Emergency department pediatric readiness of United States trauma centers in 2021: Trauma center facility characteristics and opportunities for improvement.

BACKGROUND: Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. METHODS: The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. RESULTS: The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. CONCLUSION: ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. LEVEL OF EVIDENCE: Epidemiologic, Level III.

The Association between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers.

OBJECTIVE: To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. SUMMARY BACKGROUND DATA: Most children in the US receive initial trauma care at non-pediatric centers. The National Pediatric Readiness Project (NPRP) aims to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. STUDY DESIGN: A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) in 2019-21 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15y) were calculated using Pediatric TQIP models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. RESULTS: 66,588 children from 630 centers with a median [IQR] wPRS of 79 [66-93] were analyzed. The average observed-to-expected odds of mortality (1.02 [0.97-1.06]) for centers in the highest quartile (wPRS≥93) was lower than any of the lowest three wPRS quartiles (1.19 [1.14-1.23](Q1), 1.29 [1.24-1.33](Q2), and 1.28 [1.19-1.36](Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality (standardized beta -0.095 [-0.146--0.044]). CONCLUSION: Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.

Prehospital and emergency department pediatric readiness for injured children: A statement from the American College of Surgeons Committee on Trauma Emergency Medical Services Committee.

ABSTRACT: Injury is the leading cause of death in children older than 1 year, and children make up 22% of the population. Pediatric readiness (PR) of the nation's emergency departments and state trauma and emergency medical services (EMS) systems is conceptually important and vital to mitigate mortality and morbidity in this population. The extension of PR to the trauma community has become a focused area for training, staffing, education, and equipment at all levels of trauma center designation, and there is evidence that a higher level of emergency department PR is independently associated with long-term survival among injured children. Although less well studied, there is an associated need for EMS PR, which is relevant to the injured child who needs assessment, treatment, triage, and transport to a trauma center. We outline a blueprint along with recommendations for incorporating PR into trauma system development in this opinion from the EMS Committee of the American College of Surgeons Committee on Trauma. These recommendations are particularly pertinent in the rural and underserved areas of the United States but are directed toward all levels of professionals who care for an injured child along the trauma continuum of care.

Establishing national stakeholder priorities for quality improvement in pediatric trauma care: Consensus results using a modified Delphi process.

BACKGROUND: Quality improvement efforts within pediatric trauma centers (PTCs) are robust, but the majority of children do not receive initial postinjury care at PTCs. Disparities in access to quality trauma care remain, particularly for children who initially access the trauma system outside of a PTC. The purpose of this project was to identify unmet needs for injured children within the pediatric emergency care system and to determine national priorities for quality improvement across the continuum of pediatric trauma care. METHODS: A panel of delegates representing patients and families, prehospital providers, federal funding partners, nurses, and physicians was recruited from 10 national stakeholder organizations. Potential targets were identified using an initial stakeholder meeting followed by a free text response survey. Free text items were coded and condensed as themes and then ranked by the panel using a modified Delphi approach to determine consensus priorities. Items not achieving >35% prioritization on a given iteration were dropped from subsequent iterations. Consensus was defined as 75% of members designating an item as a top-four priority. RESULTS: Nineteen themes were identified as potential targets for QI initiatives. Four iterations of panel ranking were used to achieve consensus, with four priorities identified: (1) creation of a toolkit and standard provider training for pediatric trauma triage, shock recognition, and early recognition for need to transfer to higher level of care; (2) development of minimum standards for pediatric trauma resuscitation and stabilization capability in nonpediatric centers; (3) facilitating creation of local nursing and physician champions for pediatric trauma; and (4) development and dissemination of best-practice guidelines to improve imaging practices for injured children. CONCLUSION: System-level quality improvement priorities for pediatric trauma care should focus resources on developing and implementing minimum pediatric standards for injury care, frontline provider training, stabilization protocols, imaging guidelines, and local pediatric champions. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

National Needs Assessment for a Pediatric Trauma Toolkit: General Requirements for Moderate- and High-Volume Hospitals.

BACKGROUND: Optimal outcomes have been reported for children treated at pediatric trauma centers; however, most children are treated at nonpediatric trauma centers or nonpediatric general hospitals. Hospitals that are not verified or designated pediatric trauma centers may lack the training and level of comfort and skill when treating severely injured children. OBJECTIVE: This study focused on identifying common pediatric guidelines for standardization across all trauma centers to inform a pediatric trauma toolkit. METHODS: A needs assessment survey was developed highlighting the guidelines from an expert committee review. The purpose of the survey was to prioritize needed items for the development of a pediatric trauma toolkit. Professional trauma organizations distributed the survey to their respective memberships to ensure good representation of people who care for traumatically injured children and work in trauma centers. Deidentified survey results were analyzed with frequencies and descriptive statistics provided. Data were compared by hospital trauma verification level using a chi-square test. The value of p < .05 was considered statistically significant. RESULTS: A total of 303 people responded to the survey. The majority of respondents reported a high value in the creation of a pediatric trauma toolkit for the guidelines that were included. There was variability in the reported access to the guidelines, indicating a significant need for the toolkit development and dissemination. CONCLUSION: As expected, Level III centers reported the largest gaps in access to standardized pediatric guidelines and demonstrated high levels of interest and need.

Improved Recognition of Maternal Deaths Using Modern Data Analytics.

OBJECTIVE: To use a data-fusion approach to improve ascertainment of maternal deaths not detected with standard surveillance strategies. METHODS: We conducted a retrospective cohort study from the electronic health records of a tertiary medical center from 2011 to 2018. Cases of maternal death were identified in two ways: 1) using a standard medical informatics service query of hospital data and 2) using the TriNetX discovery tool as patients with a vital status of "deceased" and evidence of antecedent pregnancy exposure based on such factors as obstetric diagnostic codes or obstetric-related procedures. Potential cases of maternal death identified by the latter method underwent chart review to confirm timing of death compared with timing of last appreciable pregnancy, and to characterize the details of these deaths. The primary outcome was pregnancy-associated mortality during pregnancy or within the first postpartum year in the discovery cohort compared with the hospital-identified cohort. Secondary outcomes included causes of death and comorbidities. RESULTS: During the study period, the standard service query identified 23 maternal deaths. The discovery tool identified 18 additional patients confirmed on subsequent chart review to represent pregnancy-associated deaths, a 78% increase in ascertainment of which a greater proportion represented postpartum deaths. The majority (61%) of newly ascertained mortalities were related to cardiac causes or other medical comorbidities. Although many hospital-ascertained cases were associated with deaths after delivery of a living newborn, more deaths after early pregnancy loss or termination were identified through the discovery tool. CONCLUSION: Improved recognition of pregnancy-associated deaths can be achieved with modern data analytics.

NF-κB upregulates glutamine-fructose-6-phosphate transaminase 2 to promote migration in non-small cell lung cancer.

BACKGROUND: Epithelial-to-mesenchymal transition (EMT) results in changes that promote de-differentiation, migration, and invasion in non-small cell lung cancer (NSCLC). While it is recognized that EMT promotes altered energy utilization, identification of metabolic pathways that link EMT with cancer progression is needed. Work presented here indicates that mesenchymal NSCLC upregulates glutamine-fructose-6-phosphate transaminase 2 (GFPT2). GFPT2 is the rate-limiting enzyme in the synthesis of uridine diphosphate N-acetylglucosamine (UDP-GlcNAc). UDP-GlcNAc is the obligate activator of O-linked N-acetylglucosamine transferase (OGT). METHODS: Analysis of our transcriptomic data indicates that GFPT2 is one of the most significantly upregulated metabolic genes in mesenchymal NSCLC. Ectopic GFPT2 expression, as well as gene silencing strategies were used to determine the importance of this metabolic enzyme in regulating EMT-driven processes of cell motility and invasion. RESULTS: Our work demonstrates that GFPT2 is transcriptionally upregulated by NF-κB and repressed by the NAD+-dependent deacetylase SIRT6. Depletion of GFPT2 expression in NSCLC highlights its importance in regulating cell migration and invasion during EMT. CONCLUSIONS: Consistent with GFPT2 promoting cancer progression, we find that elevated GFPT2 expression correlates with poor clinical outcome in NSCLC. Modulation of GFPT2 activity offers a potentially important therapeutic target to combat NSCLC disease progression.

A paradigm for achieving successful pediatric trauma verification in the absence of pediatric surgical specialists while ensuring quality of care.

BACKGROUND: Pediatric trauma centers (PTCs) are concentrated in urban areas, leaving large areas where children do not have access. Although adult trauma centers (ATCs) often serve to fill the gap, disparities exist. Given the limited workforce in pediatric subspecialties, many adult centers that are called upon to care for children cannot sufficiently staff their program to meet the requirements of verification as a PTC. We hypothesized that ATCs in collaboration with a PTC could achieve successful American College of Surgeons (ACS) verification as a PTC with measurable improvements in care. This article serves to provide an initial description of this collaborative approach. METHODS: Beginning in 2008, a Level I PTC partnered with three ATC seeking ACS-PTC verification. The centers adopted a plan for education, simulation training, guidelines, and performance improvement support. Results of ACS verification, patient volumes, need to transfer patients, and impact on solid organ injury management were evaluated. RESULTS: Following partnership, each of the ATCs has achieved Level II PTC verification. As part of each review, the collaborative was noted to be a significant strength. Total pediatric patient volume increased from 128.1 to 162.1 a year (p = 0.031), and transfers out decreased from 3.8% to 2.4% (p = 0.032) from prepartnership to postpartnership periods. At the initial ATC partner site, 10.7 children per year with solid organ injury were treated before the partnership and 11.8 children per year after the partnership. Following partnership, we found significant reductions in length of stay, number of images, and laboratory draws among this limited population. CONCLUSION: The collaborative has resulted in ACS Level II PTC verification in the absence of on-site pediatric surgical specialists. In addition, more patients were safely cared for in their community without the need for transfer with improved quality of care. This paradigm may serve to advance the care of injured children at sites without access to pediatric surgical specialists through a collaborative partnership with an experienced Level I PTC. Further risk-adjusted analysis of outcomes will need to be performed in the future. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.

Limitations of Aneuploidy and Anomaly Detection in the Obese Patient.

Obesity is a worldwide epidemic and can have a profound effect on pregnancy risks. Obese patients tend to be older and are at increased risk for structural fetal anomalies and aneuploidy, making screening options critically important for these women. Failure rates for first-trimester nuchal translucency (NT) screening increase with obesity, while the ability to detect soft-markers declines, limiting ultrasound-based screening options. Obesity also decreases the chances of completing the anatomy survey and increases the residual risk of undetected anomalies. Additionally, non-invasive prenatal testing (NIPT) is less likely to provide an informative result in obese patients. Understanding the limitations and diagnostic accuracy of aneuploidy and anomaly screening in obese patients can help guide clinicians in counseling patients on the screening options.

Epigenetic coordination of signaling pathways during the epithelial-mesenchymal transition.

BACKGROUND: The epithelial-mesenchymal transition (EMT) is a de-differentiation process required for wound healing and development. In tumors of epithelial origin aberrant induction of EMT contributes to cancer progression and metastasis. Studies have begun to implicate epigenetic reprogramming in EMT; however, the relationship between reprogramming and the coordination of cellular processes is largely unexplored. We have previously developed a system to study EMT in a canonical non-small cell lung cancer (NSCLC) model. In this system we have shown that the induction of EMT results in constitutive NF-κB activity. We hypothesized a role for chromatin remodeling in the sustained deregulation of cellular signaling pathways. RESULTS: We mapped sixteen histone modifications and two variants for epithelial and mesenchymal states. Combinatorial patterns of epigenetic changes were quantified at gene and enhancer loci. We found a distinct chromatin signature among genes in well-established EMT pathways. Strikingly, these genes are only a small minority of those that are differentially expressed. At putative enhancers of genes with the 'EMT-signature' we observed highly coordinated epigenetic activation or repression. Furthermore, enhancers that are activated are bound by a set of transcription factors that is distinct from those that bind repressed enhancers. Upregulated genes with the 'EMT-signature' are upstream regulators of NF-κB, but are also bound by NF-κB at their promoters and enhancers. These results suggest a chromatin-mediated positive feedback as a likely mechanism for sustained NF-κB activation. CONCLUSIONS: There is highly specific epigenetic regulation at genes and enhancers across several pathways critical to EMT. The sites of these changes in chromatin state implicate several inducible transcription factors with critical roles in EMT (NF-κB, AP-1 and MYC) as targets of this reprogramming. Furthermore, we find evidence that suggests that these transcription factors are in chromatin-mediated transcriptional feedback loops that regulate critical EMT genes. In sum, we establish an important link between chromatin remodeling and shifts in cellular reprogramming.

Modification of RelA by O-linked N-acetylglucosamine links glucose metabolism to NF-κB acetylation and transcription.

The molecular mechanisms linking glucose metabolism with active transcription remain undercharacterized in mammalian cells. Using nuclear factor-κB (NF-κB) as a glucose-responsive transcription factor, we show that cells use the hexosamine biosynthesis pathway and O-linked ß-N-acetylglucosamine (O-GlcNAc) transferase (OGT) to potentiate gene expression in response to tumor necrosis factor (TNF) or etoposide. Chromatin immunoprecipitation assays demonstrate that, upon induction, OGT localizes to NF-κB-regulated promoters to enhance RelA acetylation. Knockdown of OGT abolishes p300-mediated acetylation of RelA on K310, a posttranslational mark required for full NF-κB transcription. Mapping studies reveal T305 as an important residue required for attachment of the O-GlcNAc moiety on RelA. Furthermore, p300 fails to acetylate a full-length RelA(T305A) mutant, linking O-GlcNAc and acetylation events on NF-κB. Reconstitution of RelA null cells with the RelA(T305A) mutant illustrates the importance of this residue for NF-κB-dependent gene expression and cell survival. Our work provides evidence for a unique regulation where attachment of the O-GlcNAc moiety to RelA potentiates p300 acetylation and NF-κB transcription.

Roles of promoter and 3' untranslated motifs in expression of the human C5a receptor.

The C5a receptor (C5aR) is a 7 transmembrane G-protein coupled receptor (GPCR) that mediates the powerful pro-inflammatory effect of the complement activation product C5a. Excess C5a generated under pathological conditions has been implicated in a variety of conditions including sepsis, asthma and rheumatoid arthritis, but very little is known about the regulation of expression of the C5aR. The 5' promoter region and 3' untranslated region (UTR) of the C5aR mRNA were cloned, generating enhanced green fluorescent protein (EGFP)-reporter plasmids, which were transfected into the monocytic cell line U937. Most of the cloned 2kb 5' region was dispensable for the expression of the reporter constructs and the majority of regulatory sequences are in the first 200 bp. Three motifs, a NFκB, a CCAAT and a NFAT site, were identified to be of importance by site directed mutagenesis for basal expression. Analysis of the 3'UTR of the C5aR mRNA showed that it contained two AU-rich elements (AREs), however site directed mutagenesis showed that these had no effect on basal expression. While the phorbol ester PMA and dibutyryl cAMP increased C5aR protein expression, these agents had no effect on the regulation of expression via the promoter or the 3'UTR. This is the first study to investigate the role of both the promoter and 3'UTR in regulating C5aR expression and our results show that regulation of the human C5aR is similar but not identical to that of the mouse C5aR.

Multiple site acetylation of Rictor stimulates mammalian target of rapamycin complex 2 (mTORC2)-dependent phosphorylation of Akt protein.

The serine/threonine protein kinase Akt is a critical regulator of cell growth and survival in response to growth factors. A key step in Akt activation is phosphorylation at Ser-473 by the mammalian target of rapamycin (mTOR) complex 2 (mTORC2). Although Rictor is required for the stability and activity of mTORC2, little is known about functional regions or post-translational modifications within Rictor that are responsible for regulating mTORC2. Here, we demonstrate that Rictor contains two distinct central regions critical for mTORC2 function. One we refer to as the stability region because it is critical for interaction with Sin1.1 and LST8, and a second adjacent region is required for multisite acetylation. p300-mediated acetylation of Rictor increases mTORC2 activity toward Akt, whereas site-directed mutants within the acetylation region of Rictor exhibit reduced insulin-like growth factor 1 (IGF-1)-stimulated mTORC2 kinase activity. Inhibition of deacetylases, including the NAD+-dependent sirtuins, promotes Rictor acetylation and IGF-1-mediated Akt phosphorylation. These results suggest that multiple-site acetylation of Rictor signals for increased activation of mTORC2, providing a critical link between nutrient-sensitive deacetylases and mTORC2 signaling to Akt.

Binding of human antigen R (HuR) to an AU-rich element (ARE) in the 3'untranslated region (3'UTR) reduces the expression of decay accelerating factor (DAF).

We have investigated the role of the 3'untranslated region (3'UTR) in the expression of decay accelerating factor (DAF), one of the major membrane regulators of Complement activation. We show here that the 3'UTR of DAF contains an adenylate uridine rich element (ARE) AUUUAUUUAUAUUUAUUUA, which belongs to Class II Cluster 4 of the AU-rich element-containing mRNA (ARED) database. Enhanced Green Fluorescent Protein (EGFP) Reporter constructs containing the DAF 3'UTR showed reduced levels of expression when transfected into a variety of cell lines compared to 3'UTR reporter constructs without the ARE sequence. Furthermore, the inhibitor of mRNA transcription Actinomycin D had a much stronger effect on mRNA half-life of the ARE-containing 3'UTR demonstrating that this ARE destabilises the mRNA. Electrophoretic Mobility Shift Assays (EMSA) using biotinylated RNA probes, demonstrated that cytoplasmic Human antigen R (HuR) bound to the DAF ARE. Transfection experiments using HuR specific siRNA increased DAF expression whilst plasmids containing the coding sequence of HuR had the opposite effect, demonstrating that HuR reduced the stability of DAF mRNA and suggesting that it is of importance in regulating the expression of DAF. These data suggest that modulators of HuR could potentially be used to alter DAF expression and therefore increase the susceptibility of malignant cells to immunotherapy.

Modulation of CD59 expression by restrictive silencer factor-derived peptides in cancer immunotherapy for neuroblastoma.

Tumor cells escape clearance by complement by abundantly expressing CD59 and other membrane complement regulators. Existing strategies for blocking/knocking down these regulators can contribute to tumor immunoclearance in vitro; however, there are numerous difficulties restricting their use in vivo. Here, we report a new strategy for suppression of CD59 expression in neuroblastoma using peptides that target regulators of CD59 expression. We identified the neural-restrictive silencer factor (REST) as a target for modulation of CD59 expression in neuroblastoma. We next designed plasmids that encoded peptides comprising different DNA-binding domains of REST and transfected them into neuroblastoma cell lines. These peptides suppressed CD59 expression, sensitizing neuroblastoma to complement-mediated killing triggered by anti-GD2 therapeutic monoclonal antibody. These CD59-modulating peptides might be effective therapeutic adjuvants to therapeutic monoclonal antibodies used for treatment of neuroblastoma and other cancer types sharing the same mechanism for regulation of CD59 expression.

Haplotypic structure across the I kappa B alpha gene (NFKBIA) and association with multiple myeloma.

Polymorphisms in NFKBIA may be important in pre-disposition to and outcome after treatment, of multiple myeloma (MM). The NFKBIA gene product, IkappaBalpha, binds to NF-kappaB preventing its activation and is important in mediating resistance to apoptosis in B-cell lymphoproliferative diseases. This study investigates eight polymorphisms across the NFKBIA gene in large patient and control populations. Significant differences in the frequency of particular polymorphisms were noted between patients and controls. A risk haplotype [GCCTATCA] for MM was also identified (P=0.006). Analysis of the genetics of NFKBIA may lead to associations with disease progression and survival and thus more personalized therapy.

A randomized trial comparing 2 low-molecular-weight heparins for the outpatient treatment of deep vein thrombosis and pulmonary embolism.

BACKGROUND: Low-molecular-weight heparins (LMWHs) are now standard therapy for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE). No published trials have compared LMWHs, and few studies have examined outpatient therapy for PE. Only tinzaparin sodium has demonstrated superiority to unfractionated heparin in a clinical trial. METHODS: We compared 2 LMWH products, tinzaparin and dalteparin sodium, for the treatment of acute DVT and PE in a randomized, controlled clinical trial of consecutive outpatients presenting to a venous thromboembolism service at 4 tertiary-care hospitals. Patients were treated with subcutaneous tinzaparin sodium, 175 IU/kg every 24 hours, or subcutaneous dalteparin sodium, 200 IU/kg every 24 hours, for at least 5 days. Warfarin sodium therapy was started simultaneously and continued for 90 days. The primary end point was efficacy (recurrence of venous thromboembolism); safety (bleeding) was a composite end point. RESULTS: Two hundred fifty-four patients received tinzaparin (39 with PE and 215 with DVT) and 251 received dalteparin (51 with PE and 200 with DVT). Most patients had an active malignancy or idiopathic DVT/PE. The outcome events occurred in 11 (4.4%; 95% confidence interval [CI], 2.2%-7.7%) and 15 patients (5.9%; 95% CI, 3.3%-9.5%) in the dalteparin and tinzaparin groups, respectively, including 9 and 10 recurrences, respectively, and 2 and 5 major hemorrhages, respectively (P = .44). The 95% CI on the difference of -1.5% was -5.3% to 2.4%. CONCLUSIONS: Tinzaparin and dalteparin are safe and effective for the outpatient treatment of DVT or PE. Our finding of no differences between the LMWHs based on major clinical end points means that practical issues can be the deciding factor on which drug to use.

Evaluating the quality of internet-based information about alternative therapies: development of the BIOME guidelines.

BACKGROUND: The aim of the study was to develop guidelines for evaluating the quality of Internet-based information about alternative therapies. METHOD: An expert committee drafted a set of guidelines for evaluating information relating to alternative therapies. The guidelines were subsequently refined by testing them using resources already included in the BIOME databases. The first 20 unique web sites about alternative therapies for cancer retrieved using a general search engine and a United Kingdom focused search engine were then evaluated using the refined guidelines. Those undertaking the evaluations also completed a questionnaire relating to the face and content validity of the guidelines. The participants in the implementation stage were six content providers. Content providers identify, evaluate and describe resources for inclusion in the BIOME databases. RESULTS: Only one web site out of 20 was selected by all six content providers for inclusion in the BIOME databases according to the alternative therapies guidelines. All content providers were in agreement regarding the exclusion of nine sites, but there were discrepancies regarding the remaining 10 resources. There was general agreement that the guidelines were easy to understand and that all points raised were necessary. However, there were differences of opinion regarding whether all issues were covered, whether the guidelines allowed the selection of only the highest quality resources, and whether the guidelines were applicable to a wide range of Internet-based resources about alternative therapies. CONCLUSIONS: The levels of inconsistencies in the results indicate the need for the further development of the BIOME guidelines for selecting information about alternative therapies.