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CD4 receptor localized to non-raft membrane microdomains supports HIV-1 entry. Identification of a novel raft localization marker in CD4.

Despite the preferential localization of CD4 to lipid rafts, the significance and role of these microdomains in HIV-1 entry is still controversial. The possibility that CD4, when localized to non-raft domains, might be able to support virus entry cannot be excluded. Because disintegration of rafts by extraction of cellular cholesterol with methyl-beta-cyclodextrin suffers from various adverse effects, we investigated molecular determinants controlling raft localization of the CD4 receptor. Extensive mutagenesis of the receptor showed that a raft-localizing marker, consisting of a short sequence of positively charged amino acid residues, RHRRR, was present in the membrane-proximal cytoplasmic domain of CD4. Substitution of the RHRRR sequence with alanine residues abolished raft localization of the CD4 mutant, RA5, as determined biochemically using solubilization in nonionic detergents and by confocal microscopy. The possible inhibitory effect of the introduced mutations on the adjacent CVRC palmitoylation site was ruled out because wild type (wt) CD4 and RA5, but not a palmitoylation-deficient mutant, were efficiently palmitoylated. Nonetheless, the RA5 mutant supported productive virus entry to levels equivalent to that of wild type (wt) CD4. Sucrose gradient analysis of Triton X-100 virus lysates showed that Gag and envelope gp120 proteins accumulated in low buoyant, high-density fractions. This pattern was changed after virus incubation with cells. Whereas Gag proteins localized to lipid rafts in cells expressing wt CD4 and RA5, gp120 accumulated in rafts in cells expressing wt CD4 but not RA5. We propose that raft localization of CD4 is not required for virus entry, however, post-binding fusion/entry steps may require lipid raft assembly.

Amino Acid Sequence↗

Studies of acute phase protein. I. An immunohistochemical method for the localization of Cx-reactive protein in rabbits. Association with necrosis in local inflammatory lesions.

A method is presented for the immunohistochemical localization of Cx-reactive protein in rabbits, based on the use of a defined antiserum and rigorous fixation techniques requisite for this antigen. In animals in which inflammatory lesions and CxRP response were induced by intramuscular injection of typhoid vaccine, Cx-reactive protein was localized only in the area of local inflammation within muscle fibers showing morphologic evidence of necrotic change. Within such altered fibers, CxRP was observed in peripheral segments of myofiber or in subsarcolemmal sarcoplasm, in scattered deposits in sarcoplasm, and in vacuolar inclusions. No CxRP was found at any time in polymorphonuclear or mononuclear cells in the inflammatory lesion, nor in contralateral muscle, regional or distal lymph nodes, liver, spleen, thymus, heart, or kidney, except as traces in lumens of vessels or interstitium. CxRP was first detected in necrotic myofibers at the inflammatory site after a latent period of 8 to 10 hours following injection of the inflammatory stimulus and could be demonstrated in these sites for the 48 hours of the experiment. It could not be observed at the inflammatory site before appearance in the blood. Identical histologic localization in necrotic myofibers at the site of the local lesions was found following induction of granulocytopenia with nitrogen mustard. These findings are consistent with the hypothesis that CxRP is formed locally at the site of inflammation from tissue elements undergoing necrotic change. Alternatively, secondary deposition from the blood at the inflammatory site cannot be excluded, but is considered less likely in view of the failure to obtain evidence of a cellular localization of CxRP in other organs.

Acute-Phase Proteins↗

Bicalutamide 150 mg in addition to standard care in patients with localized or locally advanced prostate cancer: results from the second analysis of the early prostate cancer program at median followup of 5.4 years.

PURPOSE: We evaluated the efficacy and tolerability of 150 mg bicalutamide daily given in addition to standard care, in patients with localized or locally advanced prostate cancer. MATERIALS AND METHODS: The bicalutamide Early Prostate Cancer program consists of 3 randomized, double blind, placebo controlled trials prospectively designed for combined analysis. A total of 8,113 men with T1b-T4, M0, any N (N0 in 1 trial) prostate cancer were randomized to bicalutamide 150 mg/day (4,052) or placebo (4,061) in addition to standard care (radical prostatectomy, radiotherapy or watchful waiting). Primary end points were objective progression-free survival (PFS) and overall survival. RESULTS: At median 5.4 years of followup (21.6% progression events) bicalutamide significantly improved PFS in the overall population. This result was driven by positive results in trials 24 and 25, with the North American trial (trial 23) showing no difference. Patients with locally advanced disease gained most benefit from bicalutamide in terms of PFS, irrespective of underlying therapy. Overall survival was similar in the bicalutamide and placebo groups, across the program and in each trial. Among watchful waiting patients survival appeared to be improved with bicalutamide in those with locally advanced disease, whereas survival appeared to be reduced with bicalutamide in those with localized disease. The most common adverse events with bicalutamide were gynecomastia and breast pain. Other adverse events occurred with a similarly low incidence in the 2 treatment groups. CONCLUSIONS: This analysis confirms that bicalutamide provides benefit in patients with locally advanced disease. The current data suggest that early or adjuvant hormonal therapy for patients at low risk of disease progression, such as those with localized disease, is not appropriate.

Adult↗

What are local issues? The problem of the local review of research.

Local review of research by ethics committees in the UK has long been held to be an important right of the local research ethics committee and, even with the introduction of the European Clinical Trials Directive, the governance arrangements for research ethics committees continue to allow for local review of multicentre studies. There is no requirement for local review in either the European Union directive or in the guidelines on good clinical practice, and there is little evidence of it anywhere else in Europe. The idea that there can be "local", as opposed to "central" ethical issues in research is an interesting one, which raises important issues about the nature of research ethics and ethical review. The aim of this paper is to argue that there are no such things as local issues in research ethics, and suggest that those questions currently addressed as local issues properly belong within the research governance framework.

Bioethical Issues↗

Nitric oxide and prostaglandins influence local skeletal muscle blood flow during exercise in humans: coupling between local substrate uptake and blood flow.

Synergic action of nitric oxide (NO) and prostaglandins (PG) in the regulation of muscle blood flow during exercise has been demonstrated. In the present study, we investigated whether these vasodilators also regulate local blood flow, flow heterogeneity, and glucose uptake within the exercising skeletal muscle. Skeletal muscle blood flow was measured in seven healthy young men using near-infrared spectroscopy and indocyanine green and muscle glucose uptake using positron emission tomography and 2-fluoro-2-deoxy-D-[(18)F]glucose without and with local blockade of NO and PG at rest and during one-legged dynamic knee-extension exercise. Local blockade was produced by infusing nitro-L-arginine methyl ester and indomethacin directly in the muscle via a microdialysis catheter. Blood flow and glucose uptake were measured in the region of blockade and in two additional regions of vastus lateralis muscle 1 and 4 cm away from the infusion of blockers. Local blockade during exercise at 25 and 40 watts significantly decreased blood flow in the infusion region and in the region 1 cm away from the site of infusion but not in the region 4 cm away. During exercise, muscle glucose uptake did not show any regional differences in response to blockade. These results show that NO and PG synergistically contribute to the local regulation of blood flow in skeletal muscle independently of muscle glucose uptake in healthy young men. Thus these vasodilators can play a role in regulating microvascular blood flow in localized regions of vastus lateralis muscle but do not influence regional glucose uptake. The findings suggest that local substrate uptake in skeletal muscle can be regulated independently of regional changes in blood flow.

Adult↗

'Local Food-Nutraceuticals': bridging the gap between local knowledge and global needs.

Food use is changing very fast all over the world. This and other changes (e.g. reduced physical activity, increased longevity) result in novel health risks for the populations in European countries and beyond. Also, in recent decades the convenience food market has grown dramatically and offers novel opportunities for small and large industries alike. Simultaneously, there is a dramatic and irrevocable loss of the local knowledge which forms the basis of many cultural traditions (traditional food knowledge--TFK). The Mediterranean region is well known for a dietary tradition commonly called 'Mediterranean diet(s)', which is renowned for health benefits based among others on widely consumed foods and beverages. While the focus of research has mostly been on the more widely used elements of the Mediterranean diets (especially olive oil and red wine), in this review the focus is on 'local food'. These are ingredients, which are gathered, grown or produced locally and prepared into dishes, which often represent local specialities. Such food is derived from animals, fungi and plants, but in this paper the main subject is food of botanical origin. Particularly important among these local foods are vegetables and salads derived from wild greens (gathered food plants--GFPs) and local cultivars of fruit trees and shrubs. In this review we discuss the theoretical basis (including the concept of traditional knowledge systems) and general approach of an EU-funded multidisciplinary ethnobotanicalpharmacological project focusing on the use of such local resources in several regions of the Mediterranean including the ethnobotanical documentation of food products of selected communities in southern Italy, Spain, Greece (mostly Crete), the identification of extracts/pure compounds (leads for new health food supplements) with potent activity on a series of in vitro targets, especially ones relevant to assess for antioxidant activity, the more detailed in vivo study of some lead extracts and lastly the dissemination of such TFK in local/national languages.

Agriculture↗

Likelihood of home death associated with local rates of home birth: influence of local area healthcare preferences on site of death.

OBJECTIVES: We tested whether local cultural and social values regarding the use of health care are associated with the likelihood of home death, using variation in local rates of home births as a proxy for geographic variation in these values. METHODS: For each of 351110 adult decedents in Washington state who died from 1989 through 1998, we calculated the home birth rate in each zip code during the year of death and then used multivariate regression modeling to estimate the relation between the likelihood of home death and the local rate of home births. RESULTS: Individuals residing in local areas with higher home birth rates had greater adjusted likelihood of dying at home (odds ratio [OR]=1.04 for each percentage point increase in home birth rate; 95% confidence interval [CI] = 1.03, 1.05). Moreover, the likelihood of dying at home increased with local wealth (OR=1.04 per $10000; 95% CI=1.02, 1.06) but decreased with local hospital bed availability (OR=0.96 per 1000 beds; 95% CI=0.95, 0.97). CONCLUSIONS: The likelihood of home death is associated with local rates of home births, suggesting the influence of health care use preferences.

Adult↗

[Effects of glycerol on local cerebral glucose utilization and local cerebral blood flow of hypoxic rats].

Effects of a continuous infusion of glycerol on the hypoxic rat were assessed by measurements of local cerebral glucose utilization and local cerebral blood flow using the quantitative autoradiographic 1-[C-14]-2-deoxyglucose and [C-14]-iodoantipyrine techniques, respectively. Local cerebral glucose utilization of the hypoxic rat was decreased in most of cerebral structures except for the amygdala, septal nucleus and the white matter. Local cerebral glucose utilization of the hypoxic rat treated with glycerol was recovered to the pattern of normal control, although glucose utilization of the nucleus raphe and locus ceruleus was accelerated. Cerebral blood flow of the hypoxic rat was elevated in almost of all measured structures. In particular, blood flow in the substantia nigra and locus ceruleus was increased significantly. The pattern of local cerebral blood flow of the hypoxic rat treated with glycerol was more analogous to that of normal control than of hypoxic rat without treatment. It is suggested that glycerol has beneficial effects by elevating local cerebral glucose utilization inhibited and decreasing local cerebral blood flow overshot on the hypoxic condition.

Animals↗

Immune responses to influenza virus in rabbits after local immunization. II. Local and systemic cell mediated response.

The development of local and systemic cell mediated immunity (CMI) was investigated in rabbits after intratracheal immunization with live or inactivated influenza A virus. Lymphocytes from bronchoalveolar washings and draining lymph nodes were used for the assay of local CMI response. Spleen cells were employed for determination of systemic responses. Since alveolar macrophages were found to be susceptible to the action of migration inhibiting factor, the development of CMI in lungs was assayed by macrophage migration inhibition test using bronchoalveolar was cells. Immunization with live virus induces beter local CMI response than inactivated virus. After primary immunization the peak responses were found between second and third week. The secondary response was detectable much earlier and peaked at one week after booster. Small amounts of inactivates virus, which was unsufficient to evoke a primary response, could elicit a strong secondary response. The development of rapid and accentuated secondary response in the local lymphoid tissues suggests the presence of memory in the local CMI response. The results also show a good correlation to exist between primary local CMI response and the skin reactivity to the immunizing antigen. However, lack of such correlation during the secondary response leaves the skin tests less reliable in the evaluation of CMI in viral infections. Some of the functions of alveolar macrophages in the local immune reponses are also discussed.

Animals↗

Definitive surgery and multiagent systemic therapy for patients with localized Ewing sarcoma family of tumors: local outcome and prognostic factors.

BACKGROUND: The local management of Ewing sarcoma family of tumors (ESFT) often centers on the surgical resectability of the primary lesion and physician biases regarding differences in the morbidity between primary surgical and radiotherapeutic management. METHODS: The authors retrospectively reviewed the records of 33 patients with localized ESFT who underwent surgery and received systemic chemotherapy at St. Jude Children's Research Hospital (Memphis, TN). Two multiagent systemic chemotherapy regimens were used: 14 patients received vincristine, doxorubicin, cyclophosphamide, and actinomycin D (VACA), and 19 received VACA in combination with ifosphamide and etoposide. The primary tumor was surgically resected via a wide, local excision (n = 32) or a marginal excision (n = 1)performed either at diagnosis or after 3-5 months of systemic chemotherapy. Clinical outcome and prognostic factors for disease control were reported in the current study. RESULTS: The median follow-up for patients was 9.9 years. The 5-year and 10-year survival rates were 84.5% and 75.8%, respectively. At 5 years, the cumulative incidence of local disease recurrence was 12.5%, and the event-free survival (EFS) rate was 71.7%. The same values were found at 10 years. The site of tumor origin was a significant predictor of EFS. The survival rate of patients whose tumors arose in bone was 78.6%, and the survival rate of patients whose tumors originated in soft tissue was 25.0% (P = 0.028). No other factors investigated were predictive of outcome. CONCLUSIONS: Local disease control and overall outcome for patients with ESFT managed by multiagent systemic therapy and surgery was excellent. Local disease control rates remained near 90% at 10-year follow-up. Patients with extraosseous primary sites of disease may fare less well with this approach to therapy.

Adolescent↗

Prognostic factors for local recurrence and survival in patients with localized extremity soft-tissue sarcoma.

The charts of 423 patients with localized extremity soft-tissue sarcoma treated at our institution over a 10-year period (1968-1978) were reviewed. Data were subjected to both univariate and multivariate analysis, with independent variables in the multivariate analysis appearing in capital letters. Factors associated with an increased risk of local recurrence included the following: AGE greater than 53; PRESENTATION WITH RECURRENT DISEASE; HIGH TUMOR GRADE; positive regional nodes; TREATMENT BY LIMB-SPARING SURGERY (LSS); invasion of vital structures (LSS only); INADEQUATE MARGINS; and biopsy with delayed definitive resection. Survival was adversely affected by the following: AGE greater than 53; PAINFUL MASS; PROXIMAL SITE; SIZE greater than or equal to 10 cm; HIGH TUMOR GRADE; POSITIVE NODES; invasion of vital structures; TREATMENT BY AMPUTATION; INADEQUATE MARGINS; and local recurrence after treatment at our institution. Significant variations in both local recurrence and survival according to histopathology were also observed, with EMBRYONAL RHABDOMYOSARCOMA, ANGIOSARCOMA, and MALIGNANT PERIPHERAL NERVE TUMORS emerging as independent predictors of local recurrence. Using the Cox models for local recurrence and survival, patients were stratified into high-, intermediate-, and low-risk categories based on the presence or absence of each variable. Risk factor analysis should be part of the overall evaluation of each patient with extremity sarcoma.

Adolescent↗

Effect of split-course radiotherapy on survival and local control in advanced localized prostatic carcinoma.

PURPOSE: to analyze the effect of overall treatment time of radiotherapy on survival and local control in locally advanced prostatic cancer in a split-course treatment setting. METHODS AND MATERIALS: 168 patients with Stage C prostatic cancer treated during 1979-1989 by the split-course method where the overall treatment time is protracted. Treatment consisted of whole pelvis irradiation of 40 Gy in 4 weeks, followed by a planned 3-week interruption and an additional 26 Gy by the reduced field technique to a total dose of 66 Gy in 9 weeks and 30-33 fractions. The overall treatment time varied from 55 to 100 days. Thirty-eight percent (63) of the patients were treated primarily with radiotherapy, while the rest (105) had received androgen ablative therapy during 2 to 4.5 years before radiotherapy. To examine the effect of treatment time on local control, the patients were divided into three groups ( < or = 63 days, 64-70 days, and > 70 days) by treatment time. RESULTS: the 5-year actuarial survival rates, calculated from the date of diagnosis, were 91% for the hormonally manipulated patients and 69% for the patients treated with radiotherapy alone. The 5-year actuarial local control rates, counted from the start of radiotherapy, were 84% for radiotherapy and 80% for the hormonally manipulated group. Overall, no significant effect of treatment time could be seen, either for radiotherapy alone or for the hormonally manipulated group. The results were similar when the material was further divided by T category and histologic grade. CONCLUSIONS: no significant effect of overall treatment time (55 to 100 days) on survival or local control was found in either group. The survival time from diagnosis was longer in the hormonally pretreated group. Apparently, with adequate doses ( > or = 65 Gy) the overall treatment time becomes less important for local control of advanced prostatic cancer, even in a split-course treatment setting.

Adenocarcinoma↗

Improved local control and survival for surgically staged patients with locally advanced prostate cancer treated with up-front low dose rate iridium-192 prostate implantation and external beam irradiation.

PURPOSE: In an effort to improve upon the historically poor local control and survival rates for locally advanced prostate carcinoma, a prospective multidisciplinary clinical trial was initiated using low dose rate Iridium-192 prostate implantation and external beam irradiation. METHODS AND MATERIALS: Between January 1983 and September 1989, 57 patients with newly diagnosed bulky prostatic carcinoma (5 Stage B2, 52 Stage C) were treated at the Mayo Clinic (34 patients) and William Beaumont Hospital (23 patients) with (a) 5 Gy delivered preoperatively in one fraction, (b) pelvic lymphadenectomy with interstitial implantation of the prostate using Iridium-192 seeds via a perineal template to 30-35 Gy, and (c) 30.6 Gy external irradiation to prostate only in 17 fractions. RESULTS: After lymphadenectomy, 30/57 (53%) patients had pathologically confirmed positive lymph nodes or "D1" disease. Thirty-four patients (60%) had Gleason scores > or = 7. Mean age at diagnosis was 63.3 years. Median overall follow-up was 72 months. The 5-year actuarial survival rate was 85% and disease-free survival was 63%. The 5-year survival for patients with negative nodes was 93% and with positive nodes was 79%. The corresponding survival for patients with Gleason scores < or = 6 was 96% and > or = 7 was 78%. Multivariate analysis demonstrated that of all covariates considered, only Gleason score had prognostic significance for disease-free survival (p < 0.05) and no covariates were statistically significant for overall survival. Thirty-nine of the 57 patients had a prostatic re-biopsy performed at 18 months. Pathologically confirmed local control was ultimately achieved in 31/39 (79.5%). There was no difference in survival in patients with positive re-biopsies vs. those with negative results. The 5-year actuarial rate of clinical local control was 94%. Three patients clinically failed locally and 21 demonstrated distant progression. The median time to progression was 34 months. Nineteen percent received some form of hormonal manipulation at the time of their treatment course and an additional 42% were treated with hormones during their follow-up period, primarily after distant failure. The grade 4 rectal ulceration rate decreased to 4.5% with modification of the brachytherapy technique. Three patients experienced grade 4 urinary incontinence and three patients experienced grades 3 or 4 chronic perineal pain. CONCLUSION: These results indicate that bulky prostate carcinoma can be successfully controlled locally by this novel and aggressive approach with moderate toxicity and improved survival.

Adenocarcinoma↗

Sound localization in chinchillas. II. Front/back and vertical localization.

The ability of chinchillas to make front/back and vertical locus discriminations was examined behaviorally using a conditioned avoidance procedure. Their minimum audible angle for localizing single broadband noise bursts was 36 degrees for front/back localization and 23 degrees for vertical localization. Sound localization tests using filtered noise demonstrated that the signal must contain high frequencies in order for chinchillas to make front/back and vertical locus judgements and that frequencies in their highest audible octave (i.e., above 16 kHz) contribute to localization. These results support the view that a major selective advantage of high-frequency hearing in mammalian evolution was its utility for monaural as well as binaural sound localization.

Acoustic Stimulation↗

Localized carcinoma of the external ear is an unrecognized aggressive disease with a high propensity for local regional recurrence.

Management problems in patients with recurrent squamous cell carcinoma (SCC) of the external ear (pinna) have prompted a review of the management and treatment outcomes of patients who present with localized disease. Forty patients were seen over a 15-year period (1972 to 1991). Thirty-six were men, and 4 were women, with an age range from 43 to 93 years (average age: 71 years). Presenting TNM status was stage 0 in 2 patients, stage I in 15 patients, stage II in 13 patients, stage III in 2 patients, stage IV in 4 patients, and unknown stage in 4 patients. Thirty-six patients had clinically negative nodes at presentation (N0), and 4 had palpable nodes (N+). The primary treatment was local excision in 13 patients, Mohs' micrographic surgery in 16 patients, local excision plus external beam radiotherapy in 4 patients, and radical resection (parotidectomy/neck dissection/mastoidectomy) with or without radiotherapy in 5 patients. Two patients with stage IV disease died after diagnosis and prior to treatment, and two other patients with stage IV disease received palliative chemotherapy. Twenty patients developed recurrence from 2 months to 8 years. It included nine local recurrences, eight regional recurrences (parotid/neck/mastoid), and three distant metastases (lung or brain). After treatment of the recurrences in 20 patients, 8 are alive 15 months to 16 years later, 2 patients died of other diseases, and 10 patients died of SCC. The recurrences were managed by reoperation, radiotherapy, or chemotherapy. From the results of this study, we conclude that localized carcinoma of the external ear has a high propensity for local and regional failure and merits more aggressive treatment of the primary lesion and elective treatment of the regional lymph nodes and parotid gland in high-risk patients.

Adult↗

Effects on functional outcome after IORT-containing multimodality treatment for locally advanced primary and locally recurrent rectal cancer.

PURPOSE: In the treatment of patients with locally advanced primary or locally recurrent rectal cancer, much attention is focused on the oncologic outcome. Little is known about the functional outcome. In this study, the functional outcome after a multimodality treatment for locally advanced primary and locally recurrent rectal cancer is analyzed. METHODS AND MATERIALS: Between 1994 and 1999, 55 patients with locally advanced primary and 66 patients with locally recurrent rectal cancer were treated with high-dose preoperative external beam irradiation, followed by extended surgery and intraoperative radiotherapy. To assess long-term functional outcome, all patients still alive (n = 97) were asked to complete a questionnaire regarding ongoing morbidity, as well as functional and social impairment. Seventy-six of the 79 patients (96%) returned the questionnaire. The median follow-up was 14 months (range: 4-60 months). RESULTS: The questionnaire revealed fatigue in 44%, perineal pain in 42%, radiating pain in the leg(s) in 21%, walking difficulties in 36%, and voiding dysfunction in 42% of the patients as symptoms of ongoing morbidity. Functional impairment consisted of requiring help with basic activities in 15% and sexual inactivity in 56% of the respondents. Social handicap was demonstrated by loss of former lifestyle in 44% and loss of professional occupation in 40% of patients. CONCLUSIONS: As a result of multimodality treatment, the majority of these patients have to deal with long-term physical morbidity, the need for help with daily care, and considerable social impairment. These consequences must be weighed against the chance of cure if the patient is treated and the disability eventually caused by uncontrolled tumor progression if the patient is not treated. These potential drawbacks should be discussed with the patient preoperatively and taken into account when designing a treatment strategy.

Adult↗

Is there a place for local anesthetics structurally different from classical amid or ester local anesthetics?

PURPOSE OF REVIEW: The aim of this review is to describe the pharmacology, toxicology and chemistry of the new group of local anesthetics of phenylcarbamic acid type. RECENT FINDINGS: Basic esters of alkoxy-substituted phenylcarbamic acid have shown high local anesthetic potency, while maintaining a relatively safe toxicity profile. Their potency uniquely increases with the decreasing pH of the external medium. This is of importance when using local anesthesics in inflamed tissues, where the action of common local anesthetics is often problematic. SUMMARY: The most potent phenylcarbamic anesthetics exceed the potency of the most common clinically used local anesthetics 100-300 times. Due to the unique pH dependency of these local anesthetics, further study of their action is required.

Amides↗

Developing healthy local communities at local government level: lessons from the past decade.

There have been many approaches by the health sector to developing healthy communities based on local government areas in Australia in the past decade. Each has struggled with the need to establish realistic goals and to find ways of working more effectively with local government. This paper outlines four of these approaches--Healthy Cities, the Healthy Localities project, municipal health plans, and programs to address specific health problems or issues. Although the picture is one of huge diversity in the ways in which the issue is defined and action taken, a number of dimensions to a healthy community are emerging. However, if we are to be able to monitor change within and between the health of communities over time, indicators need to be developed and goals set. This will require a shift away from defining goals and targets in terms of populations (people), towards goals based on changes in organisations and systems. Engaging local government in this process will be vital and will require the health sector to develop a better understanding of the ways in which local government defines its role in creating healthy communities. It will also involve learning from local government the strategies that they have found most effective in dealing with complex problems that require action at many levels.

Australia↗