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As Ms. Polak stated: the school board disallowed the books because it felt that the subject matter was both inappropriate for the kindergarten age level and contrary to the religious beliefs of some parents of children who attend school in the district. Were these reasons sufficient to not approve the use of the books?

Warren says that using these books has led to some important classroom discussions. I've listened to the objections of Surrey School District Board on the use of these books and can't disagree more! My school district allows these books. Using them in my class has led to some interesting discussions about various family models.

We've discussed blended families, families with adopted children, and yes, we've discussed families with two moms or two dads. Some children in my classroom have two moms and two dads. We need to respect and accept all families. This argument would have to be settled in The Supreme Court of Canada and in late , the Court made a decision.

The judgement from the Supreme Court stated that the school board's decision needed to be made based on principles of tolerance and non-sectarianism. In response to the School Board's argument that the three books were not appropriate for the kindergarten age group, Chief Justice Beverly McLachlin said, "Tolerance is always age-appropriate. In other words, the Supreme Court ruled that the Surrey District School Board needed to reconsider its original decision. Asha's Mums is riddled with grammar and punctuation errors. The author switches the spelling of the word 'favourite' from the Canadian way to the American way.

And in the case of Belinda's Bouquet, the issues of body image and dieting are not appropriate for the kindergarten or grade 1 children.

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These topics are not handled well by the author of this story. Furthermore, the depiction of fathers in One Dad, Two Dads is not even realistic. These were some of the reasons such that led the Surrey School Board to once again disallow the books.

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What occurred in Surrey between and has many implications. As described previously, 4 , 5 participants were recruited into 1 of 4 AMD categories based primarily on the size and extent of drusen in each eye and the presence or absence of advanced AMD. The participants were randomly assigned to 1 of the following 4 treatment groups: placebo, zinc, antioxidants, or antioxidants plus zinc. The antioxidants consisted of vitamin C mg , vitamin E IU , and beta carotene 15 mg.

Zinc was given as zinc oxide 80 mg with copper as cupric oxide 2 mg.

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The participants were followed up until , when the trial ended. Of the surviving participants, Each clinical center obtained approval from their institutional review board for human subjects for the follow-up study, and each participant signed another informed consent form. Comprehensive eye examinations were conducted at baseline and semiannually throughout the clinical trial that ended in Annual visits were conducted through Using the Early Treatment Diabetic Retinopathy Study ETDRS logarithm of the minimum angle of resolution chart, certified examiners measured best-corrected visual acuity with a standardized refraction and best-corrected visual acuity protocol.

Baseline data were collected, including age, race, sex, educational level, smoking history, body mass index, use of medications, and history of diabetes mellitus, hypertension, angina, and arthritis. Stereoscopic fundus photographs of the macula were taken at baseline and annually beginning 2 years after enrollment and continuing through the follow-up study. Photographs were graded centrally using standardized grading procedures.

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The 2 primary study outcomes in the clinical trial were 1 progression to advanced AMD consisting of neovascular NV AMD or geographic atrophy involving the center of the macula CGA and 2 visual acuity loss of at least 15 letters from baseline in the study eyes. Geographic atrophy involving the center of the macula was judged by the reading center to be present when the center of the macula was probably or definitely involved. We used the life-table method to estimate unadjusted rates of progression to large drusen and advanced AMD within 10 years from entry to the study. The method was applied to various groups of participants and eyes classified by severity of AMD at baseline.

Participants lost to follow-up or who died during the course of the study were censored at the time of the last contact. We used the log-rank P value for comparing groups. Life-table rates were also calculated for persons using the simplified 5-level severity scale categories. The scale uses a patient scoring system that assigns to each eye a risk score of 1 for the presence of large drusen and a risk score of 1 for the presence of AMD RPE abnormalities.

Advanced AMD is given a score of 2 for the affected eye. In the absence of large drusen in both eyes, the presence of medium drusen in both eyes warrants a score of 1. Scores are summed across eyes and range from 0 to 4 5 steps.

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At the end of the clinical trial in April , the follow-up study enrolled of the surviving participants Annual visits for the follow-up study started in and continued through November Information regarding active vs inactive participants is also presented in the Table. Participants enrolled in the follow-up phase were more likely to be younger, nonsmokers, and white; were more likely to have less severe AMD, higher educational levels, and lower blood pressure; and were less likely to have diabetes mellitus than those who were not active participants.

The rates of loss to follow-up in the clinical trial and the follow-up study were 2. Participants were followed up for a median of The eTable in the Supplement shows the percentages and P values. Baseline AMD severity categories, from least to most severe, included no or small drusen in either eye, medium drusen in 1 eye, bilateral medium drusen, large drusen in 1 eye, bilateral large drusen, and large drusen in 1 eye with the presence of advanced AMD in the fellow eye NV AMD or CGA. Female sex HR, 1. For those in the oldest group 75 to 80 years who were in the most severe AMD category at baseline, rates approximated The probability of development of large drusen or worse in at least 1 eye was examined in participants without large drusen or advanced AMD in either eye at baseline eFigure 2A in the Supplement.

The risk of developing large drusen in participants with no drusen or only small drusen at baseline was low at However, Among participants with medium drusen in both eyes at enrollment, Time 0 corresponds to the time of the first detection of large drusen and RPE changes.

The rate of developing advanced AMD in these eyes was 9. Because of the limited duration of follow-up after the development of large drusen, we chose to present only the 5-year rates. The rate of development of advanced AMD by 5 years was Quiz Ref ID The proposition that large drusen located within 1 disc diameter of the center of the macula the central plus the 4 inner subfields of the ETDRS grid, often termed the central zone may carry a worse prognosis for progression to advanced AMD than those farther from the center is explored in eFigure 5 in the Supplement for the right eyes of participants with large drusen and no advanced AMD in either eye at baseline.

For eyes free of RPE abnormalities, comparison of progression rates for eyes with large drusen limited to the central zone and rates for eyes with large drusen limited to the outer ring of the grid the 4 outer subfields combined supports this concept year rates of As might be expected, the rate was higher All 3 of these rates increased when RPE abnormalities were present, but the difference by location narrowed and appeared to reverse slightly year rates of For eyes with large drusen in the ring only, fewer had RPE abnormalities than did not 68 vs , whereas for eyes with large drusen in both locations, the reverse was true vs Groups with lower progression rates tended to have greater proportions of eyes with very few large drusen, defined as eyes with a total drusen area in the grid of less than the area of standard circle C-2 according to the AREDS AMD measurement tool developed by the reading center , which equals the size of 4 drusen at the lower threshold of the large drusen category.

Among eyes with no RPE abnormalities, large drusen were limited to the outer ring in None of the eyes with large drusen in both locations met this definition. Corresponding proportions for eyes with RPE abnormalities were 2.

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The presence of advanced AMD in the fellow eye at baseline increased the rates of progression to advanced AMD in study eyes. These rates are also displayed according to the size of drusen and the presence of RPE abnormalities at baseline.

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In eyes with no or small drusen, the rates of development of advanced AMD by 10 years were 8. By 5 years, For participants in the highest risk category, the risk of developing advanced AMD was At 10 years, the median visual acuity score for these eyes had lost more than 2 letters eFigure 9A in the Supplement. Most severely affected were participants with a diagnosis based on subretinal fibrosis.

Less severely affected were those with a diagnosis based on the presence of serous sensory retinal detachment. We have used year follow-up data from the AREDS to estimate rates of progression to intermediate and advanced AMD and to examine the effect of retinal risk factors on these rates. Increasing severity of drusen at baseline, the presence of large drusen within 1 disc diameter of the fovea or the central zone, the presence of bilateral medium drusen, the presence of advanced AMD in the fellow eye, and the simultaneous presence of large drusen and AMD RPE abnormalities all increased the risk of progression to advanced AMD.

In addition to the importance of large drusen as a risk factor, we note that medium drusen, in particular when present bilaterally, increase the risk of advanced AMD. The age and smoking findings have been reported in population-based studies. The long-term visual acuity results are of interest because AREDS participants may constitute one of the last cohorts in whom the natural history of NV AMD is not affected by the administration of intravitreal injections of anti—vascular endothelial growth factor agents, which are now widely used.

Visual acuity changes are evident 1 year before the diagnosis of AMD.


Further research is needed to develop techniques for earlier detection and treatment of early disease so that final visual acuity results might be improved. This study has limitations. These data may not be generalizable to the overall population 55 years or older because the study draws from a group of participants who are better nourished, more highly educated, and healthier than the population at large. However, the risk factors and rates of development of disease are not dissimilar to those reported in other clinical studies.

Strengths of the study are numerous. The study observed a very large cohort of participants with varying risk of progressing to advanced AMD. Among the surviving participants in the clinical trial, The rates of loss to and unavailability for follow-up were low in the clinical trial 2.