Scotland's relative mortality disadvantage compared to the rest of Great Britain, after allowing for deprivation, is worsening. By 1991 measures of deprivation no longer explained most of the excess mortality in Scotland and the unexplained excess has persisted during the 1990s. More research is required to understand what is causing this 'Scottish effect'.

The effects of thyroid dysfunction are thought to be reversible on restoration of euthyroidism, but postmortem and epidemiologic data suggest that subclinical or treated thyroid disease is associated with increased vascular risk. In order to determine the extent of this risk, and to explore whether the nature and/or treatment of thyroid disease are critical in this relationship, we used medical record linkage to match patients with treated thyroid disease of various etiologies with routinely collected national inpatient and daycase hospital discharge records and death records, and assessed the number of hospitalizations from cardiovascular or cerebrovascular disease or death in patients with thyroid disease and control patients. Patients treated for Graves' disease had more hospitalizations from cardiovascular disease than controls (relative risk, 1.42; 95% confidence interval, 1.20 to 1.67; p < 0.001). Toxic multinodular goiter was also associated with significantly higher rates of cardiovascular disease (relative risk, 1.50; 95% confidence interval, 1.11 to 2.02; p = 0.008). Patients with Hashimoto's thyroiditis aged over 50 years had a threefold increase in cardiovascular admissions compared to controls (23.5% and 6.5%, respectively; 95% confidence interval for difference, 6.0% to 27.9%; p = 0.003). Thus, different forms of thyroid disease were associated with increased long-term vascular risk despite restoration of euthyroidism. The mechanisms that mediate this risk are unclear but may not involve thyroid hormone abnormality.

Increases in opioid-related presentations are of major concern. Changes in paracetamol pack-size have been associated with reduced discharge rates. In Scotland the age group with the highest rate of discharge (15-24 years) with paracetamol overdose is not the one with the highest mortality.

Background: The management of glaucoma has been changed in the past decade by the introduction of new drugs. The impact of these changes on clinical care of patients was examined by examining operation and prescribing rates for glaucoma in four geographical areas of Scotland for the years 1994 to 1999. Methods: A retrospective analysis of national health statistics: primary care prescribing data, hospital derived operation rates, consultant numbers, optometrist numbers, and eye test data, expressed by estimated population at risk of glaucoma. The outcome measures were prescribing volume and cost for glaucoma medications, and operation rates, corrected for population estimated to be at risk of glaucoma (PEG), for trabeculectomy, for Scotland as a whole, and for four geographical "regions" (north east, south east, central, and south west Scotland). Results: Prescribed items per 1000 population estimated to have glaucoma (PEG) increased by 24.9% between 1994 and 1999. This was above the general increase in prescribing in Scotland (17.8%). This increase varied in the four health regions evaluated (14.3% to 31.9%). Prescribing of topical β blockers increased little (6.4%), but there was a large increase in the use of new products (topical prostaglandins, carbonic anhydrase inhibitors, and α 2 agonists), at the expense of miotics (47.7% fall), and older sympathomimetics. This change in prescribing pattern was accompanied by a 61.5% increase in cost (range 42.2% to 73.4% in the four regions). New drugs accounted for more than half of total glaucoma expenditure in 1999. Operation rates (corrected for PEG) fell by 45.9% (range 43.1 to 58.6%) between 1994 and 1999. Other indicators suggested increased activity in ophthalmic areas (for example, cataract operations, eye tests, numbers of optometrists and ophthalmic surgeons all increased). Within north east Scotland operation rates decreased and prescribing increased less than in other regions, both from lowest regional baseline in 1994. Conclusions: The introduction of new drug classes has had dramatic effects on the prescribing of glaucoma treatments. There has been a decline in older treatments and an increase in new agents, which has been associated with a large reduction in operation rates for glaucoma in Scotland over 6 years. Comparison of prescribing and operation data indicates regional differences in healthcare delivery for glaucoma.

AimsTo describe how changes in legislation to restrict paracetamol sales have affected overdose discharges and death associated with the drug in Scotland. MethodsA descriptive analysis of routine death and hospital discharge data for the entire Scottish population between 1995 and 2004. Patients in Scotland participated who were discharged from hospital with a diagnosis of poisoning; deaths in Scotland from diagnosis of poisoning 1995-2003 were also analysed. Outcome measures were changes in mortality and overdose due to poisoning involving paracetamol. A comparison was made of in-hospital and out-of-hospital mortality in fatalities involving paracetamol. ResultsThe majority of paracetamol-associated deaths were due to co-proxamol. Deaths associated with paracetamol alone or with ethanol occurred principally in hospital and were a minority of deaths overall. The proportion of in-hospital deaths attributed to paracetamol increased (post/pre ratio 1.347; 95% confidence interval 1.076, 1.639; P = 0.013). Overall numbers of cases discharged with poisoning fell. The proportion of these involving paracetamol in any form increased significantly in all groups except young men aged 10 to < 20 years. ConclusionsLegislation has not reduced mortality or proportional use of paracetamol in overdose, both of which appear to have increased in Scotland since pack-size limitations. Other approaches are necessary to reduce the death rate from overdoses involving paracetamol.

Objective: To evaluate healthy life expectancy (HLE) as a measure of health inequalities by comparing geographical and area-based deprivation-related inequalities in healthy and total life expectancy (TLE). Design: Life table analysis based on ecological cross-sectional data. Setting and population: Council area quarters and postcode sector-based deprivation fifths in Scotland. Main outcome measures: Expectation of life in good self-assessed general health, or free from limiting long-term illness, and TLE, for females and males at birth. Results: Women in Scotland have a life expectation of 70.3 years in good health, 61.6 years free from limiting long-term illness, and a TLE of 78.9 years. Comparable figures for men are 66.3, 58.6 and 73.5 years. TLE and HLE decrease with increasing area deprivation. Differences are substantially wider for HLE. A 4.7-year difference is seen in TLE between women living in the most and least deprived fifth of areas. The difference in HLE is 10.7 years in good health and 11.6 years free from limiting long-term illness. The degree of deprivation-related inequality in HLE is 2.5 times wider for women and 1.8 times wider for men than in TLE. Conclusions: Differences in TLE underestimate health inequalities substantially. By including morbidity and mortality, HLE reflects the excess burden of ill health experienced by disadvantaged populations better. Inequalities in length of life and health status during life should be taken into account while monitoring inequalities in population health.

Sodium dodecyl sulphate-polyacrylamide gel electrophoresis of whole cell protein, immunoblotting with normal human serum and restriction endonuclease analysis using Taq I enzyme were applied to 38 clinically significant isolates of Moraxella (Branhamella) catarrhalis obtained during a suspected outbreak of nosocomial infection. Each of 18 strains had individual profiles by at least two of the three methods (unique strains). The remaining 20 strains were assigned to five groups (A-E) on the basis of similarity by at least two of the three methods. Isolates within groups A, D and E were homologous by all three methods. Immunoblot groups B and C had two distinct whole cell protein profiles (B1 and B2) but indistinguishable restriction endonuclease profiles (group B/C). This emphasizes the need to use more than one technique in characterizing strains from suspected outbreaks of nosocomial infection. Grouped strains were more likely to originate from the same hospital ward than unique strains and were associated with a significantly longer median time from patient admission to strain isolation (14 versus 3.5 days, p less than 0.005). Furthermore, the beta-lactamase activity was homologous within the groups. The results suggest that nosocomial infection involving several distinct Moraxella catarrhalis strains persisted over a period of months, involving at least 20 patients on three different wards. Such infection is probably common in wards harbouring suitably predisposed patients. The mode of transmission remains to be elucidated, but the above three techniques possess sufficient reproducibility and discriminatory ability to constitute suitable investigative tools.

ICD-9 code 163 (malignant neoplasm of pleura) listed as underlying cause of death detected only 40% of Scottish mesothelioma cases (all body sites) from the cancer registry in 1981 -1999. This is lower than both the previously published 55% figure, derived from UK mesothelioma register data 1986 -1991, which is based on any mention of mesothelioma on death certificates, crossreferenced to cancer registry data, and the 44% figure derived from Scottish mortality data 1981 -1999, which captured any mention of mesothelioma on the death certificate. Detection from cancer registry data increased to 75% under ICD-10 in Scotland, confirming earlier predictions of the benefit of ICD-10's more specific mesothelioma codes. Including the accidental poisoning codes E866.4 (ICD-9) and X49 (ICD-10), covering poisoning by 'unspecified' and 'other' causes, which appear to have been used as coding surrogates for mesothelioma when asbestos exposure was explicitly mentioned in deaths suggestive of a mesothelioma, and which are recorded as the underlying cause of death in 4 -7% of mesotheliomas, may improve the mesothelioma detection rate in future epidemiological studies.