Case Study Part 2: Probabilistic modelling of long-term effects of pesticides on individual breeding success in birds and mammals.

Long term exposure of skylarks to a fictitious insecticide and of wood mice to a fictitious fungicide were modelled probabilistically in a Monte Carlo simulation. Within the same simulation the consequences of exposure to pesticides on reproductive success were modelled using the toxicity-exposure-linking rules developed by R.S. Bennet et al. (2005) and the interspecies extrapolation factors suggested by R. Luttik et al. (2005). We built models to reflect a range of scenarios and as a result were able to show how exposure to pesticide might alter the number of individuals engaged in any given phase of the breeding cycle at any given time and predict the numbers of new adults at the season's end.

Case Study Part 1: How to calculate appropriate deterministic long-term toxicity to exposure ratios (TERs) for birds and mammals.

In the European Union, first-tier assessment of the long-term risk to birds and mammals from pesticides is based on calculation of a deterministic long-term toxicity/exposure ratio (TER(lt)). The ratio is developed from generic herbivores and insectivores and applied to all species. This paper describes two case studies that implement proposed improvements to the way long-term risk is assessed. These refined methods require calculation of a TER for each of five identified phases of reproduction (phase-specific TERs) and use of adjusted No Observed Effect Levels (NOELs) to incorporate variation in species sensitivity to pesticides. They also involve progressive refinement of the exposure estimate so that it applies to particular species, rather than generic indicators, and relates spraying date to onset of reproduction. The effect of using these new methods on the assessment of risk is described. Each refinement did not necessarily alter the calculated TER value in a way that was either predictable or consistent across both case studies. However, use of adjusted NOELs always reduced TERs, and relating spraying date to onset of reproduction increased most phase-specific TERs. The case studies suggested that the current first-tier TER(lt )assessment may underestimate risk in some circumstances and that phase-specific assessments can help identify appropriate risk-reduction measures. The way in which deterministic phase-specific assessments can currently be implemented to enhance first-tier assessment is outlined.

How did Project Northland reduce alcohol use among young adolescents? Analysis of mediating variables.

Project Northland is a randomized trial designed to create, implement and evaluate multilevel, community-wide strategies to prevent alcohol use among adolescents. This paper will focus on the mediating outcomes of the early adolescent phase of Project Northland when the students in the study cohort were in Grades 6-8. The project was conducted in 24 school districts and adjacent communities in northeastern Minnesota. The intervention consisted of social-behavioral curricula in schools, peer leadership activities, parental involvement and education, and community-wide activities. At the end of 3 years of intervention, significantly fewer students in the intervention school districts reported alcohol use than students in the reference districts. Mediation analyses were conducted to investigate if the intervention's effects on mediating variables could explain the reduction in alcohol use. Important mediators of Project Northland's effect on alcohol use were: (1) peer influence to use, including normative estimates, (2) functional meanings of alcohol use, (3) attitudes and behaviors associated with alcohol and drug problems like stimulus seeking, rule violations and bad judgement, and (4) parent-child alcohol-related communication around alcohol use. In addition, among those who did not use alcohol at baseline, self-efficacy to refuse offers of alcohol was a significant mediator.

The Minnesota DARE PLUS Project: creating community partnerships to prevent drug use and violence.

The research community has criticized Drug Abuse Resistance Education (D.A.R.E.) because the extant literature indicates a lack of evidence that the elementary school program prevents drug use. Yet D.A.R.E. continues to be the most widely implemented drug use prevention program in the United States and has considerable community support. To date, the junior high D.A.R.E. program has not been evaluated. The Minnesota DARE PLUS Project is a randomized trial of 24 schools and communities. During 1999-2001, students in eight schools will receive the junior high D.A.R.E. curriculum in 7th grade; eight schools also will receive the curriculum as well as additional parent involvement, peer leadership, and community components in the 7th and 8th grades; and eight schools will serve as controls. This article describes the background and conceptualization, the curriculum and additional intervention components, and the evaluation methods of the DARE PLUS Project.

Project Northland high school interventions: community action to reduce adolescent alcohol use.

Project Northland is a randomized community trial initially implemented in 24 school districts and communities in northeastern Minnesota, with goals of delaying onset and reducing adolescent alcohol use using community-wide, multiyear, multiple interventions. The study targets the Class of 1998 from the 6th to 12th grades (1991-1998). The early adolescent phase of Project Northland has been completed, and reductions in the prevalence of alcohol use at the end of 8th grade were achieved. Phase II of Project Northland, targeting 11th- and 12th-grade students, uses five major strategies: (1) direct action community organizing methods to encourage citizens to reduce underage access to alcohol, (2) youth development involving high school students in youth action teams, (3) print media to support community organizing and youth action initiatives and communicate healthy norms about underage drinking (e.g., providing alcohol to minors is unacceptable), (4) parent education and involvement, and (5) a classroom-based curriculum for 11th-grade students. This article describes the background, design, implementation, and process measures of the intervention strategies for Phase II of Project Northland.

An evaluation of a theatre production to encourage non-smoking among elementary age children: 2 Smart 2 Smoke.

OBJECTIVE: To evaluate the impact of a theatre production on smoking-related attitudes, norms, and intentions of children in grades 1-6 (aged 6-12 years). DESIGN: Seventeen schools were randomly selected among 160 that were participating in the implementation of the theatre production 2 Smart 2 Smoke. Schools that participated in the theatre production after 3 December 1997 were assigned as control schools. Assignment of schools to a given date for the theatre production was a random process. Students in grades 1-6 were surveyed before and after the theatre production and associated activities. The data were examined for pretest-posttest differences and intervention-control differences. The school was the unit of analysis. SETTING: Elementary schools in the Twin Cities metropolitan area. PARTICIPANTS: Students in grades 1-6 in 17 elementary schools. INTERVENTION: Two plays 2 Smart 2 Smoke for grades 1-3 (6-8 year olds) and grades 4-6 (9-12 year olds), respectively, with follow-up activities for the classroom and home. A national theatre company performed the plays at the schools. MAIN OUTCOME MEASURES: Intention to smoke in the future, normative expectations about how many people smoke, functional meanings of smoking, expected outcomes of smoking. RESULTS: 10% more students reported that they would never smoke a cigarette after the theatre production. Students in grades 4-6 showed changes in the functional meanings and expected outcomes of smoking. Students in grades 1-3 showed changes in normative expectations. CONCLUSIONS: Further research on the impact of live theatre productions as a smoking prevention strategy is recommended.

Criterion-related validity of a clinical measurement to determine the medial/lateral component of patellar orientation.

STUDY DESIGN: Repeated measures design using a sample of convenience. OBJECTIVE: To assess the criterion-related validity and intrarater reliability of a clinical measurement used for determining the medial/lateral position of the patella. BACKGROUND: Patellar taping is a common treatment for patellofemoral pain. Application of this intervention requires accurate assessment of patellar orientation; however, the validity of this clinical procedure has not been documented. METHODS AND MEASURES: Fourteen subjects (10 women, 4 men; average age, 41 +/- 16 years) were evaluated. Clinical assessment of medial/lateral patellar orientation using the technique described by McConnell was compared with the actual position of the patella as determined through magnetic resonance imaging (MRI). Imaging was done on 7 knees of 4 subjects who were asymptomatic and 11 knees of 10 subjects who were symptomatic. Both clinical and MRI assessments were made with the subjects supine, the knee extended, and the quadriceps relaxed. Agreement between the 2 techniques and the intrarater reliability of each measurement were quantified by means of the intraclass correlation coefficient (ICC). RESULTS: Both the clinical and MRI measures of medial/lateral patellar displacement were found to demonstrate good intrarater reliability (ICC = 0.91 and 0.85, respectively). The agreement between the clinical and MRI determinations of medial/lateral patellar position was poor (ICC = 0.44). The average amount of lateral patellar displacement as determined by the clinical method was more than twice that established through MRI. CONCLUSIONS: The clinical assessment of the medial/lateral position of the patella overestimates the true amount of lateral patellar displacement. A more valid clinical method of assessing the medial/lateral component of patellar orientation is necessary.

Project Northland: comprehensive alcohol use prevention for young adolescents, their parents, schools, peers and communities.

OBJECTIVE: Project Northland is an ongoing prevention trial with the objective of reducing underage drinking and related problems. Phase I focused on early adolescence and this study describes the multiple interventions, highlighting its parent components. METHOD: A cohort design was used with sixth graders from 24 school districts (N = 2,35 1: 97% of the eligible population: 51.3% boys), randomly assigned to intervention or reference condition. Phase I ended in eighth grade (N = 1,901: 81% retention rate). Both demand and supply reduction guided the interventions. This study examined Project Northland's impact using MMPI-A scales assessing clinical problems related to adolescents' alcohol and other drug use (Alcohol/Drug Problems Proneness scale; Alcohol/Drug Problems Acknowledgement scale), as well as MMPI-A scales related to school functioning (Adolescent-School Problems Content scale: Adolescent-Low Aspirations Content scale) and family functioning (Adolescent-Family Problems Content scale). RESULTS: Results showed significant reductions on the MMPI-A Proneness scale for those exposed to the interventions. The greatest program effects were among baseline nonusers of alcohol. CONCLUSIONS: Results suggest that the impact of Project Northland is not only on specifically targeted alcohol and drug use behaviors and their predictive factors, but also on intra-individual and familial factors generally considered precursors of more extensive problem behaviors and more resistant to change. Furthermore, the engaging home-based sixth-grade intervention, the Slick Tracy Home Team Program, is a promising population-based prevention approach that may generalize to other serious problems within a young person's family.

Sarcoidosis with orbital tumor outside the lacrimal gland: initial manifestation in 2 elderly white women.

Two elderly white women (aged 72 and 87 years) were first seen with painless, unilateral orbital swelling. Orbital scanning revealed masses infiltrating the soft tissue around the eye. Biopsy results showed nodular, noncaseating granulomas consistent with sarcoidosis. One patient's workup revealed systemic manifestations of sarcoidosis at the time of examination with hilar lymphadenopathy noted on gallium scan; the other refused a complete systemic workup. The orbital tumors resolved with systemic prednisone therapy. To our knowledge, our 87-year-old patient is the oldest to be seen with orbital sarcoidosis. These 2 patients demonstrate that this diagnosis must be considered with orbital tumors in the elderly and in unusual locations, such as these which occurred outside the lacrimal gland.

School and community influences on adolescent alcohol and drug use.

Social environment risk factors present in schools and communities have not been thoroughly investigated. This study cross-sectionally examined the social environments of schools and communities, and their influence on adolescent alcohol and drug use. Survey responses of eighth grade students (N = 2309), a random half of their parents (n = 943), community leaders (n = 118), school principals (n = 30), school counselors (n = 30) and chemical health providers (n = 14) were pooled to create indices of social environmental norms, role models, social support and opportunities for non-use of alcohol. Each index was examined for its association with prevalences from 30 schools of alcohol use onset, last-month alcohol use, heavy alcohol use and last-year marijuana use in univariate and stepwise regression analyses. Increases in the levels of norms, role models and opportunities for non-use predicted decreases in alcohol use prevalences. The explanatory power of the examined constructs in multivariate analyses was acceptably high (R2: 38-53%). These findings further support the notion that community-wide efforts need to be launched to affect changes in the normative, role model and opportunity structures of adolescents' social environments in order to curb adolescent alcohol and drug use.

Peer-planned social activities for preventing alcohol use among young adolescents.

The Project Northland peer participation program tested the feasibility of involving students in the planning and promotion of alcohol-free social activities for their peers and to determine whether such participation was associated with reduced alcohol use. The peer program was offered in 20 northeastern Minnesota schools when the study cohort was in seventh grade; students completed a survey in the beginning of sixth grade and at the end of sixth grade and seventh grade. Nearly 50% of the study cohort participated in the program. At the end of seventh grade, after controlling for confounders, an association was observed between student involvement with planning activities and a lower rate of alcohol use. This association was strongest among students who had reported alcohol use at the beginning of sixth grade. This cohort study suggests adolescent involvement in planning their own alcohol-free activities may be an efficacious strategy to prevent or reduce the prevalence of alcohol use among youth. Future studies are warranted to evaluate this association using experimental research designs.

Project Northland: outcomes of a communitywide alcohol use prevention program during early adolescence.

OBJECTIVES: Project Northland is an efficacy trial with the goal of preventing or reducing alcohol use among young adolescents by using a multilevel, communitywide approach. METHODS: Conducted in 24 school districts and adjacent communities in northeastern Minnesota since 1991, the intervention targets the class of 1998 (sixth-grade students in 1991) and has been implemented for 3 school years (1991 to 1994). The intervention consists of social-behavioral curricula in schools, peer leadership, parental involvement/education, and communitywide task force activities. Annual surveys of the class of 1998 measure alcohol use, tobacco use, and psychosocial factors. RESULTS: At the end of 3 years, students in the intervention school districts report less onset and prevalence of alcohol use than students in the reference districts. The differences were particularly notable among those who were nonusers at baseline. CONCLUSIONS: The results of Project Northland suggest that multilevel, targeted prevention programs for young adolescents are effective in reducing alcohol use.

A home-based prevention program for sixth-grade alcohol use: Results from project Northland.

Project Northland is designed to prevent alcohol use among young adolescents. The project is ongoing in 24 school districts, randomly assigned to intervention or reference conditions. Multiple interventions begin with sixth graders and continue through eighth grade. The reference districts offer their standard health curricula. Evaluation consists of school surveys with the cohort (N = 2201) and telephone surveys of half their parents. This article describes the sixth-grade home-based intervention, the Slick Tracy Home Team. Findings of broad-based participation across sex, race, and risk status were documented, as well as some increases in knowledge and family communication about alcohol use.

Peer participation in Project Northland: a community-wide alcohol use prevention project.

This paper describes the rationale, conceptual framework, and program components of a peer participation program for prevention of alcohol use among young adolescents. The peer participation program was one component of Project Northland, a community-wide program that seeks to prevent or delay onset of alcohol use among a cohort of young adolescents. The peer participation program, implemented in 20 northeastern Minnesota schools when students were in seventh grade, consisted of student groups who planned supervised, alcohol-free activities for themselves and their classmates. Program goals included 1) providing peer leadership and social support for non-use of alcohol, 2) creating opportunities for alternative behaviors to alcohol use, thereby 3) creating a norm of non-use among young adolescents.

Community ownership and program continuation following a health demonstration project.

Community ownership and maintenance of heart health programs was a major study goal of the Minnesota Heart Health Program (MHHP), a community-based National Heart, Blood and Lung Institute (NIH)-funded demonstration project. A partnership between the University of Minnesota and three Upper Midwest intervention communities was initiated in 1981. Local citizen boards were instrumental in planning, implementing and incorporating programs. Through an 8 year process of community organization, training and volunteer involvement, MHHP educational program responsibility was transferred to existing community-based groups and organizations. In 1989, when federal funding was withdrawn, 70% of all heart health intervention programs initiated by MHHP were being continued by local sponsors and supported by local funds. By 1992, maintenance of programs had decreased to an average 60%. Differential results of program incorporation among the three intervention communities are presented including findings on community sectors that most frequently sponsored programs. Factors that facilitate or impede local ownership are discussed. Research on longer-term maintenance of heart health programs in the three communities continues.

Background, conceptualization and design of a community-wide research program on adolescent alcohol use: Project Northland.

Project Northland is a community-wide research program funded by the National Institute on Alcoholism and Alcohol Abuse, for a 5-year period (1990-95). The aim of the study is to prevent or delay onset of alcohol use among young adolescents, as well as to reduce use among those who are already drinkers. Twenty communities were recruited in northeastern Minnesota, an area referred to as the Northland, Arrowhead or Iron Range region, and then were randomly assigned to either Education or Delayed Program conditions. The 10 Education school districts have agreed to participate in 3 years of intervention programs in schools, with parents and in the community-at-large. One group of young adolescents, the Class of 1998 (sixth grade students in the 1991-92 school year), form the study cohort. Surveys (1991-94) of the Class of 1998, their parents, community leaders and alcohol merchants are the primary components of the program's evaluation. Many conceptual and methodological questions emerged during the development of the research protocols for Project Northland over the past 2 years. These questions are the impetus for this article. Specifically, the focus on young adolescents and alcohol use was selected, as contrasted with older adolescents or with multiple problem behaviors. The project was designed using a community-wide model that addresses both supply and demand issues, rather than limited to a school-based model. Intervention strategies and evaluation methods were chosen that could address community-level as well as individual-level behavior change, which required the development and application of new technologies. The rationale for these decisions may be useful to others considering community-wide health promotion efforts.

Congenital anomalies of the optic nerve in one family.

We present three cases of congenital optic disc anomalies in one family who underwent an extensive diagnostic workup to exclude any intracranial pathology. One patient had elevated optic nerve heads and was hospitalized for multiple diagnostic tests including a lumbar puncture and magnetic resonance imaging scan. This patient had a sister with a previous history of having undergone head and orbital computed tomography to evaluate her symptoms of headaches with anomalous optic nerve heads. The third patient was the father of the other two patients who had previously undergone an extensive evaluation for elevated optic nerve heads and was treated for presumed pseudotumor cerebri with fenestration of the optic nerve sheath. These cases underscore the importance of a detailed family history and examination of family members to exclude congenital abnormalities of the optic nerve head before beginning an extensive workup.

Endothelial cell loss following "modern" phacoemulsification by a senior resident.

Historically, extracapsular cataract extraction (ECCE) has been shown to cause less endothelial cell loss than phacoemulsification. To further evaluate endothelial cell loss following phacoemulsification, we prospectively studied 60 patients who underwent cataract extraction with "in situ" phacoemulsification within the capsular bag following a continuous-tear circular capsulotomy, with placement of a posterior chamber intraocular lens (PC-IOL) in the capsular bag. All procedures were performed by a single senior ophthalmology resident. The average preoperative endothelial count was 2318 +/- 36 cells/mm2; the average postoperative count (at 8.5 weeks) was 2167 +/- 41 cells/mm2. The average endothelial cell loss, then, was 6.4 +/- 1.2%. This level of cell loss with a capsular-bag-fixed PC-IOL is comparable to that reported for ECCE.

Current status of health promotion activities in four midwest cities.

Community-wide surveys were conducted in Winona and St. Cloud, MN, Eau Claire, WI, and Sioux Falls, SD, in 1986 and 1987 to determine the current status of the supply and demand of health promotion activities in nine categories. Supply and demand indicators were conceptualized and defined as program options (different activities in a coded list) and participation (registrations). An annual inventory of all health promotion activities in each community was complied from interviews with providers of such activities. Interviews of probable community providers was followed by a nomination process to identify others. Providers at worksites were interviewed in a separate study with matching data endpoints. Results show that exercise programs have the highest levels of options and participation in all four cities. On the supply side of total programs offered, there was similarity in rates among three of the cities, with only Winona offering more health promotion opportunities. There was similarity also in the areas of health where most programs are offered, favoring exercise, followed by the heart disease risk factor areas of screening, smoking cessation, and nutrition education. On the demand side of participation, there was similarity in total participation rates among three of the four cities with Sioux Falls showing substantially higher demand. Exercise showed the highest participation in all cities, but there was little similarity among the cities in ranking participation in the other areas of health promotion. In the four cities combined, high levels of program options with low participation were characteristic of smoking cessation. In contrast, low levels of program options and high participation were shown in chemical dependency. Worksites are the main providers of health promotion programs for adults, with schools and colleges also major program providers. Educational organizations account for the largest percentage of total participation in health promotion.