Boundary spanning at the science-policy interface: the practitioners' perspectives.

Cultivating a more dynamic relationship between science and policy is essential for responding to complex social challenges such as sustainability. One approach to doing so is to "span the boundaries" between science and decision making and create a more comprehensive and inclusive knowledge exchange process. The exact definition and role of boundary spanning, however, can be nebulous. Indeed, boundary spanning often gets conflated and confused with other approaches to connecting science and policy, such as science communication, applied science, and advocacy, which can hinder progress in the field of boundary spanning. To help overcome this, in this perspective, we present the outcomes from a recent workshop of boundary-spanning practitioners gathered to (1) articulate a definition of what it means to work at this interface ("boundary spanning") and the types of activities it encompasses; (2) present a value proposition of these efforts to build better relationships between science and policy; and (3) identify opportunities to more effectively mainstream boundary-spanning activities. Drawing on our collective experiences, we suggest that boundary spanning has the potential to increase the efficiency by which useful research is produced, foster the capacity to absorb new evidence and perspectives into sustainability decision-making, enhance research relevance for societal challenges, and open new policy windows. We provide examples from our work that illustrate this potential. By offering these propositions for the value of boundary spanning, we hope to encourage a more robust discussion of how to achieve evidence-informed decision-making for sustainability.

A diagnosis of eosinophilic esophagitis is associated with increased life insurance premiums.

Eosinophilic esophagitis (EoE) is a chronic disease that can be diagnosed at any age, but is not associated with malignancy and does not shorten lifespan. It remains unknown whether an EoE diagnosis affects insurability or insurance premium costs. We therefore aimed to determine whether a diagnosis of EoE affects the costs of life insurance. Our investigation was a secret shopper audit study whereby we contacted national insurance companies in the United States to evaluate the effect of a diagnosis of EoE on life insurance premiums. We constructed standardized case scenarios for males and females, including a 25-year-old and a 48-year-old without other comorbid conditions, who either had or did not have a diagnosis of EoE. Companies were asked for their best estimate for a $100,000 whole life insurance policy. Comparisons between median premiums were made using the Mann-Whitney U test. There were 20 national life insurance companies contacted and a total of 73 quotes were obtained. The median premium rate was similar for EoE and non-EoE cases at the younger age ($828 [IQR $576-1,020] vs. $756 [IQR $504-$804]; P = 0.10). However, the premium for the older case without EoE was 19% less expensive compared to a case with EoE ($1990 [IQR $1,248-2,350] vs. $2,375 [IQR $2,100-2568; P = 0.02]. This finding was not explained by sex or state of residence. Based on these findings, we conclude that life insurance premiums are significantly more expensive in the older patient case with EoE when compared to the same case without EoE. Patients with EoE and their providers should be aware of the additional cost associated with this diagnosis.

Gastroesophageal reflux symptoms are not sufficient to guide esophageal function testing in lung transplant candidates.

Gastroesophageal reflux disease and esophageal dysmotility are prevalent in patients with advanced lung disease and are associated with graft dysfunction following lung transplantation. As a result, many transplant centers perform esophageal function testing as part of the wait-listing process but guidelines for testing in this population are lacking. The aim of this study is to describe whether symptoms of gastroesophageal reflux correlate with abnormal results on pH-metry and high-resolution manometry and can be used to identify those who require testing. We performed a retrospective cohort study of 226 lung transplant candidates referred for high-resolution manometry and pH-metry over a 12-month period in 2015. Demographic data, results of a standard symptom questionnaire and details of esophageal function testing were obtained. Associations between the presence of symptoms and test results were analyzed using Fisher's exact tests and multivariable logistic regression. The most common lung disease diagnosis was interstitial lung disease (N = 131, 58%). Abnormal pH-metry was seen in 116 (51%) patients and the presence of symptoms was significantly associated with an abnormal study (p < 0.01). Dysmotility was found in 98 (43%) patients, with major peristaltic or esophageal outflow disorders in 45 (20%) patients. Symptoms were not correlated with findings on esophageal high-resolution manometry. Fifteen of 25 (60%) asymptomatic patients had an abnormal manometry or pH-metry. These results demonstrate that in patients with advanced lung disease, symptoms of gastroesophageal reflux increase the likelihood of elevated acid exposure on pH-metry but were not associated with dysmotility. Given the proportion of asymptomatic patients with abnormal studies and associated post-transplant risks, a practice of universal high-resolution manometry and pH-metry testing in this population is justifiable.

Safe Conversion From Tacrolimus to Belatacept in High Immunologic Risk Kidney Transplant Recipients With Allograft Dysfunction.

There is no literature on the use of belatacept for sensitized patients or regrafts in kidney transplantation. We present our initial experience in high immunologic risk kidney transplant recipients who were converted from tacrolimus to belatacept for presumed acute calcineurin inhibitor (CNI) toxicity and/or interstitial fibrosis/tubular atrophy. Six (mean age = 40 years) patients were switched from tacrolimus to belatacept at a median of 4 months posttransplant. Renal function improved significantly from a peak mean estimated glomerular filtration rate (eGFR) of 23.8 ± 12.9 mL/min/1.73 m(2) prior to the switch to an eGFR of 42 ± 12.5 mL/min/1.73 m(2) (p = 0.03) at a mean follow-up of 16.5 months postconversion. No new rejection episodes were diagnosed despite a prior history of rejection in 2/6 (33%) patients. Surveillance biopsies performed in 5/6 patients did not show subclinical rejection. No development of donor-specific antibodies (DSA) was noted. In this preliminary investigation, we report improved kidney function without a concurrent increase in risk of rejection and DSA in six sensitized patients converted from tacrolimus to belatacept. Improvement in renal function was noted even in patients with chronic allograft fibrosis without evidence of acute CNI toxicity. Further studies with protocol biopsies are needed to ensure safety and wider applicability of this approach.

Virological response rates for telaprevir-based hepatitis C triple therapy in patients with and without HIV coinfection.

OBJECTIVES: Pegylated-interferon/ribavirin dual therapy for hepatitis C virus (HCV) infection has a lower sustained virological response (SVR) rate in HIV/HCV-coinfected patients than in HCV monoinfected patients, but little is known about the relative effectiveness of teleprevir-based triple therapy in the two groups. METHODS: Data on 33 coinfected and 116 monoinfected patients were analysed on an intention-to-treat basis. SVR12 was defined as undetectable HCV RNA at week 12 post-end-of-treatment, severe anaemia as haemoglobin ≤ 89 g/L or a drop of ≥ 45 g/L, and advanced fibrosis/cirrhosis as Fib-4 ≥ 3.25. All coinfected patients had well controlled HIV infection. RESULTS: The groups were similar in age, gender, percentage with Fib-4 ≥ 3.25 and HCV viral load, but differed in previous treatment response, with more coinfected patients being nonresponders or treatment-intolerant (75.8% vs. 50.0% for monoinfected patients; P < 0.01). During treatment, the percentages of patients with undetectable HCV RNA were similar, but, surprisingly, this percentage tended to be higher in coinfected patients. SVR12 rates were 60.6% in coinfected patients vs. 42.2% in monoinfected patients (P = 0.06). In multivariable analysis, SVR12 was associated with HIV infection [odds ratio (OR) 3.55; P < 0.01], African American race (OR 0.37; P = 0.03) and previous treatment response (OR 0.46; P = 0.03). Rates of severe anaemia (45.5 vs. 58.6% in coinfected and monoinfected patients, respectively; P = 0.18) were similar in the two groups, but rash (15.2 vs. 34.5%, respectively; P = 0.03) and rectal symptoms (12.1 vs. 43.1%, respectively; P < 0.01) were less common in coinfected patients. CONCLUSIONS: Virological responses of coinfected and monoinfected patients did not differ significantly, but tended to be higher in coinfected patients, who had a 60.6% SVR12 rate. Telaprevir-based triple therapy is a promising option for coinfected patients with well-controlled HIV infection.

Neutrophil chemokines secreted by tumor cells mount a lung antimetastatic response during renal cell carcinoma progression.

The mechanism by which renal cell carcinoma (RCC) colonizes the lung microenvironment during metastasis remains largely unknown. To investigate this process, we grafted human RCC cells with varying lung metastatic potential in mice. Gene expression profiling of the mouse lung stromal compartment revealed a signature enriched for neutrophil-specific functions that was induced preferentially by poorly metastatic cells. Analysis of the gene expression signatures of tumor cell lines showed an inverse correlation between metastatic activity and the levels of a number of chemokines, including CXCL5 and IL8. Enforced depletion of CXCL5 and IL8 in these cell lines enabled us to establish a functional link between lung neutrophil infiltration, secretion of chemokines by cancer cells and metastatic activity. We further show that human neutrophils display a higher cytotoxic activity against poorly metastatic cells compared with highly metastatic cells. Together, these results support a model in which neutrophils recruited to the lung by tumor-secreted chemokines build an antimetastatic barrier with loss of neutrophil chemokines in tumor cells acting as a critical rate-limiting step during lung metastatic seeding.

Enhanced tumorigenicity of fibroblasts transformed with human herpesvirus 8 chemokine receptor vGPCR by successive passage in nude and immunocompetent mice.

The human herpes virus 8 (HHV-8)-encoded G protein-coupled chemokine receptor (vGPCR) has been implicated in the pathogenesis of Kaposi's sarcoma (KS), particularly because of its high constitutive signaling activity. Here, we used retroviral transduction to generate vGPCR-expressing 3T3 fibroblasts that are tumorigenic in nude mice, but as expected fail to induce tumors in their immunocompetent counterparts. However, tumor fragments obtained from nude mice grow progressively in immunocompetent BALB/c mice. Unexpectedly, vGPCR-expressing cells established from grafted tumor fragments gave rise to tumors in immunocompetent mice. These tumors exhibit a striking histological resemblance to KS including plump spindle cell morphology, a high degree of vascularization and brisk mitotic activity. High expression of vGPCR was confirmed in the cell lines and tumors using a newly developed vGPCR-specific monoclonal antibody. Finally, short interfering RNA directed at vGPCR abrogated or significantly delayed tumorigenesis in mice, demonstrating that the tumor development is specifically driven by vGPCR. This novel model for vGPCR-mediated oncogenesis will contribute to our understanding of the role of vGPCR in the pathogenesis of HHV-8 and may even be important in identifying critical molecular and epigenetic changes during tumor progression in vivo.

Is there a possibility for a glutaraldehyde-free porcine heart valve to grow?

OBJECTIVE: A challenging issue is to create a heart valve with growth and remodeling potential, which would be of great interest for congenital heart valve surgery. This study was performed to evaluate the growth and remodeling potentials of a decellularized heart valve. METHODS: In 4 juvenile sheep (age 12 +/- 1 weeks) with a weight of 24.3 +/- 4.4 kg, a 17-mm diameter decellularized porcine valve was implanted as pulmonary valve replacement. Valve growth was evaluated by transthoracic echocardiography. At explantation, valves were evaluated by gross examination, light microscopy (hematoxylin and eosin, von Kossa, Sirius red, Weigert and Gomori staining), electron microscopy and immunohistochemistry. Atomic absorption spectrometry was performed to evaluate calcium content. RESULTS: All animals showed fast recovery. The mean follow-up was 9.0 +/- 1.8 months. All sheep at least doubled their weight (54.3 +/- 9.2 kg). Echocardiography showed no regurgitation and a flow velocity of 0.7 +/- 0.1 m/s at the latest follow-up. The valve diameter increased from 17.6 +/- 0.5 to 27.5 +/- 2.1 mm (p < 0.018). Gross examination showed a similar wall thickness of the implanted valve and native pulmonary wall, with smooth and pliable leaflets. Histology showed a monolayer of endothelial cells, fibroblast ingrowth and production of new collagen. No calcification was seen at von Kossa staining, confirmed by low calcium content levels of the valve wall and leaflets at atomic absorption spectrometry. CONCLUSIONS: This glutaraldehyde-free heart valve showed not only the absence of calcification, but also remodeling and growth potential.

Strategies for diagnosis of bacterial vaginosis in a resource-poor setting.

This study evaluated Amsel's criteria, the FemExam card and pH plus amine methods for the diagnosis of bacterial vaginosis (BV) in a resource-poor setting. Two hundred Azerbaijani women participated in a study about reproductive health that included a gynaecological examination and an interviewer-administered survey. Using the WHO syndromic diagnosis algorithm, nearly all women (99%) had abnormal vaginal discharge. The prevalence of BV by Gram stain was 35%; using pH plus amine, the FemExam card and Amsel's criteria, prevalence ranged from 29% to 49%. No behavioural or demographic characteristics were associated with BV as diagnosed by Gram stain. The sensitivity ranged from 0.59 to 0.74 and specificity from 0.65 to 0.92 using the three methods. The pH plus amine test is better than syndromic management protocols, and although it is not the most sensitive or specific of the three methods it will be easiest to implement in resource-poor settings.

Factors associated with condom use among young Denver inner city women.

BACKGROUND: Despite the availability of condoms and theoretically based interventions to promote their use, sexually active women aged 15 to 25 years continue to put themselves at risk for sexually transmitted diseases and unintended pregnancy. METHODS: One hundred ninety-eight inner city women were interviewed about knowledge and attitudes about condoms. Using the Transtheoretical Model, regression techniques were used to identify factors associated with condom use at last sex and the proportion of acts protected by a condom in the last 90 days. RESULTS: Constructs including intention to use (OR = 1.69, CI 1.07-2.65) and positive outcome expectancies (OR = 1.59, CI 1.03-2.46) were associated with condom use at last act of sexual intercourse. Similarly, intention to use condoms (RR = 1.58, CI 1.37-1.82), positive outcome expectancies (RR = 2.71, CI 2.41-2.99), perceived peer's use of condoms (RR = 2.25, CI 1.95-2.60), and number of places condoms were discussed (RR 1.05, CI 1.02-1.07) were associated with the proportion of protected acts. CONCLUSIONS: Constructs specified in the Transtheoretical Model are useful in describing condom use and have implications for targeting human immunodeficiency virus (HIV)/sexually transmitted diseases (STD)/unintended pregnancy interventions.

An artificial lung reduces pulmonary impedance and improves right ventricular efficiency in pulmonary hypertension.

OBJECTIVE: Artificial lungs may have a role in supporting patients with end-stage lung disease as a bridge or alternative to lung transplantation. This investigation was performed to determine the effect of an artificial lung, perfused by the right ventricle in parallel with the pulmonary circulation, on indices of right ventricular load in a model of pulmonary hypertension. METHODS: Seven adult male sheep were connected to a low-resistance membrane oxygenator through conduits anastomosed end to side to the pulmonary artery and left atrium. Banding of the distal pulmonary artery generated acute pulmonary hypertension. Data were obtained with and without flow through the device conduits. Outcome measures of right ventricular load included hemodynamic parameters, as well as analysis of impedance, power consumption, wave reflections, cardiac efficiency, and the tension-time index. RESULTS: The model of pulmonary hypertension increased all indices of right ventricular load and decreased ventricular efficiency. Allowing flow through the artificial lung significantly reduced mean pulmonary artery pressure, zero harmonic impedance, right ventricular power consumption, amplitude of reflected waves, and the tension-time index. Cardiac efficiency was significantly increased. CONCLUSIONS: An artificial lung perfused by the right ventricle and applied in parallel with the pulmonary circulation reduces ventricular load and improves cardiac efficiency in the setting of pulmonary hypertension. These data suggest that an artificial lung in this configuration may benefit patients with end-stage lung disease and pulmonary hypertension with right ventricular strain.

Factor variability of the Center for Epidemiological Studies Depression Scale (CES-D) among urban Latinos.

Establishing comparable measurement properties across different populations or in different population subgroups is a crucial yet often neglected step in instrument development. Failure to have comparable factor structures across groups makes any comparison between groups suspect. Previous analyses of the measurement structure of the Center for Epidemiologic Studies Depression Scale (CES-D) in diverse racial/ethnic populations have resulted in conflicting results. In the present analysis, data from three studies of urban Latinos (N = 1,403) were analyzed using structural equation modeling techniques to (1) fit the original four-factor solution separately in men and women; (2) evaluate configural and metric invariance between men and women; and (3) evaluate the mediating effects of age and acculturation on the fit of this model to the data. Results indicated that the four-factor model proposed by Radloff provided adequate fit to the data for Latina women when age and acculturation were included in the model. The four-factor model did not fit the data for Latino men; thus tests of configural and metric invariance across these two groups failed. We conclude that the CES-D may not measure the same constructs in Latino men and women and that further evaluation of the use of this measure in diverse populations is needed. Additionally, prior to comparison with other groups in which the four-factor solution is observed, the effects of age and acculturation should be controlled in Latinas.

Psychosocial factors associated with self-reported male condom use among women attending public health clinics.

BACKGROUND: Previous research has identified factors associated with condom use. However, less information exists on the impact that a history of sexually transmitted disease (STD) has on condom use. GOAL: To identify factors associated with self-reported male condom use that relate to a history of STD. STUDY DESIGN: Women attending STD clinics completed a survey that assessed sexual behavior, STD history, and psychosocial characteristics. Binomial regression was used to estimate the association between these factors and condom use. RESULTS: Of the 12 factors included in the regression model, 11 were significant for all women. When the analysis was stratified by STD history, high condom use self-efficacy, high convenience of condom use, and high frequency of condom use requests were significantly associated with increased condom use among women with or without a history of STD. Factors such as greater perceived condom use norms, higher perceived level of risk, and greater need for condom use in long-term relationships were significantly associated with increased condom use among women with a history of STD. Factors such as shorter duration of a relationship, less violence in the relationship, and lifetime drug use were associated with increased condom use among women with no history of STD. CONCLUSIONS: The pattern of psychosocial factors determining condom use is modified by a positive history of STD. These findings suggest that a history of STD could be an important factor in targeting condom use interventions.

Preterm delivery in patients admitted with preterm labor: a prediction study.

OBJECTIVE: To develop a model for prediction of preterm delivery in patients treated with parenteral tocolysis using combinations of maternal demographic and clinical factors. METHODS: We performed a retrospective cohort study using a perinatal database to identify women admitted with preterm labor and treated with parenteral tocolysis from 1980 to 1994. We developed an explanatory model using multiple logistic regression to determine the effect of four variables (prior preterm delivery, substance abuse, maternal complications and third-trimester care) on the likelihood of preterm delivery. For the prediction model, we initially included these four variables and then removed them in a stepwise fashion to determine the combination of the variables that offered the greatest model sensitivity and specificity. RESULTS: A total of 900 women were identified for the study and 247 (27%) had a preterm delivery. In the explanatory model, prior preterm delivery (OR 2.4; 95% CI 1.5-3.6), substance abuse (OR 2.2; 95% CI 1.2-5.1), initiation of care in the third trimester (OR 2.0; 95% CI 1.3-2.8) and medical complications of pregnancy (OR 1.8; 95% CI 1.2-2.6) increased the likelihood of preterm delivery. For the prediction tool, a three-variable model (prior preterm delivery, substance abuse and initiation of care in the third trimester) had high specificity (98%) and modest negative predictive value (73%). CONCLUSIONS: A simple three-variable model can correctly identify 98% of women with preterm labor treated with parenteral tocolysis who will not deliver preterm. Patients with no prior history of preterm delivery, no substance abuse and initiation of prenatal care before the third trimester have a 73% probability of not delivering preterm.

Multiple-threshold models for genetic influences on age of onset for Alzheimer disease: findings in Swedish twins.

Twin studies of dementia have typically used relatively simple 2 x 2 contingency tables with one threshold to estimate the relative importance of genetic variance for liability to disease. These designs are inadequate for addressing issues of age at onset, censoring of data, and distinguishing shared environmental effects from age effects. Meyer and Breitner [1998: Am J Med Genet 81:92-97] applied a multiple-threshold model to the NAS-NRC Twin Panel (average age of onset, 63.5 years) and report that additive genetic effects and shared environmental effects account for 37% and 35% of the variation, respectively, in age of onset for Alzheimer disease. We apply a modified version of their model to the Study of Dementia in Swedish Twins (average age of onset, 75 years) and find that genetic effects account for 57%-78% of the variance, whereas shared environmental effects are of no importance. Heritability is lower when thresholds are freely estimated rather than fixed to the population prevalences. We interpret the findings to suggest that models with free thresholds confound influences on longevity with influences for the disease. Multiple-threshold models, however, do not confound age effects with shared environmental influences.

Higher risk of HIV transmission during trauma resuscitations.

Despite an appreciation of the potential for blood borne pathogen exposure, compliance of universal precautions is low. While reports of HIV positive rates in trauma patients have varied from 0.15% to 7.8%, the estimated prevalence of HIV in Louisiana is 0.32%. We made use of two unique, complimentary data sources: the Trauma Registry and the HIV/AIDS Reporting System database of known HIV positive patients to estimate the relative prevalence of HIV which may indicate an increase risk of blood borne pathogen transmission to health care workers during trauma resuscitations. In one year, 1031/1159 patients were evaluated from the Trauma Registry Database and 22 similar patients (2.13%) were found in both the Trauma Registry and the HIV/AIDS Reporting System Database. Our prevalence is an indicator of the minimum risk since it is based on only reported cases of HIV and justifies intensification of education and enforcement of the practice of universal precautions.

Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater.

BACKGROUND: Ampullary tumors should be resected because of the high incidence of malignancy and the unreliability of preoperative endoscopic diagnosis. Controversy exists about whether to perform a transduodenal excision (TDE) or a pancreatoduodenectomy. This study evaluated the safety and long-term efficacy of TDE. METHODS: The records of 21 patients with a pathologic diagnosis of ampullary adenoma who underwent TDE were reviewed. Demographics, symptoms, pathologic findings, and outcomes were analyzed and long-term follow-up was ascertained. RESULTS: Twenty-one patients (mean age, 61 years) underwent TDE. Final pathology showed adenoma in all patients including 1 (5%) with invasive cancer, 2 (9%) with microinvasive cancer, 6 (28%) with high-grade dysplasia, and 1 (5%) with low-grade dysplasia. The overall survival was 85% (mean follow-up of 38 months). One of 3 late deaths was likely related to disease progression. Sixteen of the 18 remaining patients (89%) had no evidence of tumor recurrence. One benign ampullary recurrence was successfully treated endoscopically. One additional patient developed an ampullary cancer and underwent pancreatoduodenectomy. CONCLUSIONS: TDE of benign ampullary tumors, even those with varying grades of dysplasia, can be performed with acceptable morbidity and low rates of recurrence. Postoperative endoscopic surveillance is mandatory to identify recurrent tumors.

Evaluation and extensions of a structural equation modeling approach to the analysis of survival data.

Recently a new method for the analysis of survival data using a structural equation modeling approach has been suggested by Pickles and colleagues using twin data they demonstrated the application of this model to study the correlation in age of onset. The purpose of the current research is twofold: 1) to evaluate the statistical performance of the model as presented by Pickles and colleagues, and 2) to expand and evaluate the model in more applications, including both genetically informative data and other multivariate examples. Results evaluated from this study involve three areas of method performance: Type-I error rates, power, and parameter estimates under four different distributions (normal, Gamma-2, Gamma-6 and g-and-h) and four different sample sizes (n = 125, 250, 500 and 750). Results based on the original Pickles model indicated that in all sample size and distribution conditions the Type-I error rate was adequate, in fact below the nominal level of .05. Additionally, power was greater than .80 for sample sizes of 500 or more for all distribution conditions. Parameter estimates were upwardly biased when the population value was rho = .20. This bias varied across distributions; the g-and-h distribution showed the largest bias. Results from the expanded model indicated that Type-I error rates were adequate. Power results were not affected by distribution type; sample sizes of 500 were above the .80 level. Parameter estimates continued to be upwardly biased in this more general model, although the degree of bias was smaller.

Ethnic differences in hormone replacement prescribing patterns.

OBJECTIVE: To determine whether prescription patterns of hormone replacement therapy (HRT) differ in African-American, Asian, Latina, Soviet immigrant, and white women. DESIGN: Retrospective review of computerized medical records. SETTING: The general internal medicine, family medicine, and gynecology practices of an academic medical center. PATIENTS: Women aged 50 years or older with at least one outpatient visit from January 1, 1992, to November 30, 1995. MEASUREMENTS AND MAIN RESULTS: Use of HRT was defined as documentation of systemic estrogen use. The main predictor variable was self-identified ethnicity. Age, diagnosis (coronary heart disease, hypertension, diabetes, osteoporosis, or breast cancer), and median income were included in the analysis. Of the 8,968 women (mean age, 65.4 years) included, 50% were white, 20% Asian, 15% African American, 9% Latina, and 6% Soviet immigrants. Whites (33%) were significantly more likely to be prescribed HRT than Asians (21%), African Americans (25%), Latinas (23%), or Soviet immigrants (6.6%), p < 0.01 for each. Multivariate analysis, comparing ethnic groups and controlling for confounding variables, showed that Asians (odds ratio [OR] 0.56; 95% confidence interval [CI] 0.49, 0.64), African Americans (OR 0.70; 95% CI 0.60, 0.81), Latinas (OR 0.70; 95% CI 0.58, 0.84), and Soviet immigrants (OR 0.14; 95% CI 0.10, 0. 20) were each less likely to be prescribed HRT than were white women. Although women with osteoporosis were more likely to receive HRT (OR 2.28; 95% CI 1.71, 2.99), those with coronary heart disease were not (OR 0.88; 95% CI 0.68, 1.09). CONCLUSIONS: Physicians at this medical center were more likely to prescribe HRT for white women and women with osteoporosis. Further study is needed to address whether these differences in HRT prescribing result in different health outcomes.

Urge incontinence: new health-related quality of life measures.

OBJECTIVES: To develop and evaluate the psychometric properties of two new urge incontinence-specific instruments that measure quality of life and symptom annoyance. DESIGN: New instruments were developed and validated in racially, ethnically, and age-diverse community-dwelling women with urge or mixed incontinence with a primary urge component. MEASUREMENTS: A total of 83 women with a minimum of six urge losses per week were sequentially recruited. We began with the previously developed Incontinence Impact Questionnaire and Urogenital Distress Inventory and added information from focus groups, expert clinical opinion, and literature review. Final selection of questions was based on a combination of factor analysis, item-scale analysis, and reliability of scales to identify the best performing questions from the preliminary instruments. Both convergent and divergent validity were evaluated using established health-related quality of life measures, frequency of incontinence episodes, global ratings of interference with daily activities and effect on feelings, and overall severity. RESULTS: Mean age of subjects was 63.8 years, 37% were non-white, 23% had a high school education or less, and 24% had a household income of less than $10,000/year. Ten percent reported urge incontinence alone, with the remainder having mixed incontinence. Six domains were identified for the Urge-IIQ and one domain for the Urge-UDI. All domains had adequate reliability (Cronbach's alpha 0.74 - 0.95) and test-retest reliability (intraclass correlations > or = 0.59). CONCLUSIONS: The newly developed Urge-Incontinence Impact Questionnaire and Urge-Urinary Distress Inventory are reliable, and evidence of validity was found in a diverse population. These instruments are available for use in trials of new therapeutic interventions for urge incontinence.