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.

The bone morphogenetic proteins (BMPs) are a group of transforming growth factor ,B (TGF-Pi)-related factors whose only receptor identified to date is the product of the daf-4 gene from Caenorhabditis elegans. Mouse embryonic NIH 3T3 fibroblasts display high-affinity 125I-BMP-4 binding sites. Binding assays are not possible with the isoform 125I-BMP-2 unless the positively charged N-terminal sequence is removed to create a modified BMP-2, 125I-DR-BMP-2. Cross-competition experiments reveal that BMP-2 and BMP-4 interact with the same binding sites. Affinity cross-linking assays show that both BMPs interact with cell surface proteins corresponding in size to the type I (57-to 62-kDa) and type II (75-to 82-kDa) receptor components for TGF-, and activin. Using a PCR approach, we have cloned a cDNA from NIH 3T3 cells which encodes a novel member of the transmembrane serine/threonine kinase family most closely resembling the cloned type I receptors for TGF-,B and activin. Transient expression of this receptor in COS-7 cells leads to an increase in specific 125I-BMP4 binding and the appearance of a major affinity-labeled product of -64 kDa that can be labeled by either tracer. This receptor has been named BRK-1 in recognition of its ability to bind BMP-2 and BMP-4 and its receptor kinase structure. Although BRK-1 does not require cotransfection of a type II receptor in order to bind ligand in COS cells, complex formation between BRK-1 and the BMP type II receptor DAF-4 can be demonstrated when the two receptors are coexpressed, affinity labeled, and immunoprecipitated with antibodies to either receptor subunit. We conclude that BRK-1 is a putative BMP type I receptor capable of interacting with a known type II receptor for BMPs.The transforming growth factor ,B (TGF-,B) superfamily contains a large number of growth, differentiation, and morphogenetic cytokines that are active as homo-or heterodimers.This superfamily includes the TGF-1 family, the activin family, the Mullerian inhibiting substance (MIS), and the bone morphogenetic protein (BMP)/Vg family, which composes the largest group (reviewed in reference 39). Human BMP-2 and BMP-4 and their Drosophila homolog dpp are highly related (74 to 76% sequence identity [72]), as are BMP-5, BMP-6, and BMP-7 and their Drosophila homolog 60A (69 to 73% sequence identity [21]). Given the high degree of structural similarity among these family members, it is expected that their receptors will also form a family of related molecules. activin (2, 40) have been cloned. It has recently been determined that the product of the daf-4 gene from Caenorhabditis elegans, which is involved in both inhibition of dauer larva formation and exit from the dauer stage, is a type II receptor for BMP-2 and BMP-4 (24). Each of these receptors is predicted to be a transmembrane serine/threonine kinase. Ligand binding to each of these type II receptors in a variety of cell types does not appear to require coexpression of additional receptor components, indicating that type II receptors are capable of...

We conducted a study to determine if use of a new flocculant-disinfectant home water treatment reduced diarrhea. We randomly assigned 492 rural Guatemalan households to five different water treatment groups: flocculantdisinfectant, flocculant-disinfectant plus a customized vessel, bleach, bleach plus a vessel, and control. During one year of observation, residents of control households had 4.31 episodes of diarrhea per 100 person-weeks, whereas the incidence of diarrhea was 24% lower among residents of households receiving flocculant-disinfectant, 29% lower among those receiving flocculant-disinfectant plus vessel, 25% lower among those receiving bleach, and 12% lower among households receiving bleach plus vessel. In unannounced evaluations of home drinking water, free chlorine was detected in samples from 27% of flocculant-disinfectant households, 35% of flocculant-disinfectant plus vessel households, 35% of bleach households, and 43% of bleach plus vessel households. In a setting where diarrhea was a leading cause of death, intermittent use of home water treatment with flocculant-disinfectant decreased the incidence of diarrhea.

Bismuth subsalicylate (BSS) is a compound without significant aqueous solubility that is widely used for the treatment of gastrointestinal disorders. BSS was able to bind bacteria of diverse species, and these bound bacteria were subsequently killed. A 4-log10 reduction of viable bacteria occurred within 4 h after a 10 mM aqueous suspension of BSS was inoculated with 2 x 10(6) Escherichia coli cells per ml. Binding and killing were dependent on the levels of inoculated bacteria, and significant binding but little killing of the exposed bacteria occurred at an inoculum level of 2 x 10(9) E. coli per ml. Intracellular ATP decreased rapidly after exposure of E. coli to 10 mM BSS and, after 30 min, was only 1% of the original level. Extracellular ATP increased after exposure to BSS, but the accumulation of extracellular ATP was not sufficient to account for the loss of intracellular ATP. The killing of bacteria exposed to BSS may have been due to cessation of ATP synthesis or a loss of membrane integrity. Bactericidal activity of BSS was also investigated in a simulated gastric juice at pH 3. Killing of E. coli at this pH was much more rapid than at pH 7 and was apparently due to salicylate released by the conversion of BSS to bismuth oxychloride. It is proposed that the binding and killing observed for BSS contribute to the efficacy of this compound against gastrointestinal infections such as traveler's diarrhea.

Continuing medical education's transition from an emphasis on dissemination to changing clinical practice has made it increasingly necessary for CME providers to develop effective interorganizational collaborations. Although interorganizational collaboration has become commonplace in most sectors of government, business, and academia, our review of the literature and experience as practitioners and researchers suggest that the practice is less widespread in the CME field. The absence of a rich scholarly literature on establishing and maintaining interorganizational collaborations to provide continuing education to health professionals means there is little information about how guidelines and principles for effective collaboration developed in other fields might apply to continuing professional development in health care and few models of successful collaboration. The purpose of this article is to address this gap by describing a successful interorganizational CME collaboration-Cease Smoking Today (CS2day)-and summarizing what was learned from the experience, extending our knowledge by exploring and illustrating points of connection between our experience and the existing literature on successful interorganizational collaboration. In this article, we describe the collaboration and the clinical need it was organized to address, and review the evidence that led us to conclude the collaboration was successful. We then discuss, in the context of the literature on effective interorganizational collaboration, several factors we believe were major contributors to success. The CS2day collaboration provides an example of how guidelines for collaboration developed in various contexts apply to continuing medical education and a case example providing insight into the pathways that lead to a collaboration's success.

A commitment to practice change (CTC) approach may be used in educational program evaluation to document practice changes, examine the educational impact relative to the instructional focus, and improve understanding of the learning-to-change continuum. The authors reviewed various components and procedures of this approach and discussed some practical aspects of its application using as an example of a study evaluating a presentation on menopausal care for primary care physicians. The CTC approach is a valuable evaluation tool, but it requires supplementation with other data to have a complete picture of the impact of education on practice. From the evaluation perspective, the self-reported nature of the CTC data is a major limitation of this method. Keywords commitment to practice change; program evaluation; continuing educationThe translation of new knowledge into clinical practice can be a slow process, often taking a decade or more for research findings to find their way into routine patient care (Sussman, Valente, Rohrbach, Skara, & Pentz, 2006). The resulting gaps in the quality of healthcare have led to calls for action in many parts of the world (Committee on Quality of Healthcare in America, 2001;Legido-Quigley, McKee, Nolte, & Glinos, 2008). The traditional role of continuing medical education (CME)-updating physicians on the latest scientific evidenceis not sufficient to respond to this reality (Marinopoulos et al., 2007). Therefore, in the past five years there has been a marked shift toward focusing CME activities on improving practice rather than disseminating information (Davis, Davis, & Bloch, 2008;Regnier, Kopelow, Lane, & Alden, 2005). This shift in the goals of CME programming has resulted in a concomitant shift in how CME activities need to be evaluated. Evaluators must now go beyond measuring learner satisfaction and change in medical knowledge to the level of physician performance and patient outcomes. To date, only a limited number of CME evaluations have assessed impact at this level (Tian, Atkinson, Portnoy, & Gold, 2007). There is a pressing need to equip evaluators with valid, reliable and feasible methods of assessing practice and/or patient outcomes (Davis, Barnes, & Fox, 2003;Marinopoulos et al., 2007).The commitment to change (CTC) approach is one tool available to CME evaluators for assessing the impact of education on clinical practice. The central, distinguishing feature of the CTC approach is that it asks participants in an educational activity to write down descriptions of the changes they propose to make as a result of what they learned during the (Purkis, 1982). Since 1982, when the CTC approach was introduced to medical educators as an evaluation method (Purkis, 1982), it has been increasingly used in the CME field to both facilitate and measure practice change (Wakefield, 2004). This trend is likely due, in part, to the perception that the CTC approach is relatively easy to implement and low-cost (Curry & Purkis, 1986;Jones, 1990). There are, however, significant...

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.

The study shows that (1) the appropriate target of an educational intervention may be a team rather than an individual, (2) implementing even relatively simple practice guidelines can be a complex process, and (3) change requires scientific and practical knowledge. A richer understanding of implementation mechanisms and contextual factors is needed to guide educational planning.