Improving the view of Scotland's health: the impact of a public health observatory upon health improvement policy, action and monitoring in a devolved nation.

The Scottish Public Health Observatory (ScotPHO) is a collaboration of the observatory sections/functions of several organizations. It operates within a small country, part of the UK, with devolved legislative and executive powers in health and in many areas relating to wider social determinants of health. The short-term impact of ScotPHO on health improvement action, policy and monitoring is described. A key factor in ScotPHO's impact is the directness of its contact with Scottish government policy and analysis leadership. The context and organization of ScotPHO differentiates it from other PHOs in the UK and Ireland, but many of the health and information challenges faced are similar and the Association of Public Health Observatories enables experience and expertise to be shared.

Fluorescent granular cells of the thymus can be identified as dendritic macrophages.

Fluorescent granular cells of the thymus lobule containing neurotransmitter monoamines express Ia antigen and S-100 protein, which attests to their macrophage origin; positive staining with aldehyde fuchsin points to secretion of peptide hormones by these cells. These facts and the absence of phagocytic activity allow to identify these cells as dendritic macrophages.

Hair growth-modulation by adrenergic drugs.

Since we have recently shown that the beta 2-adrenoreceptor (beta 2-AR) expression of selected regions of the hair follicle (HF) epithelium as well as the number of adrenergic nerve fibers in murine skin change in a hair cycle-dependent manner, this has raised the possibility that adrenergic nerves may exert "trophic" functions during HF cycling. To further explore this concept, we have investigated the effect of neuro-pharmacological manipulations on hair growth (anagen) induction in quiescent telogen mouse skin in vivo. Here, we demonstrate that subcutaneous injections of the noradrenaline (NA)-depleting agent guanethidine, or of the neurotoxin 6-hydroxydopamine, but not of the beta 2-AR agonist isoproterenol induce a premature onset of anagen in the lower back skin of C57BL/6 mice. On day 20 after the start of treatment, more than 80% of the guanethidine-treated mice and ca. 65% of the 6-hydroxydopamine-treated (6-OHDA) mice exhibited premature skin darkening and hair growth at the site of drug application, whereas less than one-third of all control animals showed macroscopic signs of anagen development. This was confirmed by histology, demonstrating mature anagen VI HFs only at the immediate site of treatment with guanethidine or 6-OHDA as opposed to resting telogen HFs in the neighboring untreated skin area. This observation further supports the concept that sympathetic nerves are intimately involved in hair growth control and invites one to explore the neuro-pharmacological manipulation of piloneural interactions as a novel therapeutic strategy for the management of hair growth disorders.

Coping in family supporters of elderly people with dementia.

Research into supporters of elderly people with dementia has a brief but significant history. Initially, research sought to establish the nature and extent of the distress that supporters endured in the fulfilment of their caring role. More recently, researchers have turned their attention towards the identification of coping techniques used by supporters in the community. The Dundee Study of Supporters and Dementia is concerned with factors associated with the maintenance and care of the demented elderly in the community, and with the impact of dementia on family supporters. A total of 228 family supporters of community-resident elderly (50 per cent of elders with dementia, 50 per cent without) were interviewed. Part of the interview focused on self-reported coping, and identified coping strategies using open-ended questions and a revised, 31-items Ways of Coping checklist. Findings indicated that the majority of supporters of community-resident elderly relatives reported coping well. Supporters predominantly used emotion-focused coping strategies as their main way of coping. However, those supporters who reported using a problem-focused strategy were found to score better on measures of coping than those supporters using an emotion-focused strategy. The supporters' main coping strategy was not associated with characteristics of the elder-supporter dyad. Factors derived from the Ways of Coping checklist produced a pattern of associations with characteristics of the elder-supporter dyad, but the same factors were largely not associated with other measures of coping. The implications of the findings are discussed with regard to coping research, and for interventions to improve the well-being of supporters of an elderly relative with dementia in the community.

Profiling the care needs of the population with dementia: a survey in central Scotland.

OBJECTIVE: To demonstrate a low-cost method of producing local information for dementia service planning. DESIGN: (1) Multiservice census. (2) Stratified random sample survey (stratified by setting) to assess needs. SETTING: All community and institutional settings in Forth Valley Health Board area. PARTICIPANTS: (1) People age 65 + defined by health and social care professionals as having 'problems of memory/confusion (as is caused by dementia)' (N = 2060). (2) As (1) excluding those with score < 2 on Levin's checklist and no relevant known diagnosis (N = 286). MAIN OUTCOME MEASURES: Coverage of population with dementia against EURODEM prevalence. Place of residence of sufferers. Level of care needs. MAIN RESULTS: Identified population, pro-rating for identifiable non-response, accounted for 78% of EURODEM prevalence. Assuming unidentified 22% to live at home, 45% of total population with dementia were in some form of institutional care. Survey demonstrated high levels of need in local population with dementia known to services. Assistance was required more than once a day with mobility by 48%, personal care by 60%, domestic tasks by 75% and because of behavioural problems by 57%. Assistance was required at night by 59% because of personal care needs and by 54% because of behaviour problems. CONCLUSIONS: The value of a broad-based survey 'snapshot' across the range of settings was confirmed. It can be accomplished relatively quickly and cheaply and complements information collected in other ways.

Identifying older people with dementia: the effectiveness of a multiservice census.

A census of all relevant services in an area can be used to identify people with mental impairment suggestive of dementia. Two censuses in Tayside, Scotland, were used to test the effectiveness of this method. False positives accounted for 12% of returns. After excluding false positives, by comparison with expected dementia prevalence based on EURODEM, 66% of all sufferers and 50% of those living in the community were identified by the censuses. By pro-rating for non-response, the proportion of sufferers known to services was estimated as 72%. The characteristics of those not known to services are unclear and further research is needed on this. The cost of a census in an area of 250,000 population is under pounds 3000. A multiservice census offers a simple, inexpensive, practicable method of constructing a sample frame for population needs assessment.

A population needs assessment profile for dementia.

The Tayside Profile for Dementia Planning is an instrument designed to obtain data for population needs assessment and planning. It provides a brief tool to collect a minimum dataset by non-specialists. Third-party informants-informal carers or involved professionals-are used as data sources. The key concept is the use of a descriptive profile rather than a summative score or categorization. The profile consists of a set of needs indicators, information on current service response and demographic and background data. Key levels of dependency are measured by time interval dependency. Validity, reliability, acceptability and usability are satisfactory, with the crucial exception that informal carers and professionals appear to perceive needs differently. Further research is needed to assess which type of informant provides the more useful data.

Apical lung hernia: radiologic findings in six cases.

OBJECTIVE: We performed this study to characterize the clinical and radiologic manifestations of apical lung hernias. CONCLUSION: Apical lung hernias typically manifest as unilateral, right-sided air radiolucencies at the thoracic inlet on chest radiographs. They are frequently intermittent and can cause lateral tracheal deviation. Radiologic studies performed at midinspiration may not show hernias. Airway fluoroscopy or CT performed at maximal inspiration may be necessary to confirm the diagnosis.

Where needs and demands diverge: health promotion in primary care.

UNLABELLED: This study reviews Forth Valley Health Board's 'Be Better Hearted' coronary heart disease health promotion programme by analysis of data routinely collected between 1988 and 1993. Associations between socioeconomic deprivation, prevalence of risk factors, and attendance at health promotion clinics are of particular interest in relation to future health promotion strategy. METHOD: A study was made of computerised records of 20,053 baseline risk factor assessments in the primary care setting and 1,058 follow-up attendances. A method of classification by socioeconomic status was applied. RESULTS: Baseline data provided a profile of new attenders over time with regard to age, gender, risk factors and socioeconomic status but lack of follow-up information prevented evaluation of the outcome of the programme. There was a statistically significant association between prevalence of risk factors (such as smoking, obesity and lack of exercise) and deprivation. In the most affluent areas 19.0% of the target population participated in the programme; in deprived areas this fell to 10.7%. There was thus a failure to involve those most in need of health promotion. CONCLUSION: If equity in provision of health promotion is to be achieved, measures must be taken locally and nationally to reach deprived sections of the population. In this type of health promotion programme, baseline and follow-up information should be entered on computer at the clinical locus to enable monitoring of outcome. These conclusions are particularly relevant to the national arrangements for health promotion in primary care which were introduced in July 1993.

Amphotericin B lipid complex compared with amphotericin B in the treatment of cryptococcal meningitis in patients with AIDS.

The study objective was to obtain preliminary information regarding the safety and efficacy of amphotericin B (AmB) lipid complex (ABLC) in the treatment of AIDS-associated cryptococcal meningitis. Of 55 patients randomly assigned to 6 weeks of therapy with ABLC (1.2-5.0 mg/[kg.d], with ascending doses for three sequential cohorts) or AmB (0.7-1.2 mg/[kg.d]), 46 received > or = 12 doses. Transfusion requirements, mean decreases in hemoglobin level, and mean increases in creatinine level were significantly greater with AmB than with ABLC. The total number of adverse events, infusion-related events, and occurrences of hypomagnesemia and hypokalemia associated with each form of therapy were similar. Among 21 recipients of ABLC at a dosage of 5 mg/kg (daily for 2 weeks and then thrice weekly for 4 weeks), symptoms and signs resolved for 18 (86%). Of those receiving > or = 12 doses of ABLC, cultures converted to negative for 8 (42%), were undeterminable for 3 (16%), and remained positive for 8 (42%) despite resolution of symptoms. Although preliminary, these data suggest ABLC has significant activity in patients with AIDS-associated cryptococcal meningitis. Because this formulation has less hematologic and renal toxicity than does AmB, further evaluation of ABLC is warranted.

High dose cyclophosphamide, fractionated total body irradiation with involved field irradiation and autologous bone marrow transplantation in malignant lymphoma.

The objective of this clinical trial was to determine if radiation to areas of recurrence or bulky disease prior to total body irradiation (TBI) and chemotherapy followed by autologous bone marrow transplantation (ABMT) altered the site of relapse and/or prolonged survival. Forty-eight patients with recurrent or refractory malignant lymphoma were treated with high-dose cyclophosphamide and fractionated TBI followed by ABMT. Thirty-four patients were eligible to receive involved field radiation therapy (IF-RT) to sites of recurrence or bulky disease. The overall response rate in 46 evaluable patients was 89% with 33 complete remissions (CR) and 8 partial remissions (PR). In a multivariant analysis increasing LDH, decreased serum albumin, older age, and lack of sensitivity to prior chemotherapy were associated with poorer survival. There were 10 deaths due to treatment related complications, 8 died of pulmonary complications of whom 6 were in CR. Of 11 who had received IF-RT and subsequently relapsed, 4 recurred in or adjacent to the involved field. We conclude that intensive chemo-radiotherapy proved to be an effective salvage therapy for patients with recurrent malignant lymphoma, resulting in a projected actuarial 33% DFS at 5 years, but was associated with a high transplant-related mortality.

Perceived usefulness of the Director of Public Health Annual Report: a consumer survey.

The Annual Report of the Director of Public Health for Forth Valley was evaluated in terms of its usefulness as perceived by recipients. Six months after publication, more than half had retained their copy and a similar proportion had made use of it or anticipated using it in the coming year. Its main use was as a reference. The Report had least impact upon Consultants and General Practitioners.

Recombinant human erythropoietin therapy for anemic cancer patients receiving cisplatin chemotherapy.

PURPOSE: To assess whether the administration of recombinant human erythropoietin (r-HuEPO) would increase the hematocrit, reduce the requirement for transfusion, and improve the quality of life in anemic cancer patients receiving myelosuppressive, cisplatin-based chemotherapy. PATIENTS AND METHODS: One hundred thirty-two anemic cancer patients receiving cyclic, cisplatin-containing, myelosuppressive chemotherapy were evaluated. Patients received either r-HuEPO (150 U/kg) or placebo, subcutaneously, three times a week for 3 months. Responses were assessed by measuring changes in hemoglobin/hematocrit, transfusion requirement, and quality of life. RESULTS: The mean hematocrit increased by 6.0 percentage points in the r-HuEPO group versus 1.3 in the placebo group. A decrease in transfusion requirement did not reach significance over all 3 months, but there was a significant reduction in the percentage of patients transfused in the second and third months (27% r-HuEPO vs. 56% placebo) and a trend toward reduction in the mean total number of units transfused (1.20 units r-HuEPO vs. 2.02 units placebo), suggesting a lag of 1 month before r-HuEPO can affect the transfusion requirement. Pretreatment serum erythropoietin levels were lower in responders than in nonresponders (73.5 IU/L and 86.3 IU/L means, respectively). However, the magnitude of this difference was not helpful in defining which patients were likely to respond. There was a significant improvement in overall quality of life between the two treatment arms in favor of the r-HuEPO-treated group. There were no significant adverse effects associated with r-HuEPO. CONCLUSIONS: r-HuEPO is safe and can cause a significant improvement in the hematocrit and quality of life of anemic cancer patients receiving myelosuppressive, cisplatin-based chemotherapy. After 1 month of r-HuEPO, there is also a reduction in transfusion requirement.

Inducible expression of cellular retinoic acid-binding protein II in rat ovary: gonadotropin regulation during luteal development.

Two members of the superfamily of small intracellular carrier proteins for lipophilic compounds are cellular retinoic acid-binding protein and cellular retinoic acid-binding protein II [CRABP(II)]. CRABP is found in many adult tissues, whereas CRABP(II) is more restricted and is reported as abundant primarily in skin. Here we report a much greater expression of CRABP(II) in rat corpus luteum than in any other organ/tissue examined, including skin. A rat complementary DNA clone encoding CRABP(II) was isolated and the ovarian expression followed during gonadotropin induction of follicular development in the pseudopregnant rat. The pattern of rat CRABP(II) messenger RNA and protein expression correlated with the appearance of corpora lutea and the rise in progesterone production as the corpora lutea developed, and was similar to the induction of 3 beta-hydroxysteroid dehydrogenase. Immunohistochemical localization revealed that CRABP(II) appeared in luteal cells and was dramatically restricted to their cytoplasmic compartment, with no apparent presence in the nucleus. This suggests that CRABP(II) may be expressed to restrict retinoic acid from occupying nuclear retinoic acid receptors, implying that the differentiation and maintenance of the rat corpus luteum may involve in part a release of certain pathways from retinoid suppression.

Community care for demented and non-demented elderly people: a comparison study of financial burden, service use, and unmet needs in family supporters.

OBJECTIVE: To measure and compare perceived financial burden, use of services, and perceived unmet service needs of supporters of demented and non-demented elderly people. DESIGN: Comparison study of age and sex matched demented and non-demented elderly people and their supporters. SETTING: 25 primary health care teams in Dundee. SUBJECTS: 114 community resident elderly (age over 65) people with dementia, 114 age and sex matched comparators, and the main informal supporter of each elderly person. MAIN OUTCOME MEASURES: Carers' perceptions of financial impact of looking after an old person, service use (from a list of locally available services), unmet service needs, and needs for three types of generic service (help with supervision, housework, or personal care). RESULTS: Financial impact was low, except for extra household expense in the dementia group. There was significantly greater use of mainstream domiciliary and day care services in the dementia group. Dementia was nevertheless associated with a high level of unmet need, mainly for more mainstream support and help with supervision of the elderly person. CONCLUSION: Supervisory care for demented elderly people should be further developed within an expanded domiciliary service to meet supporters needs.

Late intensification therapy in adult acute lymphoid leukemia: long-term follow-up of the Southeastern Cancer Study Group experience.

One hundred and ninety-two evaluable patients were treated on a multicenter protocol for adult acute lymphoid leukemia to determine in a prospective randomized fashion if late intensification chemotherapy beginning after about six months of treatment would improve remission duration and survival. The complete remission rate was 60%. The median remission duration from beginning of maintenance was 18.7 versus 25.9 months (P = 0.36) for standard maintenance therapy and late intensification, respectively, and the median survival from randomization was 25.8 versus 28.5 months (P = 0.94) respectively. There was a suggestion that the late intensification strategy was helpful with respect to remission duration, and this trend was sustained in long-term follow-up. However, relapse proved to be common during the earlier phases of treatment; thus, insufficient numbers of patients were available at the randomization point to conclusively address the possible value of late intensification. Intensive therapy earlier in the course of treatment should be evaluated, including transplantation in selected patients.