Nanoformulated SOD1 ameliorates the combined NASH and alcohol-associated liver disease partly via regulating CYP2E1 expression in adipose tissue and liver.

Enhanced free fatty acid (FFA) flux from adipose tissue (AT) to liver plays an important role in the development of nonalcoholic steatohepatitis (NASH) and alcohol-associated liver disease (AALD). We determined the effectiveness of nanoformulated superoxide dismutase 1 (Nano) in attenuating liver injury in a mouse model exhibiting a combination of NASH and AALD. Male C57BL6/J mice were fed a chow diet (CD) or a high-fat diet (HF) for 10 wk followed by pair feeding of the Lieber-DeCarli control (control) or ethanol (ET) diet for 4 wk. Nano was administered once every other day for the last 2 wk of ET feeding. Mice were divided into 1) CD + control diet (CD + Cont), 2) high-fat diet (HF) + control diet (HF + Cont), 3) HF + Cont + Nano, 4) HF + ET diet (HF + ET), and 5) HF + ET + Nano. The total fat mass, visceral AT mass (VAT), and VAT perilipin 1 content were significantly lower only in HF + ET-fed mice but not in HF + ET + Nano-treated mice compared with controls. The HF + ET-fed mice showed an upregulation of VAT CYP2E1 protein, and Nano abrogated this effect. We noted a significant rise in plasma FFAs, ALT, and monocyte chemoattractant protein-1 in HF + ET-fed mice, which was blunted in HF + ET + Nano-treated mice. HF + ET-induced increases in hepatic steatosis and inflammatory markers were attenuated upon Nano treatment. Nano reduced hepatic CYP2E1 and enhanced catalase levels in HF + ET-fed mice with a concomitant increase in SOD1 protein and activity in liver. Nano was effective in attenuating AT and liver injury in mice exhibiting a combination of NASH and AALD, partly via reduced CYP2E1-mediated ET metabolism in these organs.NEW & NOTEWORTHY Increased free fatty acid flux from adipose tissue (AT) to liver accompanied by oxidative stress promotes nonalcoholic steatohepatitis (NASH) and alcohol-associated liver injury (AALD). Obesity increases the severity of AALD. Using a two-hit model involving a high-fat diet and chronic ethanol feeding to mice, and treating them with nanoformulated superoxide dismutase (nanoSOD), we have shown that nanoSOD improves AT lipid storage, reduces CYP2E1 in AT and liver, and attenuates the combined NASH/AALD in mice.

Constructing a Sensitizing Definition of Certification in Nursing for Research Purposes: A Hybrid Methodology Using Consensus-Building Approach.

OBJECTIVE: The aim of this study was to construct a sensitizing definition of certification in nursing for research purposes that can provide a foundation from which to further develop a coherent research program building evidence about the impact of certification on healthcare outcomes. BACKGROUND: The lack of a single definition of certification in nursing makes it difficult to draw conclusions about the relationship between specialty certification and patient outcomes. METHODS: This study was guided by the Delphi-Chaffee hybrid methodology proposed by Grant et al. DISCUSSION: Constructing a single, sensitizing definition of certification: 1) provides coherency for direction of certification research; 2) serves as a guide for researchers; and 3) facilitates multimethodological approaches to exploring the relationship among the different components of the definition of certification. CONCLUSION: A sensitizing definition of certification provides an opportunity for researchers to study the relationship between nursing certification and patient outcomes.

Conceptualization and Operationalization of Certification in the US and Canadian Nursing Literature.

OBJECTIVE: To identify how certification is defined, conceptualized, and discussed in the nursing literature. BACKGROUND: Although it is hypothesized that credentialing is associated with better patient outcomes, the evidence is relatively limited. Some authors have suggested that the lack of consistency used to define certification in nursing literature may be one of the dominant obstacles in credentialing research. METHODS: This scoping review was guided by Arksey and O'Malley's framework, and quantitative and qualitative analyses were conducted. RESULTS: The final data set contained a total of 36 articles, of which 14 articles provided a referenced definition of certification. Thematic analysis of the definitions yielded 8 dominant themes. CONCLUSION: The lack of a common definition of certification in nursing must be addressed to advance research into the relationship between certification processes in nursing and healthcare outcomes.

Nanoformulated copper/zinc superoxide dismutase attenuates vascular cell activation and aortic inflammation in obesity.

OBJECTIVE: Endothelial cell (EC) oxidative stress can lead to vascular dysfunction which is an underlying event in the development of cardiovascular disease (CVD). The lack of a potent and bioavailable anti-oxidant enzyme is a major challenge in studies on antioxidant therapy. The objective of this study is to determine whether copper/zinc superoxide dismutase (CuZnSOD or SOD1) after nanoformulation (nanoSOD) can effectively reduce EC oxidative stress and/or vascular inflammation in obesity. METHODS: Human aortic endothelial cells (HAECs) were treated with native- or nanoSOD for 6 h followed by treatment with linoleic acid (LA), a free fatty acid, for 6-24 h. To determine the in vivo relevance, the effectiveness of nanoSOD in reducing vascular cell activation was studied in a mouse model of diet-induced obesity. RESULTS: We noted that nanoSOD was more effectively taken up by ECs than native SOD. Western blot analysis further confirmed that the intracellular accumulation of SOD1 protein was greatly increased upon nanoSOD treatment. Importantly, nanoSOD pretreatment led to a significant decrease in LA-induced oxidative stress in ECs which was associated with a marked increase in SOD enzyme activity in ECs. In vivo studies showed a significant decrease in markers of EC/vascular cell activation and/or inflammation in visceral adipose tissue (VAT), thoracic aorta, and heart collected from nanoSOD-treated mice compared to obese control mice. Interestingly, the expression of metallothionein 2, an antioxidant gene was significantly increased in nanoSOD-treated mice. CONCLUSION: Our data show that nanoSOD is very effective in delivering active SOD to ECs and in reducing EC oxidative stress. Our data also demonstrate that nanoSOD will be a useful tool to reduce vascular cell activation in VAT and aorta in obesity which, in turn, can protect against obesity-associated CVD, in particular, hypertension.

Effects of leptin replacement alone and with exendin-4 on food intake and weight regain in weight-reduced diet-induced obese rats.

Weight loss in obese humans produces a relative leptin deficiency, which is postulated to activate potent orexigenic and energy conservation mechanisms to restrict weight loss and promote weight regain. Here we determined whether leptin replacement alone or with GLP-1 receptor agonist exendin-4 attenuates weight regain or promotes greater weight loss in weight-reduced diet-induced obese (DIO) rats. Forty percent restriction in daily intake of a high-fat diet in DIO rats for 4 wk reduced body weight by 12%, body fat by 29%, and plasma leptin by 67% and normalized leptin sensitivity. When food restriction ended, body weight, body fat, and plasma leptin increased rapidly. Daily administration of leptin [3-h intraperitoneal (ip) infusions (4 nmol·kg(-1)·h(-1))] at onset and end of dark period for 3 wk did not attenuate hyperphagia and weight regain, nor did it affect mean daily meal sizes or meal numbers. Exendin-4 (50 pmol·kg(-1)·h(-1)) infusions during the same intervals prevented postrestriction hyperphagia and weight regain by normalizing meal size. Coadministration of leptin and exendin-4 did not reduce body weight more than exendin-4 alone. Instead, leptin began to attenuate the inhibitory effects of exendin-4 on food intake, meal size, and weight regain by the end of the second week of administration. Plasma leptin in rats receiving leptin was sevenfold greater than in rats receiving vehicle and 17-fold greater than in rats receiving exendin-4. Together, these results do not support the hypothesis that leptin replacement alone or with exendin-4 attenuates weight regain or promotes greater weight loss in weight-reduced DIO rats.

Didactic CME and practice change: don't throw that baby out quite yet.

Skepticism exists regarding the role of continuing medical education (CME) in improving physician performance. The harshest criticism has been reserved for didactic CME. Reviews of the scientific literature on the effectiveness of CME conclude that formal or didactic modes of education have little or no impact on clinical practice. This has led some to argue that didactic CME is a highly questionable use of organizational and financial resources, and a cause of lost opportunities for physicians to engage in meaningful learning. The authors' current program of research has forced them to reconsider the received wisdom regarding the relationship between didactic modes of education and learning, and the role frank dissemination can play in bringing about practice change. The authors argued that the practice of assessing and valuing educational methods based only on their capacity to directly influence practice reflects an impoverished understanding of how change in clinical practice actually occurs. Drawing on case studies research, examples were given of the functions didactic CME served in the interest of improved practice. Reasons were then explored as to why the contribution of didactic CME is often missed or dismissed. The goal was not to advocate for a return to the status quo ante where lecture-based education is the dominant modality, but rather to acknowledge both the limits and potential of this longstanding approach to delivering continuing education.

Knowledge systems, health care teams, and clinical practice: a study of successful change.

Clinical teams are of growing importance to healthcare delivery, but little is known about how teams learn and change their clinical practice. We examined how teams in three US hospitals succeeded in making significant practice improvements in the area of antimicrobial resistance. This was a qualitative cross-case study employing Soft Knowledge Systems as a conceptual framework. The purpose was to describe how teams produced, obtained, and used knowledge and information to bring about successful change. A purposeful sampling strategy was used to maximize variation between cases. Data were collected through interviews, archival document review, and direct observation. Individual case data were analyzed through a two-phase coding process followed by the cross-case analysis. Project teams varied in size and were multidisciplinary. Each project had more than one champion, only some of whom were physicians. Team members obtained relevant knowledge and information from multiple sources including the scientific literature, experts, external organizations, and their own experience. The success of these projects hinged on the teams' ability to blend scientific evidence, practical knowledge, and clinical data. Practice change was a longitudinal, iterative learning process during which teams continued to acquire, produce, and synthesize relevant knowledge and information and test different strategies until they found a workable solution to their problem. This study adds to our understanding of how teams learn and change, showing that innovation can take the form of an iterative, ongoing process in which bits of K&I are assembled from multiple sources into potential solutions that are then tested. It suggests that existing approaches to assessing the impact of continuing education activities may overlook significant contributions and more attention should be given to the role that practical knowledge plays in the change process in addition to scientific knowledge.

Care of the underserved: faculty development needs assessment.

INTRODUCTION: Because role models are crucial to training physicians to care for the underserved, we examined pediatric faculty's knowledge, attitudes, self-efficacy, skills, and precepting behaviors regarding care for this population. METHODS: Faculty knowledge, attitudes, self-efficacy, and skills/precepting behaviors were surveyed. RESULTS: Fifty-five (65%) of 85 faculty responded. The mean (standard deviation) knowledge score was 5.9 (1.3) of 8 possible. More than one-third of faculty did not recognize the eligibility criteria, services, and outcomes associated with common resources serving the underserved. Overall attitudes toward underserved families were positive, mean 3.3 (0.3), as was mean self-efficacy, 3.0 (0.7). Self-efficacy was lowest for accessing community resources for underserved families, 2.4 (0.7). Although most faculty performed the surveyed skills, fewer than 50% reported, precepting of these same skills with students. Precepting was lowest for accessing public and community resources. CONCLUSIONS: Low rates of student precepting as well as specific knowledge and self-efficacy deficits highlight potential targets for faculty development.

Definitions of Physician Certification Used in the North American Literature: A Scoping Review.

INTRODUCTION: The authors sought to identify how physician specialty certification is defined in the North American literature. METHODS: A rigorous, established six-stage scoping review framework was used to identify the North American certification literature published between January 2006 and May 2016 relating to physician specialty certification. Data were abstracted using a charting form developed by the study team. Quantitative summary data and qualitative thematic analysis of the purpose of certification were derived from the extracted data. RESULTS: A two stage screening process identified 88 articles that met predefined criteria. Only 14 of the 88 articles (16%) contained a referenced purpose of certification. Eighteen definitions were identified from these articles. Definitional concepts included lifelong learning and continuous professional development, assessment of competence and performance, performance improvement, public accountability, and professional standing. DISCUSSION: Most articles identified in this scoping review did not define certification or describe its purpose or intent. Future studies should provide a definition of certification to further scholarly examination of its intent and effects and inform its further evolution.

Effect of nanoformulated copper/zinc superoxide dismutase on chronic ethanol-induced alterations in liver and adipose tissue.

BACKGROUND: We previously reported that nanoformulated copper/zinc superoxide dismutase (Nano) attenuates non-alcoholic fatty liver disease and adipose tissue (AT) inflammation in obese animals. Here, we sought to determine whether Nano treatment attenuates alcohol-associated liver disease (AALD) and AT inflammation in alcohol-fed mice. METHODS: We pre-treated E-47 cells (HepG2 cells that over-express CYP2E1) with native- or nano-superoxide dismutase (SOD) for 6 h, followed by treatment with ethanol and/or linoleic acid (LA), a free fatty acid. For in vivo studies, male C57BL/6 mice were fed the Lieber-DeCarli control or ethanol liquid diet for 4 weeks. The mice received Nano once every 2 days during the last 2 weeks of ethanol feeding. RESULTS: Our in vitro studies revealed that Nano pretreatment reduced LA + ethanol-induced oxidative stress in E-47 cells. Our in vivo experiments showed that ethanol-fed Nano-treated mice had 22% lower hepatic triglyceride levels than mice fed ethanol alone. Nano-treated ethanol-fed mice also had 2-fold lower levels of Cd68 and similarly reduced levels of Ccl2 and Mmp12 mRNAs, than in untreated ethanol-fed mice. We also noted that ethanol feeding caused a remarkable increase in hepatic and/or plasma MCP-1 and CCR2 protein, which was blunted in ethanol + Nano-treated animals. The hepatic content of SREBP-1c, a transcription factor that promotes lipogenesis, was higher in ethanol-fed mice than controls but was attenuated in ethanol + Nano-treated animals. Further, livers of ethanol + Nano-treated mice had significantly higher levels of phosphorylated adenosine monophosphate-activated protein kinase (AMPK) than both control and ethanol-fed mice. In AT, the levels of Il6 mRNA, a hepatoprotective cytokine, and that of Arg1, a marker of anti-inflammatory macrophages, were significantly increased in ethanol + Nano-treated mice compared with control mice. CONCLUSION: Our data indicate that Nano treatment attenuates ethanol-induced steatohepatitis and that this effect is associated with an apparent activation of AMPK signaling. Our data also suggest that Nano induces Arg1 and Il6 expression in AT, suggesting anti-inflammatory effects in this tissue.

Clinical skills and self-efficacy after a curriculum on care for the underserved.

BACKGROUND: Despite calls for medical school curricula that address care for the underserved, published evaluations of such curricula are few and often do not assess clinical skills. This study assesses the changes in self-efficacy and clinical skills resulting from faculty-led or web-based curricula on care for the underserved. METHODS: Third-year students on 6-week 2003-2004 pediatric clerkships were block-randomized to a curriculum on caring for the underserved in one of three formats: established (readings only), faculty-led, or web-based. Primary outcomes were pre- and post-curriculum changes in self-efficacy and clinical skills. ANCOVA was used to test differences among curriculum groups, adjusting for prior experiences with the underserved. Analyses were performed in 2007. RESULTS: A total of 138 students participated, with 121 (88%) completing both pre- and post-tests. Compared to the established-curriculum students, both faculty-led and web-based students improved their self-efficacy in establishing achievable goals with underserved families, while web-based students improved their self-efficacy around knowledge of community resources. Significantly more new skills were performed by both faculty-led (mean [SD]=3.3[1.8]) and web-based curriculum students (2.9[1.5]), compared to established-curriculum students (1.5[1.4]). Compared to established-curriculum students, more faculty-led and web-based students also reported new skills in locating resources to meet the needs of underserved patients and in following up on referrals to ensure that families accessed needed care. CONCLUSIONS: Web-based and faculty-led curricula improve medical student self-efficacy and clinical skills. Results from specific self-efficacy and skill items facilitate targeted curricular improvement.

Gaps between knowing and doing: understanding and assessing the barriers to optimal health care.

INTRODUCTION: A significant gap exists between science and clinical practice guidelines, on the one hand, and actual clinical practice, on the other. An in-depth understanding of the barriers and incentives contributing to the gap can lead to interventions that effect change toward optimal practice and thus to better care. METHODS: A systematic review of English language studies involving human subjects and published from January 1998 to March 2007 yielded 256 articles that fulfilled established criteria. The analysis was guided by two research questions: How are barriers are assessed? and What types of barriers are identified? The studies abstracted were coded according to 33 emerging themes; placed into seven categories that typified the barriers; grouped as to whether they involved the health care professional, the guideline, the scientific evidence, the patient, or the health system; and organized according to relationship pattern between barriers. RESULTS: The results expand our understanding of how multiple factors pose barriers to optimal clinical practice. The review reveals increasing numbers of behavioral and system barriers. Quantitative survey type assessments continue to dominate barrier research; however, an increasing number of qualitative and mixed-method study designs have emerged recently. DISCUSSION: The findings establish the evolution of research methodologies and emerging barriers to the translation of knowing to doing. While many studies are methodologically weak, there are indications that designs are becoming more aligned with the complexity of the health care environment. The review provides support for the need to examine multiple factors within the knowledge-to-action process.

Hemostasis and Safety of a Novel Fibrin Dressing Versus Standard Gauze in Bleeding Cancellous Bone in a Caprine Spine Surgery Model.

BACKGROUND: Decorticated bone is a significant source of blood loss in scoliosis surgery. Current hemostatic methods include packed gauze (GS), physical barriers such as bone wax, and xenograft collagen-based materials. We assessed the safety and efficacy of a novel fibrin dressing (dextran-thrombin-fibrinogen [DTF]) compared to GS. This dressing comprises lyophilized thrombin and fibrinogen embedded in an elastic electrospun nanofiber dextran matrix. PURPOSE: The study tests the hypothesis that DTF is more efficacious than GS in control of bleeding from cancellous bone. STUDY DESIGN: A preclinical Good Laboratory Practices (GLP) study. METHODS: We enrolled 10 goats that were followed for 28 ± 1 days. Each animal was randomly assigned to the test or control group. Both test and control animals had 4 cancellous bone injuries. Test animal injuries were treated with DTF, whereas standard GS was used to control bleeding in the control animals. Bleeding at the bone injury site was characterized as either none, oozing, flowing, or pulsatile and was assessed at 4 and 8 minutes after dressing application. Goats were survived 28 ± 1 days and then necropsied. RESULTS: Application of the fibrin dressing to bleeding cancellous bone, both posterior spinal lamina, and iliac crest graft sites, resulted in control of bleeding within 4 minutes at all injury sites. Eighty percent of control injury sites continued to bleed after 8 minutes and required application of bone wax to control bleeding. There were no differences in prothrombin time, partial thromboplastin time, or fibrinogen levels between test and control animals at 1 or 28 days. We observed no adverse histologic reactions at 28 days. CONCLUSION: The fibrin dressing is an efficacious and safe method of controlling blood loss from cancellous bone in a spine surgery model.

A combination of dietary N-3 fatty acids and a cyclooxygenase-1 inhibitor attenuates nonalcoholic fatty liver disease in mice.

We sought to determine whether a combination of purified n-3 fatty acids (n-3) and SC-560 (SC), a cyclooxygenase-1-specific inhibitor, is effective in ameliorating nonalcoholic fatty liver disease in obesity. Female wild-type mice were fed a high-fat and high-cholesterol diet (HF) supplemented with n-3 in the presence or absence of SC. Mice treated with SC alone exhibited no change in liver lipids, whereas n-3-fed mice tended to have lower hepatic lipids. Mice given n-3+SC had significantly lower liver lipids compared with HF controls indicating enhanced lipid clearance. Total and sulfated bile acids were significantly higher only in n-3+SC-treated mice compared with chow diet (CD) controls. Regarding mechanisms, the level of pregnane X receptor (PXR), a nuclear receptor regulating drug/bile detoxification, was significantly higher in mice given n-3 or n-3+SC. Studies in precision-cut liver slices and in cultured hepatoma cells showed that n-3+SC enhanced not only the expression/activation of PXR and its target genes but also the expression of farnesoid X receptor (FXR), another regulator of bile synthesis/clearance, indicating that n-3+SC can induce both PXR and FXR. The mRNA level of FGFR4 which inhibits bile formation showed a significant reduction in Huh 7 cells upon n-3 and n-3+SC treatment. PXR overexpression in hepatoma cells confirmed that n-3 or SC each induced the expression of PXR target genes and in combination had an enhanced effect. Our findings suggest that combining SC with n-3 potentiates its lipid-lowering effect, in part, by enhanced PXR and/or altered FXR/FGFR4 signaling.

Nanoformulated copper/zinc superoxide dismutase exerts differential effects on glucose vs lipid homeostasis depending on the diet composition possibly via altered AMPK signaling.

Evidence suggests that superoxide dismutase 1 (SOD1) promotes glucose vs lipid metabolism depending on the diet type. We recently reported that nanoformulated SOD1 (Nano) improved lipid metabolism without altering glucose homeostasis in high-fat (HF) diet-fed mice. Here, we sought to determine the effects and potential mechanisms of Nano in modulating glucose and lipid homeostasis in mice fed a normal chow diet (CD) vs HF diet. Mice were fed a CD or a HF diet (45%) for 10 wk and injected with Nano once every 2 days for 15 days. The fasting glucose level was lower (P < 0.05) in CD + Nano-treated mice compared to control. Conversely, blood glucose was not altered but serum triglycerides were lower in HF + Nano-treated mice. Genes involved in fatty acid synthesis were reduced by Nano in the skeletal muscle of CD but not of HF diet-fed mice. Adenosine monophosphate-activated protein kinase (AMPK), which promotes both glucose and lipid metabolism depending on the fuel availability, is activated by Nano in CD-fed mice. Moreover, Nano increased phosphorylation of ACC, a downstream target of AMPK, in both CD and HF diet-fed mice. Nano increased mitochondrial respiration in C2C12 myocytes in the presence of glucose or fatty acid, and this effect is inhibited by Compound C, an AMPK inhibitor. Our data suggest that Nano promotes glucose and lipid metabolism in CD and HF diet-fed mice, respectively, and this effect is mediated partly via AMPK signaling.

Caring for the underserved: blending service learning and a web-based curriculum.

BACKGROUND: Recognition of health disparities among underserved individuals, whose demographic, geographic, or economic characteristics impede access to health-related services, has led to calls for the development of medical school curricula that address care for the underserved, but reports of the development and evaluation of such curricula are limited. METHODS: Two formats of a curriculum addressing care for the underserved were developed and implemented during the 6-week pediatric clerkship for third-year medical students during the 2003-2004 academic year. One format was faculty-led; the other was web-based. Skills for providing care to underserved families were taught through didactic, experiential, and service-learning curriculum components. Novel core curriculum elements included a screening tool for recognizing underserved patients and an independent clinical project through which students linked underserved families with community health resources. Analyses from 2004-2005 compared pre- and post-curriculum knowledge and attitudes of web-based students (n = 29) to those receiving either the faculty-led (n = 36) or the established "readings-only" curriculum (n = 35). Qualitative data from service learning projects were analyzed to assess clinical skills. RESULTS: Compared to students in the established curriculum, both web-based and faculty-led students demonstrated improved knowledge (p < 0.001) and attitudes (p < 0.05) about caring for the underserved. Both web-based and faculty-led students were successful in recognizing and addressing underserved health issues in the clinical setting. CONCLUSIONS: Faculty-led and web-based curricula can equally improve student knowledge, attitudes, and skills about caring for the underserved.

Nanoformulated copper/zinc superoxide dismutase reduces adipose inflammation in obesity.

OBJECTIVE: An intimate association exists between oxidative stress and inflammation. Because adipose tissue (AT) inflammation is intricately linked to metabolic disorders, it was hypothesized that reducing oxidative stress would be effective in ameliorating AT inflammation in obesity. METHODS: Wild-type mice were fed a high-fat diet (HF) for 8 weeks followed by a 2-week treatment with nanoformulated copper/zinc superoxide dismutase (NanoSOD). The mice were divided into: 1) chow diet, 2) HF, and 3) HF + NanoSOD. RESULTS: The HF + NanoSOD-treated mice showed a significant decrease in plasma and liver triglycerides when compared with HF-fed mice. Interestingly, NanoSOD reduced the expression of macrophage and inflammatory markers in visceral AT (VAT) and stromal cells derived from VAT. Moreover, the activation of proinflammatory signaling pathways, in particular, the extracellular signal-regulated kinases, was blunted in VAT on NanoSOD treatment. However, markers of oxidative stress were not altered significantly in the HF + NanoSOD group in the experimental conditions. Pretreatment of either macrophages or adipocytes significantly reduced the inflammatory response invoked in an in vitro coculture system, further supporting the role of NanoSOD in inhibiting obesity-linked inflammation. CONCLUSIONS: This data suggest that NanoSOD is effective not only in reducing AT macrophage accumulation and AT inflammation but also in promoting triglyceride metabolism in obesity.

Contents of a core library in continuing medical education: a Delphi study.

INTRODUCTION: In developing their professional competence, those who are interested in the practice of continuing medical education (CME) should recognize the knowledge base that defines their field. This study systematically identifies and organizes a list of books and journals comprising a core library (100 books/15 journals) for CME professionals. METHODS: The Delphi method was applied to elicit and combine the judgments of a fifty member panel considered knowledgeable about the CME field. The panelists participated in three iterations of the survey to first identify and then rank order nominated works. Separate ranked lists were created for books and journals. RESULTS: Forty-four participants completed the study (88% response rate). 268 books and 34 journals were identified. Mean ratings ranged from 4.78 (high) to 1.50 (low). DISCUSSION: The results of the study reflect the panel's judgment. The list is not definitive; instead, it describes what a select group of individuals knowledgeable about the CME field considered important. The list should therefore be seen as a general guide and a resource to facilitate decision-making, not as a prescription for creating a library.

Education through telemedicine networks: setting quality standards.

Quality standards for educational programming have received limited attention in telemedicine. We selected five sets of standards from the distance education literature established by: (1) the American Council on Education; (2) the American Distance Education Consortium; (3) the Council of Regional Accrediting Commissions; (4) the Distance Education and Training Council; (5) the Innovations in Distance Education Project. The standards were reviewed to determine the purposes they were intended to serve and the process by which they were established. The content of the five sets of standards were summarized around the 'four commonplaces' of education: learner, teacher, curriculum and context. Four major findings emerged. First, none of the sets of standards addresses all of the issues that are potentially relevant to telemedicine education; all emphasize certain topics while neglecting others. Second, there are some important aspects of telemedicine that are not addressed at all, such as patient confidentiality. Third, the standards generally provide a framework for defining high quality in distance education, leaving to those at the local level the task of deciding how a standard applies in their setting. Finally, the standards reviewed have many elements that could potentially apply to telemedicine education. Setting quality standards for education through telemedicine requires a systematic approach and a means for continuous improvement of those standards.