To evaluate the validity of quantitative lymphoscintigraphy as a useful lymphedema assessment tool for patients with breast cancer surgery including axillary lymph node dissection (ALND). METHODS: We recruited 72 patients with lymphedema after breast cancer surgery that included ALND. Circumferences in their upper limbs were measured in five areas: 15 cm proximal to the lateral epicondyle (LE), the elbow, 10 cm distal to the LE, the wrist, and the metacarpophalangeal joint. Then, maximal circumference difference (MCD) was calculated by subtracting the unaffected side from the affected side. Quantitative asymmetry indices (QAI) were defined as the radiopharmaceutical uptake ratios of the affected side to the unaffected side. Patients were divided into 3 groups by qualitative lymphoscintigraphic patterns: normal, decreased function, and obstruction. RESULTS: The MCD was highest in the qualitative obstruction (2.76±2.48) pattern with significant differences from the normal (0.69±0.78) and decreased function (1.65±1.17) patterns. The QAIs of the axillary LNs showed significant differences among the normal (0.82±0.29), decreased function (0.42±0.41), and obstruction (0.18±0.16) patterns. As the QAI of the axillary LN increased, the MCD decreased. The QAIs of the upper limbs were significantly higher in the obstruction (3.12±3.07) pattern compared with the normal (1.15±0.10) and decreased function (0.79±0.30) patterns. CONCLUSION: Quantitative lymphoscintigraphic analysis is well correlated with both commonly used qualitative lymphoscintigraphic analysis and circumference differences in the upper limbs of patients with breast cancer surgery with ALND. Quantitative lymphoscintigraphy may be a good alternative assessment tool for diagnosing lymphedema after breast cancer surgery with ALND.

Connecting with The Biggest Loser: an extended model of parasocial interaction and identification in health-related reality TV shows.

This study investigates audience responses to health-related reality TV shows in the setting of The Biggest Loser. It conceptualizes a model for audience members' parasocial interaction and identification with cast members and explores antecedents and outcomes of parasocial interaction and identification. Data analysis suggests the following direct relationships: (1) audience members' exposure to the show is positively associated with parasocial interaction, which in turn is positively associated with identification, (2) parasocial interaction is positively associated with exercise self-efficacy, whereas identification is negatively associated with exercise self-efficacy, and (3) exercise self-efficacy is positively associated with exercise behavior. Indirect effects of parasocial interaction and identification on exercise self-efficacy and exercise behavior are also significant. We discuss the theoretical and practical implications of these findings.