Among these, millets are known for their climate-resilient features including adaptation to a wide range of ecological conditions, less irrigational requirements, better growth and productivity in low nutrient input conditions, less reliance on synthetic fertilizers, and minimum vulnerability to environmental stresses  and its wild progenitor, green foxtail (S. viridis) are extensively studied since they are considered as models for studying the traits related to C4 photosynthesis, stress biology, and bioenergy characteristics  of agronomic importance identified in millets to other major cereals. In the above context, this article advocates for initiating extensive research on millets to dissect their agronomic, nutritional as well as stress tolerance traits and develop strategies to transfer the useful traits to cultivated major cereals such as rice, wheat, maize, and sorghum.Panicoids (subfamily: panicoideae) are a group of C4 photosynthetic trait is highly advantageous to millets. In the C4 system, carbon dioxide (CO2) is concentrated around ribulose-1,5-bisphosphate carboxylase/oxygenase (RuBisCO), which in turn suppresses ribulose 1,5-bisphosphate (RuBP) oxygenation and photorespiration  depending on the temperature and increases the in planta catalytic activity of RuBisCO  and nitrogen use efficiency (NUE) which are ~1.5 to 4-fold higher than C3 photosynthesis  whereas rice and wheat requires a maximum of 20–24 weeks. However, the prevalence of stress conditions and their consequences are circumvented by several traits such as short stature, small leaf area, thickened cell walls, and the capability to form dense root system , malate dehydrogenase (MDH), malic enzyme (ME), phosphoenolpyruvate carboxylase (PEPC), phosphoenolpyruvate carboxylase kinase (PPCK) and pyruvate orthophosphate dikinase (PPDK) were also identified and compared to that of sorghum, maize, rice and Brachypodium. The study showed that foxtail millet has a higher number of MDH (7 genes) and PPDK (3 genes) than other crops. Zhang et al.   has enabled the development of high-throughput molecular markers in other millet crops. In finger millet, the transcriptome of high and low seed calcium genotypes was sequenced, and thousands of simple sequence repeat (SSR) containing microsatellite markers were identified (Kumar et al., It is realized that millets hold great promise for food security and nutrition amid ever-increasing agricultural costs, climate change and burgeoning mouths to feed worldwide. They are nutritious, possess additional health benefits, requires significantly fewer input costs for cultivation and are naturally tolerant to most biotic and abiotic stresses. These features accentuate millets as crops of choice for the world population amid growing concerns about climate change. Given the same, there is a growing need to investigate the natural genetic variation across their diverse germplasms to exploit them for crop improvement with regard to many agronomically and nutritionally important traits. With the advent of NGS technologies and high-throughput GWAS platforms, identification of candidate genes/alleles/QTLs regulating such traits is possible at a pace and precision not contemplated before, which in turn would facilitate the development of breeding lines for crop improvement. Moreover, a renewed focus on millets has important implications for the improvement of cereals and bioenergy grasses given their common ancestry from poaceae family and the presence of significant synteny between the genomes.MP and TB conceived the idea and drafted the opinion article. MM improved the manuscript and provided revisions to the manuscript. All the authors have read and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Uptake of e-health, the use of information communication technologies (ICT) for health service delivery, in allied health appears to be lagging behind other health care areas, despite offering the potential to address problems with service access by rural and remote Australians. The aim of the study was to conduct a scoping review of studies into the application of or attitudes towards ehealth amongst allied health professionals conducted in Australia.Studies meeting inclusion criteria published from January 2004 to June 2015 were reviewed. Professions included were audiology, dietetics, exercise physiology, occupational therapy, physiotherapy, podiatry, social work, and speech pathology. Terms for these professions and forms of ehealth were combined in databases of CINAHL (EBSCO), Cochrane Library, PsycINFO (1806 – Ovid), MEDLINE (Ovid) and AMED (Ovid).Forty-four studies meeting inclusion criteria were summarised. They were either trials of aspects of ehealth service delivery, or clinician and/or client use of and attitudes towards ehealth. Trials of ehealth were largely from two research groups located at the Universities of Sydney and Queensland; most involved speech pathology and physiotherapy. Assessments through ehealth and intervention outcomes through ehealth were comparable with face-to-face delivery. Clinicians used ICT mostly for managing their work and for professional development, but were reticent about its use in service delivery, which contrasted with the more positive attitudes and experiences of clients.The potential of ehealth to address allied health needs of Australians living in rural and remote Australia appears unrealised. Clinicians may need to embrace ehealth as a means to radicalise practice, rather than replicate existing practices through a different mode of delivery.The online version of this article (doi:10.1186/s12913-016-1791-x) contains supplementary material, which is available to authorized users. Arguabldelivery , with oudelivery , 5 and tdelivery , with lidelivery  for examIn Australia, there are strong arguments for ehealth in allied health. Limited service provision to rural and remote Australia has been associated with poor recruitment and retention of allied health clinicians –8. TertiA high level of access to the internet amongst Australians (83/100)  demonstrWe conducted a scoping review of the empirical support for allied ehealth through Australian applications. The specific questions were: (1) What aspects of ehealth use by allied health clinicians have been addressed in research conducted in Australia? and (2) What are the outcomes of this research?This review did not involve primary research involving humans, hence approval from an ethics committee was not sought.Scoping reviews address the purpose of this study: that is, to examine the nature and extent of research about a topic or to answer a question , 17. We We adopted the World Health Organization definition of ehealth as the use of ICT for the delivery of health services . A selecTelehealth and Telemedicine, and Telemedicine and e-health. Figure Included were primary studies conducted in any part of Australia, involving one or more allied health profession that directly addressed any aspect of and/or attitude towards ehealth, published from January 2004 to June 2015. Excluded were conference proceedings, books/book sections, and journal articles without primary data, those whose primary focus was not ehealth, or data specific to allied health practitioners was not provided. The electronic search was supplemented by hand searches of included studies and the journals Each study was summarised according to citation, participant group and clinical problem, study focus and design, ICT employed, and key outcomes. Authors TI, KS and AHC completed the study extraction; to check for consistency, TI and KS both summarised three of the studies, and TI and AHC both summarised two of the studies. Disagreements about studies meeting inclusion criteria were resolved through consensus discussion by TI, KS and AHC.n = 33), or surveys and qualitative studies providing clinician and in some cases client opinions (n = 11). Study designs for the direct trials were descriptive outcome studies of groups (n = 5) or cases (n = 6), single group comparisons across conditions (n = 10), comparison across treatment and control groups , or Randomised Controlled Trials . Figure Studies were broadly categorised as either direct trials of ehealth  and The University of Queensland (UQ). The USyd focus was on telehealth for evidence-based stuttering interventions for children –21, adolThe UQ studies addressed speech pathology assessment and treatment of a variety of disorders across child –28 and aSix of the eight studies in physiotherapy , 43–47 aIn the one podiatry study , videocoIn the only direct trial study involving more than one allied health discipline, Crotty and colleagues  evaluateMost surveys and qualitiative studies focused on attitudes towards and use of ehealth by speech pathologists  and occuTwo studies addressed specific aspects of ehealth following its implementation , 61. Meyn = 5) trialled the prototype, resulting in only a small increase in confidence in using the terminology. Finally, in one study including a number of allied health professions, attitudes towards website use to provide information to clients was explored [The only study involving dieticians related to use of an ehealth records prototype to assist in the adoption of international terminology standards . Fewer texplored . There wResearch into Australian ehealth in allied health has been limited in scope. Efficacy studies, conducted mostly in speech pathology and physiotherapy, have demonstrated reliable and valid assessment, and similar intervention outcomes across ehealth and face-to-face delivery, but the actual experience of ehealth was at best a simulated one in many studies. A picture that emerges from this review and the large national survey  is of alThe focus on the fidelity of intervention and limited real-life ehealth applications with few attempts to understand the client perspective also fails to align with patient- or client-centred care. Further, evidence of limited use of the web to provide clients with information ignores a push towards self-managed care, facilitated by an increase in health service users’ reliance on the internet for health-related information .Limited uptake of ehealth may be attributable to a desire for new technologies to support existing ways of working, rather than embracing its potential to revolutionalise work practices . WithoutWe addressed only a subset of allied health professions. Still, the clinician uses and attitudes in these studies reflect the findings of the large survey with a more comprehensive list of professions . As withThe concerns clinicians have about ehealth  have notFinally, our review focused on the Australian context, which functions with a particular health care system, with ehealth reliant on internet access that varies in quality and reliability across parts of the country , 15. IntThe potential benefits of ehealth remain unrealised in allied health. Research has demonstrated that traditional allied health assessment and intervention services can be reliably and validly implemented through ehealth. This research provides a foundation on which to build ehealth initiatives, but does not address key concerns of clinicians or demonstrate innovative service delivery. Enlisting stakeholder support from communities who stand to benefit from ehealth and applying comprehensive research strategies may assist in shifting the research to exploring revolutionary practices that will deliver benefits to both service providers and recipients.


We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions.The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight “measures working groups” identified relevant constructs and effective measurement approaches, which were then categorized as “essential” or “optional” common data elements (CDEs) for the EC4 projects.Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics.The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields.NCT01116726, April 29, 2010; NCT01116739, May 3, 2010; NCT01129440, May 21, 2010; and NCT01205971, September 19, 2010.All the trial that used the BRFQ were registered at Clinicaltrial.gov  Significant disparities are seen in the oral health of children across racial and ethnic minority groups, including Latino, American Indian and Alaska Native, and African American populations in the United States. Investigators conducting research with these populations have assessed child and family socio-demographic, biological, behavioral, social, and psychological variables that are theorized to influence oral health. Building on the results of this work has been challenging because of varying methods employed in defining and measuring these constructs. The need to identify predictors, mediators and moderators that influence intervention effects and compare them across populations requires consistency in measurement. The National Institutes of Health and other institutions have emphasized the need to develop common data elements (CDEs) to facilitate data interoperability in large clinical research networks and consortia . DevelopThe Early Childhood Caries Collaborating Centers (EC4) and their common Data Coordinating Center (DCC) are funded by the National Institute of Dental and Craniofacial Reseach (NIDCR). The Center to Address Disparities in Children’s Oral Health at the University of California San Francisco (UCSF), the Center for Research to Evaluate and Eliminate Dental Disparities at Boston University (BU), and the Center for Native Oral Health Research at the University of Colorado Denver (UCD) were funded to conduct research that would add to knowledge regarding means of reducing oral health disparities through ECC prevention in at-risk communities. NIDCR required these Centers to develop essential CDEs, including identification of constructs reflecting important characteristics of children and their parents/caregivers. Clinical trials conducted by all Centers collected CDEs in a standardized fashion to facilitate comparisons of risks and outcomes across the studies.The Basic Research Factors Questionnaire (BRFQ) has been used in four EC4 clinical trials. It also has been used in observational studies to understand the risk factors for ECC within a given population and to compare risk factors across population groups. It was administered to parents/caregivers of young children aged 0–5 years. It has been used with low-income and underserved families, including low income Spanish and English-speaking Latinos in San Diego and Monterey Counties in California; with low-income, racially and ethnically diverse, underserved families living in urban, public housing developments in Boston; and with American Indian families living in reservation communities in the Southwest and the Northern Plains .This paper describes the process of developing the BRFQ, providing ECC prevention investigators with an opportunity to more knowledgeably choose all or some of the battery for use in their research. Doing so will facilitate comparability with other available data related to the efficacy of oral disease prevention efforts in diverse populations. In turn, this more standardized approach to defining and measuring variables will assist the larger scientific community in making supportable generalizations across studies and lead to more confident understanding of the probable outcomes of various prevention approaches and strategies.individual characteristics of children and their parents/caregivers, including sociodemographics, oral hygiene practices, dental care utilization, and pediatric oral health-related quality of life;parent/caregiver level characterstics, including oral health knowledge, attitudes and behaviors, and psychosocial factors such as chronic stress, social support, and self-reported parental oral health.community-level influences, including social environment, physical environment, and community cultural components.As work on clinical trials within their respective Centers began, NIDCR convened EC4 investigators to develop a common, parent-report instrument that assessed factors potentially related to ECC that became the BRFQ. The BRFQ was to be the vehicle for collecting information on variables likely to be predictors, mediators, or moderators of pediatric oral health. Using the conceptual framework described by Fisher-Owens et al.  as a staDevelopment of the Measures working groups: Forty-five investigators from across the Centers and NIDCR were involved in the process, functioning as eight measures working groups, each focused on one or more categories of constructs and their measurement Table . MeasureBased on their prior research experience and literature reviews, groups identified critical constructs to be measured across all studies in the three Centers, located and evaluated validated measures of such constructs, and, when necessary, developed new measures. The groups then developed recommendations regarding which constructs and measures should be utilized for the EC4 clinical trials. Each project evaluated, at the construct level, the compiled measures that the work groups proposed. Issues of respondent burden, relative value of different response options, literacy level, translation and cultural applicability, and areas of construct overlap were discussed. Next, recommended measures were reviewed by investigators across the three Centers and were revised with input from investigators experienced in using the measures in diverse communities.In next step, the DCC compiled items, created consistent formatting, and facilitated other administrative and data management streamlining. Measures working groups reviewed and assisted with developing consistent administration instructions and response options to be used across projects. The BRFQ was developed for use both as an interviewer-administered and as a self-administered instrument.th grade reading level. Each Center had advisory boards and advisory committees that had members and stakeholders form the participating communities. The measures developed by the working groups were reviewed by these members for cultural appropriateness.Cultural appropriateness: Throughout the measures development process, the measures working groups ensured that items were culturally appropriate and written at no higher than a 6Role of EC4 Steering Committee: The eight measures working groups reported their recommendations in their respective domains to the EC4 Steering Committee Fig. . The EC4Translations: Essential and optional CDEs were translated into Spanish and back translated to English to ensure proper translation by a single IRB-approved translation service. Following translation, bilingual team members from the BU and UCSF study teams reviewed the translations for dialects and idioms of local Spanish-speaking populations, and the BU and UCSF versions then were harmonized.Pilot Testing: Pilot testing, including cognitive interviews after BRFQ administration, of both essential and study-specific optional items was conducted separately by each of the four trials as well as other projects in the three Centers, and final refinements were based on those results. If a trial planned to enroll Spanish-speaking participants, then the pilot testing included Spanish-language materials.The EC4 followed a systematic multi-step process in selecting and defining measures included in the BRFQ. Several of the measures were previously validated at the time of selection, and other measures are undergoing the process of validation.The measures working groups, their areas of focus, and major decisions and recommendations are detailed below.Behavioral Interventions Measures Working Group –This group established a set of 11 oral health messages judged to be critical for ECC prevention Table . These mCommunity, Social Environment, and Cultural Measures Working Group – This group began by identifying constructs at the community and social levels, for each Center and across Centers, that investigators thought could impact children’s oral health. They identified available measures and, when necessary, developed new measures. Among measures proposed by the group were water fluoridation, quality of housing, and perceptions of social environment ; the group recommended recording residential ZIP codes to enable linking to Census and Area Resource File data. However, community water fluoridation was not measured in the BRFQ because all participants in the CREEDD and CANDO trials lived in areas with community water fluoridation. Thus, investigators determined the more important issue for these randomized trials was asking about tap water consumption. Measuring community water fluoridation for CNOHR trials was difficult because the population was rural and had many soucres of water including well water. Also, water fluoridation was spotty and inconsistent in these areas. There were a total of seven optional CDEs under the domain “Physical Living Conditions” and “Alcohol Use” Table .Cost Measures Working Group – The goal of this group was to develop methodologies to uniformly measure societal and personal/familial costs of preventive interventions and also relative intervention costs in the context of possible treatment averted. The group collaborated with the Health Services Utilization/Insurance Group to develop a limited number of measures to address both utilization and costs. These measures address utilization of services for dental problems in dental clinics, hospital emergency departments, and hospital and outpatient surgery centers (where anesthesia often is used to treat severe ECC cases). Cost measures also address family costs related to travel for services and time spent at providers’ offices or clinics obtaining and waiting for services. The final set included 15 essential items under the domain “Insurance/Utilization & Cost” Table .Health Service Utilization/Insurance Measures Working Group – This group’s charge was to identify uniform questions related to dental service utilization. These included time since the last dental visit, age of first dental visit, reason for last visit, barriers to care, dental home status, types of services received, type of health insurance, delay in getting appointments, and perceptions related to the availability of services and child dental need. The group reviewed and selected items from a list that initially included multiple versions of questions related to access and utilization concepts at the individual, community, and state levels. The final set included a total of 14 essential items under the domains “Insurance/Utilization & Cost” Table  and 14 oHealth Status, Health History, and Child Developmental Measures Working Group – This group identified measures of parent-reported oral and general health, quality of life, major medical conditions, medications, allergies, special needs and physical development of children. They identified some items from NHANES related to oral and general health status and selected the BU-developed Pediatric Oral Health-Related Quality of Life (POQL) measure . They maOral Health Knowledge and Behavior Measures Working Group – This group focused on identifying existing measures to capture parent/caregiver oral health knowledge and behaviors. The group sought to identify or develop items that would capture parent/caregiver knowledge and behavior related to each of the 11 intervention targets specified by the Behavioral Intervention Measures Working Group Table  OptionalPsychosocial Factors Measures Working Group – Each Center had originally planned to assess psychosocial constructs, so the group began by exchanging their respective Centers’ proposed psychosocial measures and the rationales for these choices. The group then identified constructs of interest across Centers and began identifying and developing appropriate measures. The group eventually recommended measures related to several psychososcial constructs: perceived discrimination, social support, sense of coherence, chronic stress, parenting stress, psychological distress, self-efficacy, and constructs from the Health Belief Model –13. OnlySociodemographic Measures Working Group – The purpose of this group was to identify uniform questions related to relevant socio-demographic variables. Items were compiled from the National Cancer Institute’s Biomedical Informatics Grid, National Health and Nutrition Examination Survey  NationalFor each clinical trial, the relevant university IRB reviewed and approved the BRFQ instrument protocol and the consent process.The UCD studies were approved by the Colorado Multiple Institutional Review Board. The UCSF study was approved by UCSF Committee on Human Research, the UCLA Medical Institutional Review Board and the San Diego State University Institutional Review Board. The BU study was approved by Boston University Medical Campus Institutional Review Board.Selected measures were refined by the measures working groups and forwarded in March, 2009, to the EC4 Steering Committee for final review. Table Across the four trials, baseline BRFQ data were collected for a total of 3,265 caregiver participants  acculturation scale, which measures the degree to which participants are culturally tied to both Anglo and Hispanic communities . AccultuBoth BU and UCSF included additional oral health knowledge questions beyond the essential set to ensure that there were knowledge questions that mapped directly to their intervention. For example, BU included questions regarding knowledge about timing of first dental visit and bedtime sippy cup use. UCSF asked additional questions related to its intervention including fluoride exposure, and application of fluoride varnish and dental sealants.The EC4 was charged with serving as a national resource for information and research on programs and interventions to promote oral health for all children, including the most vulnerable populations. The EC4 is using the BRFQ for studies with large Hispanic, African-American, and American Indian populations. Development of the BRFQ was integral to measuring components of that mission. Creation of this standard set of measures was intended to facilitate comparisons of risk factors and oral health outcomes across disparate populations of young children at risk for ECC.Despite its value, the BRFQ has limitations related to its primary purpose for use in randomized clinical trials of ECC prevention to identify effective interventions, and not necessarily for identifying risk factors for ECC. A key premise underlying our use of the BRFQ was the expectation that successful randomization would balance the distribution of important baseline risk factors among the different arms of each trial. Thus, the BRFQ does not include variables on a number of important ECC risk predictors such as community water fluoridation. Neither does the BRFQ include detailed assessments of caregiver or child dental fear/anxiety, although these variables may be important determinants of dental service utilization and children’s oral health status. Last but not least, preliminary analyses have suggested between-population differences in the measurement properties of at least some of the BRFQ subscales. The analyses to determine which subscales have invariance across populations are complicated, and it is not possible to summarize those results in this paper, which focuses on the process of developing a set of CDEs in a multi-institution consortium.To ensure understanding of the full range of determinants and factors contributing to oral health disparities, the BRFQ includes individual-level, parent/family-level, and community-level variables. This approach draws on contemporary knowledge of measures commonly used in oral health and disparities research and includes both identifiable risk factors and structural measures, such as education, income, ethnicity, social structure, and social environments-all of which appear to be major determinants of parental attitudes, beliefs, knowledge and behavior. A number of studies have suggested a strong association of these factors with oral health outcomes , 27.For each study, the relevant university IRB reviewed and approved the BRFQ instrument and protocol used. The BRFQ meets a critical need for standardizing variables of interest across pediatric oral health investigations and facilitating collection of data that can be generalized to the variety of solutions that are sought for addressing disparities in children’s oral health. UCD has published work demonstrating the validity of several BRFQ-based measures in American Indian populations –30, and Investigators outside the EC4 have used or adapted the BRFQ in a variety of projects , and hasThe process described in this paper may be useful to other multi-institution endeavors such as clinical research networks and consortia developing CDEs . Based oAs knowledge about ECC continues to advance, additional items may need to be added to the BRFQ, and the inclusion of some current items may be reconsidered. Measures of diet/sugar consumption, fluoride exposure, and additional community-level influences may be warranted, for example. The BRFQ does not include certain key information that could be obtained from a clinical examination of the child or parent/caregiver or from biologic or microbiome samples or genomic or metabolomic analyses.Additional uses of the BRFQ will contribute to the evidence base needed to determine the most effective ways to prevent ECC. It will be a good practice for any study adopting any published scale to also test the scale in its own population to confirm psychometrics. Finally, adaptations may be needed to reflect oral health related behaviors and attitudes within other cultures or for factors associated with caries incidence in older age groups.


The changing environment always questions the survival mechanism of life on earth. The plant being special in the sense of their sessile habit need to face many of these environmental fluctuations as they have a lesser escape option. To counter these adverse conditions, plants have developed efficient sensing, signaling, and response mechanism. Among them the role of phytohormones in the management of hostile ecological situations is remarkable. The strigolactone, a newly emerged plant hormone has been identified with many functions such as growth stimulant of parasitic plants, plant architecture determinant, arbuscular mycorrhiza symbiosis promoter, and also in many other developmental and environmental cues. Despite of their immense developmental potential, the strigolactone research in the last few years has also established their significance in adverse environmental condition. In the current review, its significance under drought, salinity, nutrient starvation, temperature, and pathogenic assail has been discussed. This review also opens the research prospects of strigolactone to better manage the crop loss under hostile ecological conditions. The plant hormones traditionally have been classified into growth promoting  or inhibiting (ethylene and abscisic acid) categories, thus particularly focused on development. The plant hormones have also been addressed for their role under stress conditions and the significance of phytohormones like abscisic acid (ABA), ethylene (ET), salicylic acid (SA), and jasmonic acid (JA) has been demonstrated.The plant being sessile, need to manage their lifestyle under ongoing ecological constraints. In general, plant has the capability to sustain themselves under mild environmental changes. But in order to do so the plant makes changes in almost every aspect of their biology like morphology, anatomy, physiology, and molecular biology. It has been known since last few decades that the crop productivity is negatively influenced by biotic and abiotic stresses. Usually, crop responds by perception of these stress and subsequent signal transduction followed by the regulation at the molecular level. Among the array of candidates, phytohormones appeared to be a crucial tool to address the stress management. The plant hormones are key determinants of plant behavior, which, along with other signals like reactive oxygen species (ROS), CaStriga, Orobanche, Alectra, and Phelipanche  are a small group of carotenoid derived compounds, exuded from the roots of 80% land plants and offer a symbiotic relation with soil arbuscular mycorrhiza (AM)  of Pisum sativum, more axillary growth (max) of Arabidopsis thaliana, decreased apical dominance of Petunia hybrida and dwarf or high-tillering dwarf (htd) of Oryza sativa , but still exhibited branching phenotype as that of max3 and max4 mutant plants, which was restored after SL treatment -inhibitor abamine and SG treated ABA deficient mutants' exhibit reduced ABA and SL levels. Moreover, the ABA mutants further revealed suppression of LeCCD7 and LeCCD8 transcripts  has also been characterized in Arabidopsis using complementary approach. Interestingly, OaMAX2 restored the drought tolerant phenotype of Atmax2 mutant, which suggested the conservation of MAX2 signaling in parasitic and non-parasitic plants  levels, which is a positive move toward seed germination. On application of GR24 under high temperature, the germination of SL defective Arabidopsis and rice  and SL-insensitive (atd14-1), the altered response to nitrogen deficiency was observed. Moreover, under limited nitrogen conditions the alteration of expression levels of SL biosynthesis genes (MAX3 and MAX4) was noticed  and signaling (max2) mutants. The supplementation of GR24  and D2 (an inhibitor of SL biosynthesis) in the media of wild types displayed greater susceptibility to R. fascians, only in later study. Moreover, the infection also triggers up regulation of genes associated with SL production , which was accompanied by reduction in the content of plant defense hormones (Torres-Vera et al., Pythium irregulare and Fusarium oxysporum (Blake et al., Besides a role in growth and development, SLs has also been recognized as a player to offer resistance to specific pathogens Marzec, . First sThe interaction of phytohormones and stress is well known events in plant stress management. The current list of these candidates involves both the classical and newly discovered phytohormones and the list is still continuing with the advent of novel growth stimulatory phytochemicals. The plant hormones in most of the cases are originally defined and described in terms of development and its role in stress is usually being given the next preference. But, the recent outlook for key hormones like ABA, ET, JA, SA has put the clear categorization of plant hormones under two separate heads i.e., development and stress related. In this continuation, the SL has been recognized as an important emerging player in plant stress management.Striga and Orobanche and stimulate seed germination of these parasitic weeds (Bouwmeester et al., The SL was originally described to favor AM symbiosis establishment and offer as host detection cues for root parasitic plants such as Though the significance of SL has been recognized in salinity, drought, temperature, nutrient starvation, and plant resistance, but its establishment as stress related hormones demand further studies. The queries that need to answer at this juncture may include—the disparity of SL biosynthesis/signaling in stress related contrasting genotype, their significance in multiple stress management to address the exact field problems, possibility of cross talk with other stress related hormones, interaction with plant transcription factors and related signaling pathway.SM has compiled the literature and written the manuscript. SU has helped in compilation of manuscript. All three authors have edited and revised the approved manuscript submitted.CSIR-NETWORK PROJECT BSC107.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In the last decade, Makerere University College of Health Sciences (MakCHS) has taken strides in research and training to improve healthcare through collaborative training and research programs. However, there is limited data on the trends of MakCHS faculty contributions to research and on faculty growth to take leading roles in health research. This paper reviews MakCHS faculty research publications over 15.5 years and outlines possible strategies to enhance faculty research outputs.We used a mixed methods approach. A systematic review of research publications by faculty at MakCHS  to quantify the number of research articles, areas researched, authorship contribution by MakCHS faculty, source of funding, as well as affiliated local and international collaborations. Graphs were used to shown trends in publications and leadership of authorship by faculty. Annual individual faculty research productivity was presented as publication per capita. Qualitative data on high priority needs to improve research outputs was collected through focus group discussions (FGDs) with faculty members, and analysed manually into emerging themes.Of 298 faculty at MakCHS at 2015, 89 (30%) were female and 229 (77%) were junior and mid-level faculty (senior lecturer and below). The PubMed and Google Scholar searches yielded 6927 published articles, of which 3399 (49%) full-text articles were downloaded for analysis, 426/3825 (11%) available as titles/abstracts only, and 598/4423 (14%) were excluded. Only 614 articles were published in 2014, giving a publication per capita of 2.1 for any authorship, and 0.3 for first and last authorship positions. MakCHS faculty increasingly contributed as first, second, third, and last authors. Up to 57% of research was in infectious diseases, followed by non-communicable diseases (20%) and non-communicable maternal child health (11%). Priority needs to improve research outputs, as expressed by faculty, were (1) an institutionally led faculty career development program, (2) skills building in research methods and scientific writing, (3) protected time for research related activities, (4) opportunities for collaborative research, and (5) use of individual development plans.Faculty research productivity was low and dominated by infectious diseases and non-communicable disease research. There is a need for structured institutional support to optimise faculty research outputs. Only with increased research productivity will MakCHS and other academic institutions be able to make a significant contribution in addressing national health challenges.The online version of this article (doi:10.1186/s12961-017-0196-6) contains supplementary material, which is available to authorized users. Research at academic institutions is relevant to influence national health policies to improve service delivery and health outcomes , 2. BetwIn addition to the social responsibility to address global health challenges , academiWe aimed at generating evidence on MakCHS faculty engagement in research over a period of 15.5 years by documenting the areas researched, levels of authorship contribution and source of funding, as well as affiliated local and international collaborations. This work builds on a previous report of 4-year data that 58% of research publications between 2005 and 2009 were led by MakCHS faculty or students as first authors [MakCHS is the medical school at Uganda’s oldest and largest public university (founded in 1922). MakCHS initially started as a Faculty of Medicine in 1924 until 2008, when it was reconstituted as a college consisting of four schools, namely Makerere University School of Biomedical Sciences, Makerere University School of Health Sciences, Makerere University School of Medicine, and Makerere University School of Public Health. The college is headed by a principal and each school is headed by a Dean. MakCHS’ mission is to improve health and promote health equity by providing quality education, research and health services. MakCHS offers 12 undergraduate programs and 31 graduate programs.We used a mixed methods approach comprising of firstly, a review of research publications by faculty at MakCHS to quantify the number of research articles, areas researched, authorship contribution, source of funding, as well as affiliated local and international collaborations, from January 1, 2000, to June 30, 2015. Secondly, qualitative data was collected from focus group discussions (FGDs) with faculty members at departmental level to determine high priority needs to improve faculty research outputs. This work was approved by the School of Medicine Research and Ethics Committee, and written informed consent was obtained from the faculty members that participated in FGDs.We conducted a review of published work by MakCHS faculty through PubMed and google scholar searches by last name of faculty, as listed on the human resources list and MakCHS departments. The human resources list included first, last, and middle (where applicable) names of faculty, current academic position, department of service, and employment status . The search was filtered by publication date from January 1, 2000, to June 30, 2015, and the search words are shown in Additional file Using a guide, FGDs were held at departmental level to document individual and institutional needs to enhance engagement of faculty in research-relevant activities. A convenient sample of two surgical departments , and two medical departments  in the School of Medicine, that had at least nine faculty members to participate in FGDs, was used. In addition, two FGDs that included members from all departments were conducted. FGDs were conducted until saturation of ideas. A total of six FGDs were conducted by faculty career development group members. Each FGD consisted of at least nine faculty members and lasted 1–2 hours. Faculty were asked, ‘In your opinion, what are the major challenges that limit your research productivity?’, ‘What support do you need to improve your research productivity and career development?’, ‘How could your department support you to improve your research productivity?’, and ‘How could MakCHS support you to improve your research productivity and career progression?’. Data from FGDs were recorded (text and audio), transcribed and analysed manually according to emerging themes to prioritise faculty needs to improve individual and institutional research outputs.Of 298 faculty at MakCHS in 2015, 89 (30%) were female and 229 (77%) were junior and mid-level faculty at levels of senior lecturer and below  of the research publications were by faculty from the School of Medicine, followed by School of Public Health 28%) and School of Biomedical Sciences 17%). Up to 57% of research was in infectious diseases, followed by non-communicable diseases (NCDs) at 20% and non-communicable maternal child health illnesses at 11%  publications had information on research funding, of which 883/2172 (41%) were funded by institutions in the United States and Canada, 491/2172 (23%) were funded by European institutions and 133/2172 (6%) were locally funded in Uganda.Up to 2278/3399 (67%) publications had data on collaborations, of which 1010/2278 (44%) involved collaborations with in-country institutions, 539/2278 (24%) had collaborations with academic institutions in the United States and 322/2278 (14%) had collaborations with institutions in Europe  female) and 15 were senior faculty (7 (47%) female). Below are the needs that academic faculty felt should be addressed to improve their research outputs  an institutionally led structured career development program; (2) skills’ building in research methods and scientific writing; (3) protected time for research related activities; (4) opportunities for collaborative research; and (5) individual development planning and time management. Our results are comparable with reports from medical school faculty in America, where up to 42% seriously considered quitting academic careers because of absence of faculty development programs, difficulties balancing work and family, lack of recognition of clinical and teaching commitments, and lack of regular evaluation of academic progress . A furthWe found that 426/3825 (11%) of faculty research appeared as titles/abstracts only without full publications in peer-reviewed journals. Qualitative data from faculty also revealed that a bulk of research theses by faculty and graduate students continue to lie on unit shelves without publication in peer-reviewed journals. Part of the reasons highlighted included limited skills, mentorship and time for productive scientific writing, as expressed by faculty. Unpublished research theses and reports are low hanging fruits that could be targeted to increase faculty and institutional research publications. Strategies to bridge the do–publish gap of research at MakCHS are clearly needed to minimise the research–policy–practice gaps in healthcare. Our results also emphasise individual and institutional challenges in developing functional and multidisciplinary research groups, grant writing skills and networks between local and international scientists in relevant fields [Noteworthy is the fact that a majority of published research was funded by foreign agencies, with the National Institutes of Health and European agencies as the leading funders. Indeed, there has been an increase in funding for research in Africa in the last decade , and insMakCHS continues to seize opportunities for faculty to actively participate in research through research-and-training partnerships between universities in high- and low-income countries  such as Faculty research productivity was low and dominated by infectious diseases and non-communicable disease research. There is a need for structured institutional support to optimise faculty research outputs. Only with increased research productivity will MakCHS and other academic institutions be able to make a significant contribution in addressing national health challenges. We recommend longitudinal monitoring and evaluation of individual faculty, and institutional research and instructional productivity.


Periodontal disease is a neglected bacterial infection that causes destruction of the periodontium in pregnant women. Yet its impact on the occurrence of adverse pregnancy outcomes has not systematically evaluated and there is no clear statement on the relationship between periodontal disease and preterm low birth weight. The objective of this study was to summarize the evidence on the impact of periodontal disease on preterm low birth weight.We searched the following data bases from January 2005 to December 2015: CINAHL , MEDLINE, AMED, EMBASE (excerpta medica database), Cochrane library and Google scholar. Only case-control studies with full text in English were eligible. Critical appraisal of the identified articles was done by two authors independently to provide the possible relevance of the papers for inclusion in the review process. The selected Case control studies were critically appraised with 12 items structured checklist adapted from national institute of health (NIH). Odds ratio (OR) or risk ratios (RR) were extracted from the selected studies. The two reviewers who selected the appropriate studies also extracted the data and evaluated the risk of bias.Of 229 articles, ten studies with a total of 2423 participants with a mean age ranged from 13 to 49 years were met the inclusion criteria. The studies focused on preterm birth, low birth weight and /or preterm low birth weight and periodontitis. Of the selected studies, 9 implied an association between periodontal disease and increased risk of preterm birth, low birth weight and /or preterm low birth weight outcome (ORs ranging from 2.04 to 4.19) and only one study found no evidence of association.Periodontal disease may be one of the possible risk factor for preterm low birth weight infant. However, more precise studies with randomized clinical trial with sufficient follow-up period must be done to confirm the association. Periodontal diseases are bacterial infections of the tooth supporting structures, which causes inflammation and destruction of the periodontium. This bacterial infections are adhered to the periodontal tissue by biofilm, which is a complex structure of bacteria and discernable by the excretion of a protective and adhesive matrix . The proSearching strategy and inclusion: An electronic database search for relevant case- controlled studies published in English (as translation funding was not available) was conducted from February 2015 to September 2015 on the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, Allied and Complementary Medicine (AMED), EMBASE, Cochrane library and Google scholar. The search terms used were gingivitis, periodontal disease, low birth weight, Oral health, and preterm delivery. To identify relevant article, titles and abstracts of retrieved papers were exported to Endnote where duplicates were identified and removed by one reviewer (AT). If needed full texts of peer-reviewed relevant articles were retrieved, assessed and their reference lists were hand searched to identify further relevant studies.Selection of studies: The method segment of listed case- controlled studies was extracted and two reviewers  employed the pre-determined inclusion criteria to screen for relevant full text case- controlled studies. Both the reviewers were blinded to journal, authors, and results. There were no any conflicts between the two reviewers in final selection decisions. Studies were included for data extraction and analyses, if they met the following predetermined inclusion criteria.Inclusion criteria : Articles were included in this systematic review if they full field the following criteriaStudy type: Full text case control articles written in english which are recently published (since 2000) in peer reviewed journals, primary journals, be on human subjectsParticipants: Females of the reproductive age group.Operational definition of periodontitis and outcome measures: Preterm birth (PTB): delivery at fewer than 37 weeks of gestation. Low birth weight (LBW): delivery of an infant with a birth weight of less than 2.5 kg . All articles were evaluated based on 12 points of the checklist and the quality of the articles were given as very good, goo and poor if the articles got more than 8, between 5 and 8 and less than 5 points respectively. The checklist assesses the methodological quality of articles based on important criteria, such as: appropriateness of research questions or objective, clarity of definitions on cases, clearly stated definition, inclusion and exclusion criteria, randomization of the cases and controls, measures of exposure/ risk, blindness of evaluator, and motioned and controlled cofounders (founders .Data extraction: The following data were extracted from the included case-control studies: outcome measures (RR/OR), and follow-up period, and study year, smoking, and alcohol used. The operational definition of periodontitis was extrapolated from the studies and reported. These data were then compiled into a standard table. The two reviewers , who selected the appropriate studies also extracted the data and evaluated the risk of bias.Search yield: The search from the databases and manual search from Google retrieved 229 articles, after removal of duplicates. After screening title, abstracts and references 154 papers were removed. Full text was obtained for 75 papers. Of which, 65 papers were eliminated as they did not meet inclusion criteria and finally, a total of 10 articles were considered for the systematic review . Results from nine case-control studies suggest that periodontal disease is a possible risk factor for adverse pregnancy outcomes [outcomes –26. Nineoutcomes –21 , preoutcomes , 23 or poutcomes –26. One outcomes  (Table 2Periodontal and other oral health problems have been supposed to be a risk factor for preterm birth and /or low birth weight in many literatures. Nevertheless, the association between periodontal health status of a pregnant women and adverse pregnancy outcomes is still controversial. In this review, it has been tried to focus on the results of all case control studies extracted from the literature, which had been conducted to find out the association between periodontal disease and two adverse pregnancy outcomes namely low birth weight and preterm birth. However, the operational definition of Periodontitis differed widely among the selected and reviewed studies since each articles considered special criteria. In this systematic review, nine of the included articles found that periodontal disease is associated with low birth weight and preterm birth –26. OtheLimitation of the study: The authors faced the following limitations during this systematic review; Inconsistent definitions of periodontal disease, and Lack of follow up of the cases in some of the included studiesPractical implications: this systematic review suggested clinicians to include oral health condition of a pregnant woman with other risk factors in to consideration during antenatal care.This systematic review found that periodontal disease is associated with low birth weight and preterm birth effects. However, more precise studies with proper design, suitable sample size and sufficient follow up period are needed for confirmation. During pregnancy, immunoresponsiveness and inflammatory response mediators have been changed due to increased progesterone and estrogen levels; this changes result in increased susceptibility of pregnant mothers to periodontal disease.Adverse pregnancy outcomes are generally associated with elevated local and systemic inflammatory mediators and intra-uterine infections.This systematic review suggests that there is an association between periodontal disease and preterm and low birth weight. Pregnant mothers who are diagnosed as having periodontal disease may have a high risk of delivering premature and low birth weight child regardless of other confounding factors.


Neonatal instability of the hip (NIH), where the femoral head can move away from the acetabulum, in the first weeks of life, is an important risk factor for developmental dysplasia of the hip (DDH). In rural areas in Australia, there is a recent trend to increased late diagnosis of DDH. Clinical screening of infant hips, a common practice in Australia, is experience dependent. Best practice early screening techniques are still debated with different techniques and timing used internationally. This systematic review examines early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth, and the early interventions informed by these findings and considers the findings for the context of rural Australia.The Cochrane Library, Medline, CINAHL and PEDro were searched for original research or systematic reviews, and clinical studies 1998 to 2015 involving dynamic ultrasound. Critical Appraisal Skills Programme tools were used to appraise the studies.Nineteen studies were included. Early Dynamic Ultrasound (DUS) is consistently described as a reliable assessment of NIH. Early DUS is recommended for risk factors including geographical areas of high prevalence. Approaches to early intervention of hips with excessive movement are somewhat discipline-related and include: primary prevention (advice), secondary prevention (abduction supports), and conservative management (removable splints).In the context of increased prevalence of DDH in rural Australia, contemporary evidence suggests that introduction of early DUS could provide rural infants with more effective screening than clinical examination alone. Targeted early advice about posturing and simple removable supports to abduct infant hips could prevent some cases of DDH in rural Australia. Neonataal head” . DDH is al head” .Despite serious long-term consequences for children with late diagnosis of DDH, best practice early screening techniques are debated with considerable variation in routine screening protocols internationally. This systematic review investigates early dynamic ultrasound screening (eDUS) methods for the detection of NIH, and how results can inform early interventions to potentially prevent either missed cases or delayed onset DDH.Clinical screening of all neonatal hips is currently accepted as the most economic assessment of hips in many European countries, UK, USA, Canada and Australia, with infants considered at risk of DDH or with hips demonstrating subluxation then undergoing Graf ultrasound examination at 6 weeks of age. Graf ultrasound , a morphClinical screening for DDH relies on detection of hip subluxation or dislocation soon after birth using Barlow or Ortolani methods and is experience-dependent with skilled, trained and experienced operators more reliably performing the procedure , 7. As fDynamic ultrasound hip examination was reported as early as 1988 . The twoThe purpose of this study is to explore the role of early dynamic ultrasound (eDUS) in screening and early intervention of NIH with a view to reducing the frequency of DDH. The primary outcome of the study is to describe the efficacy of eDUS and the secondary outcome to describe early interventions instigated as a result of eDUS findings. These results are then considered for the specific context of rural Australia.Developmental dysplasia of the hip, or congenital hip dysplasia, or neonatal instability of hip, or hip laxity, or hip dislocation, or hip abduction, or hip development, or alpha angle, or acetabular coverAND dynamic ultrasound, or anterior dynamic ultrasound, or ultrasound screen$ or ultrasound scan$AND screening, detection, or management, or conservative management, or outcome.The Cochrane Library, Medline, CINAHL and PEDro databases were searched for articles from 1998 to 2015 using the following search terms:Three levels of screening were used. Initially titles of the articles were reviewed. Abstracts were then reviewed. Included were original research or systematic reviews in English, and clinical studies involving dynamic ultrasound. Excluded were expert opinion, case studies, and studies where the first ultrasound was not performed in the first 6 weeks after birth. Full articles were obtained for studies meeting the criteria above, and level 3 screening performed where inclusion required that eDUS studies dealt with at least one of the following categories of information: screening, initial management, conservative management or treatment outcomes. The search was broadened to include articles cited by this initial yield that met the study inclusion criteria.Articles were appraised using Critical Appraisal Skills Programme (CASP) tools for evaluating randomised controlled studies, qualitative and quantitative research studies, based on the 1994 guides for medical literature. CASP is a robust tool developed by the Oxford Regional Health Authority from the educational methods of McMaster University of Canada , in respAfter applying the limitations, 139 articles were reviewed and of these, 26 articles were evaluated more comprehensively with 15 articles remaining and a further four added from citations in these papers , eight of medium quality (4–7.5), and one scored low Table . Five stExcluding the literature reviews and two articles which made no comment on eDUS as a screening tool: four studies reported on LDUS , 24–26, ADUS can be used reliably up to 6–8 weeks after birth , 15, 16.Early studies in this review period recognised that eDUS studies improve the diagnostic value of static morphologic ultrasound studies , 26 partTiming and types of early intervention following eDUS are reported in Table There was consensus from the majority of papers in Table There were inconsistent approaches to early interventions for unstable/subluxable hips between studies. A number of studies recognise that eADUS screening provides opportunity for more frequent surveillance only , 28, 29.This literature review did not support universal eDUS screening of neonatal hips, however contemporary recommendations support eDUS for areas of high prevalence and reduced operator reliability of clinical screening. Rural Australia can be considered a geographical area with high prevalence of DDH where a concerning trend in increased late diagnosis has been found , 11. RurAustria and some other parts of Europe, including parts of Scandinavia, advise universal eDUS . The US Based on the literature reviewed, there is little evidence to support conservative management with Pavik harness immediately after eDUS finding of NIH. Recently, Australia has seen increasing rates of late diagnosis of DDH (after 3 months) , 35. ThePrimary prevention measures in the first 6 weeks of life, including advice and instructions on positioning to optimise hip flexion and abduction, including avoiding swaddling with legs wrapped tightly together, could easily be instigated as routine practice in rural Australia. Certainly, an early educational program in Japan, highlighting the dangers of traditional swaddling, demonstrated improvement in hip development with significantly lower numbers of infants with late occurring DDH , showingThe limitations of this article is translating best evidence to the context of rural Australia where sparse populations and distance significantly impact on access to specialist services. Strengths of this study include; that it distinguishes between hip laxity (NIH) and dysplasia (DDH), and the use of the CASP tools ensured a focus on studies of acceptable rigor.In the context of increased DDH in rural Australia, contemporary evidence suggests that introduction of eDUS could provide rural infants with more effective screening than clinical examination alone. Targeted early interventions such as improved postural management for optimal hip development, and simple removable supports to abduct infant hips could prevent some cases of DDH.


Although clinical guidelines recommend the provision of care to reduce client chronic disease risk behaviours, such care is provided sub-optimally by primary healthcare providers. A study was undertaken to determine the effectiveness of an intervention in increasing community-based clinician implementation of multiple elements of recommended preventive care for four risk behaviours.A three-group stepped-wedge trial was undertaken with all 56 community-based primary healthcare facilities in one health district in New South Wales, Australia. A 12-month implementation intervention was delivered sequentially in each of three geographically and administratively defined groups of facilities. The intervention consisted of six key strategies: leadership and consensus processes, enabling systems, educational meetings and training, audit and feedback, practice change support, and practice change information and resources. Client-reported receipt of three elements of preventive care: assessment; brief advice; referral for four behavioural risks: smoking, inadequate fruit and/or vegetable consumption, alcohol overconsumption, and physical inactivity, individually, and for all such risks combined were collected for 56 months (October 2009–May 2014). Segmented logistic regression models were developed to assess intervention effectiveness.A total of 5369 clients participated in data collection. Significant increases were found for receipt of four of five assessment outcomes  and two of five brief advice outcomes . No significant increases in care delivery were observed for referral for any risk behaviour, or for physical inactivity.The implementation intervention was effective in enhancing assessment of client risk status but less so for elements of care that could reduce client risk: provision of brief advice and referral. The intervention was ineffective in increasing care addressing physical inactivity. Further research is required to identify barriers to the provision of preventive care and the effectiveness of practice change interventions in increasing its provision.ACTRN12611001284954. Registered 15 December 2011. Retrospectively registered.Australian Clinical Trials Registry  The primary health risk behaviours for the most common non-communicable diseases are tobacco smoking, poor nutrition, risky alcohol use, and physical inactivity , 2. SystIn a number of high-income countries including Australia, ambulatory community-based healthcare services are a key setting for the delivery of care to reduce client chronic disease risk behaviours –13. LimiPractice change theories –22 and rFew controlled trials of implementation interventions designed to increase the provision of multiple elements of preventive care addressing multiple risks in community-based health services have been reported . In a syGiven the limited and equivocal evidence regarding the ability to improve community-based healthcare provision of preventive care addressing multiple chronic disease risk behaviours, a study was undertaken to assess the effectiveness of a multi-strategic implementation intervention in increasing the provision of multiple elements of preventive care for multiple risk behaviours across a network of community healthcare facilities.A stepped-wedge trial , 27 was Adult community healthcare facilities that provide the following services were eligible for inclusion: community nursing, diabetes, aged care, counselling, dietetics, psychology, physiotherapy, and occupational therapist services.Child-based services were excluded given the differential type and focus of preventive health risk behaviour care required for this client group. In-patient services were excluded based on the focus of the study being on community-based ambulatory care services. Specialist community-based services such as sexual assault, palliative care, genetics, and child protection services were excluded due the sensitive nature of such consultations.The facilities employed approximately 1400 clinicians . All clinicians and managers within the eligible services were eligible to receive the intervention.All adult clients who attended a face-to-face appointment were eligible to receive the intervention. A sample of approximately 20 adult clients per facility group  was randomly selected from electronic records each week during the 56-month study period. All such clients who had at least one visit to an eligible community health service within the prior 2 weeks and who met the following inclusion criteria were eligible: 18 years of age or older, spoke English, mentally and physically capable of completing a telephone interview, not considered to be inappropriate to be contacted by a clinician, not having previously participated in the study, not involved in another community health care focused study, and not living in aged care facilities or gaol. Clients were blinded to the experimental manipulation of intervention delivery to facility groups, but not to care delivery. The selected clients were mailed an information letter and assessed for eligibility based on information from the medical record and a telephone interview.Clinical guidelines recommend that the opportunistic provision of preventive care occur in accordance with the “5A’s” behavioural counselling framework or variations thereof , 30. BasBased on such recommendations, and taking account of competing clinical priorities and the brevity of the client consultation , 30, 31,Prior to this study, no single model of preventive care addressing the health risks of interest was in place across community health services in the health district.Six types of implementation strategies, based on practice change theory and evidence demonstrating their effectiveness in modifying clinical practice –24 and iConsensus for the model of preventive care was sought and formalised through the development of a District wide preventive care policy, that was implemented by the District Clinical Governance Office prior to the commencement of the trial (December 2010). Engagement with Health District Executives within each of the facility groups occurred prior to the intervention and was maintained during the intervention periods through monthly meetings with the research team. At the facility level, engagement by the research team with local managers and clinicians occurred prior to and throughout the intervention period. Engagement (face-to-face and telephone meetings) was undertaken prior to, and during the intervention periods to inform and to: gain the support of key stakeholders regarding the need for the intervention; to gain agreement on the need to achieve key performance targets, and to encourage advocacy for and leadership of the intervention and model of preventive care.Prior to intervention commencement, an existing electronic medical record system, utilised by all facilities across the district, was modified by the district information technology services. An electronic tool was developed to (1) prompt and record preventive care delivery, including standardized assessment questions for each behaviour, and for clients with one or more risks, standardised brief advice on how to improve behaviours in order to meet the Australian national guidelines, and referral to recommended referral services and/or additional local referral avenues,( 2) produce tailored client and GP/Aboriginal Medical Service information letters based on the clients’ risks and care provided, and (3) generate care delivery performance reports for managers (see audit and feedback strategy). The modifications sought to standardise previous inconsistent approaches to the prompting, focus, and recording of the elements of care for the risk behaviours of interest, through providing a single electronic template with radio button/tick box response options. At the commencement of implementation rollout in each group, a hard copy preventive care form was provided for use in home visits.At the commencement of the clinical practice change intervention in each group, existing clinicians were provided with online competency-based training (2 h) and 1 h of face-to-face training regarding the implementation of the model of care by the research team. Training modules covered the policy guidelines and key performance indicators; the rationale, importance and model of preventive care; the provision and recording of preventive care in the standardised electronic recording tool, service managers were provided with 2 h of face-to-face training regarding the audit and feedback strategy, and in providing leadership in preventive care. Online training modules were incorporated into existing service orientation procedures for new clinicians at the same time. Prior to this study, no single training program had been implemented across the health district that addressed the delivery of care regarding the health risks of interest.Monthly care provision monitoring reports were introduced at the health district, facility and service levels. Reports included comparison against target benchmarks, and indicated the proportion of eligible clients who were assessed, and of those identified as having behavioural risks, the proportions provided with brief advice and offered referrals. Reports were emailed to and discussed with service managers by the research team on a monthly basis, commencing from the third month of the intervention in the first group of services. Where required, discussions focused on developing strategies to improve performance. Managers were encouraged to provide the reports to their staff each month.Implementation support officers employed by the research team were allocated to each facility to provide approximately one face-to-face visit per month and fortnightly telephone support for managers, during the 12-month intervention period for each group of services. Implementation support officers provided both proactive and reactive support to managers and clinicians to facilitate clinician provision of preventive care. This may have included, for instance, supporting clinicians to use and/or trouble-shoot problems with the electronic medical records system and standardized electronic tool, disseminating resources to managers and clinicians, discussing the audit and feedback strategy with managers, and assisting service managers to develop strategies to improve performance.During face-to-face training at the commencement of the intervention for each group of services, services and clinicians were provided an email helpline, a clinician resource pack , an internet site for accessing additional clinician resources, referral information, and a workstation care provision reminder. Each month, clinicians were e-mailed tips/update information and newsletters.Prior to the implementation of the intervention in each group of facilities, preventive care delivery was provided according to usual practice. The level of such care has been reported to be variable and limited , 37. TheOutcome and client characteristic data were collected via client computer-assisted telephone interview conducted by trained interviewers blinded to group allocation (approximately 25 min). Additional client and service characteristics data were obtained from the clients’ electronic medical record.Information collected by the telephone interview was employment status; Aboriginal and/or Torres Strait Islander status, marital status, level of education, and conditions requiring medication/medical attention. The following client information was collected from the electronic medical records: age, gender, country of birth, postcode, service type, and number of visits to the service in the prior 12 months.Using established survey items –41, clieAccording to national guidelines –45, clieThe primary outcome measures of client-reported receipt of three elements of preventive care for each of four risk behaviours were based on items used in previous surveys , 46, 47.Analysis was undertaken using SAS V9.4. Client residential postcodes were used to calculate client socio-economic disadvantage  and geogClient reported fruit and vegetable intake was combined (fruit and/or vegetable intake), as was client reported clinician provision of care for this combined risk. For each risk behaviour, client reported receipt of each element of preventive care was dichotomised (yes/no). For each risk behaviour, receipt of referral was defined as receiving either an offer of referral to the telephone helplines, advice to use support from their General Practitioner/Aboriginal Medical Service, or advice to use support from another professional.For the outcomes involving clinician assessment of client risk, all participants were included in the analysis. For the outcomes of clinician provision of brief advice and of referral, only those participants that reported being at-risk were included.Analysis of receipt of care for “all risks combined” was undertaken, with such care defined as assessment for all four risks, the provision of brief advice for all of a clients’ identified risks, and the provision of any referral for all of a clients’ identified risks.To examine change in provision of preventive care for each care element across each risk behaviour for the three groups combined, segmented logistic regression models (15 models) were used, with separate intercepts and slopes included for the three distinct time “segments”: baseline, intervention, and post intervention follow-up . ClusterAdditional logistic regression models were applied for each group separately to provide an indication of intervention effect within groups, excluding the intervention period. Time was also included in these models so that any change in the outcome across the study period was not incorrectly attributed to the intervention. The intervention effects from these models are expressed as odds ratios (ORs) with 95% confidence intervals.p < 0.01 was used to determine statistical significance.Number of visits in the last 12 months was included as a covariate in all logistic regression models. A .All 56 eligible community health facilities participated in the trialOf the 9507 clients selected to participate across all three groups , 8512 (90%) were able to be contacted, of which 6845 (80%) were identified as eligible to participate . Of the eligible clients, 5639 (82%) completed data collection , 2377 during the “baseline” periods, 1250 during the intervention periods, and 2012 during the post intervention follow-up periods.  , approximately half were living with a partner (56%), and 58% were retiredp values) and the prevalence of each outcome for the baseline and follow-up periods are shown in Table The results of the segmented logistic regressions , fruit and vegetable intake , alcohol consumption , and all risks combined . There were significantly increased odds of clients reporting receipt of three of the five advice outcomes: inadequate fruit and/or vegetable intake , alcohol overconsumption  and all relevant risks combined . No significant increases were observed for referral for any risk behaviour, individually or combined, or for the risk behaviour physical inactivity , and for Group 2 an increase in smokers receiving brief advice   and provider  barriers have been reported to impede the effectiveness of primary care provision of care to promote client physical activity , 59. TheThe study findings should be considered in light of a number of its design and methodological characteristics. First, the use of a stepped wedge study design enabled: accounting for the effect of temporal trends through each group acting as its own “control”; the practical difficulty of recruiting a sufficient number of like community healthcare facilities to be addressed; and all community healthcare facilities to receive the intervention, a key requirement for clinician engagement , 61.Second, the intervention was implemented in a single health district, thereby potentially limiting its generalisability to other districts and jurisdictions. However, as the intervention was designed based on international guidelines and practice change evidence, its ability to be tailored and scaled to accommodate variations between jurisdictions in terms of information systems, clinical processes and jurisdictional requirements is considered to be high. Third, the use of client self-report may have contributed to an overestimate of care provision , 63. FouThe 12-month implementation intervention was effective in enhancing primary healthcare clinician assessment of client risk status, but less so for elements of care that could reduce client risk: provision of brief advice and referral. Further research is required to identify and understand the mechanisms for enhancing the effectiveness of implementation interventions for promoting preventive care, particularly in regard to referral, and for care addressing physical inactivity.


Freshwater biodiversity is highly threatened and is decreasing more rapidly than its terrestrial or marine counterparts; however, freshwaters receive less attention and conservation investment than other ecosystems do. The diverse group of freshwater megafauna, including iconic species such as sturgeons, river dolphins, and turtles, could, if promoted, provide a valuable tool to raise awareness and funding for conservation. We found that freshwater megafauna inhabit every continent except Antarctica, with South America, Central Africa, and South and Southeast Asia being particularly species rich. Freshwater megafauna co-occur with up to 93% of mapped overall freshwater biodiversity. Fifty-eight percent of the 132 megafauna species included in the study are threatened, with 84% of their collective range falling outside of protected areas. Of all threatened freshwater species, 83% are found within the megafauna range, revealing the megafauna's capacity as flagship and umbrella species for fostering freshwater conservation. Freshwater ecosystems cover less than one percent of the planet, but they are among the most diverse and dynamic systems globally ; large hippo (Hippopotamus amphibius); or the Nile crocodile (Crocodylus niloticus)—are also large in size and spectacular in appearance  habitats for completing their entire life cycle as TM  and the Chinese paddlefish (Psephurus gladius) are Critically Endangered (possibly extinct). In addition, six species are Near Threatened, six species lack sufficient information to assess their conservation status (Data Deficient), and 25 species are Not Evaluated for the Red List  and Ungava seal (Phoca vitulina ssp. mellonae), have more than half of their range within protected areas , habitat alteration 65%), and pollution . The beluga, or European sturgeon  habitat for completing any critical stage in the species life cycle. In addition to their potential to act as flagship species, megafauna species fulfill important ecological roles, such as ecosystem engineers: For example, the large hippo  in China (Li and Pimm Rhinopithecus roxellana), blackthroat , and Liangbei toothed toad . Similarly, the jaguar conservation network in South America, established to maintain habitat quality and connectivity, benefits co-occurring mammal species such as the threatened lowland tapir , defined as “sites contributing significantly to the global persistence of biodiversity” IUCN , need toEvidence-based conservation planning depends on baseline information on species; this includes regularly updated and comprehensive Red List assessments, with a priority focus on additional research for Data Deficient species and new assessments of the many species yet to be evaluated. Conservation planning might also focus on the identification of evolutionarily distinct and globally endangered (EDGE) species ZSL  based onad hoc conservation planning , Atlantic salmon , sturgeons, or crocodiles. Such data are fundamental to tracking the status and the trends of megafauna species  or the smaller-bodied axolotl  raising political will as needed to conserve freshwater megafauna and freshwater biodiversity in general and (2) identifying flagship species targeted to specific regions or stakeholders , and 74 species are listed in the Convention on International Trade in Endangered Species of Wild Fauna and Flora CITES; . The SecFor example, actions implemented for conservation of freshwater megafauna could simultaneously help reach multiple Aichi Targets: reducing the fragmentation and degradation of freshwater habitats (target 5), improving the long-term sustainability of freshwater fisheries (target 6), decreasing pollution effects in freshwater ecosystems (target 8), improving the effectiveness of freshwater protected areas (target 11), and closing data gaps regarding the conservation status of freshwater species, which will allow better monitoring of trends in species extinctions and the implementation of actions to reverse those trends (target 12). Moreover, knowledge of and attention to freshwater megafauna can support the Ramsar Convention to maintain or restore the ecological character of Ramsar sites through effective planning and integrated management (target 5 of Ramsar's 2016–2024 Strategic Plan; Resolution XII.2; Ramsar Freshwater is both a resource for human use as well as part of a diverse mix of ecosystems containing a unique biodiversity. The unusually large and fast decline in freshwaters is a product of their relatively small extent and distinct internal connectivity, as well as with their close links to surrounding terrestrial areas. Freshwater ecosystems are quickly and significantly affected by the overharvesting of regional fishes, shellfishes, and plants; the overabstraction of water; pollution; and the fragmentation of rivers. The effective management of these threats is further complicated when river catchments cross political or administrative borders WWF .Despite these major challenges and the high value of freshwater ecosystems in terms of biodiversity, livelihoods, and economics, the fact that freshwater ecosystems are declining at greater rates than other systems suggests that there is less investment in their conservation and management. Therefore, there is a major conflict between the human use of freshwater and the conservation of freshwater ecosystems. Given that the availability of freshwater, both spatially and temporally, is predicted to decrease in many regions in the future, this conflict is likely to increase. Solutions to the water-supply crisis have focused on engineering approaches, such as the construction of dams for water storage and power generation, interbasin water transfers, or the construction of dikes and channels for flood protection. Frequently, these measures will accelerate the decline in freshwater biodiversity as fundamental habitats and connectivity are degraded or lost (Vörösmarty et al. Freshwater megafauna have a great potential—yet to unfold—to communicate to the public, to policymakers, and to donors the immense value of freshwater ecosystems, including a unique biodiversity. Here, we provide spatially explicit and quantitative data supporting a better use of freshwater megafauna as a conservation tool. Our results and recommendations demonstrate the potential for freshwater megafauna to generate greater public awareness and political will to better support the conservation of freshwater ecosystems and to stop—or even reverse—their current widespread and tragic decline.Supplemental dataBIOSCI online.Supplementary data are available at Click here for additional data file.


Residents are commonly involved in establishing goals of care for hospitalized patients. While education can improve the quality of these conversations, whether and how postgraduate training programs integrate such teaching into their curricula is not well established. The objective of this study was to characterize perceptions of current teaching and assessment of goals of care conversations, and program director interest in associated curricular integration.An electronic survey was sent to all postgraduate program directors at the University of Calgary. Quantitative data was analyzed using descriptive statistics and qualitative comments were analyzed using thematic analysis.The survey response rate was 34% (22/64). Formal goals of care conversation teaching is incorporated into 63% of responding programs, and most commonly involves lectures. Informal teaching occurs in 86% of programs, involving discussion, direct observation and role modeling in the clinical setting. Seventy-three percent of programs assess goals of care conversation skills, mostly in the clinical setting through feedback. Program directors believe that over two-thirds of clinical faculty are prepared to teach goals of care conversations, and are interested in resources to teach and assess goals of care conversations. Themes that emerged include 1) general perceptions, 2) need for teaching, 3) ideas for teaching, and 4) assessment of goals of care conversations.The majority of residency training programs at the University of Calgary incorporate some goals of care conversation teaching and assessment into their curricula. Program directors are interested in resources to improve teaching and assessment of goals of care conversations.The online version of this article (doi:10.1186/s12909-016-0839-2) contains supplementary material, which is available to authorized users. Residents are often involved in establishing goals of care with their patients, however, they may struggle with the complexity of the communication involved . Goals oWhen goals of care are either not discussed, or not addressed appropriately, the misunderstandings and intensity of care that exceeds that desired by the patient or is medically unwarranted has many consequences. For example, while resource overutilization is often cited,  perhaps The provincial health service  has a policy and procedure encouraging advance care planning and providing a medical order framework of “Goals of Care Designations” . DespiteAn electronic survey based on a review of the literature was developed by the primary investigator (AR) and reviewed by two palliative care physicians, one of whom is also a physician consultant for advance care planning and goals of care designations (JS), contributing content validity; minor changes to wording were made as a result. The survey asked about formal and informal approaches to teaching and assessment of goals of care conversations, and program directors’ interest in future implementation of teaching and assessment of these conversations  at the University of Calgary from September 2014 to January 2015. The initial invitation and two reminders were sent to all program directors as a group; a final reminder was sent individually to program directors who had not yet responded.E-mail invitations to participate in the survey were sent to all postgraduate program directors  overall, comprising 40% 6/15), 33% (12/36) and 23% (3/13) of adult surgical, adult medical, and pediatric medical/surgical programs, respectively. Formal and informal goals of care conversation teaching is incorporated into 63 and 86% of these programs, respectively. Formal curriculum time dedicated to goals of care teaching is 1–4 h/year and 4–8 h/year in 46 and 14% of these programs, respectively. Of formal teaching methods, didactic lectures are most common, role play and internet resources least common, and reflective writing not used. Informal teaching methods include discussion in the clinical setting, direct observation, and role modeling  and assessment (55%) into their programs.Four themes identified were general perceptions of goals of care conversations, need for goals of care conversation teaching, ideas for goals of care conversation teaching, and assessment of goals of care conversations. These themes and the corresponding subthemes and supporting quotes are provided in Table Most postgraduate medical education programs at this institution incorporate some goals of care conversation teaching within their curricula; the majority of teaching and assessment takes place informally within the clinical setting. Previous research into needs for communication teaching has mainly focused on trainees; this project is unique in assessing postgraduate medical education program directors within an academic institution.Many program directors identified formal goals of care conversation teaching as a gap in their curricula; others perceived that such teaching is already well-integrated into their respective programs. Programs that identified a gap were interested in methods to more consistently teach goals of care conversations, and proposed a number of creative ideas. For programs that already incorporate such teaching, evaluation of the quality and consistency of such teaching will be important.Several program directors believed that residents are comfortable and highly skilled in discussing goals of care with patients and families, while research from other institutions has suggested otherwise. In the absence of formal goals of care conversation teaching, learning occurs through unsupervised practice and vicariously through observing senior trainees and faculty . FurtherProgram directors also believed that most faculty are comfortable in teaching goals of care conversations. Faculty perceptions of their own competence in this area may be inaccurate, given the link between communication skills and self-concept, and limitations of self-assessment . ResidenIt is interesting to note that programs at our institution do not use reflective writing to teach goals of care conversations. Reflection has been identified as critical in developing and maintaining competency in clinical reasoning as a medical expert, and in the communicator and, professional roles;  writing Strengths of this study include the inclusion of both quantitative and qualitative data, allowing for both generalizations and elaboration of responses, respectively. Limitations include a low survey response rate and the single-centre focus of the study, such that the results are not generalizable outside of our local context. In addition, we did not elicit trainee and faculty perspectives; future research to obtain their perspectives will provide valuable information about the impact of current goals of care conversation teaching, gaps in current education, and how those gaps might be addressed..Teaching and assessment of goals of care conversations occurs most commonly in the clinical setting. Future study of residents’ perspectives and opinions of the many healthcare providers, patients and families they work with will broaden our understanding of the current educational milieu and allow us to tailor educational initiatives to trainee and program needs.


Service delivery and organisation of healthcare has always been part of the journal’s remit, and many of the published papers already reflect the challenges of implementing evidence-based care,11 so this change is making explicit a long-held interest of the journal, its authors and readers. The International Primary Care Respiratory Group (IPCRG) in its Research Needs Statement prioritised real-life studies evaluating ‘overall management strategies’ over efficacy trials of specific drugs or treatments.13 Similarly, the Primary Care Respiratory Society (PCRS-UK) includes ‘promoting and disseminating real life primary care research in respiratory conditions to support policy and education activities’ as one of its core activities.14 This extension of emphasis therefore resonates with both the parent primary care organisations.The 16 This is a broad agenda which extends from preliminary work exploring the factors affecting implementation,11 developing implementation strategies,1 piloting the processes,2 testing the impact of implementation,9 and promoting scaling up and sustainability.6 This has been conceptualised as an additional cycle which takes an effective complex intervention,17 explores the existing context, and develops and evaluates strategies for embedding change in routine care.18 Other models have extended the spectrum of efficacy and effectiveness trials to encompass implementation science  are not wholly appropriate for reporting implementation studies, though some of the methodological criteria will be useful. It is for this reason that we, together with colleagues, launched the Standards for Reporting Implementation studies (StaRI) initiative. npj PCRM will be encouraging authors of implementation studies to use StaRI, recently published in the BMJ,25 with an accompanying explanation and elaboration document.26 The checklist for authors to complete is freely available from http://www.bmj.com/content/bmj/suppl/2017/03/06/bmj.i6795.DC1/pinh034338.w2.pdf. Developed following an e-Delphi and an international consensus meeting, an underpinning theme of StaRI is the distinction between the implementation strategy (‘how the intervention was implemented’) and the evidence-based intervention that is being implemented. These dual strands run through the reporting standards with a requirement to consider the context, methods, outcomes and implications of both the implementation strategy and the intervention. The resultant clarity will, we hope, not only help authors of implementation papers, but will also be valuable for clinicians, heath service managers and researchers, planning initiatives to disseminate and implement guidelines and improve the quality of care.Existing methodologically-based reporting standards  and npj PCRM encourages on-line supplements for additional information. Publication of protocols, already the norm for randomised trials, will offer opportunity for publishing details of the implementation strategy and intervention.7One of the key challenges of using StaRI will be including the substantial descriptions of context, implementation strategy and intervention within the permitted word counts. We expect that authors will look for innovative ways to succinctly provide adequate detail (the Explanation and Elaboration document offers some suggestionsnpj PCRM hopes to contribute to efforts to improve the standard of reporting of implementation science thereby enhancing its value to researchers and clinicians, and ultimately raising the quality of care for people with respiratory conditions.Implementation studies resonate with primary care readers, but poor quality of reporting has made them difficult to identify, and their value is limited if descriptions are inadequate. By expecting adherence to the StaRI standards,