Food supply and bioenergy production within the global cropland planetary boundary.

Supplying food for the anticipated global population of over 9 billion in 2050 under changing climate conditions is one of the major challenges of the 21st century. Agricultural expansion and intensification contributes to global environmental change and risks the long-term sustainability of the planet. It has been proposed that no more than 15% of the global ice-free land surface should be converted to cropland. Bioenergy production for land-based climate mitigation places additional pressure on limited land resources. Here we test normative targets of food supply and bioenergy production within the cropland planetary boundary using a global land-use model. The results suggest supplying the global population with adequate food is possible without cropland expansion exceeding the planetary boundary. Yet this requires an increase in food production, especially in developing countries, as well as a decrease in global crop yield gaps. However, under current assumptions of future food requirements, it was not possible to also produce significant amounts of first generation bioenergy without cropland expansion. These results suggest that meeting food and bioenergy demands within the planetary boundaries would need a shift away from current trends, for example, requiring major change in the demand-side of the food system or advancing biotechnologies.

When do medical students become human subjects of research? The case of program evaluation.

Intense national dialogue exists around federal requirements protecting the rights of human subjects in clinical research. There is much less discussion surrounding protections for human subjects in such areas as evaluation research when the subjects are also students. Differential interpretation of 45 CFR 46 (the standing regulation on research involving human subjects) by institutional review boards (IRBs) leaves many confused about whether research using student data requires IRB review. At the heart of the uncertainty are "dual purpose activities," for example, when student data from program evaluation or routine assessments subsequently become the basis for faculty scholarship that is disseminated as "generalizable knowledge" to the community of medical educators. The authors identify two factors that should be considered as institutions develop applications and interpretations of 45 CFR 46. First, medical educators should enter into dialogues with their IRBs to become more familiar with these regulations and their application in evaluation or assessment studies. Second, for reasons of professionalism, faculty should seek opportunities to model in their role as researchers those ethical behaviors that are central to an honest relationship between physician and patient. In the educational context this means faculty disclosure of how student data may be used by faculty in their own scholarship and determination of when student consent is needed. The authors also describe how one medical school addressed this thorny challenge with assistance from the university IRB and offer suggestions to improve institutional procedures.

Color perception through atmospheric haze.

The radiance of most objects seen at a distance through the atmosphere is dominated by scattered light of a blue hue that should make the landscape appear predominately blue. However, common experience shows that people can see colors at a distance. A possible explanation of this paradox is that the visual system splits the light into a haze layer and the background landscape. A straightforward mathematical description of this splitting explains the results of a color matching study in the Great Smoky Mountains National Park. In this study, hues of objects seen through haze were found to be constant with changes in optical depth while colorfulness decreased exponentially.

Current practices regarding newborn intracranial haemorrhage and obstetrical care and mode of delivery of pregnant haemophilia carriers: a survey of obstetricians, neonatologists and haematologists in the United States, on behalf of the National Hemophilia Foundation's Medical and Scientific Advisory Council.

We undertook this survey to determine institutional practices of obstetricians, neonatologists and haematologists regarding care of pregnant haemophilia carriers and newborns with haemophilia and intracranial haemorrhage (ICH). Our purpose was also to determine whether institutions had written guidelines to manage such patients. Questionnaires were sent to 1000 obstetricians and through the Haemophilia Treatment Centres (HTC) to 180 paediatric haematologists and 180 neonatologists, each representing an institution. Twenty-three per cent of obstetricians, 22% of neonatologists and 16% of paediatric haematologists returned completed surveys. Over 94% of the respondents had no written guidelines for management of pregnant haemophilia carriers or their newborns or for neurologic assessment of newborns. For known haemophilia carriers, 57% of the obstetricians routinely preferred vaginal delivery and 11% preferred caesarean section. Availability of perinatal services influenced prenatal management (P < 0.05). In term newborns with documented ICH, only 23% of neonatologists would evaluate for haemophilia, whereas in pre-term newborns with ICH, this number dropped even further to 3%. For all newborns with haemophilia, 40% preferred routine administration of clotting factor concentrates (CFC) immediately following birth to offset the trauma of delivery and 89% of paediatric haematologists favoured early prophylaxis with CFC. Guidelines are needed for management of pregnant haemophilia carriers as well as newborns with haemophilia. Physicians need to be made aware that ICH may be a presenting sign of haemophilia in both term as well as pre-term newborns, so that appropriate therapy can be instituted early in the event of a bleed.

When (not if) evaluation flexibility is desirable. Examples from the CPHPE initiative.

The evaluation literature often debates whether evaluators should be flexible in evaluation design and activities in order to collaborate with program directors and be responsive to programming needs. Two conditions are specified under which evaluation flexibility is not only desirable but essential. Two examples from the cluster evaluation of the W. K. Kellogg Foundation's Community Partnerships for Health Professions Education initiative are provided to illustrate why flexibility under these conditions proved to be essential. One of the examples, related to the "community" involvement in the initiative, illustrates the need for flexibility as programs experience goals clarification. The other example, related to the coincidental national health care reform efforts, illustrates the need for flexibility both to capture programs' efforts to protect their integrity and to ensure against spurious conclusions as a result of external turbulence in policy environments. How the cluster evaluation team addressed these issues is also described.

Evaluating the impact on public policy of foundation-sponsored programs in the health professions.

The leaders of national philanthropic foundations have long been active in informing public policy makers about their organizations' accomplishments and lessons learned in health care and other issues. The public policy context also is seen increasingly as an important factor influencing changes in the health care market. This article outlines how public policy was monitored and evaluated in a recent initiative in health care by a prominent national foundation. The markers of policy change in the evaluation of this initiative represented a mixture of the initiative's efforts to inform policy makers, the success the participant projects had in making policy makers aware of the initiative's goals, and actual changes in policy outcomes.

Multidisciplinary education outcomes of the W.K. Kellogg Community Partnerships and Health Professions Education initiative.

This evaluation highlights several points to be considered by others instituting multidisciplinary approaches to health professions education. Community-based, multidisciplinary experiences appear to reinforce support students' interests in pursuing primary care careers. The multidisciplinary, community-based approach to health professions education did not affect academic learning. Project leaders and students reported no risks in terms of board scores between CPHPE students and others in traditional programs. The multidisciplinary, community-based approach to health professions education created opportunities at some sites for students to see "team medicine" in action. It was practical and helped students to understand how they could be more effective in their roles as opposed to competitive. Students require socialization within their own individual disciplines as well as socialization across disciplines. The differences in the structures of traditional health professions education schools interfered with the development of multidisciplinary contexts for learning at some sites. Campus faculty were not necessarily socialized to engage in multidisciplinary efforts. Their disciplines generally do not recognize and reward this behavior. Early and continuous faculty development may significantly help projects to improve communication and develop a better understanding of the contexts of curricular changes across disciplines. This evaluation was exploratory. Further research is needed to better understand what forms of multidisciplinary curriculum are most effective and economically feasible, what forms survive over time, and whether the intended final outcomes of the CPHPE initiative are achieved, not only with medical students but also with the other health professions students.

An exploratory look at hydrocarbon data from the Photochemical Assessment Monitoring Stations network.

This paper describes some characteristics of speciated nonmethane organic compound (NMOC) data collected in 1994 at five Photochemical Assessment Monitoring Stations (PAMS) and archived in the U.S. Environmental Protection Agency's Aerometric Information Retrieval System (AIRS). Topics include data completeness, distribution of individual NMOCs in concentration categories relative to minimum detectable levels, percentage of total NMOC associated with the sum of the 55 PAMS target compounds, and use of scatterplots to diagnose chromatographic misidentification of compounds. This is an early examination of a database that is expanding rapidly, and the insights presented here may be useful to both the producers and future users of the data for establishing consistency and quality control.

Reported emissions of organic gases are not consistent with observations.

Regulatory agencies and photochemical models of ozone rely on self-reported industrial emission rates of organic gases. Incorrect self-reported emissions can severely impact on air quality models and regulatory decisions. We compared self-reported emissions of organic gases in Houston, Texas, to measurements at a receptor site near the Houston ship channel, a major petrochemical complex. We analyzed hourly observations of total nonmethane organic carbon and 54 hydrocarbon compounds from C-2 to C-9 for the period June through November, 1993. We were able to demonstrate severe inconsistencies between reported emissions and major sources as derived from the data using a multivariate receptor model. The composition and the location of the sources as deduced from the data are not consistent with the reported industrial emissions. On the other hand, our observationally based methods did correctly identify the location and composition of a relatively small nearby chemical plant. This paper provides strong empirical evidence that regulatory agencies and photochemical models are making predictions based on inaccurate industrial emissions.

The emperor's new clothes: the OSCE reassessed.

In response to increasing concerns about the prevalence of knowledge- based assessments of medical student competency, leaders in medical education have emphasized the importance of methods that quantify student performance. As a result, the use of objective structured clinical examinations (OSCEs) is viewed by many as the newest and most promising technique for assessing students' abilities. In considering the implementation of a fourth-year OSCE, faculty at the College of Human Medicine at Michigan State University became uncomfortable with some of the technical limitations of the method (limited generalizability; weak linkages to the curriculum; little opportunity provided for improvement in examinees' skills; and others), as well as the possible ramifications of such an innovation within their school's specific curricular and organizational contexts. This essay is offered as a reflection of the challenges and possible alternatives that have emerged as the faculty have considered how best to design and implement performance-based assessment within their institution. Rather than using the OSCE as a milestone marker of student performance, they consider the possibility of smaller assessment events, closely tied to the curriculum and consistent with the guiding principles of the medical school.

Community partnerships: educational linkages to increase the number of primary care practitioners.

The Community Partnerships initiative is focused on the creation of academic, non-hospital community health centers shaped by people and institutions at the local level. In our view, public policy-makers need such positive ideas and programs to support--things to be for rather than against. Incessant lamenting about the problems of the health care system will change the system less than will positive programs shaped and supported by the people whose needs they serve. All of us in medical education recognize the need for change in medical education. The Community Partnerships program represents one strategy for change that brings communities directly into the sphere of influence and enables them to enhance the relevance of the educational experience for health professions students.

Community partnership model for health professions education.

Many health professions schools have neglected the US population's health by emphasizing acutely ill patients in hospitals, biomedical research of disease, and high technology. Because most students will eventually fill practitioner roles in primary and secondary care, it is logical that the health professions must shift their curricula's focus to prepare practitioners for the health care needs of the community. The Community Partnership Model is one approach that focuses on public health care needs by educating students in multiprofessional teams in a new organizational structure known as the academic, community-based, primary health care center. This partnership between academic institutions and communities is designed to shift the educational and socializing activities of health professions training outside hospitals to the community setting where research, teaching, and service take place in one structure.

Gender differences in Manning criteria in the irritable bowel syndrome.

The objective of this study was to determine if gender differences exist when using the Manning criteria for diagnosis of irritable bowel syndrome. In an outpatient setting, 61 women and 36 men with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified/eligible gastroenterologists who also systematically rated the presence or absence of the six Manning criteria. Irritable bowel syndrome was defined as the absence of an organic disease explanation for the entry complaints. This determination was made by two other board-certified gastroenterologists after patients had been in the study for 9 months. These raters were independent of the study and rated the transcripts of patients' clinic visits, all other available clinical data from this and other clinics, all laboratory data obtained during the 9-month study period, and the results of a 9-month telephone follow-up to patients and their physicians. Sixty-five percent of the study population had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome for this study. A similar proportion and type of organic disease and irritable bowel syndrome were experienced by men and women. For the total sample of 97 subjects, the correlation of the Manning criteria with irritable bowel syndrome was 0.22 (P less than 0.01). In the 61 women, correlation between the Manning criteria and irritable bowel syndrome was significant (r = 0.47; P less than 0.01). In the 36 men, however, the correlation was in the opposite direction, although it was not significant (r = -0.16). It was concluded that significant gender differences exist when using the Manning criteria for the diagnosis of irritable bowel syndrome and that the Manning criteria were not of diagnostic value in men.

Evaluation and implementation of public health registries.

A rapid proliferation of registries has occurred during the last 20 years. Given the long-term commitment of resources associated with registries and limited public health funding, proposals for new registries should be carefully considered before being funded. A registry is defined as a data base of identifiable persons containing a clearly defined set of health and demographic data collected for a specific public health purpose. Criteria for evaluating whether a registry is needed, feasible, or the most effective and efficient means of collecting a specific set of health data are presented. They include an evaluation of the stated purpose; a review of the function, duration, and scope of the registry; consideration of existing alternative data sources; an assessment of the practical feasibility of the registry; the likelihood of sufficient start-up and long-term funding; and an evaluation of the cost effectiveness of the registry. Creating a public health registry is a complex process. A range of technical and organizational skills is required for a registry to be successfully implemented. Eight requirements are identified as crucial for the successful development of a new registry. They include an implementation plan, adequate documentation, quality control procedures, case definition and case-finding (ascertainment) procedures, determination of data elements, data collection and processing procedures, data access policy, and a framework for dissemination of registry data and findings.