Rumination mediates associations between microaggressions and sleep quality in Black Americans: the toll of racial microstressors.

Disparities in health outcomes between Black and White Americans are well-documented, including sleep quality, and disparities in sleep may lead to disparities in health over the life course. A meta-model indicates that cognitive processes may underly the connection between race and poor sleep quality, and ultimately, health disparities. That is, there are race-specific stressors that disproportionately affect Black Americans, which are associated with poor health through biological, cognitive, and behavioral mechanisms (e.g., sleep). Among these race-specific stressors is discrimination, which has been linked to poor sleep quality, and there is a body of literature connecting perseverative cognition (e.g., rumination and worry or vigilance) to poor sleep. Microaggressions, a more subtle but pervasive form of discrimination, are another race-specific stressor. Although less research has considered the connection of microaggressions to perseverative cognition, there are some studies linking microaggressions to health outcomes and sleep. Therefore, using a cross-sectional survey, we tested the following hypotheses: racism-related vigilance and rumination would mediate the relationship between discrimination and poor sleep as well as between microaggressions and poor sleep among Black Americans (N = 223; mean age = 35.77 years, 53.8% men, 86% employed, 66.8% with college degree or higher education). Results of seven parallel mediation models showed that neither rumination nor racism-related vigilance mediated a relationship between discrimination and poor sleep quality. However, rumination partially mediated relationships between the six microaggression sub-scales and poor sleep quality: there were significant indirect effects for Foreigner/Not Belonging (ß = .13, SE = 0.03, 95% CI 0.08, 0.20), Criminality (ß = .11, SE = 0.03, 95% CI 0.05, 0.17), Sexualization (ß = .10, SE = 0.03, 95% CI 0.05, 0.17), Low-Achieving/Undesirable (ß = .10, SE = 0.03, 95% CI 0.05, 0.15), Invisibility (ß = .15, SE = 0.04, 95% CI 0.08, 0.23), and Environmental Invalidations (ß = .15, SE = 0.04, 95% CI 0.08, 0.23). Overall, these findings indicate support for the meta-model, demonstrating a specific pathway from racial microstressors to poor sleep quality. Furthermore, these results suggest the importance of developing clinical and community approaches to address the impact of microaggressions on Black Americans' sleep quality.

Psychometric Testing of a Scale Measuring Preceptor Preparedness: The Cap-ExPresSTM Study.

Background and Purpose: Preceptors educate nursing students to practice as novice, generalist nurses. There are no instruments measuring preceptor preparedness. The purpose of this study was to psychometrically test the Capstone-Experience Preceptor Preparedness Scale (Cap-ExPresS™). Methods: A cross-sectional multi-site survey design was used. Results: A convenience sample of 118 preceptors was recruited from four Midwest hospitals. Exploratory factor analysis supported a 22-item scale representing four factors demonstrating internal consistency reliability using Cronbach's alpha: total scale, 0.95, student-centeredness, 0.90, pedagogic competence, 0.90, clinical competence, 0.81, and nurse professionalism, 0.87. Test-retest reliability was adequate for clinical competence at 0.71, 0.50-0.61 for other scores. Some evidence of predictive validity was observed via regression. Conclusions: Psychometric testing supported the validity and reliability of inferences made about preceptor preparedness with Cap-ExPresS™ scores. Scale scores indicate preceptor learning needs, evaluate interventions influencing preceptor preparedness, and assist clinicians to develop best practices for preceptor preparedness.

Retrospective Analysis of Vision Rehabilitation for Veterans With Traumatic Brain Injury-Related Vision Dysfunction.

INTRODUCTION: Traumatic brain injury (TBI) can trigger vision-based sequelae such as oculomotor and accommodative abnormalities, visual-vestibular integrative dysfunction, visual field loss, and photosensitivity. The need for diagnosis and management of TBI-related vision impairment has increased because of the increasing frequencies of combat warfighters returning from Iraq and Afghanistan with TBIs. The purpose of this research was to learn the sequelae of rehabilitation service delivery to veterans with TBI-related visual dysfunction after they are diagnosed. To accomplish this, we investigated vision rehabilitation assessments and interventions provided to veterans with TBI-related visual dysfunction at the Department of Veterans Affairs (VA) specialty polytrauma facilities for the 2 years following their injury. The research questions asked what assessments, interventions, and prescribed assistive devices were provided by VA specialty clinics (e.g., occupational therapy, polytrauma, and blind rehabilitation) and how service delivery was affected by demographic and clinical variables. MATERIALS AND METHODS: A retrospective design was used to analyze VA data using natural language processing of unstructured clinician notes and logistic regression of structured data. Participants included 350 veterans with TBI who received rehabilitation at one of the five VA Polytrauma Rehabilitation Centers (Tampa, FL; Richmond, VA; Minneapolis, MN; San Antonio, TX; and Palo Alto, CA) between 2008 and 2017 and who were administered the 2008 congressionally mandated "Traumatic Brain Injury Specific Ocular Health and Visual Functioning Exam." The outcome variables were vision assessments, interventions, and prescribed assistive technology discovered via natural language processing of clinician notes as well as the vision rehabilitation specialty clinics providing the clinical care (polytrauma, occupational therapy, outpatient blind rehabilitation, inpatient blind rehabilitation, optometry, and low vision) extracted from VA structured administrative data. RESULTS: Veterans receiving rehabilitation for TBI-related vision dysfunction were most frequently assessed for saccades, accommodation, visual field, and convergence. Intervention was provided most frequently for eye-hand coordination, saccades, accommodation, vergence, and binocular dysfunction. Technology provided included eyeglasses, wheelchair/scooter, walker/cane, aids for the blind, and computer. There was an overlap in the services provided by specialty clinics. Services available and delivered were significantly associated with the comorbidities of each patient and the specialty clinics available at each VA Polytrauma Rehabilitation Center. CONCLUSIONS: The delivery of patient services should be driven by the needs of veterans and not by system-level factors such as the availability of specific vision rehabilitation services at specific locations. Traditional low vision and blind rehabilitation programs were not designed to treat the comorbidities and symptoms associated with TBI. To address this challenge, blind rehabilitation and neurologic recovery cross training is needed. Our findings document how five VA Polytrauma Rehabilitation Centers implemented this training in 2008. The next step is to extend and standardize this new paradigm to community care, where these post-deployment patients now reside.

Indirect and direct effects of simultaneous alcohol and cannabis use on alcohol hangovers.

INTRODUCTION: Simultaneous use of alcohol and cannabis (i.e., using both on same occasion) is a risk factor for heavier drinking and negative alcohol consequences; however, little research has investigated risk conferred for specific negative consequences. One theoretically relevant negative consequence may be alcohol hangovers; however, no studies have tested cross-sectional or prospective relations between simultaneous use and experiencing alcohol hangovers. METHOD: The current study (N = 2,964) used public-access data from the National Longitudinal Study on Adolescent to Adult Health (Add Health) to test whether simultaneous alcohol and cannabis use conferred risk for hangover frequency directly or indirectly through heavier drinking. The current study also tested moderated mediation by depressive symptoms, considering simultaneous users have higher levels of depressive symptoms, and depressive symptoms largely mirror those of a hangover. RESULTS: In a cross-sectional model, simultaneous use was associated with more frequent hangovers both directly and indirectly through heavier drinking. In a prospective model, simultaneous use indirectly predicted more frequent hangovers through heavier drinking; however, the direct path was not significant. None of the paths from simultaneous use to drinking or hangovers were moderated by depressive symptoms in either model. CONCLUSIONS: The current study suggests that, both concurrently and prospectively, heavier drinking explained significant variance in the relation between simultaneous use and hangover frequency. The significant direct effect of simultaneous use in the cross-sectional model suggests that simultaneous users may have individual characteristics, outside of depressive symptoms, that confer risk for more frequent hangovers above and beyond heavier drinking.

Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Recommendations for Rehabilitation.

SIGNIFICANCE: We know the prevalence of traumatic brain injury (TBI)-related vision impairment and ocular injury symptoms. Lacking is an understanding of health care utilization to treat these symptoms. Utilization knowledge is important to structuring access to treatment, identifying clinical training needs, and providing evidence of the effectiveness of treatment. PURPOSE: This article reports rehabilitation, glasses/contacts, and imaging/photography/video recommendations made by optometrists and ophthalmologists as part of the Department of Veterans Affairs-mandated Performance of Traumatic Brain Injury Specific Ocular Health and Visual Functioning Examination administered to veterans with TBI at Department of Veterans Affairs polytrauma specialty facilities. METHODS: Using a retrospective design, natural language processing, and descriptive and regression statistics, data were analyzed for 2458 Operation Enduring Freedom/Operation Iraqi Freedom veterans who were administered the mandated examination between 2008 and 2017. RESULTS: Of the 2458 veterans, vision rehabilitation was recommended for 24%, glasses/contacts were recommended for 57%, and further imaging/photography/video testing was recommended for 58%. Using key words in the referral, we determined that 37% of veterans were referred to blind rehabilitation, 16% to occupational therapy, and 3% to low-vision clinics. More than 50% of the referrals could have been treated by blind rehabilitation, occupational therapy, or low-vision clinics. Rehabilitation referrals were significantly associated with younger age, floaters, photosensitivity, double vision, visual field and balance deficits, dizziness, and difficulty reading. In comparison, prescriptions for glasses and contacts were associated with older age, photosensitivity, blurred vision, decreased visual field and night vision, difficulty reading, and dry eye. Imaging/photography/video testing was associated with floaters, photosensitivity, and headache. CONCLUSIONS: Findings delineate service delivery models available to veterans with TBI-related vision impairment. The challenge these data address is the lack of clear paths from diagnosis of TBI to identification of vision dysfunction deficits to specialized vision rehabilitation, and finally to community reintegration and community based-vision rehabilitation.

Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Vision Rehabilitation Utilization.

SIGNIFICANCE: Visual dysfunction is frequently associated with traumatic brain injury (TBI). Although evidence regarding the prevalence of symptoms of this population has been published, little is known about health care utilization. A retrospective review of the data derived from the Department of Veterans Affairs (VA)-mandated "Traumatic Brain Injury Specific Ocular Health and Visual Functioning Examination for Polytrauma Rehabilitation Center Patients" provided a unique opportunity to investigate vision rehabilitation utilization. PURPOSE: The purpose of this study was to understand (a) the frequency of vision rehabilitation follow-up visits at 6, 12, and 24 months; (b) the association between follow-up and demographic, comorbidity, and severity of TBI covariates as well as ocular and visual symptoms, geographic access, and evaluating facility; and (c) why some veterans did not follow up with recommendations. METHODS: Retrospective and survey designs were used. The sample included 2458 veterans who served in the Operation Enduring Freedom/Operation Iraqi Freedom conflicts and received care at one of the five VA Polytrauma Rehabilitation Centers between January 1, 2008, and December 31, 2017. Quantitative and qualitative descriptive analyses and stepwise logistic regression were performed. RESULTS: About 60% of veterans followed up with recommended vision rehabilitation with visits equally split between VA Polytrauma Rehabilitation Centers and community VA facilities. For each 10-year increase in age, there was a corresponding reduction of 12% in the odds of follow-up. Veterans with decreased visual field had 50% greater odds of follow-up than those who did not. Veterans with difficulty reading had 59% greater odds of follow-up than those who did not. Those who had a double vision had 45% greater odds of follow-up than those who did not. CONCLUSIONS: Our findings suggest that the need for vision rehabilitation may extend as long as 2 years after TBI. Access to vision rehabilitation is complicated by the paucity of available neuro-optometric services.

Immersive Virtual Reality to Improve Outcomes in Veterans With Stroke: Protocol for a Single-Arm Pilot Study.

BACKGROUND: Over the last decade, virtual reality (VR) has emerged as a cutting-edge technology in stroke rehabilitation. VR is defined as a type of computer-user interface that implements real-time simulation of an activity or environment allowing user interaction via multiple sensory modalities. In a stroke population, VR interventions have been shown to enhance motor, cognitive, and psychological recovery when utilized as a rehabilitation adjunct. VR has also demonstrated noninferiority to usual care therapies for stroke rehabilitation. OBJECTIVE: The proposed pilot study aims to (1) determine the feasibility and tolerability of using a therapeutic VR platform in an inpatient comprehensive stroke rehabilitation program and (2) estimate the initial clinical efficacy (effect size) associated with the VR platform using apps for pain distraction and upper extremity exercise for poststroke neurologic recovery. METHODS: This study will be conducted in the Comprehensive Integrated Inpatient Rehabilitation Program at the James A Haley Veterans' Hospital. Qualitative interviews will be conducted with 10 clinical staff members to assess the feasibility of the VR platform from the clinician perspective. A prospective within-subject pretest-posttest pilot design will be used to examine the tolerability of the VR platform and the clinical outcomes (ie, upper extremity neurologic recovery, hand dexterity, pain severity) in 10 veteran inpatients. A VR platform consisting of commercially available pain distraction and upper extremity apps will be available at the participants' bedside for daily use during their inpatient stay (approximately 4-6 weeks). Clinician interviews will be analyzed using qualitative descriptive analysis. Cohen d effect sizes with corresponding 95% CIs will be calculated for upper extremity neurologic recovery, hand dexterity, and pain. The proportion of participants who achieve minimal clinically important difference after using the VR platform will be calculated for each clinical outcome. RESULTS: This study was selected for funding in August 2020. Institutional review board approval was received in October 2020. The project start date was December 2020. The United States Department has issued a moratorium on in-person research activities secondary to COVID-19. Data collection will commence once this moratorium is lifted. CONCLUSIONS: Our next step is to conduct a large multi-site clinical trial that will incorporate the lessons learned from this pilot feasibility study to test the efficacy of a VR intervention in inpatient rehabilitation and transition to home environments. When VR is used in patients' rooms, it serves to provide additional therapy and may reduce clinician burden. VR also presents an opportunity similar to home-based practice exercises. VR can be implemented in both clinical settings and people's own homes, where engagement in ongoing self-management approaches is often most challenging. This unique experience offers the potential for seamless transition from inpatient rehabilitation to the home. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/26133.

Development and Psychometric Properties of the Self-Blame Attributions for Cancer Scale.

OBJECTIVES: To adapt the Cardiac Self-Blame Attributions Scale into the Self-Blame Attributions for Cancer Scale (SBAC) for use in patients with cancer and analyze its psychometric properties. SAMPLE & SETTING: 113 patients receiving radiation therapy at the University of Kansas Cancer Center. METHODS & VARIABLES: The SBAC and other self-report measures were administered during outpatient oncology appointments for radiation therapy to establish the psychometric properties of the SBAC. RESULTS: A two-factor structure represented behavioral and characterological self-blame attributions. Reliability estimates for each factor were excellent and evidence of convergent and discriminant validity was found, indicating support for the SBAC as a valid and reliable measure of self-blame attributions in patients with cancer. IMPLICATIONS FOR NURSING: The SBAC may help healthcare providers, including nursing staff, to identify the self-blame patterns exhibited by patients with cancer. Future research can assess the reliability and validity of SBAC across stages of treatment and establish the predictive validity of the scale in individuals with cancer.

A critique of validity analysis from instruments assessing the affective domain.

BACKGROUND: Schools and colleges of pharmacy need to show evidence that their students have internalized professional values, and many choose to do so through quantitative instruments. A review of the literature was completed to identify the evidence of validity of the scores from instruments designed to assess pharmacy students in the affective domain. METHODS: Electronic databases were searched to identify instruments. Basic information regarding the instruments, the facets of validity assessed, and the evidence for validity were reviewed. RESULTS: Of the studies identified, 25 focused on assessing the affective domain and reported evidence of at least one facet of validity. Most reported evidence of validity from two or more sources, and most reported evidence concerning test content and internal structure (i.e. internal consistency reliability or factor analysis). Other sources of validity were missing from most studies. IMPLICATIONS: More research is needed to investigate the validity of the scores of instruments developed to assess pharmacy students within the affective domain, especially regarding relations to other variables, response processes, and consequences of use.

Scale development and psychometric properties of the Cardiac Self-Blame Attributions scale in patients with cardiovascular disease.

Patients with cardiovascular disease may attribute their cardiovascular disease to their behaviors (behavioral self-blame) or to their dispositions (characterological self-blame). However, findings are mixed on the effects of behavioral self-blame and characterological self-blame on health outcomes, possibly because there are no validated, multiple-item measures. This study developed and tested an 11-item Cardiac Self-Blame Attributions scale via questionnaire data from 121 patients with cardiovascular disease. Results yielded a two-factor structure that explained 65 percent of the variance, with good reliability and discriminant validity. Findings suggest that the scale is reliable and valid and can be used to understand the cardiac attributions patients create.

Comparison of factor structure models for the Beck Anxiety Inventory among cardiac rehabilitation patients.

OBJECTIVE: Individuals with cardiovascular disease (CVD) experience greater rates of distress symptoms, such as anxiety and depressive symptoms, than the general population. These psychological outcomes have been linked to greater risk for negative outcomes following a cardiac event; however, research examining the relationship between specific components of anxiety and outcomes in CVD is limited. Further, prior research has not investigated the structure of anxiety symptoms in CVD. This study sought to compare previously established one, two, and four-factor models of the Beck Anxiety Inventory (BAI) in individuals enrolled in cardiac rehabilitation (CR). METHODS: Our sample included 208 individuals with CVD recruited during enrollment in a phase II CR program. Participants completed the BAI at enrollment in CR (Time 1) and again 12weeks later at CR completion (Time 2, n=151). RESULTS: Consistent with prior literature, 41% of our sample reported at least mild symptoms of anxiety (BAI>8), and the BAI proved to be a reliable measure within this sample (α=0.89). Confirmatory factor analysis (CFA) results indicated that a second-order model with four first order factors, consisting of cognitive, autonomic, neuromotor, and panic components, fit our data well. A multi-group CFA approach supported measurement invariance across time. CONCLUSION: These results suggest that anxiety following CVD can be evaluated based on cognitive, autonomic, neuromotor, and panic components as well as the encompassing anxiety construct.

Sample size in psychological research over the past 30 years.

The American Psychological Association (APA) Task Force on Statistical Inference was formed in 1996 in response to a growing body of research demonstrating methodological issues that threatened the credibility of psychological research, and made recommendations to address them. One issue was the small, even dramatically inadequate, size of samples used in studies published by leading journals. The present study assessed the progress made since the Task Force's final report in 1999. Sample sizes reported in four leading APA journals in 1955, 1977, 1995, and 2006 were compared using nonparametric statistics, while data from the last two waves were fit to a hierarchical generalized linear growth model for more in-depth analysis. Overall, results indicate that the recommendations for increasing sample sizes have not been integrated in core psychological research, although results slightly vary by field. This and other implications are discussed in the context of current methodological critique and practice.

Statistical analysis of low molecular mass heparin nanoencapsulation.

The objective of this study was to use Box-Behnken design (BBD) to investigate the influence of formulation variables on the properties of heparin-loaded poly(lactic-coglycolic acid) (PLGA)-polymethacrylate-RLPO (E-RLPO) nanoparticles (NP) in terms of mean diameter (as size) and drug encapsulation efficiency. The NPs were prepared by the double emulsion solvent evaporation method. The independent variables were: X1 - polymer mass ratio (PLGA:E-RLPO) in the oil phase, X2 - concentration of polyvinyl alcohol (PVA) as emulsion stabilizer, and X3 - volume of the external aqueous phase (W2). Particle size (analyzed by dynamic light scattering) and encapsulation efficiency (EE, estimated by spectrophotometry) were the investigated responses. The polynomial equation obtained from regression analysis of the reduced model (p = 0.0002, F = 25.7952 and R2 = 0.96) provided an excellent fit. The optimal size for the NP was found to be 134.2 ± 16.5 nm with formulation variables of 48.2:61.8, 0.321 (%,m/V) and 263 mL for X1, X2 and X3, respectively. Probably, due to electrostatic interaction between the negatively charged drug and the positively charged E-RLPO, the percent EE of heparin was between 74.4 ± 6.5 % (lowest value) and 92.1 ± 5.3 % (highest value). The data suggest that BBD is a useful tool in rational design of heparin-loaded NPs.

Validation of a TAI Short Form with an adolescent sample.

Although test anxiety is increasingly used in research with multiple constructs, it is not always possible to administer a lengthy scale to measure it. Taylor and Deane (2002) developed a 5-item short form of the 20-item Test Anxiety Inventory (TAI; see Spielberger, Gonzalez, Taylor, Algaze, & Anton, 1978). Although evidence of reliability and validity was good, there were several limitations, including the age and gender of the sample, and the lack of data obtained with the short form rather than the original TAI. The current study attempts to address those limitations and augment previous results with additional types of validity evidence (i.e., coefficients of divergent validity and exploratory factor analysis) in a sample of 152 seventh- and eighth-graders. Results were high reliability (.86) and good evidence of multiple facets of validity. Previous results were confirmed and extended for adolescents and for use in applied psychological and educational settings.

Formulation of dacarbazine-loaded Cubosomes--part II: influence of process parameters.

The purpose of this study is to investigate the combined influence of process parameters (independent variables) such as homogenization speed (X(1)), duration (X(2)), and temperature (X(3)) during the preparation of dacarbazine-loaded cubosomes. Box-Behnken design was used to rationalize the influence of these three factors on two responses, namely particle size (Y(1)) and encapsulation efficiency (Y(2)). Independent and dependent variables were analyzed with multiple regressions to establish a full-model second-order polynomial equation. F value was calculated to confirm the omission of insignificant parameters or interactions of parameters from the analysis to derive a reduced-model polynomial equation to predict the Y(1) and Y(2) of dacarbazine-loaded cubosomes. Pareto charts were also obtained to show the effects of X(1), X(2), and X(3) on Y(1) and Y(2). For Y(1), there was a model validated for more accurate prediction of response parameter by performing checkpoint analysis. The optimization process and Pareto charts were obtained automatically and they predicted the levels of independent parameters X(1), X(2), and X(3) (0.889794, 0.11886, and 0.56201, respectively) and minimized Y(1). The optimal process parameters (homogenization's speed = approximately 24,000 rpm, duration = 5.5 min, and temperature = 76 degrees C) led to the production of cubosomes with 85.6 nm in size and 16.7% in encapsulation efficiency. The Box-Behnken design proved to be a useful tool in the preparation and optimization of dacarbazine-loaded cubosomes. For encapsulation efficiency (Y(2)), further studies are needed to enhance the result and improve the model for such water-soluble drug encapsulation in cubosomes.

Formulation of dacarbazine-loaded cubosomes-part I: influence of formulation variables.

The purpose of this study was to investigate the combined influence of three-level, three-factor variables on the formulation of dacarbazine (a water-soluble drug) loaded cubosomes. Box-Behnken design was used to obtain a second-order polynomial equation with interaction terms to predict response values. In this study, the selected and coded variables X(1), X(2), and X(3) representing the amount of monoolein, polymer, and drug as the independent variables, respectively. Fifteen runs of experiments were conducted, and the particle size (Y(1)) and encapsulation efficiency (Y(2)) were evaluated as dependent variables. We performed multiple regression to establish a full-model second-order polynomial equation relating independent and dependent variables. A second-order polynomial regression model was constructed for Y(1) and confirmed by performing checkpoint analysis. The optimization process and Pareto charts were obtained automatically, and they predicted the levels of independent coded variables X(1), X(2), and X(3) (-1, 0.53485, and -1, respectively) and minimized Y(1) while maximizing Y(2). These corresponded to a cubosome formulation made from 100 mg of monoolein, 107 mg of polymer, and 2 mg with average diameter of 104.7 nm and an encapsulation efficiency of 6.9%. The Box-Behnken design proved to be a useful tool to optimize the particle size of these drug-loaded cubosomes. For encapsulation efficiency (Y(2)), further studies are needed to identify appropriate regression model.

The effects of race and age on axillary lymph node involvement in breast cancer patients at a Midwestern safety-net hospital.

BACKGROUND: Black and premenopausal patients have been shown to have poorer stage for stage survival than the overall population. The purpose of this study was to define the effects of age and race on axillary lymph node involvement at a Midwestern safety-net hospital. The hypothesis was that black patients under the age of 50 would be found to have increased rates of axillary involvement in breast cancer. METHODS: A retrospective case review was performed of 184 breast cancer patients from 2000 to 2005. Statistical analysis was performed by race and age. Patients under 50 years of age were defined as premenopausal. RESULTS: The overall rate of axillary involvement was 47.8%. Black patients had an overall rate of axillary involvement of 52.9%. However, premenopausal black patients had a 70.8% rate of axillary involvement (P < .05). Premenopausal white patients had a 46.3% rate of axillary involvement. Logistic regression analysis was performed, and premenopausal age and tumor size were found to be independent predictors of positive lymph node status in black patients. CONCLUSION: In our study, premenopausal black patients had a much higher rate of axillary lymph node involvement than any other group. This finding was consistent even when tumor size was taken into account. More research needs to be done to better define this difference and to detect this disease at an earlier stage.

Therapeutic reactance in a depressed client sample: a comparison of two measures.

The impact of client variables on psychotherapy is of both theoretical and practical importance. Reactance--the premise that individuals seek to maintain control over personal freedoms when threatened by a perceived loss thereof--has been shown to have an impact on the effectiveness of therapeutic interventions. Developing an effective means of quantitatively assessing this characteristic prior to treatment could facilitate treatment planning and maximize treatment outcome. The present study compared two paper-and-pencil measures of reactance: the Therapeutic Reactance Scale (TRS) and Resistance Potential (RP). Ninety-eight men and women diagnosed with depression completed both measures. The TRS and RP failed to correlate despite their presumed ability to measure the same construct. The RP exhibited extremely poor internal consistency, calling into question results that have been based on this measure. The TRS results provided evidence of convergent, divergent, and construct validity for this instrument.