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Alien species are a significant threat to natural ecosystems and human economies. Despite global efforts to address this challenge, the documented number of alien species is rapidly increasing worldwide. However, the magnitude of the impact of alien species may vary significantly across habitats. For example, some habitats are naturally less prone to biological invasions due to stringent abiotic and biotic characteristics, selecting for a limited number of introduced species possessing traits closely related to the native organisms. Subterranean ecosystems are quintessential examples of habitats with strong environmental filters (e.g. lack of light and scarcity of food), driving convergent adaptations in species that have successfully adapted to life in darkness. Despite these stringent environmental constraints, the number of records of alien species in subterranean ecosystems has increased in recent decades, but the relevant literature remains largely fragmented and mostly anecdotal. Therefore, even though caves are generally considered very fragile ecosystems, their susceptibility to impacts by alien species remains untested other than for some very specific cases. We provide the first systematic literature survey to synthesise available knowledge on alien species in subterranean ecosystems globally. This review is supported by a database summarising the available literature, aiming to identify gaps in the distribution and spread of alien invertebrate species in subterranean habitats, and laying the foundations for future management practices and interventions. First, we quantitatively assessed the current knowledge of alien species in subterranean ecosystems to shed light on broader questions about taxonomic biases, geographical patterns, modes of dispersal, pathways for introductions and potential impacts. Secondly, we collected species-specific traits for each recorded alien species and tested whether subterranean habitats act as ecological filters for their establishment, favouring organisms with pre-adaptive traits suitable for subterranean life. We found information on the presence of 246 subterranean alien species belonging to 18 different classes. The dominant alien species were invertebrates, especially insects and arachnids. Most species were reported in terrestrial subterranean habitats from all continents except Antarctica. Palaearctic and Nearctic biogeographic regions represented the main source of alien species. The main routes of introductions into the recipient country are linked to commercial activities (84.3% of cases for which there was information available). Negative impacts have been documented for a small number of case studies (22.7%), mostly related to increased competition with native species. For a limited number of case studies (6.1%), management strategies were reported but the effectiveness of these interventions has rarely been quantified. Accordingly, information on costs is very limited. Approximately half of the species in our database can be considered established in subterranean habitats. According to our results, the presence of suitable traits grants access to the stringent environmental filter posed by subterranean environments, facilitating establishment in the new habitat. We recommend that future studies deepen the understanding of invasiveness into subterranean habitats, raising public and scientific community awareness of preserving these fragile ecosystems., (© 2023 The Authors. Biological Reviews published by John Wiley & Sons Ltd on behalf of Cambridge Philosophical Society.)

Chronic granulomatous disease (CGD) is a rare primary immune disorder caused by mutations in one of the five subunits of the NADPH oxidase complex expressed in phagocytes. Two-thirds of CGD cases are caused by mutations in CYBB that encodes NOX2 or gp91phox. Some rare X91+-CGD point mutations lead to a loss of function but with a normal expression of the mutated NOX2 protein. It is therefore necessary to ensure that this mutation is indeed responsible for the loss of activity in order to make a safe diagnosis for genetic counselling. We previously used the X-CGD PLB-985 cell model of M.C. Dinauer obtained by homologous recombination in the original PLB-985 human myeloid cell line, in order to study the functional impact of such mutations. Although the PLB-985 cell line was originally described by K.A. Tucker et al. in1987 as a distinct cell line isolated from a patient with acute nonlymphocytic leukemia, it is actually identified as a subclone of the HL-60 cells. In order to use a cellular model that meets the quality standard for the functional study of X91+-CGD mutations in CGD diagnosis, we developed our own model using the CRISPR-Cas9 technology in a certified PLB-985 cell line from DSMZ-German Collection of Microorganisms and Cell Cultures. Thanks to this new X-CGD model, we demonstrated that the G412E mutation in NOX2 found in a X91+-CGD patient prohibits access of the electron donor NADPH to its binding site explaining the absence of superoxide production in his neutrophils., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Immunology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Biological control (BC) of invasive alien plants (IAP) can be an effective environmental management approach. It has only very recently been adopted in Europe and is underutilized compared to other continents where this method has been successfully implemented for over a century. This is in sharp contrast to the BC of invertebrate pests, which has been taken up widely within Europe. It has been suggested that this is related to the risk-adverse attitude of Europeans towards weed BC. Scientific and public perception have a major influence on environmental policy actions. Public perception and knowledge regarding BC is an understudied subject despite its relevance for the application of this management alternative. We aimed to assess the knowledge and perception of BC of IAP among European professionals compared with their peers from other continents. To this end we conducted an online survey including multiple choice and open questions among over 700 people professionally engaged with managing the natural environment, of which approximately half were from Europe (EU) and the others from outside (non-EU). We assessed relationships between the geographical location of the respondents and their knowledge, and perceptions of BC of weeds versus BC of invertebrate pests. We found that respondents' location influenced both perceptions and knowledge of BC for weeds. Compared to non-EU respondents, EU professionals showed less appreciation for BC (e.g., regarding safety, sustainability, and cost-effectiveness), and perceived it as a riskier method, particularly in the case of practitioners and researchers. More profoundly insect pest BC tended to be considered less safe than weed BC for non-EU respondents. Confidence in weed BC as a method, as well as in the validity of the associated pre-release risk assessments, strongly increased with the level of expertise in weed BC. While a much higher proportion of non-EU respondents were correctly aware of the presence/absence of BC in their own countries and identified successful examples of BC accurately, both groups of respondents were similarly aware of unsuccessful BC examples, including BC agents against animals, stressing the bias of EU respondents towards examples of BC failure. The appreciation of weed BC in Europe could be elevated by a combination of increasing knowledge of the technique and pre-release risk assessment and promoting successful examples of weed BC, which may bring major benefits for the management of IAP across the region., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper, (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

We argue that doctoral education in water needs an elevated focus towards educating game changers who can drive innovation and change towards more sustainable futures across academic and non-academic settings. Today's doctoral graduates in water are increasingly employed outside academia, and challenged to understand complex and interconnected systems, to integrate and synthesize information from different disciplines and to lead the way toward increasingly creative, resilient, robust, and socially sustainable solutions. Supervisors are challenged by interdisciplinary research topics and by growing diversity of objectives, too often at the cost of their wellbeing. The need to keep up with the rapid scientific and technological development and floods of big data is pressing. We synthesize key insights from higher education literature and doctoral programs in water research to identify priority actions targeted at four key actor groups: supervisors and supervisees, research group, university, and industry. The actions contribute to appropriate resourcing, enabling an environment for enhanced teamwork practices, and systematic structures for progress. Establishing supporting structures will leverage the much-needed communities of practice involved in co-creating and transforming supervision and education of doctoral students in interdisciplinary water research., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Much research effort has been invested in understanding ecological impacts of invasive alien species (IAS) across ecosystems and taxonomic groups, but empirical studies about economic effects lack synthesis. Using a comprehensive global database, we determine patterns and trends in economic costs of aquatic IAS by examining: (i) the distribution of these costs across taxa, geographic regions and cost types; (ii) the temporal dynamics of global costs; and (iii) knowledge gaps, especially compared to terrestrial IAS. Based on the costs recorded from the existing literature, the global cost of aquatic IAS conservatively summed to US$345 billion, with the majority attributed to invertebrates (62%), followed by vertebrates (28%), then plants (6%). The largest costs were reported in North America (48%) and Asia (13%), and were principally a result of resource damages (74%); only 6% of recorded costs were from management. The magnitude and number of reported costs were highest in the United States of America and for semi-aquatic taxa. Many countries and known aquatic alien species had no reported costs, especially in Africa and Asia. Accordingly, a network analysis revealed limited connectivity among countries, indicating disparate cost reporting. Aquatic IAS costs have increased in recent decades by several orders of magnitude, reaching at least US$23 billion in 2020. Costs are likely considerably underrepresented compared to terrestrial IAS; only 5% of reported costs were from aquatic species, despite 26% of known invaders being aquatic. Additionally, only 1% of aquatic invasion costs were from marine species. Costs of aquatic IAS are thus substantial, but likely underreported. Costs have increased over time and are expected to continue rising with future invasions. We urge increased and improved cost reporting by managers, practitioners and researchers to reduce knowledge gaps. Few costs are proactive investments; increased management spending is urgently needed to prevent and limit current and future aquatic IAS damages., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Severity scoring systems are inherent to ICU practice for multiple purposes. Acute Physiology and Chronic Health Evaluation (APACHE) scoring systems are designed for ICU mortality prediction. This study aims to validate APACHE IV in COVID-19 patients admitted to the ICU., Methods: All COVID-19 patients admitted to the ICU between March 13, 2020, and October 17, 2020, were retrospectively analyzed. APACHE II and APACHE IV scores as well as SOFA scores were calculated within 24 hours after admission. Discrimination for mortality of all three scoring systems was assessed by receiver operating characteristic curves. Youden index was determined for the scoring system with the best discriminative performance. The Hosmer-Lemeshow goodness-of-fit test was used to assess calibration. All analyses were performed for both the overall population as in a subgroup treated with anti-Xa adjusted dosages of LMWHs., Results: 116 patients were admitted to our ICU during the study period. 13 were excluded for various reasons, leaving 103 patients in the statistical analysis of the overall population. 57 patients were treated with anti-Xa adjusted prophylactic dosages of LMWH and were supplementary analyzed in a subgroup analysis. APACHE IV had the best discriminative power of the three scoring systems, both in the overall population (APACHE IV ROC AUC 0.67 vs. APACHE II ROC AUC 0.63) as in the subgroup (APACHE IV ROC AUC 0.82 vs. APACHE II ROC AUC 0.7). This model exhibits good calibration. Hosmer-Lemeshow p values for APACHE IV were 0.9234 for the overall population and 0.8017 for the subgroup. Calibration p values of the APACHE II score were 0.1394 and 0.6475 for the overall versus subgroup, respectively., Conclusions: APACHE IV provided the best discrimination and calibration of the considered scoring systems in critically ill COVID-19 patients, both in the overall group and in the subgroup with anti-Xa adjusted LMWH doses. Only in the subgroup analysis, discriminative abilities of APACHE IV were very good. This trial is registered with NCT04713852., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Jeroen Vandenbrande et al.)

Introduction: Persistent back/and or leg pain is a common outcome after spinal surgery (otherwise known as failed back surgery syndrome [FBSS]). Studies have shown that spinal cord stimulation (SCS) at 10 kHz provides effective analgesia in FBSS patients with both back and leg pain symptoms and in those with predominant back pain. This study is the first to evaluate the therapy in FBSS patients with predominant leg pain., Methods: The safety and efficacy of 10 kHz SCS was evaluated in an uncontrolled, open-label, prospective study of FBSS patients with predominant leg pain in the Netherlands. Follow-ups were performed at 1, 3, 6, and 12 months post implantation., Results: Sixty out of 68 patients (88%) experienced sufficient pain relief during a stimulation trial. Of these, 58 proceeded to permanent implantation of a 10 kHz SCS system. After 12 months of treatment, 80% of patients experienced ≥ 50% reduction in baseline leg pain, and a similar proportion (76%) experienced ≥ 50% reduction in baseline back pain. At least two-thirds of patients were also leg pain and back pain remitters (visual analog scale [VAS] ≤ 2.5 cm). The therapy was also associated with a general improvement in patients' quality of life, as measured by secondary outcomes including disability, perception of health improvement, mental well-being, and satisfaction. A positive impact on opioid consumption was also observed., Conclusions: Consistent with previous findings, 10 kHz SCS for the treatment of FBSS patients with predominant radicular symptoms is safe and effective and is associated with improved quality of life., (© 2020 The Authors. Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.)

Limiting the spread and impacts of invasive alien species (IAS) on biodiversity and ecosystems has become a goal of global, regional and national biodiversity policies. Evidence based management of IAS requires support by risk assessments, which are often based on expert judgment. We developed a tool to prioritize potentially new IAS based on their ecological risks, socio-economic impact and feasibility of management using multidisciplinary expert panels. Nine expert panels reviewed scientific studies, grey literature and expert knowledge for 152 species. The quality assessment of available knowledge revealed a lack of peer-reviewed data and high dependency on best professional judgments, especially for impacts on ecosystem services and feasibility of management. Expert consultation is crucial for conducting and validating rapid assessments of alien species. There is still a lack of attention for systematic and methodologically sound assessment of impacts on ecosystem services and weighting negative and positive effects of alien species., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: This retrospective, matched case-control cohort study describes the incidence, indications, anesthesia techniques and outcomes of pregnancies complicated by surgery in a single tertiary-referral hospital., Methods: Retrospective review of the hospital records of 171 patients who had non-obstetric surgery in the current pregnancy, between 2001 and 2016. Pregnancy outcomes of these women were firstly compared with all contemporary non-exposed patients (n=35 411), and secondly with 684 non-exposed control patients, matched for age, time of delivery and parity., Results: The incidence of non-obstetric surgery during pregnancy was 0.48%, mostly performed during the second trimester (44%) and under general anesthesia (81%). Intra-abdominal surgery (44%) was the most commonly performed procedure, predominantly using laparoscopy (79%). Women undergoing surgery delivered earlier and more frequently preterm (25% vs. 17%, P=0.018); and birth weight was significantly lower [median (95% CI) 3.16 (3.06 to 3.26) vs. 3.27 (3.22 to 3.32) kg, P=0.044]. When surgery was performed under general anesthesia, low birth weight was more frequent (22% vs 6%, P=0.046). Overall pregnancy outcomes were neither influenced by trimester nor location (intra- vs extra-abdominal) of surgery. However, preterm birth rate secondary to surgery was higher for interventions during the third trimester, compared with other trimesters (10% vs 0, P <0.001)., Conclusion: Pregnant women who underwent surgery delivered preterm more frequently and their babies had lower birth weights. Laparoscopic surgery did not increase the incidence of adverse pregnancy outcomes. General anesthesia was associated with low birth weight. Whether these associations suggest causation or reflect the severity of the underlying condition remains speculative., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The number of alien plants escaping from cultivation into native ecosystems is increasing steadily. We provide an overview of the historical, contemporary and potential future roles of ornamental horticulture in plant invasions. We show that currently at least 75% and 93% of the global naturalised alien flora is grown in domestic and botanical gardens, respectively. Species grown in gardens also have a larger naturalised range than those that are not. After the Middle Ages, particularly in the 18th and 19th centuries, a global trade network in plants emerged. Since then, cultivated alien species also started to appear in the wild more frequently than non-cultivated aliens globally, particularly during the 19th century. Horticulture still plays a prominent role in current plant introduction, and the monetary value of live-plant imports in different parts of the world is steadily increasing. Historically, botanical gardens - an important component of horticulture - played a major role in displaying, cultivating and distributing new plant discoveries. While the role of botanical gardens in the horticultural supply chain has declined, they are still a significant link, with one-third of institutions involved in retail-plant sales and horticultural research. However, botanical gardens have also become more dependent on commercial nurseries as plant sources, particularly in North America. Plants selected for ornamental purposes are not a random selection of the global flora, and some of the plant characteristics promoted through horticulture, such as fast growth, also promote invasion. Efforts to breed non-invasive plant cultivars are still rare. Socio-economical, technological, and environmental changes will lead to novel patterns of plant introductions and invasion opportunities for the species that are already cultivated. We describe the role that horticulture could play in mediating these changes. We identify current research challenges, and call for more research efforts on the past and current role of horticulture in plant invasions. This is required to develop science-based regulatory frameworks to prevent further plant invasions., (© 2018 Cambridge Philosophical Society.)

Induction of cytochrome P450 1A (CYP1A) can be used as a biomarker of exposure to planar halogenated aromatic hydrocarbons (PHAHs). Our objective was to characterize the induction of CYP1A activity and protein in three avian species following in vivo treatment with beta-naphthoflavone (BNF) and/or isosafrole. Alkoxyresorufin-O-dealkylase (alk-ROD) activities of hepatic microsomes from Herring Gulls (Larus argentatus) (HGs), Double-crested Cormorants (Phalacrocorax auritus) (DCCs) and chickens (Gallus domesticus) were measured using ethoxy-, methoxy-, pentoxy- and benzyloxy-resorufin, in the presence and absence of the inhibitors ellipticine or furafylline. Immunoreactivity of microsomal proteins with antibodies to several CYP1A proteins was investigated. CYP1A protein and alk-ROD activities of HGs and DCCs, but not chickens, were induced by isosafrole. Ellipticine was a potent and non-selective inhibitor of alk-ROD activity in all three species, while furafylline inhibition of alk-ROD activities varied among species and treatments. In all three species, BNF induced a protein immunoreactive with monoclonal antibody to CYP1A1 from the marine fish Stenotomus chrysops (scup), but a CYP1A2-like protein was not detected in avian microsomes probed with polyclonal antibodies to mouse CYP1A2. Variations in responses among avian species indicate that CYP1A proteins and substrate specificities should be characterized for each species used in PHAH biomonitoring programs.

Using the 1994-95 National Health Interview Supplement Disability Supplement, the authors study levels of disabilities and accommodations among US adults with arthritis disability, compared to people with disability due to other conditions. Arthritis-disabled people are defined in two ways. One definition covers a broad range of arthritis and rheumatic conditions, and the other concentrates solely on arthritis. The authors find that arthritis-disabled people have more total disabilities than other-disabled peop e. However, their disabilities are less severe, have shorter durations, and accumulate more gradually over time. Despite more disabilities, people with arthritis disability use fewer assistive and service accommodations than other-disabled people. They do use more mobility aids. Because arthritis is the leading chronic condition for middle-aged and older adults, th s profile of extensive but mild-to-moderate disability is experienced by many millions of adults. Accommodations for arthritis may also be extensive but aimed more toward self-care than toward assistive and medical services.

Unlabelled: This paper is an integrated analysis of newspaper coverage, epidemiological rates, and recent social history of six prominent diseases., Hypotheses: Newspaper coverage of a disease has three developmental stages (emergence, maturation, and decline & death). Trends in newspaper coverage of a disease reflect trends in its mortality, prevalence, and incidence. Magnitudes of newspaper coverage of diseases reflect their differential mortality rates., Data: Using the LEXIS-NEXIS news archive for major U.S. newspapers, we retrieve articles about cancer, heart disease, AIDS, diabetes, Alzheimer disease, and arthritis for the period 1977-1997. We also obtain mortality, prevalence, and incidence trends for the six diseases., Results: During the two decades, newspaper coverage emerges for AIDS and Alzheimer disease and is in the mature stage for the other diseases; declines begin for heart disease and AIDS. Trends in news coverage closely parallel mortality trends, and less consistently prevalence and incidence trends. Sharp downturns and upturns in mortality are mirrored in news volume. High-mortality diseases prompt both the most news coverage and the largest proportions of articles with death topics., Conclusion: Newspaper coverage of diseases is responsive to their mortality levels and trends.

Previously we showed that the polychlorinated biphenyl 3,3',4,4'-tetrachlorobiphenyl (TCB) caused a release of reactive oxygen species (ROS) from cytochrome P450 1A (CYP1A) of the fish scup (Stenotomus chrysops), and from rat and human CYP1A1. This was linked to a TCB- and NADPH-dependent oxidative inactivation of the enzyme, which in scup and rat was inversely related to the rates of TCB oxidation. We examined the relationship between rates of TCB oxidation, CYP1A inactivation and ROS production in liver microsomes from additional vertebrate species, including skate (Raja erinacea), eel (Anguilla rostrata), killifish (Fundulus heteroclitus), winter flounder (Pleuronectes americanus), chicken (Gallus domesticus), cormorant (Phalacrocorax auritus), gull (Larus argentatus), and turtle (Chrysemys picta picta). TCB oxidation rates were induced in all fish and birds treated with aryl hydrocarbon receptor agonists. Induced rates of TCB oxidation were <1 pmol/min/mg microsomal protein in all fish, and 6-14 pmol/min/mg in the birds. In all species but one, TCB oxidation rates correlated positively with EROD rates, indicating likely involvement of CYP1A in TCB oxidation. Incubation of liver microsomes of most species with TCB+NADPH resulted in an immediate (TCB-dependent) inhibition of EROD, and a progressive loss of EROD capacity, indicating an oxidative inactivation of CYP1A like that in scup. NADPH stimulated production of ROS (H(2)O(2) and/or O(2)(-*)) by liver microsomes, slightly in some species (eel) and greatly in others (chicken, turtle). Among the birds and the fish, NADPH-stimulated ROS production correlated positively with EROD activity. TCB caused a significant stimulation of ROS production by liver microsomes of flounder, killifish, cormorant and gull, as well as scup. The stimulation of CYP1A inactivation and ROS generation indicates an uncoupling of CYP1A by TCB in many species, and when compared between species, the rates of CYP1A inactivation correlated inversely with rates of TCB oxidation. Some feature(s) of binding/active site topology may hinder TCB oxidation, enhancing the likelihood for attack of an oxidizing species in the active site.

Primary Objective: Health surveys, especially those for older persons, include numerous detailed items about disability. There has been little effort to develop a global disability item, that is, one question that covers the concept of disability briefly but well. This article discusses how parsimony can be achieved through a single item, or less desirably by reductions of detailed items., Main Outcome and Results: Results of three analyses on the issue of compact disability indicators, using public-use data sets (AHEAD, HRS, BRFSS), are presented. The analyses study relationships of global disability to both detailed disability items and global health. Overall, the results show that a global disability item has good coverage of specific disabilities and is distinct from self-rated health., Conclusions: Routine inclusion of a global disability item in surveys is recommended, and specific suggestions are made to aid its design.

Introduction: we have tested the hypothesis that the co-occurrence of common impairments (motor and cognitive impairments, vision and hearing loss, depressive symptoms) of later life have exacerbating effects on disability [activities and instrumental activities of daily living, social and role function, (in)activity]., Method: data were drawn from a community-based sample of 624 people aged 57 and older., Results: motor impairments and depressive symptoms were associated with all disability measures, even when the effects of other impairments, age and gender were controlled. This indicates independent, predominant effects of motor impairments and depressive symptoms. Although several significant first-order interaction effects (indicating exacerbation) of impairments on disability were found, they were not very strong, but vision and hearing losses exacerbate the impact of the other impairments on disability., Conclusions: impairments, particularly motor impairments and depressive symptoms, largely act 'solo', by main effects on disability. Only a few combinations including vision or hearing loss further exacerbate the effects of other impairments on disability.

This study examined relationships between three sensory and communication abilities and two areas of nursing home resident behavior. Data from 18,873 nursing home residents include measures of hearing, visual, and communication abilities, and social engagement and time spent in activities. Increasing level of visual impairment is associated with low levels of social engagement and low time in activities. Both moderate and severe hearing impairment are associated with low time in activities, while inadequate communication is associated with limits in both social engagement and time in activities. The combined effects of visual and communications impairments are associated with low social engagement. Increasing attention to sensory and communication losses may lead to improve quality of life in this population.

Objectives: Personal and equipment assistance are common strategies to reduce disability. This study sought to determine how often assistance reduces or even completely resolves health-related difficulties in everyday tasks., Methods: Data are from the NHANES I Epidemiologic Followup Study. Adults aged 35 to 90 reported difficulty doing 12 everyday tasks on their own without assistance. Those stating that they had much difficulty or were unable were asked if they had personal assistance and/or equipment assistance, and their degree of difficulty with assistance. Use and efficacy of assistance are studied by gender, age, intrinsic (unassisted) degree of difficulty, and type of assistance., Results: Most people use assistance for the 12 tasks; "personal assistance only" is the principal type used for upper-extremity and body transfer tasks; "equipment only" ranks first for lower-extremity tasks. Assistance reduces difficulty for the great majority of persons (75% to 85%) and completely resolves difficulty for about 25%. Equipment only proves to be the most efficacious strategy for reducing and resolving limitations., Conclusions: Equipment's success may be due to greater perceived gains when people accomplish the assistance by themselves.

This study examines cross-sectional age differences, longitudinal age changes, and secular changes in obligatory, committed, and discretionary activities, using activity questionnaire completed by men and women participants in the Baltimore Longitudinal Study of Aging between 1958 and 1992. (1) Time spent, on obligatory activities and passive leisure is greatest, and on committed activities and active leisure least, for older adults. (2) Longitudinal patterns usually mirror cross-sectional ones. There are pronounced exceptions for women whose paid work time has been increasing and housework decreasing, while cross-sectional patterns show the reverse. (3) Over recent decades, time in committed activities shifted in opposite ways for men and women. Men decreased paid work and increased housework, repairs and yardwork, shopping, and child-care, while women increased paid work and decreased housework. In sum, the age structure of activities has persisted in the midst of new social opportunities; gender roles have proven more malleable than age roles.

Objectives and Methods: Gender differences in the prevalence and impact of arthritis are discussed, using data and analytic results from national health surveys., Results: Most cases of arthritis are osteoarthritis, an ancient disease that causes pain, physical dysfunction, and social disability, but not death. Arthritis prevalence rates rise sharply with age; it is the leading chronic condition in mid and late life. Women's rates exceed men's at all ages. Women's higher rates of disability and medical services for arthritis in the population are due mainly to higher prevalence. Among persons with arthritis, women are only a little more likely than men to be disabled or receive medical services. Persons with arthritis often have other chronic conditions as well (called comorbidity). Combining arthritis and visual problems gives a strong exacerbating push to disability., Conclusions: Because biomedical research emphasizes pathogenesis and therapies for fatal conditions, Americans' health future will become dominated by nonfatal ones, especially arthritis. I recommend a better balance and new orientation for arthritis research that stays true to older persons' health and disability experience.

Objectives: This paper analyzes the impact of seven chronic conditions (three nonfatal: arthritis, visual impairment, hearing impairment; four fatal: ischemic heart disease, chronic obstructive pulmonary disease, diabetes mellitus, malignant neoplasms) on US adults aged 18 and older. Impact refers to how readily a condition prompts activity limitations, physician visits, and hospital stays., Methods: Data come from three national health surveys and vital statistics. For comparability, a single disease classification scheme was applied, and new rates were estimated. Frequency, impact, and prominence of the target conditions are studied via rates, ratios of rates, and ranks, respectively., Results: In young adulthood, the nonfatal conditions prompt limitations less readily than do the fatal ones, but by older ages, arthritis and visual impairment have a limiting impact equivalent to that of fatal conditions. Despite high prevalence and limitations, nonfatal conditions stand well below fatal conditions for health services use., Conclusions: Although statistics on frequency, impact, and prominence all indicate conditions "importance," they give only weak clues about specific service needs of affected persons. The persistent finding that nonfatal conditions do not receive health services care commensurate with their prevalence and impact reflects long-standing imbalanced attention on fatal conditions in research and medical care.

For persons with serious chronic morbidity, disability is a very dynamic process as morbidity advances or retreats, and as interventions succeed or fail. This article studies trajectories of function (cognitive, emotional, social, physical, and global well-being) over a year for 165 persons whose chronic morbidity prompted a hospital stay. Changes in functioning from hospital admission to one year post-discharge are analyzed; functional statuses were measured nine times in that period. Both intra-individual and inter-individual changes are studied by means of a combination of visual and statistical techniques. (1) Individuals: After the hospital stay, functions typically improve in the first month, stabilize for several months, then begin to fluctuate and worsen. Individual trajectories are very changeful over a year, yet there is short-run continuity (from one measurement point to the next). (2) Groups: Persons with fracture of hip show the most striking and protracted improvements over the year, compared to persons with other conditions. Chances of functional recovery are highest for persons with just one chronic condition; those chances decline as comorbidity increases. Having many social contacts is associated with initial high function that is maintained over the year; having few contacts is associated with stable low function. The analyses point to the scientific value of short remeasurement intervals for persons with severe or multiple morbidity.

Building on prior conceptual schemes, this article presents a sociomedical model of disability, called The Disablement Process, that is especially useful for epidemiological and clinical research. The Disablement Process: (1) describes how chronic and acute conditions affect functioning in specific body systems, generic physical and mental actions, and activities of daily life, and (2) describes the personal and environmental factors that speed or slow disablement, namely, risk factors, interventions, and exacerbators. A main pathway that links Pathology, Impairments, Functional Limitations, and Disability is explicated. Disability is defined as difficulty doing activities in any domain of life (from hygiene to hobbies, errands to sleep) due to a health or physical problem. Feedback effects are included in the model to cover dysfunction spirals (pernicious loops of dysfunction) and secondary conditions (new pathology launched by a given disablement process). We distinguish intrinsic disability (without personal or equipment assistance) and actual disability (with such assistance), noting the scientific and political importance of measuring both. Disability is not a personal characteristic, but is instead a gap between personal capability and environmental demand. Survey researchers and clinicians tend to focus on personal capability, overlooking the efforts people commonly make to reduce demand by activity accommodations, environmental modifications, psychological coping, and external supports. We compare the disablement experiences of people who acquire chronic conditions early in life (lifelong disability) and those who acquire them in mid or late life (late-life disability). The Disablement Process can help inform research (the epidemiology of disability) and public health (prevention of disability) activities.

This article studies the excess levels of disability experienced by persons with arthritis, compared to persons without the disease. The data set is the Supplement on Aging (1984 National Health Interview Survey); it has information for a national probability sample of community-dwelling persons ages 55 + (N = 16,148). (1) Arthritis people have more difficulty in physical functions, personal care, and household care than do nonarthritis persons. The excess disability is greatest for physical functions (walking, reaching, stooping, etc.). Disabled arthritis people have especially high degrees of difficulty in physical activities that require endurance and strength. (2) Various models are tested for walking, grasping, shopping, and light housework to show how comorbidity propels disability for arthritis people and to show arthritis' own contribution to disability in the presence of other chronic conditions. Difficulties escalate for arthritis people when they have other concurrent conditions. These models affirm that arthritis has a pronounced effect on physical dysfunctions, but these are not readily translated into personal and household care problems. Apparently, arthritis people often make successful accommodations so their roles and daily activities are not seriously affected by the disease.

This article studies risk factors for physical and social disability among U.S. adults ages 55+ who have arthritis, compared to non-arthritis persons of those ages. The dependent variables refer to difficulties in walking, physical functioning (motions and strength), personal care, and household care. The data set is the Supplement on Aging (SOA) (n = 16,148) that accompanied the 1984 National Health Interview Survey. The SOA data are cross-sectional; relationships of risk factors to disability suggest causation but do not directly demonstrate it. Logistic regressions show that risk factors are similar for arthritis and non-arthritis people, with one important exception. (1) The similarities are: For both groups, odds of disability rise with age, diminish with education, and are higher for non-whites and non-married persons. Disability rises with number of chronic diseases and impairments, and it is elevated for underweight persons (Body Mass Index (BMI) less than 20; further analysis indicates this reflects incomplete control of their severe illness status). Long duration of arthritis and recent medical care for it are associated with disability. (2) The exception is: Severe overweight (BMI greater than or equal to 30) is a disability risk factor for arthritis people, but not for non-arthritis people. Previous research has shown that obesity/overweight is a risk factor for etiology of osteoarthritis; our analysis now shows its continued importance for disability when the disease is present.

Physical, mental, and social disability are defined. A sociomedical scheme for disability research is presented. How physical and social disability are measured in general health surveys and in arthritis research is described and evaluated. Societal and individual impacts of arthritis are distinguished. The public health importance of arthritis compared with other chronic conditions is portrayed, and the empirical literature on links between arthritis, impairment, physical disability, and social disability is reviewed. Osteoarthritis is at the forefront of the discussion because of its prevalence, but the theoretical and measurement issues presented are broadly relevant for the rheumatic diseases.

This analysis asks how satisfaction with one's main work role (whether that is a paid job or housework) is related to physical health. Data from a Detroit survey show that: (1) Dissatisfied people have poorer health status and take more curative health actions than do satisfied people. The dissatisfied people have higher health risks due to more smoking, drinking, and stress, and they also have health attitudes that encourage symptom perception. Poorer health explains why they take more curative actions; they actually have less faith in the value of medical care and restricted activity and less access to care than do satisfied people. (2) Work satisfaction is more important for nonemployed people than employed ones. Dissatisfied homemakers have especially numerous symptoms and high drug use. And dissatisfied, nonemployed men report a great deal of recent restricted activity and medical care. The data suggest that the homemakers focus on their day-to-day symptoms and try to relieve them by drugs; on the other hand, poor health has forced the men to quit work, and they are very unhappy about the situation. (3) Women (whether they are employed or homemakers) are more sensitive to work satisfaction than are employed men. Apparently employed men adjust better to job stresses and suffer few health consequences, whereas women cannot buffer their dissatisfactions as well. In summary, the Detroit data indicate that work satisfaction is related to good health for both sexes, and that being a dissatisfied homemaker poses especially high risks of poor health.

This paper considers medical care given by physicians to men and women in the United States. It asks how often significant sex differences in care occur, and if these differences are attributable to medically relevant factors or not. Sex differences in diagnostic services, therapeutic services, and dispositions for follow-up are studied for All Visits, 15 major groups of complaints, and 5 specific complaints (fatigue, headache, vertigo/dizziness, chest pain, and back pain). Data are from the 1975 National Ambulatory Medical Care Survey (NAMCS). The analysis reveals that medical care is often similar for men and women, but a sizable numbers of significant sex differences occur (about 30 to 40 per cent of the services and dispositions studied), and they tend to show more medical care for women. Most of the differences persist even after controlling for medically relevant factors (patient age, seriousness of problem, diagnosis, prior visit status, and reasons for visit). Notably, women still receive more total prescriptions, and return appointments for many complaint groups. They receive more services for back pain and headaches and more follow-up plans for vertigo/dizziness and back pain. Remaining sex differences may be due to missing medical factors, patient requests for care, patient distress and needs for nurturance, and physician sex bias. In contrast to a recent San Diego study, national data show few significant sex differences in the extent and content of diagnostic services given for five common complaints.

The statistical results concur closely with descriptive ones presented earlier, indicating that the latter are not results of random variations. The main effects of employment, the contingent effects of parenthood, and the time trends modeled here are the same as reported earlier. (Only two differences occur. First, among white married women, mothers have statistically more acute conditions than nonmothers. We saw this parenthood effect earlier for nonemployed married women, but not for employed ones [results were inconsistent]. The statistical analysis smooths those inconsistencies and reveals that employed mothers also experience more acute conditions than their nonmother peers. Second, among white married women, older housewives show statistically increased chronic limitation over time. Earlier we saw a rise for housewives without children. The latter parenthood effect is statistically smaller than the age effect.) The singular advantage of the statistical analysis has been its ability to highlight interaction effects among the variables, some of which were not considered in the descriptive section. Comparing the models, note how those for short- and long-term disability are very similar to each other but distinctly different from the acute-condition models. This means that social roles and age influence short- and long-term disability in the same way. Specifically, both are greater for older and nonemployed women, being especially high for older nonemployed women and housewives without children. By contrast, the most consistent factor affecting acute-condition incidence and impact is presence of children. Children increase their mothers' experience of acute problems but reduce the amount of recuperative time and medical care taken for them.

Health surveys repeatedly show that females have higher rates of illness, disability days, and health services utilization than do males. Numerous reasons for these sex differences have been hypothesized, based on four general factors thought to differ by sex and to influence self-reported health: genetic characteristics, physical risks, illness behavior, and reporting behavior. This paper briefly reviews these hypotheses, then discusses research strategies to test them. The strategies vary in the type of dependent variables used (medical vs. sociomedical health indicators) and the main method of controlling predictor factors (elimination vs. statistical control). A study was completed in 1978 in the Detroit metropolitan area to (a) explore reasons for sex differences in health and (b) reveal how strongly illness behavior (perception and evaluation of symptoms, propensities to take curative actions or disability days) affects common health indicators, particularly those for the national Health Interview Survey. The study's research design (use of a health diary, and focus on hypotheses about illness behavior) is described.

The Framingham Heart Study has reported high rates of coronary heart disease among clerical women, compared to other working women and housewives. Using data from the National Health Interview Survey, we find that U.S. clerical women have the best overall profile compared to other occupation groups. They have low injury and chronic limitation rates, little restricted activity, and average health services use. The Framingham clerical women worked mostly before 1960 when clerical work was devalued and the combination of job and family roles put great pressures on women; contemporary clerical women may have more job satisfactions and fewer pressures from multiple roles, and thus lower health risks. In contrast to women, clerical men have a poor health profile compared to other employed men. They have more recent hospitalization and job limitations from chronic conditions. This suggests that men with serious health problems take clerical jobs that are not physically demanding. A health survey of Detroit adults indicates that Detroit clerical men match the national profile, but Detroit clerical women do not. Both groups are dissatisfied with their jobs, compared to other workers. The Detroit data suggests that role pressures and dissatisfactions contribute to poor health, and that people with health problems (especially men) gravitate toward clerical jobs. We need to know more about how perceived role burdens, role dissatisfactions, and weak coping skills influence health.

Research on the health care behavior of older adults in response to symptoms will benefit from having data collection methods that can monitor health actions as they occur on a daily basis. In the present study, symptom experiences over a 2-week period and the actions taken in response to them were studied with a self-kept daily diary. Participants were 142 community-resident older persons, aged 62-94. Diary information about number of daily symptoms and the accompanying pain/discomfort was correlated with health perceptions and psychosocial indices obtained in an interview prior to the diary period. Women tended to take a more active response to symptoms than men, particularly in the area of personal care actions. Preventive health behaviors were not strongly related to symptom-related actions. Satisfaction with one's income was the only predictor of seeking professional assistance. Overall, the diary method is feasible to use with older adults, although certain groups may require special consideration (e.g., the visually impaired, persons with multiple symptoms per day, or those with a limitation on writing ability).

Health statistics routinely show higher morbidity and health services use for women, while mortality rates are higher for men. This analysis empirically identifies reasons for women's poorer health. It is based on retrospective (interview) and prospective (health diaries) data from the Health In Detroit Study. Three kinds of risk factors, which may help explain females' excess, are considered: acquired risks, psychosocial aspects, and health-reporting behavior. Men and women differ markedly in acquired risks: smoking and job hazards are higher for men, but inactivity, nonemployment, stress, and many other factors are higher for women. Psychosocial aspects predispose women to more illness and health care. Women also had keener interest in the survey. When all of the risk factors are controlled, the morbidity gap narrows considerably. In fact, indicators of general and chronic health reverse to reveal higher morbidity for men. Similarly, females' excesses for therapeutic care (short- and long-term disability, medical visits, lay consultation, drug use) diminish when risks and morbidity level are controlled. They actually reverse to a male excess for disability and medical care. Though most of the unveiled male excesses are statistically nonsignificant, their pattern allows a reasonable interpretation. Our results are closely compatible with recent analyses of sex mortality differences in several California sites, which could not eliminate men's mortality excess by controlling for social factors. In conclusion, contemporary women's poorer health profile stems largely from their roles and stress (acquired risks), and to a smaller degree from their health attitudes. When social factors are taken into account, health data suggest a disadvantage for men, and mortality data maintain men's disadvantage. Do the reasons lie in biology?

In the 1970s, the United States population experienced a notable drop in mortality rates, after several decades of relative stability. Has this increased longevity been enjoyed equally by males and females, so that sex mortality differentials are essentially the same as before? Or has one sex benefited more than the other? This paper focuses on the mortality experience of males and females between 1970 and 1977, by age and by leading causes of death. The 1970-1977 data are compared with two earlier periods (1920-1950 and 1950-1970) to show how recent trends contrast with previous ones. Overall, the recent data suggest a new situation for sex mortality differentials. In prior decades, females' longevity advantage over males increased. This continuing increase appeared for virtually all ages and leading causes. But in the 1970s, the increase slowed. Females' situation relative to males actually worsened for several age groups (under 1, 55-64) and for several leading causes (conditions of early infancy, bronchitis/empysema/asthma, homicide, peptic ulcer). Moreover, the pace of females' gains for heart diseases and cancer has slowed, and relative gains have stopped for cerebrovascular diseases and accidents. Reasons for recent changes in sex mortality differentials and possible future trends are discussed.

This article looks at role burdens experienced by women and men, asking if heavy burdens are linked with poor physical health status and frequent health care. The role burden variables refer to job schedule, feelings about roles and life, time constraints and pressures, family dependency, and levels of role involvement and responsibility. The data source is the Health In Detroit Study, which has health items from a retrospective interview and prospective health diaries. Results show that dissatisfaction with roles/life and feelings of very great or very little time pressure are associated with poor health. To a lesser extent, very low or very high objective time constraints, irregular and short job schedules, no or high family dependency, and very low or very high income responsibility are linked with poor health. By contrast, having numerous roles is associated with good health. Some of these results point toward social causation (how the quantity and quality of roles influence health) and others to social selection (how health influences role involvements). The relationships are similar for women and men. But women are more at risk of poor health because, more often than men, they tend to have few roles (especially nonemployment), more dissatisfaction with their main role and life, low time constraints, low income responsibility, and irregular job schedules. In conclusion, role burdens may lie more in subjective feelings about one's activities than in their objective characteristics. Having low quality roles may jeopardize health, whereas having numerous ones can help maintain or enhance it.

This article studies triggers of physical symptoms and health care on a daily basis. The data used are health diaries kept for 6 weeks by 589 adults in metropolitan Detroit. The results show that bad moods consistently trigger physical problems and health actions (medical drug use, medical care, lay consultation, restricted activity) for men and women of all ages. Negative events have small effects on these outcomes, sometimes acting as triggers, but sometimes as dampers. Physical malaise (feeling bad overall) is an especially strong trigger for symptomatic people to take health actions. Troubles of all kinds--bad moods, physical malaise, symptoms, negative events--tend to repeat from one day to the next. Yesterday's troubles help trigger symptoms and health care today, but they have less influence than today's troubles do. When troubles continue for 2 days in a row, this spurs people especially to seek professional help. Women tend to respond more predictably and simply to triggers than men do, and older people appear to be more sensitive and responsive to triggers. The results indicate that the social stress and health model, which typically considers the longrun of major life events and chronic mental and physical conditions, is also apt for the shortrun of daily negative events, bad moods and physical discomfort and symptoms.

There is speculation that women receive different medical care than men because physicians have stereotyped views about women's symptoms and treatment preferences. This paper asks if men and women who visit physicians for mental distress receive comparable medical care and, if not, whether medical considerations or psychosocial ones explain the differences. Data are from a large national survey of ambulatory care visits in the United States. We find that women and men are equally likely to report mental distress as their main problem to physicians. Physicians determine that distressed men have mental disorders more often than distressed women. On the whole, distressed men and women receive similar numbers of diagnostic services, therapeutic services and dispositions for follow-up care. The kinds of services and dispositions differ a little: women tend to receive limited examinations, blood pressure checks and drug prescriptions more often; men are more likely to have general examinations, medical counseling or no service at all. Women are retained for follow-up care with the same physician more often; men tend to be sent elsewhere for additional care or no follow-up plans at all are made for them. Sex differences in care are statistically small (only 6% of the many comparisons are significant at P less than 0.05). But the significant differences highlight two points: when differential care occurs, it is in non psychiatrists' offices and it usually shows women receiving more of a given service or disposition. Differential care for women and men can be due to medical factors (such as patient age, prior visit status, seriousness of problem) or psychosocial ones (such as patient requests, patient emotionality, physician sex bias).(ABSTRACT TRUNCATED AT 250 WORDS)

This article examines how often physicians prescribe therapeutic drugs to men and women who present the same complaints or receive the same diagnoses. Data are from the 1975 National Ambulatory Medical Care Survey and pertain to visits made by U.S. adults to office-based physicians that year. For most common complaints and diagnoses, women receive prescriptions more often than men do. The differences are on the small side (1 to 18% more of women's visits result in prescriptions than men's), but they are very persistent across a wide variety of health problems. Medical differences between men and women patients do not explain this. Controlling for medically relevant factors (patient age, seriousness of the problem, presence of an illness/injury or not, prior visit status, acute vs. chronic problem), the sex differences persist. Women are especially likely to get prescriptions during visits for weight gain/obesity and visits classed as observation without need for further care. The results suggest that psychosocial factors may help explain why women receive prescriptions more often during office visits than men do. Those factors could stem from patient behaviors such as overt requests for drug therapy or from physician behaviors such as sex-biased prescribing.

This article traces health from daily symptoms to death for American (U.S.) men and women in three age groups 17-44, 45-64, 65+. How do leading problems change as our perspective shifts from daily symptoms to annual incidence and prevalence rates of diseases and injuries; then to problems that induce long term limitations; to conditions brought to physicians for care; to diagnoses for hospital stays; and finally to causes of death? We study the top 15 conditions in each of these stages of health. Young adults are bothered most by acute and chronic respiratory diseases, but deaths among them are due to diseases and violent injuries that seldom figure in daily life. Fatal chronic diseases becomes more prevalent in middle ages and spur professional care, but they rarely cause daily symptoms. For older people, life threatening chronic conditions stretch through all stages of health. Arthritis also becomes a dominant facet of symptoms, social limitations and ambulatory care. Men's and women's leading daily symptoms are very similar; so are their leading acute and chronic conditions, limiting conditions, diagnoses for health care and causes of death. What distinguishes the sexes is the rate, not the ranks, of health problems they suffer. We elaborate the iceberg of morbidity metaphor, as a device to highlight stage, age and sex differences in health.

Older people often suffer from comorbidity, or several chronic conditions simultaneously. Disability rises rapidly as the number of chronic conditions grows, although very ill people who acquire another condition experience attenuated increases. High prevalence conditions such as arthritis tend to have a low or occasionally moderate impact for community residents, while low prevalence ones such as osteoporosis have a high impact; paired conditions sometimes give extra propulsion to disability, as when cerebrovascular disease and hip fracture co-occur. Further research is needed to pin-point combinations of conditions posing great risks and to identify demographic segments in which comorbidity has elevated effects.

Health status and health behavior of males and females in the United States are compared; the data employed in the analysis are from community studies and the surveys of the National Center for Health Statistics. Females generally show a higher incidence of acute conditions, higher prevalence of minor chronic conditions, more short-term restricted activity, and more use of health services (especially outpatient services) and medicines. By contrast, males have higher prevalence rates for life-threatening chronic conditions, higher incidence of injuries, more long-term disability, and after about age 50, higher rates of hospitalization. These sex differences appear at all ages, except for early childhood when boys have a worse health profile than girls. The following interpretations are consistent with the data; they are hypotheses rather than demonstrated facts. Women are more frequently ill than men, but with relatively mild problems. By contrast, men feel ill less often, but their illnesses and injuries are more serious. These morbidity differences help to explain sex differentials in health behavior; frequent symptoms lead to more restricted activity, physician and dentist visits, and drug use for women; severe symptoms lead to more permanent limitations and hospitalization for men. But attitudes about symptoms, medical care, drugs, and self-care are also extremely important. Males may be socialized to ignore physical discomforts; thus, they are unaware of symptoms that females feel keenly. Also, men may be less willing and able to seek medical care for perceived symptoms. When diagnosis and treatment are finally obtained, men's conditions are probably more advanced and less amenable to control. Finally, men may be less willing and able to restrict their activities when ill or injured. Four important factors than underlie sex differentials in health are discussed: inherited risks of illness, acquired risks of illness and injury, illness and prevention orientations, and health reporting behavior. Statistics show that women ultimately have lower mortality rates than men--despite women's more frequent morbidity and possibly because of more care for their illnesses and injuries. The apparent contradiction between sex differences in morbidity and mortality (females are sicker but males die sooner) is explored.

This paper examines male-female differences in complaints and diagnoses for ambulatory care visits. Data are from the 1973 National Ambulatory Medical Care Survey, a national probability survey of visits to office-based physicians. The results suggest that: (1) Men are often unaware of serious health problems, they delay seeking diagnosis and care for symptoms, and they hesitate to admit symptoms and known health problems when they do visit a physician. (2) Women appear to have a more diffuse view of illness. They often report both mental and physical symptoms, and their physical symptoms "radiate" throughout the body rather than remain localized. (3) Both sexes confuse reproductive, digestive, and urinary symptoms because the body systems overlap. (4) Some sex differences in diagnoses for a particular symptom reflect real morbidity differences. (5) There is little evidence that women and men differ in their perception, interpretation, and description of physical symptoms. (6) The evidence for sex bias in physicians' diagnoses is scant.

Data from the national Health Interview Survey for 1957-72 show that females have higher age-standardized rates of acute conditions, chronic conditions, and disability due to acute conditions, compared to males. More males, however, suffer limitations of activity or mobility due to chronic conditions, Females' excess morbidity for acute conditions persists when reproduction-related events are excluded. From 1957-72, females' disadvantage for acute conditions continues unchanged. But for chronic conditions, males are "catching up" to females in overall prevalence, and their conditions are becoming more severe relative to females'. These trends are compatible with trends in sex mortality differences over the same period. Four types of explanation are advanced to account for females' excess morbidity: interview behavior, illness behavior, acquired health risks, and inherited health risks. Empirical evidence suggests the first two factors inflate female rates compared to males; the last two do the opposite. It is hypothesized that excess female morbidity is due primarily to social and psychological factors, and a procedure to test this is stated.