The effect of a low-carbohydrate diet on the nonalcoholic fatty liver in morbidly obese patients before bariatric surgery.

BACKGROUND: Bariatric surgery may be complicated by enlargement of the liver, especially of the left lobe, caused by nonalcoholic fatty liver disease often present with morbid obesity. METHODS: The effect of a very low carbohydrate diet for 4 weeks before surgery on liver density and volume was assessed in 14 candidates for bariatric surgery. Computed tomography (CT) scans were performed before and at termination of the diet period. RESULTS: The CT scans clearly showed a significant increase in mean liver density (p = 0.06) and a decrease in mean liver volume (p = 0.01). The increased mean density of the left lobe was markedly greater than that of the right lobe. CONCLUSIONS: The findings show that 4 weeks of a very low carbohydrate diet reduces liver fat content and liver size, particularly of the left lobe. This approach may render bariatric surgery or any foregut operations less difficult in morbidly obese patients and may be a useful treatment for nonalcoholic fatty liver disease.

Violence prevention in schools and other community settings: the pediatrician as initiator, educator, collaborator, and advocate.

Attention to the problem of youth violence has resulted in a proliferation of violence prevention and intervention strategies. Examined in this paper are those strategies that can be categorized as educational, environmental/technological, and recreational. In the educational category are conflict resolution and mediation, crime prevention and law-related education, handgun violence education, life skills training, self-esteem development, public education, and media education. The environmental/technological category covers a range of strategies: metal detectors, school police, concrete barriers, dress codes, and safe corridor programs, among others. The rather broad recreational category is based upon the importance of physical activity as an outlet for stress and anger and as a component of a multicomponent program. Multi-intervention programs are described as well as some of the major gaps in current violence prevention programming. The suggested role of the pediatrician in violence prevention efforts is described as both initiator and collaborator, as counselor, and as advocate. Because of their great credibility with respect to issues related to children and youth, pediatricians can influence not only parents in their contacts with them in the health care setting, but also school administrators and community leaders. Pediatricians have access to the media, and they can speak to the issue in public forums as well. Furthermore, pediatricians can join existing community efforts to determine ways in which violence prevention and intervention strategies can be incorporated into agency activities.

Patient and provider factors associated with selected measures of quality of care.

Studies assessing quality of general pediatric care are handicapped by (1) lack of explicit criteria, (2) the broad spectrum of medical needs presented, and (3) the need to distinguish between influence of patient and provider factors. In this study, part of a comprehensive study of utilization of pediatric services at five sites (three neighborhood health centers, an emergency room, and a hospital-based primary care program), we selected three measures sampling different aspects of quality of care, including (1) immunization status, (2) screening procedures, and (3) ongoing care for ten tracer conditons. Adequacy of follow-up of the tracer conditions was assessed along two dimensions: (1) whether a return appointment was scheduled, and (2) whether the patient kept the appointment ("compliance"). Results indicate that attainment of fully immunized status varies inversely with age, while for the tracer conditions, arrangement of follow-up (provider factor) was associated with site, and compliance (patient factor) was associated with both site and pattern of use. Accomplishment of follow-up was better for patients diagnosed in a primary care facility than in the emergency room and for patients with close ties to a primary care facility than for those with limited or no involvement with primary care. These findings support the value of continuity of care in a setting designed to deliver comprehensive care.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge.

All hospitals should set policies that require the discharge of every newborn in a car safety seat that is appropriate for the infant's maturity and medical condition. Discharge policies for newborns should include a parent education component, regular review of educational materials, and periodic in-service education for responsible staff. Appropriate child restraint systems should become a benefit of coverage by Medicaid, managed care organizations, and other third-party insurers.

American Academy of Pediatrics. Committee on Injury and Poison Prevention. Transporting children with special health care needs.

Children with special health care needs should have access to proper resources for safe transportation. This statement reviews important considerations for transporting children with special health care needs and provides current guidelines for the protection of children with specific health care needs, including those with a tracheostomy, a spica cast, challenging behaviors, or muscle tone abnormalities as well as those transported in wheelchairs.

Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step technique may improve outcome.

BACKGROUND: Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may, however, be a considerable challenge early in the surgeon's learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The two-step (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the band's tubing posteriorly with no wide posterior gastric wall dissection. PATIENTS AND METHODS: Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique. The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). RESULTS: All procedures were completed laparoscopically. The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation postoperatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in the TS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups. The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. CONCLUSION: Our experience with both the RGT and TS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Intentional injury surveillance in a primary care pediatric setting.

OBJECTIVE: To describe intentional injuries identified by primary care providers caring for children and adolescents, as reported through a prospective surveillance system. SETTING: Pediatric departments at four sites affiliated with a large health maintenance organization in eastern Massachusetts. DESIGN: Primary care providers completed brief injury encounter reports for patients aged 3 to 18 years treated for an intentional injury during a 20-month study period. For comparison purposes, a convenience sample of medical record was reviewed. RESULTS: Two hundred eleven injury encounter reports were received, representing a reported rate of 4.1 intentional injuries per 1000 panel members per year. These injuries ranged from contusions and lacerations to sexual assault and homicide. The median age of children at the time of injury was 14 years (interquartile range, 12 to 16 years), older than the population median age of 10 years (interquartile range, 6 to 14 years) (P<.001, Wilcoxon Signed Rank Test). Boys had a relative risk 1.5 times that of girls (P<.05, binomial test). Almost half of the injuries to adolescent girls resulted from encounters with other girls; 10% were the result of dating violence. In most cases, the patient and his or her assailant were friends or acquaintances (56%). This prospective surveillance detected, at most, 67% of intentional injuries seen, while medical record review detected 59% of the total identified injuries. CONCLUSIONS: Primary care pediatricians can identify and treat children and adolescents for intentional injuries. As these patients may form an appropriate group for interventions directed at reducing the risk of future intentional injuries, more effective public health surveillance must be developed.

Short-term effectiveness of anticipatory guidance to reduce early childhood risks for subsequent violence.

OBJECTIVE: To determine whether newly developed anticipatory guidance materials designed to teach the use of time-outs and the importance of reductions in childhood television viewing would be recalled by parents and if their use would result in changes in self-reported parental behavior. SUBJECTS AND SETTING: A total of 559 parents of children aged 14 months to 6 years recruited at the time of routine child health maintenance visits at 2 managed care pediatric departments in eastern Massachusetts. METHODS: In-person parent interviews were conducted in the waiting room prior to office visits, with follow-up telephone calls 2 to 3 weeks after the visit. Two groups of families were enrolled: a control group who received usual anticipatory guidance and an intervention group who received written materials. Intervention group providers were trained to include study topics during the office visit and to introduce the written materials. RESULTS: Provider training and the provision of written materials increased the parents' specific recall of anticipatory guidance of at least 2 to 3 weeks following the office visit. This effect was specific to the areas of intervention and did not carry over to other commonly used topics of anticipatory guidance. Among parents who had never used a time-out prior to the office visit, there was a significant increase in the use of time-outs. Parents who received anticipatory guidance regarding the link between exposure to television violence and subsequent violence in children were somewhat more likely to report reductions in weekend television viewing than were parents in the control group, although this change was not statistically significant. CONCLUSIONS: Certain parenting behaviors have been associated with subsequent violence. Brief, inexpensive anticipatory guidance in relevant areas, provided in the context of routine health supervision visits, appears to result in favorable short-term changes in parenting practices.

Colorectal surgery in octogenarians.

BACKGROUND: Elderly patients are often viewed as high-risk surgical candidates. Recent reports, however, have recommended applying the standard surgical approach to this group. Many of these series report mortality rates that are substantially higher than those in the younger population. Therefore, the applicability of these procedures for the elderly may be questionable. STUDY DESIGN: We retrospectively studied 140 patients older than 80 years who underwent colorectal surgery at our institution between January 1990 and January 1995. Of these, 123 underwent colon or rectal resections and 17 had diverting colostomy only. Ninety-seven (79 percent) of the colorectal resections were for carcinoma. In this study, perioperative care, operative results, and survival are analyzed. RESULTS: Elective and emergent colorectal resections totaled 80.5 and 19.5 percent, respectively. The mortality rate for elective resections was 3 percent and for emergency resections it was 21 percent. Postoperative morbidity was 27 percent and the average hospital stay was 13.1 days. Diverting colostomy was associated with a 24 percent mortality rate. The survival rate after colorectal resections for one, two, and five years was 85, 72, and 40 percent, respectively. CONCLUSIONS: The results support the view that elective colorectal resection in the elderly population is worthwhile and should be performed for the same indications as in younger patients. Although emergent operations were associated with a poor outcome, the majority of the patients survived and left the hospital.

Management of pancreatic pseudocysts.

BACKGROUND: Operative internal drainage has been standard treatment for chronic unresolved pancreatic pseudocysts (PPs). Recently, percutaneous external drainage (PED) has become the primary mode of treatment at many medical centers. STUDY DESIGN: A retrospective chart review was performed of 96 patients with PPs who were managed between 1987 and 1996. Longterm followup information was obtained by telephone and mail questionnaire. RESULTS: Twenty-seven patients underwent computed tomographic (CT)-guided PED. PP resolution occurred in 17 patients. Clinical deterioration or secondary infection mandated urgent pancreatic debridement in 7 (26%) patients and cystgastrostomy in 2 (7%) patients. There was one hospital death in this group. Thirty-two patients underwent cystgastrostomy or cystjejunostomy (n = 21), distal pancreatectomy (n = 8), pancreatic debridement and external drainage (n = 2), or cystectomy (n = 1). Two (6%) patients required postoperative pancreatic debridement for failure of resolution and peritonitis and two patients underwent PED of abscess. There was one hospital death in the expectantly managed group of 37 patients. Median followup of 3 years (range, 0.5-9.3 years) in 66 patients revealed that 6, 3, and 4 patients of PED, surgery, and expectantly managed groups, respectively, had radiologic evidence of recurrent PPs. CONCLUSIONS: Operative management for PPs appears to be superior to CT-guided PED. Although the later was often successful, it required major salvage procedures in one third of the patients. An expectant management protocol may be suitable for selected patients.

Teflon buttress inhibits recanalization of uncut stapled bowel.

The uncut Roux limb operation is designed to have the benefits of a Roux limb but still have electrical continuity from proximal to distal bowel, thus eliminating the risk of Roux stasis syndrome. The main complication has been recanalization of the uncut staple line leading to bile reflux. This study aims to employ a new technique, which will not allow recanalization of an uncut staple line but will not interfere with normal bowel myoelectric activity. Fourteen mongrel dogs, 25 to 35 kg, underwent a midline laparotomy under general anesthesia. An uncut staple line was placed 25 cm from the ligament of Treitz. In seven animals an uncut staple line alone was placed, and in the other seven animals the bowel was stapled between a sandwich of Teflon reinforcing strips such that the staples were held on both sides of the bowel by the Teflon. A jejunojejunostomy was placed 6 cm proximal to the staple line. Insulated bipolar electrical leads were placed around the staple line. After the electrical leads were monitored 2 days to 3 months postoperatively for bowel myoelectric activity, The animals were killed and the operative sites inspected. No animal suffered morbidity or mortality from the procedure. All seven unreinforced staple lines recanalized and all seven reinforced staple lines remained competent. The duodenal pacemaker potentials were transmitted through the staple line in five animals (3 controls and 2 with Teflon reinforcement) with in 1 week postoperatively. The uncut staple line does not reliably transmit the duodenal pacemaker potentials. The staple line does not recanalize when it is reinforced with a permanent material, increasing the utility of the "uncut" Roux limb operation.

Asthma and gastroesophageal reflux: fundoplication decreases need for systemic corticosteroids.

An association between gastroesophageal reflux (GER) and asthma has been suggested for many decades. Although antireflux therapy (medical and surgical) has been shown to be beneficial in patients with asthma, response to therapy has not been well quantified. The aim of this study was to evaluate long-term outcome in patients with asthma and associated GER undergoing fundoplication. From a database of more than 600 patients with GER treated surgically between 1991 and 1996, 39 patients with asthma as their primary indication for surgery were identified. Asthma symptom scores were determined using the National Asthma Education Program classification, and medication frequency scores were determined preoperatively and at latest follow-up (median follow-up 2.7 years). Comparisons were made using the Wilcoxon rank-sum test. Asthma symptom scores decreased significantly after antireflux surgery. More important, the medication scores for use of systemic corticosteroids decreased significantly postoperatively (2.2 preoperatively vs. 0.7 postoperatively; P = 0.0001). Of the nine patients who required daily oral corticosteroids, seven have discontinued treatment entirely (78%). In patients with asthma associated with GER, symptoms of asthma are improved following fundoplication. Especially important has been the ability to wean patients from systemic corticosteroids postoperatively. Fundoplication should be offered to those patients with GER-associated asthma, especially those who are steroid dependent.

Laparoscopic fundoplication for dysphagia and peptic esophageal stricture.

Peptic esophageal stricture with dysphagia is a late manifestation of severe gastroesophageal reflux disease (GERD). Although laparoscopic fundoplication is an effective antireflux operation, its efficacy for persons with peptic esophageal stricture and dysphagia has not been well defined. The aim of this study was to evaluate outcomes after fundoplication in this subgroup of GERD patients. Forty GERD patients with moderate, severe, or incapacitating dysphagia and peptic esophageal stricture were compared to a control group of 121 GERD patients without significant dysphagia or stricture. Reflux symptom severity was scored by each patient preoperatively and at most recent follow-up postoperatively (mean 1.5 years) using a scale ranging from 0 to 4 (0 = symptoms absent; 4 = symptoms incapacitating). Symptom scores were compared by the Wilcoxon rank-sum test. Postoperative redilation and fundoplication failure rates were also determined. At a mean follow-up of 1.5 years after fundoplication, the median dysphagia score had improved from 3 to 0 (P <0.001) in stricture patients and remained low (score 0) in the control group. The median heartburn score also improved from 3 to 0 (P <0.001) in stricture patients, with an identical response in the control group (P <0.001). Among dysphagia/stricture patients, 35 (87.5%) reported overall satisfaction and have not required secondary medical treatment or esophageal dilation. Four patients (10%) have required endoscopic redilation for residual dysphagia and one (2.5%) had reoperation for fundoplication herniation shortly after operation. Laparoscopic fundoplication is an effective therapy for patients with dysphagia and peptic esophageal stricture.

Structured triacylglycerol emulsion, containing both medium- and long-chain fatty acids, in long-term home parenteral nutrition: a double-blind randomized cross-over study.

Structured lipid emulsion, an innovative approach in which both medium-chain and long-chain fatty acids are esterified to the same glycerol backbone, has been recently shown to be a safe and efficient way of providing energy to patients requiring parenteral nutrition. As yet, no assessment has been made of its safety and effect on liver functions during long-term treatment. Twenty-two home parenteral nutrition patients with Crohn's disease or short bowel syndrome were enrolled in a double-blind randomized, cross-over study. Twenty patients who completed the study were treated for 4 wk with a structured lipid emulsion and for 4 wk with long-chain triacylglycerol emulsion. Determined every 1 or 2 wk were blood pressure, body weight, respiratory rate, blood count, liver functions, albumin, transferrin, plasma lipids, free fatty acids (FFAs), and, at the end of each treatment period (weeks 4 and 8), plasma dicarboxylic acids and 3-OH-fatty acids. No differences were observed between the groups or within the groups between the two treatments with respect to either clinical safety and adverse event occurrence or laboratory assessments. Plasma dicarboxylic acids and 3-OH-fatty acids were similar and within normal range. No alteration of liver function occurred in any of the patients treated with the structured lipid emulsion, whereas two of the patients receiving long-chain triaclyglycerol emulsion developed abnormal liver function, which resolved after switching to the structured lipid emulsion. In conclusion, structured triacylyglycerols containing both medium- and long-chain fatty acids appear to be safe and well tolerated on a long-term basis in patients on home parenteral nutrition, and it may be associated with possible reduction in liver dysfunction.

Laparoscopy: searching for the proper insufflation gas.

BACKGROUND: Although many aspects of laparoscopic surgery have been determined, the question of which insufflation gas is the best arises repeatedly. The aim of this study was to review the findings on the major gases used today in order to provide information and guidelines for the laparoscopic surgeon. METHODS: We reviewed the literature for clinical and laboratory studies on the currently used laparoscopic insufflation gases: carbon dioxide (CO(2)), nitrous oxide (N(2)O), helium (He), air, nitrogen (N(2)), and argon (Ar). The following parameters were evaluated: acid-base changes, hemodynamic and respiratory sequelae, hepatic and renal blood flow changes, increase in intracranial pressure, outcome of venous emboli, and port-site tumor growth. RESULTS: The major advantage of CO(2) is its rapid dissolution in the event of venous emboli. Hemodynamic and acid-base changes with CO(2) insufflation usually are mild and clinically negligible for most patients. Although N(2)O is advantageous for procedures requiring local/regional anesthesia, it does not suppress combustion. Findings show that Ar may have unwanted hemodynamic effects, especially on hepatic blood flow. There are almost no hemodynamic or acid-base sequelae with the use of He, air, and N(2), but they dissolve slowly and carry a potential risk of lethal venous emboli. CONCLUSIONS: Clearly, CO(2) maintains its role as the primary insufflation gas in laparoscopy, but N(2)O has a role in some cases of depressed pulmonary function or in local/regional anesthesia cases. Other gases have no significant advantage over CO(2) or N(2)O and should be used only in protocol studies. The relation of port-site metastasis to a specific type of gas requires further research.

Prospective study of 250 patients undergoing laparoscopic gastric banding using the two-step technique: a technique to prevent postoperative slippage.

BACKGROUND: The use of LAP-BAND adjustable gastric banding (LAGB) has gained tremendous popularity, but creation of the retrogastric tunnel is a considerable challenge, especially in the surgeon's early experience, and is associated with up to 10% band slippage and occasional gastric perforation. The two-step technique involves a crural dissection toward the angle of His through a pars flaccida approach. The technique facilitates passage of the band with no extensive posterior gastric wall dissection. METHODS: A prospective study investigated 250 patients (207 women and 43 men) who underwent LAGB from January 1999 to May 2002 using a two-step dissection technique. The mean age of these patients was 37 years (range, 18-58 years). Their mean preoperative weight was 120 kg (range, 90-169 kg), and their mean body mass index was 44 kg/m2 (range, 36-68 kg/m2). RESULTS: All the procedures except two were completed laparoscopically, and there were no deaths. The mean operative time was 61 min (range, 35-150 min), and the mean hospital stay was 1.2 days (range, 1-5 days). At 3 years, the mean body mass index had decreased from 44 kg/m2 to means of 39.9, 37.3, 34.4, 32.4, and 31.7 kg/m2 at 3, 6, 12, 24, and 36 months, respectively. The mean excess weight loss was 42.1% at 1 year, 51.4% at 2 years, and 55.5% at 3 years. There were four band slippages (1.6%), no band erosion, and no major morbidity. CONCLUSIONS: The use of LAGB with the two-step technique is technically simple, avoids intimate posterior gastric wall dissection, and facilitates tight posterior band support. It therefore is associated with only minimal perioperative complications and a low slippage rate.

The Lap-Band system in the United States: one surgeon's experience with 271 patients.

BACKGROUND: The LAP-BAND system is considered an important bariatric surgery procedure in many countries and is rapidly gaining acceptance in the United States. Outcomes data emerging in the United States parallel European and Australian experience. The purpose of this study was to examine our experience with this procedure in the United States. METHODS: Between November 2000 and September 2002, 271 patients (236 women) underwent LAP-BAND system placement. The mean age of patients was 40 years (18-63); preoperative mean body weight was 125 kg (93-192). Surgeries were performed using either the two-step (pars flaccida to perigastric) or the pars flaccida technique with three (1.1%) conversions to open procedures. Mean operative time was 42 min (23-86); average hospital stay was 1 day (4 h to 7 days). RESULTS: The mean body mass index (BMI) decreased from a baseline of 45.3 kg/m(2) (35-68) to 41.9 ( n = 178), 39.5 ( n = 101), 38.4 (n = 81), 36.5 (n = 72), 35.9 (n = 51), and 35.1 (n = 21) kg/m(2) at 3, 6, 9, 12, 18, and 24 months, respectively, after surgery. Mean excess weight loss was 40% at 12 months and 43% at 24 months. As patients lost weight, comorbid conditions improved. No deaths occurred, no bands had to be removed, and postoperative complications were minor: 20 (7.3%) access port problems, 18 (6.6%) gastric pouch dilatations, five (1.8%) gastric slippages, and five (1.8%) stoma obstructions. All were managed conservatively or repaired laparoscopically using the original bands. Additional complications included four cases of pneumonia and one case of pulmonary embolism. One patient required reoperation because of trocar site bleeding. CONCLUSIONS: The LAP-BAND system is a safe and effective bariatric procedure leading to considerable weight loss and reduction in comorbidity.

Evaluation of a community-based youth violence prevention project.

PURPOSE: To investigate the association of exposure to a community-based youth violence prevention project with adolescents' knowledge and attitudes about violence. METHODS: Two samples of 400 teens each from Boston neighborhoods were surveyed by random-digit dialed telephone techniques: one at the start of the project and one after 1 year of implementation. Regression analyses were used to investigate associations between exposure to different educational formats and outcome measures. RESULTS: Only self-reported exposure to the mass media campaign was significantly associated with higher scores in both knowledge and attitudes. An independent interaction between gender and exposure to the mass media campaign was found among males. Analyses using a historic control group support a program effect and not recall bias. Exposure to workshops or one-on-one discussions about violence prevention were not significantly associated with outcome scores. CONCLUSION: The measurable effect of the mass media may be somewhat related to the strength of that stimulus over the study period and suggests that 12 months is too short a time frame for evaluating community-based educational efforts.

Adolescents' knowledge and attitudes about and experience with violence.

PURPOSE: Educational interventions directed to the prevention of youth inter-personal violence make assumptions about the educational needs of adolescents for violence-prevention despite little available data. This paper provides new information on background levels of adolescents' knowledge of, attitudes about and experience with violence. METHODS: Over 400 teens across Boston's neighborhoods were surveyed by rando-digit dialed telephone techniques. RESULTS: Results show that while boys are more often involved in violence, almost one quarter of girls report fighting. Black teens witness more violence and are threatened more often than whites, but they do not fight more. Knowledge scores indicate a need for improvement in adolescents' understanding of risk factors. Attitude scores indicate that adolescents believe fighting can and should be avoided, but they lack knowledge of behavioral options. Regression analyses show a positive relationship between violence experience and knowledge and attitudes. CONCLUSION: These data suggest that preventive interventions should be directed to both improving adolescents' knowledge and understanding of personal risk and increasing their repertoire of conflict-resolution skills.

Patterns of teen exposure to a community-based violence prevention project.

This paper describes the implementation of a community-based youth violence prevention project that utilized an educational curriculum and a mass media campaign. The extent of penetration of the intervention into target areas and the degree of contamination of control areas are assessed, and the most frequently contacted forms of educational outreach are identified. Two sources of data, provider interviews and a random digit dialed telephone survey, were used to track the source and extent of teens' exposure to the intervention. Agency provider data revealed that 40% of the 92 contacted agencies actually conducted violence prevention education, reaching 22% of the target area teens. Approximately one-half of the surveyed teens reported some exposure to the program, with 13% of the teens in target areas reporting participation in interactive educational activities associated with the project. The most common source of exposure was the media campaign. Most teens report a single exposure, usually to the media campaign, although 29% report contact with more than one form of violence prevention education. While the project did not achieve community saturation, the data show that the community-based model of intervention for violence prevention is feasible and effective in reaching teenagers. This research highlights some difficulties in evaluating prevention programs, including reconciling community ownership with project identification, the ethics of curtailing services for control purposes, and factors influencing recall of participation.