Sudden cardiac death (SCD) remains an unsolved problem in the twenty-first century. It is often due to rapid onset, ventricular arrhythmias caused by a number of different clinical conditions. A proportion of SCD patients have identifiable diseases such as cardiomyopathies, but for others, the causes are unknown. Viral myocarditis is becoming increasingly recognized as a contributor to unexplained mortality, and is thought to be a major cause of SCD in the first two decades of life. Myocardial inflammation, ion channel dysfunction, electrophysiological, and structural remodeling may play important roles in generating life-threatening arrhythmias. The aim of this review article is to examine the electrophysiology of action potential conduction and repolarization and the mechanisms by which their derangements lead to triggered and reentrant arrhythmogenesis. By synthesizing experimental evidence from pre-clinical and clinical studies, a framework of how host (inflammation), and viral  factors can induce ion electrophysiological and structural remodeling is illustrated. Current pharmacological options are mainly supportive, which may be accompanied by mechanical circulatory support. Heart transplantation is the only curative option in the worst case scenario. Future strategies for the management of viral myocarditis are discussed. Both EADs and DADs can therefore result in membrane depolarization, and if these are of sufficient amplitude, triggered activity can be elicited.Mechanisms of arrhythmias can be divided into triggered activity and reentry Figure . TriggerReentry involves re-activation of the myocardium that has recovered from refractoriness, and may involve an obstacle for the circus-type, or without an obstacle in phase 2 reentry , extracellular resistance (ro) and membrane capacitance (cm). The existence of electrical communication pathways between successive cardiomyocytes was shown, mediated by gap junctions  is the time over which Na+ channels are inactivated and cannot open again. They can be reactivated when the membrane potential is restored to the resting value. Thus, APD usually approximates ERP, i.e., a shorter repolarization time course usually leads to shorter ERP. When APDs are prolonged, sudden increase in heart rate can engage the steep portion of APD restitution curve, producing APD alternans, unidirectional conduction block, wave break and reentry  activation. This can phosphorylate the Ca2+ release channel, ryanodine receptor 2 (RyR2), to increase abnormal Ca2+ release from the sarcoplasmic reticulum  and delayed rectifier (IKr) currents were downregulated , which is normally responsible for capacitative, store-operated Ca2+ entry by increasing ICa (Lupescu et al., +/K+-ATPase and a number of K+ channels (mediating IKr and inward rectifying currents, IKir; Almilaji et al., Viruses can also alter the function or expression of ion channels or induce structural remodeling of the myocardium. CVB3 can increase the Finally, there may be interaction between genetic predisposition of ion channel dysfunction and viral myocarditis (Salerno et al., 2 and a T-lymphocyte count of more than 7 cells/mm2 (Basso et al., Diagnosis of viral myocarditis can be difficult, and requires a series of investigations. Blood tests may reveal cardiac damage as reflected in raised troponins and high sensitive C-reactive protein assays Guo, . PolymerFor arrhythmic risk stratification, using different indices based on ECG parameters have been used for congenital arrhythmic syndromes and heart failure Tse, ,b, but nThe major problem of viral myocarditis is the limited number of drugs available for modifying the course of the disease and preventing the arrhythmic complications (Kindermann et al., 2+ overload. Thus, EADs can be inhibited the late INa (Belardinelli et al., ATP channel openers such as mexiletine, with previously demonstrated cardioprotective effects during ischaemia, could suppress APD prolongation during acute myocarditis and may therefor protect against Ca2+ overload, DADs and spatial heterogeneities in APDs (Niwano et al., The use of animal models has advanced our understanding of the mechanisms of arrhythmias and provide a platform for assessing the efficacy of pharmacological therapy (Chen et al., In conclusion, viral myocarditis is an important cause of mortality especially in infants, adolescents and young adults, predisposing to life-threatening cardiac arrhythmias. Current drug options are inadequate and are mainly supportive. More efforts need to be devoted to the development of novel pharmacological agents that can prevent viral invasion of cardiac tissue as well as viral- or host-induced inflammation, and reducing arrhythmic complications of the myocarditis.GT: Design of manuscript; drafted and critically revised the manuscript for important intellectual content; preparation of figures. JY: Drafted and critically revised the manuscript for important intellectual content. EL: Drafted and critically revised the manuscript for important intellectual content. BY: Interpreted primary research papers; critically revised the manuscript for important intellectual content.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.


To address health disparities, local health departments need high-resolution data on subpopulations and geographic regions, but the quality and availability of these data are often suboptimal. The Boston Public Health Commission and the Los Angeles County Department of Public Health faced challenges in acquiring and using community-level data essential for the design and implementation of programs that can improve the health of those who have social or economic disadvantages. To overcome these challenges, both agencies used practical and innovative strategies for data management and analysis, including augmentation of existing population surveys, the use of combined data sets, and the generation of small-area estimates. These and other strategies show how community-level health data can be analyzed, expanded, and integrated into existing public health surveillance and program infrastructure to inform jurisdictional planning and tailoring of interventions aimed at achieving optimal health for all members of a community. Public health surveillance data often lack the geographic resolution to sufficiently describe or make statistical inferences about certain subpopulations and geographic areas. Because of this limitation, local health agencies must rely on data for populations that differ from their constituent communities –4. As a The Institute of Medicine recommends investing resources in disease surveillance systems that provide granular data to inform efforts designed to reduce health disparities among subpopulations . SimilarBoston, Massachusetts, and Los Angeles County, California, 2 jurisdictions with diverse populations , have prState and national systems for surveillance and data collection, such as the Behavioral Risk Factor Surveillance System (BRFSS) and state vital record systems, contain a set of variables on race, Hispanic/Latino ethnicity, income, educational attainment, and other sociodemographic characteristics; these variables vary by survey or data system. Data on additional sociodemographic variables such as ethnicity, housing type (subsidized vs market-rate), type of employment, and length of residence in the United States can strengthen the capacity of these surveillance systems to identify differences in the health of at-risk populations but are often not collected. The absence of these data can result in an incomplete understanding of how health outcomes are associated with local sociodemographic and cultural characteristics.Every 2 years, BPHC conducts a random-digit–dialed, citywide community health surveillance survey of 2,500 to 3,000 Boston residents — the Boston Behavioral Risk Factor Surveillance Survey (Boston BRFSS) ,17. In 2A similar strategy was used by LACDPH to better characterize caregivers in Los Angeles County. In 2007, LACDPH expanded its random-digit–dialed, countywide Los Angeles County Health Survey (LACHS) of 8,000 households to include a series of questions on caregiving for the elderly and disabled ,19,20. DEven with limited funding, many states and local jurisdictions have the capacity to add additional variables to existing population surveys like the BRFSS.Population surveys may yield small sample sizes that reduce the reliability of survey estimates and limit the ability of local health departments to detect differences in health outcomes by race, ethnicity, and/or other sociodemographic characteristics . In juriAugment sample size. In 2009, BPHC was awarded grants from the Centers for Disease Control and Prevention (CDC) that included funding for administration of the BRFSS in 2010 and 2012 to a grant-specific sample of the Boston population (different from the sample of the Boston BRFSS described previously) consisting of 1,500 city residents  is sufficient for monitoring general population health trends in Boston but lacks power to conduct subgroup analyses in smaller neighborhoods. To mitigate this shortcoming, BPHC generates neighborhood and subgroup estimates by combining survey data from several years. Combining data across years requires consistent survey methodology, survey instruments, and weighting procedures across time.Generate small-area estimates. With multiple municipalities in Los Angeles County, program planning and resource-allocation decisions often require granular, geographically subdivided health data that are not readily available through existing sources. The LACHS provides relatively precise point estimates for many health indicators in larger regions but lacks the sample size and data for producing similarly precise estimates for cities or council districts. Recently, LACDPH applied small-area estimation to generate stratified estimates of obesity and smoking prevalence by city and city council district using data from the LACHS, the US Census, and the LA County Population Estimates and Projection System. Small-area estimation applies statistical procedures to generate a series of dependent variable projections based on regression modeling; the method uses multiple sources of information that provide data not available from a single source  passed a similar statewide regulation. BPHC and MADPH aligned their standards so that institutions in Boston could collect data in a single format to satisfy both local and statewide regulations. Although the new regulations required high levels of technical assistance, training, and coordination among agencies, the newly consistent data will help agencies to understand where racial and ethnic subpopulations in Boston seek medical care.Embed requirements in contracts. In Los Angeles County, data collection is often standardized through the subcontracting process. Wherever feasible, LACDPH embeds standardized data collection requirements in its subcontracts with funded partners. To gauge and identify program gaps in clinical preventive services in the ambulatory care setting, LACDPH includes requirements in subcontracts with clinical organizations, calling for participating clinic networks to collect and provide certain data on patient demographics and clinical indicators.Using existing data and the aforementioned strategies may still be insufficient for local decision making. Existing data sources may focus on populations that are not relevant to program objectives or have data collection time points that do not align with program timetables. New community data are often required to better tailor interventions to address health disparities in target populations.Although primary data collection at the population and program levels can be resource-intensive, it can offer high geographic resolution and subpopulation-specific information. Generally, primary data collection requires technical expertise for the design, implementation, and analysis of data sets as well as a sizable financial investment . BecauseCollect primary health assessment data. To address health disparities in regions of Los Angeles County that have high rates of poverty and obesity, LACDPH conducted 2 health and nutrition examination surveys (LA HANES) during 2010–2012. These surveys recruited low-income adults who relied on multipurpose public health centers for preventive services, health education, and community programming. The first survey  was conducted during the first 15 months of a regional, 2-year, CDC-funded obesity prevention initiative. The second survey  was completed approximately 12 months later. The surveys collected data on self-reported sociodemographic characteristics, self-reported health behaviors, and measured height and weight, waist circumference, blood pressure, and urinary cotinine , collectively they strengthen local data systems for supporting and achieving optimal health for all. The experiences of Boston and Los Angeles County illustrate how local health departments can strengthen disease surveillance and community-level data collection to build capacity and implement replicable strategies for addressing social and economic disadvantages associated with poor health.


Allelopathy is a common biological phenomenon by which one organism produces biochemicals that influence the growth, survival, development, and reproduction of other organisms. These biochemicals are known as allelochemicals and have beneficial or detrimental effects on target organisms. Plant allelopathy is one of the modes of interaction between receptor and donor plants and may exert either positive effects  or negative effects . To ensure sustainable agricultural development, it is important to exploit cultivation systems that take advantage of the stimulatory/inhibitory influence of allelopathic plants to regulate plant growth and development and to avoid allelopathic autotoxicity. Allelochemicals can potentially be used as growth regulators, herbicides, insecticides, and antimicrobial crop protection products. Here, we reviewed the plant allelopathy management practices applied in agriculture and the underlying allelopathic mechanisms described in the literature. The major points addressed are as follows: (1) Description of management practices related to allelopathy and allelochemicals in agriculture. (2) Discussion of the progress regarding the mode of action of allelochemicals and the physiological mechanisms of allelopathy, consisting of the influence on cell micro- and ultra-structure, cell division and elongation, membrane permeability, oxidative and antioxidant systems, growth regulation systems, respiration, enzyme synthesis and metabolism, photosynthesis, mineral ion uptake, protein and nucleic acid synthesis. (3) Evaluation of the effect of ecological mechanisms exerted by allelopathy on microorganisms and the ecological environment. (4) Discussion of existing problems and proposal for future research directions in this field to provide a useful reference for future studies on plant allelopathy. Eichhornia crassipes Mart. Solms) (Centaurea stoebe L. ssp. micranthos) (Alliaria petiolata M. Bieb)  , spottedranthos)  and garlM. Bieb) . AllelopThe definition of allelopathy was first used by Molish in 1937 to indicate all of the effects that directly and indirectly result from biochemical substances transferred from one plant to another . Almost Allelochemicals, which are non-nutritive substances mainly produced as plant secondary metabolites or decomposition products of microbes, are the active media of allelopathy. Allelochemicals consist of various chemical families and are classified into the following 14 categories based on chemical similarity : water-sAllelopathy is a natural ecological phenomenon. It has been known and used in agriculture since ancient times , 2014. AChromolaena odorata (L.) (Asteraceae) fallow in a field study conducted over 2 years, and suggested that the use of bush fallow with C. odorata might become an integrated management practice in the management of nematode pests in crop production in south-western Nigeria. Intercropping is a common practice among farmers in developing countries for maximizing land resources and reducing the risks of single crop failure. Weed population density and biomass production can be markedly reduced using crop rotation and intercropping systems (Sorghum bicolor L.), sesame (Sesamum indicum L.) and soybean (Glycine max L.) in a cotton (Gossypium hirsutum L.) field produced greater net benefits and a significant inhibition on purple nutsedge (Cyperus rotundus L.) in comparison with the cotton alone in a 2-year experiment (Nicotiana tabacum L.), the stand establishment and growth of maize (Zea mays L.) were improved compared to mung bean (Vigna radiata L.), whereas mungbean stand establishment and growth were suppressed. Therefore, the allelopathic nature of crops must be considered in crop rotation, intercropping and stalk mulching (Competition is one of the main modes of interaction between cultivated crops and their neighboring plants . Allelop systems . Intercrperiment . Recentlmulching .Triticum aestivum L.) straw inhibits the growth of Ipomoea weeds in corn (Zea mays L.) and soybean fields, thereby reducing the need for herbicide application. Rye  mulch significantly reduced the germination and growth of several problematic agronomic grass and broadleaf weeds  yield by approximately 20% in paddy fields (1998–2003) compared with the respective controls. In the southeastern region of Brazil, coffee (Coffea arabica) fruit peels, which contain allelochemicals such as phenols, flavonoids and caffeine, are often used as an organic amendment in agricultural practice to control weeds (Panicum virgatum L.) plants and residues reduced the biomass and density of associated weeds, and their research provided weed management strategies in agroecosystems and important information for the introduction of switchgrass into new ecosystems. Water extracts of Conyza bonariensis (L.) Cronquist, Trianthema portulacastrum L., and Pulicaria undulata (L.) C. A. Mey. can be applied at a concentration of 10 g L–1 to manage the weed Brassica tournefortii Gouan by inhibiting germination and seedling growth (Orobanche spp.), a noxious parasitic weed, which suggests that soybean has the potential to be used as a trap crop to reduce the seed bank of sunflower broomrape  root exudates, was more effective in inhibiting weed growth after formulation as a wettable powder, while crop species were tolerant to it. Some microorganisms are capable of using sorgoleone as a carbon source. Sorgoleone can be mineralized via complete degradation to CO2 in soil, although the different chemical groups of the molecule were not mineralized equally (Pinus L.), hinoki (Chamaecyparis obtusa Endl.), or Japanese cedar (Cryptomeria japonica D. Don) and bamboo  vinegar, which provided a practical method of utilizing plant allelopathy in paddy fields.Allelochemicals with negative allelopathic effects are important components of plant defense mechanisms against weeds and herbivory. The technology that modifies allelochemicals for the production of environmentally friendly pesticides and plant growth regulators allows the effective management of agricultural production and confers few environmental problems in the soil due to the fairly high degradability of allelochemicals . Uddin e equally . The str equally , 2004. A equally . There a equally . Ogata e2O, improve the utilization rate of nitrogen fertilizer and reduce pollution to the environment (Plantago lanceolata L.) plant has inhibitory effects on soil nitrogen mineralization, suggesting that plantain could be utilized to reduce soil nitrogen leaching.Nitrogen leaching is a severe ecological problem due to water pollution. Mineralization of soil organic nitrogen, especially the nitrification of nitrogen fertilizer, is one of the main reasons for the enrichment of nitrogen in the soil. Biological nitrification inhibition (BNI) has gradually become the main target in investigating the effect of plants on soil nitrification. In recent years, studies have proven that nitrification-inhibiting substances (NIS) produced by plants are the first choice for soil nitrification management. For example, biological nitrification inhibition substances (BNIS) are allelochemicals that are able to inhibit soil nitrification. Wheat allelochemicals, such as ferulic acid, p-hydroxybenzoic acid and hydroxamic acid, can act on soil microbes to inhibit soil nitrification, reduce the emission of Nironment . Dietz e8 generation line derived from crosses between the local rice cultivars N9S and PI 312777, is considered to be the first commercially acceptable weed-suppressive cultivar in China . Upon exposure to hordenine and gramine, which are allelochemicals from barley (Hordeum vulgare) roots, the radicle tips of white mustard  exhibited damaged cell walls, increases in both the size and number of vacuoles, disorganization of organelles, and cell autophagy (Brassica juncea L.) roots displayed irregularly shaped cells arranged in a disorganized manner and disruption of cell organelles (Convolvulus arvensis L. and catmint (Nepeta meyeri Benth.) can alter the random amplification of polymorphic DNA (RAPD) profiles of receiver plants (Cymbopogon citrates) and other aromatic plants that has been suggested to have allelopathic traits  affected cell proliferation and DNA synthesis in plant meristems ; 2(3H)-b lettuce ; and sor lettuce . Burgos Phaseolus aureus). Acropora millepora when compensatory transcriptional action by the coral holobiont insufficiently mitigated the damage caused by allelochemicals produced by Chlorodesmis fastigiata (The generation and clearing of reactive oxygen species (ROS) and the balance of the redox state in the cell play an important role in allelopathic effects. After exposure to allelochemicals, the recipient plants may rapidly produce ROS in the contact area , and altstigiata .Hordeum spontaneum, Avena ludoviciana, and wild mustard seedlings were found to be inhibited by an aqueous extract of barley aerial parts through increasing lipid peroxidation  in the leaves of transgenic (with Cu/ZnSOD and APX genes) and non-transgenic potato (Solanum tuberosum L.) seedlings, in addition to increasing membrane permeability and altering the activities of SOD and APX. Cymbopogon citratus) essential oil damages the membrane system of barnyard grass , causing lipid peroxidation and electrolyte leakage. Microcystis aeruginosa. They found O2– to be the precursor of H2O2 and showed that the hydroxyl radical OH·was generated at significant levels, demonstrating that PA caused oxidative stress in M. aeruginosa and that futile redox cycling of PA was the main source of excessive intracellular O2– and consequent H2O2 and OH·production.Many studies have shown that allelochemicals significantly inhibit the activity of antioxidant enzymes and increase free radical levels, resulting in greater membrane lipid peroxidation and membrane potential alteration, which diminish the scavenging effect on activated oxygen and damage the whole membrane system of plants . The groxidation . Zuo et Allelochemicals can alter the contents of plant growth regulators or induce imbalances in various phytohormones, which inhibits the growth and development of plants, for example, with respect to seed germination and seedling growth. Most phenolic allelochemicals can stimulate IAA oxidase activity and inhibit the reaction of POD with IAA, bound GA or IAA to influence endogenous hormone levels .Pyrus communis). Through treatment of wheat seedlings with high concentrations of ferulic acid (2.50 mM), 3, and CTK, with a simultaneous increase in ABA. An aqueous extract from rice was shown to significantly stimulate IAA oxidase activity in barnyard grass and reduce IAA levels, thereby damaging the growth regulation system and inhibiting seedling growth (Ageratina adenophora Sprengel weeds. DTD at a higher concentration (1.5 mM), significantly increased the ABA content in the roots of rice seedlings, but this decreased sharply after 96 h of treatment. HHO also significantly enhanced the ABA content for 48 and 96 h. However, the application of DTD or HHO decreased the IAA and ZR contents in rice roots. The IAA/ABA and ZR/ABA ratios decreased quantitatively in response to higher concentrations of DTO or HHO. These results suggest that the endogenous hormones might have dependent as well as interactive effects on the responses of rice seedlings and their adaptability to DTD or HHO stress. Moreover, the results from another study indicated that cyanamide (1.2 mM) caused an imbalance of plant hormone (ethylene and auxin) homeostasis in tomato (Solanum lycopersicum L.) roots (g growth . Yang et.) roots .Allelochemicals exert different effects on the synthesis, functions, contents and activities of various enzymes. Previous studies have shown that the key enzyme λ-phosphorylase involved in seed germination might be inhibited by chlorogenic acid, caffeic acid and catechol . AdditioChrysanthemum indicum L.) inhibited the activities of root dehydrogenase and nitrate reductase (NiR), reduced the contents of soluble sugar and soluble protein, and inhibited the root growth of stem cuttings of the same species (Spirodela polyrhiza L.) and found that DEP is toxic to this species due to the inhibition of GS isoenzymes in nitrogen assimilation and antioxidant enzymes. species . Cheng  on the microalga Phaeodactylum tricornutum, Cymbopogon citratus) leaves significantly decreased the chlorophyll a and b and carotenoid contents of barnyard grass and affected alpha-amylase activity in seeds, indicating that essential oil interferes with photosynthetic metabolism. However, aqueous extracts of leaves from Trema micrantha (Ulmaceae), an allelopathic plant, did not lead to inhibition of the synthesis of photosynthetic pigments in radish (Raphanus sativus L.)  .+/K+-ATPase involved in the absorption and transport of ions at the cell plasma membrane, which suppresses the cellular absorption of K+, Na+, or other ions.Many allelochemicals affect nutrient absorption in plant roots or induce water stress through long-term inhibition of water utilization. Allelochemicals can inhibit the activities of Na3– uptake in corn seedlings, although ammonium uptake was less sensitive to this treatment than NO3–. Ferulic acid also inhibits Cl– uptake and increases the initial net K+ loss from roots exposed to a low K ammonium nitrate solution and delays recovery that results in a positive net uptake. 4+-N on nitrogen absorption were stronger than those of NO3–-N. 3–, SO42–, K+, Ca2+, Mg2+, and Fe2+ by cucumber seedlings. Through further study, +, NO3–, and H2PO4–. Sorgoleone and juglone significantly inhibited H+-ATPase activity and the proton-pumping function across the root cell plasmalemma, which affected solute and water uptake in peas (Pisum sativum L.), soybeans and corn  residues negatively affected plant development, the efficiency of translocation of assimilates and nutrient accumulation in radish plants , psbA, mcyB, prx, and faab, ferulic acid 5-hydroxylase (F5H), and caffeic acid O-methyltransferases (COMT), which are involved in the biosynthesis of phenolic compounds in rice, is consistent with their inhibitory effects on barnyard grass, while barnyard grass induces the expression of genes related to the synthesis of phenolic compounds in allelopathic rice  helped to control Panama disease (Fusarium wilt) in banana (Musa spp.) and showed that intercropping/rotation of banana with Chinese chive could control Panama disease and increase cropland biodiversity.Researchers have found that there are significant relationships between crop growth and soil microbes under the application of allelochemicals or in the presence of allelopathic plants Figure . Recent Chromolaena odorata (Asteraceae) fallow  fallow . Pearse Pseudomonas, Paenibacillus polymyxa, endophytes and Chryseobacterium balustinum Aur9, have been shown to alter plant gene expression and regulate plant allelochemical synthesis and signaling pathways to enhance disease resistance, adaptability and defense capabilities in response to biotic and abiotic stresses in plants  and environmental factors, as shown in Figure Allelochemicals can be degraded after they have been released into the soil; the half-life of allelochemicals varies from a few hours to a few months , and thiExplaining how allelochemicals function is complicated due to the many classes of chemicals and different structures that have been identified as agents in allelopathy. There is no generic allelochemical, and we should certainly anticipate different mechanisms of action among allelopathic chemicals. Moreover, it should be investigated in future studies whether allelochemicals are absorbed through transport proteins or whether different allelochemicals have the same molecular targets in different species . The sysAllelopathy is a complex process. Many allelochemicals have been identified to date. Due to the different sensitivities of different receptors to the same allelochemical and the various allelopathic activities of different allelochemicals, considerable further work is required in the field of allelochemical research. Very little is known about the transportation and biodegradation of allelochemicals in soil or the population genetics of allelopathic species, the establishment of practical ways of using allelochemicals in the field, the rapid adaptation of weeds to avoid them, the diversity of the soil microbial community that is maintained in their presence or the role of signal transduction in herbivore defense. These areas should be the focus of future investigations.Considerable research has showed that allelopathy has good application potential in agricultural production. Until now, many allelopathic crops have been used in agricultural production, but the applications are limited to small-scale and regional areas. The structure and mode of action of many allelochemicals have been deeply revealed in recent years, and this has laid a good foundation for projects where allelochemicals are used to obtain the basic structures or templates for developing new synthetic herbicides.The commonly used methods of weed control  are effective in agricultural production. However, there are many disadvantages associated with these methods, for example, the evolution of herbicide resistance in weeds, the negative impacts of herbicides on environmental, human and animal health, the expense of herbicides, the losses in soil structure and the enormous labor requirements. Many of the above problems can be allayed by creating diversity in weed control practices with the application of allelopathy. The combination of more than one weed control method has been proved to be effective in reducing the probability of herbicide resistance development in weeds. Moreover, the combined application of reduced synthetic herbicides dose and allelopathic extracts can provide control that is as effective as that obtained from the standard dose of herbicides . FurtherAllelopathy has been known and used in agriculture since ancient times; however, its recognition and use in modern agriculture are very limited. Allelopathy plays an important role in investigations of appropriate farming systems as well as in the control of weeds, diseases and insects, the alleviation of continuous cropping obstacles, and allelopathic cultivar breeding. Furthermore, allelochemicals can act as environmentally friendly herbicides, fungicides, insecticides and plant growth regulators, and can have great value in sustainable agriculture. Although allelochemicals used as environmentally friendly herbicides has been tried for decades, there are very few natural herbicides on the market that are derived from an allelochemical. However, there are a few research investigations testing natural-product herbicides. With increasing emphasis on organic agriculture and environmental protection, increasing attention has been paid to allelopathy research, and the physiological and ecological mechanisms of allelopathy are gradually being elucidated. Moreover, progress has been made in research on the associated molecular mechanisms. It is obvious that allelopathy requires further research for widespread application in agricultural production worldwide.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.


Prioritizing patients’ information needs maximizes efficiency. This study examined the information sources and priorities in a sample of older adults newly diagnosed with symptomatic myeloma requiring immediate therapy. An association analysis of whether information needs were influenced by sociodemographic variables such as age, gender, education, marital status, and income was also conducted. The Information Needs Questionnaire (INQ) and an investigator-developed interview schedule were administered to 20 older adults diagnosed with symptomatic myeloma during a 30- to 45-minute semistructured interview. We found that older adults newly diagnosed with symptomatic myeloma have different priorities of information needs when compared with younger patients diagnosed with various types of cancer. The top three priorities related to treatment, prognosis, and self-care. Sociodemographic variables did not influence the priorities of information needs among older adults with symptomatic myeloma. The Internet, physicians, family, and friends were among the top sources of information. Advanced practitioners in oncology should support and identify interventions that can enhance patients’ learning process from these sources. Well poised to assist patients in searching credible and reliable Internet sources, advanced practitioners in oncology can provide patient education about different treatments and the impact of such treatments on prognosis . Providing pertinent information to patients with cancer is considered an important part of standard care . PatientOncology advanced practitioners (APs) play a critical role in providing patients the information they need and can potentially help patients assume a more active role in decision-making. Conversely, a lack of information can hinder patients’ participation in treatment decision-making or increase uncertainty. Unfortunately, patients still often report difficulties obtaining the type and amount of information they want or need . OncologA new diagnosis of myeloma that requires immediate therapy  involves presentation of information about a wide choice of drugs and treatment regimens, including bortezomib (Velcade), lenalidomide (Revlimid), thalidomide , dexamethasone , and autOlder adults with cancer have various information needs that are often not met by clinicians . BecauseThe purpose of this study was to examine the priority information needs of a sample of older adults newly diagnosed with myeloma. The study also examined the common information sources patients used since the time of their diagnosis.Design and SampleA cross-sectional survey approach involving administration of the Information Needs Questionnaire (INQ) with 36 paired comparisons and an interview schedule during a one-time semistructured interview was employed. The convenience sample consisted of 20 older adults (at least 60 years of age) referred through the Seattle Cancer Care Alliance (SCCA) or the Northwestern University Myeloma Program (NUMP) by several hematologists and oncologists in the greater Seattle or Chicago areas, respectively. Eligibility criteria included adults 60 years of age and older who were (1) newly diagnosed (within the first 6 months) with myeloma requiring immediate therapy, (2) able to read and write English, and (3) able to give informed consent. Non-English speakers were not included in the study because the questionnaire is only available in English and there are limited resources available to the researchers to translate to other languages.Procedures and Study LocationsAfter obtaining approval from the University of Washington (UW) and Northwestern University (NU) Human Subjects Divisions, eligible participants were recruited to participate in the study. Participants were recruited by mail from both university- and community-based medical practices. At NUMP, the researcher also utilized a direct approach in the recruitment of study participants. A review of clinic schedules at SCCA, NUMP, and UW-affiliated clinics was performed weekly to identify potential study participants.A total of 79 potential participants were recruited by mail at SCCA from October 2009 through July 2010. Fourteen participants responded and participated in the study (a 17.7% response rate). At NUMP, the researcher identified potential participants through a review of clinic schedule and approached them in person about participation. All six potential participants agreed to participate (a 100% response rate). Informed written consent was obtained from all study participants.The researcher administered the interview schedule and INQ  during aMeasuresThe INQ was developed by Degner and colleagues and initially applied in studies of women with breast cancer . FurtherThe INQ contains nine categories of information topics, each with a statement of definition: (1) prognosis (likelihood of cure), (2) stage of disease (spread and extent of cancer), (3) side effects (possible side effects of treatment), (4) treatment options (treatment available), (5) social activities , (6) family risk (hereditary risk), (7) home self-care , (8) impact on family , and (9) sexuality .The Thurstone scaling method  is the tp = .075), with 28 degrees of freedom, indicating that there is demonstrable consistency between the Case V model and the data in this study  to the p value of each subject was applied to correct for multiple testing, as described by As described by is study . A multiPriorities of Information Needs(Rank Ordering of Nine Information Items)The Thurstone scale analysis for 20 participants newly diagnosed with active myeloma indicated that the top three priority information needs were related to the "different types of treatments" and corresponding advantages/disadvantages, prognosis (likelihood of cure), and self-care or "caring for myself at home" . The iteThe Thurstone scaling method produced rank orderings or profiles of information needs for older adults newly diagnosed with myeloma. Thus, it overcame the "ceiling effect" of Likert-type scales, in which a majority of participants could rate most information needs as either somewhat or very important . When asSources of Information Related to MyelomaWhen patient participants were asked where they had received their information related to myeloma and its therapy, various sources were identified: the Internet (n = 12); physicians, both primary oncologist and second-opinion physicians (n = 7); family and friends (n = 4); books (n = 3); pamphlets (n = 3); nurses (n = 2); and myeloma patients or other cancer patients (n = 3). Some patient participants reported two or three different sources of information.Analysis of whether information needs were influenced by sociodemographic variables such as age, gender, education, marital status, and income did not reveal any association.In this study, the Thurstone scaling successfully produced a profile of information needs priorities in older adults newly diagnosed with myeloma that is different from that of younger patients with various types of cancer. This profile suggests that older adults newly diagnosed with myeloma want to discuss the treatment options available to them as well as how these options may impact overall outcomes.The top two information priorities in myeloma patients are consistent with similar study findings reported in older patients  with lung cancer  and oldeIt was surprising that disease stage was not one of the top three information priorities in this sample of active myeloma patients. However, as the outcome of myeloma is not heavily influenced by the stage of disease at the time of diagnosis compared with other malignancies, this could explain why the study participants ranked disease stage as the fifth of nine priorities. In myeloma, risk stratification using genomic information has more prognostic significance than disease stage in the new era of novel agents . It is aOlder adults value independence , so it wThe priorities of information needs reported in this current study contrast with those of younger patients who have been shown to identify prognosis, disease stage, and treatment options as their top priorities in several studies . Given tStudy LimitationsSeveral study limitations must be acknowledged. The rankings in this study must be interpreted with caution, because a single assessment of information needs with a small sample size may not be generalizable. As suggested by Butow and others, periodic assessment of an individual patient’s information needs is imperative, given the changing dynamics of such information needs priorities . The genThe low response rate (17.7%) to mailed invitations at SCCA is a potential source of response bias. One could argue that patients who did not respond to the mailed flyer may have different profiles of information needs. Moreover, since this is a cross-sectional study, the findings may not be applicable to myeloma patients who are beyond the first 6 months from diagnosis, and these results do not explain any aspect of changes in information priorities over time. A longitudinal approach in a future study should be able to document any changes in the priorities of information needs at different periods of the disease trajectory .This study is also limited to myeloma patients who are symptomatic and required immediate therapy. Patients with inactive myeloma (smoldering or indolent myeloma) may have a different information needs profile, and additional studies are needed to compare their information needs with those patients with symptomatic myeloma.By profiling information needs in advance, APs may better communicate myeloma-related information to their patients, thereby improving practice and outcomes. A computerized version of INQ has already been tested and was able to efficiently and quickly produce the priority of information needs in patients diagnosed with prostate cancer . The useIn terms of meeting treatment and prognosis information needs, a team approach is best to help patients make informed decisions.Oncology APs can provide important information to patients in terms of how the therapy will work and what side effects to expect. They can also share self-care management strategies. As APs and oncology nurses are so frequently in contact with patients, they are in an ideal position to provide additional information related to treatment, prognosis, and self-care. Where information is scant, APs can consult with multidisciplinary team members such as physician residents and fellows, clinical psychologists, and licensed clinical social workers to provide additional information and support. Individualized assessment of information needs at various time points is imperative, given that they often shift over time.This study showed that the top three information priorities in myeloma patients related to treatment, prognosis, and self-care and that they could serve as a starting point to elicit further informational needs. By doing so, APs can eventually improve efficiency in delivering pertinent information to symptomatic myeloma patients. The Internet, physicians, family, and friends are among the top sources of information. Oncology APs should support and identify measures that can enhance patients’ learning processes from these sources. With their graduate education and training, APs are well poised to meet patients’ information needs by assisting them in their search for credible and reliable Internet sources and by educating them about different treatments and their impact on prognosis .AcknowledgmentsThis work was supported by the National Institutes of Health  and the Achievement Rewards for College Scientists (ARCS) Foundation, Seattle, WA . The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH and the ARCS Foundation.


Although numerous studies have investigated the neurobiology and neuroendocrinology of posttraumatic stress disorder (PTSD) after single finished trauma, studies on PTSD under ongoing threat are scarce and it is still unclear whether these individuals present similar abnormalities.The purpose of this review is to present the neurobiological and neuroendocrine findings on PTSD under ongoing threat. Ongoing threat considerably affects PTSD severity and treatment response and thus disentangling its neurobiological and neuroendocrine differences from PTSD after finished trauma could provide useful information for treatment.Eighteen studies that examined brain functioning and cortisol levels in relation to PTSD in individuals exposed to intimate partner violence, police officers, and fire fighters were included.Hippocampal volume was decreased in PTSD under ongoing threat, although not consistently associated with symptom severity. The neuroimaging studies revealed that PTSD under ongoing threat was not characterized by reduced volume of amygdala or parahippocampal gyrus. The neurocircuitry model of PTSD after finished trauma with hyperactivation of amygdala and hypoactivation of prefrontal cortex and hippocampus was also confirmed in PTSD under ongoing threat. The neuroendocrine findings were inconsistent, revealing increased, decreased, or no association between cortisol levels and PTSD under ongoing threat.Although PTSD under ongoing threat is characterized by abnormal neurocircuitry patterns similar to those previously found in PTSD after finished trauma, this is less so for other neurobiological and in particular neuroendocrine findings. Direct comparisons between samples with ongoing versus finished trauma are needed in future research to draw more solid conclusions before administering cortisol to patients with PTSD under ongoing threat who may already exhibit increased endogenous cortisol levels.We reviewed the neurobiological and neuroendocrine findings in PTSD under ongoing threat.PTSD under ongoing threat demonstrated similar brain abnormalities as PTSD after finished trauma.Several studies found increased cortisol levels in PTSD under ongoing threat.Hydrocortisone administration might not be beneficial for individuals with PTSD under ongoing threat with elevated endogenous cortisol levels.Direct comparisons between ongoing versus finished trauma are needed to provide robust conclusions and clinical recommendations. Traumatic experiences refer to direct or indirect exposure to actual or threatened death, serious injury, or sexual violation  is involved in the regulation of negative feedback of the hypothalamic–pituitary–adrenal (HPA) axis, regulation of emotions, and behavioral inhibition; the prefrontal cortex (PFC) is associated with complex cognitive processes , from which the medial PFC (mPFC) is involved in extinction of conditioned fear and emotion regulation , the central executive network (CEN), and the salience network (SN) , PET, neuroimaging, cortisol, and HPA-axis. We combined all of the following search terms: posttraumatic stress disorder and population  with: neurobiology  or neuroendocrinology . Examples of search streams are (1) “posttraumatic stress disorder” AND “police officers” AND “amygdala,” (2) “posttraumatic stress disorder” AND “intimate partner violence” AND “cortisol.” The search was conducted for articles from 1990 to 2016 published in English. The inclusion criteria were the following: (1) adult populations of victims of IPV, war trauma, police officers, and fire fighters, (2) ongoing character of trauma: IPV victims with recent incidents, in an abusive relationship at the time of the study or living in a shelter, and police officers and fire fighters in active duty, (3) outcome measure of PTSD symptoms, and (4) a comparison group of healthy controls or trauma-exposed individuals with or without PTSD. Studies with victims of IPV who were living in shelters were included, because these women were still living in fear of their abuser and were afraid to live on their own. We retrieved four structural studies on brain volume of hippocampus and amygdala, and three functional studies on brain activity of PFC, amygdala, and insula  and 2.Four studies with three different samples  measured the hippocampal volume as presented in The above-mentioned studies indicated that amygdala volume was not significantly smaller in victims of IPV or police offenders with PTSD compared to controls  examined brain activity of amygdala and PFC during an acoustic-cue paradigm with pleasant, neutral, and traumatic memories  was the focus of four studies. Johnson, Delahanty, and Pinna  examinedFinally, two studies administered dexamethasone to examine cortisol suppression. The first one recruited 64 women, 15 with IPV–PTSD, 27 with IPV–PTSD +MDD, 8 with IPV without PTSD or MDD, and 14 controls (Griffin, Resick, & Yehuda, The aim of this review was to present the neurobiological and neuroendocrine findings on PTSD under ongoing threat and examine whether PTSD under ongoing threat is characterized by abnormal patterns similar to those previously found in PTSD after finished trauma. We found no significant differences in brain volumes of amygdala and parahippocampal gyrus between PTSD under ongoing threat groups and trauma-exposed or healthy controls (Fennema-Notestine et al., Previous studies examining PTSD after finished trauma have supported a relationship between PTSD and smaller volumes of left amygdala, hippocampus, and ACC, although these results were not consistent across studies (Karl et al., The reviewed fMRI studies on PTSD under ongoing threat revealed hyperactivation of amygdala and insula, hypoactivation of PFC, and decreased connectivity in response to negative stimuli (Lindauer, Booij, et al., increased cortisol levels, whereas two found a relation between PTSD and decreased baseline cortisol levels. Finally, three studies supported that lower cortisol response was associated with trauma exposure, but not with PTSD (Johnson et al., Concerning neuroendocrinology, the findings were highly inconsistent. Some studies revealed an association between PTSD and increased cortisol output, morning cortisol levels, and CAR compared to trauma-exposed controls (Austin-Ketch et al., The inconsistent findings may be explained by several factors that might have interfered and masked the association between neurobiological and neuroendocrine abnormalities and PTSD under ongoing trauma, such as history of childhood abuse, trauma exposure, comorbidity, presence of dissociative symptoms or complex PTSD, small sample sizes, methodological differences, and differences in number, type, and time of cortisol measurements. PTSD is associated with history of childhood abuse (Ozer et al., Moreover, several methodological shortcomings and differences could have played a role in the variability of the findings. Particularly, the majority of studies on neurobiology had small sample sizes that might not be sufficient to detect significant effects. Furthermore, there are various MRI analysis techniques with different levels of sensitivity and specificity. For instance, it is suggested that automatic volumetric analysis might fail to detect subtle differences in brain structures compared to manual segmentation (Lindauer, Vlieger, et al., The differences as well as the similarities between PTSD after ended trauma and PTSD under ongoing threat are crucial for clinical practice. The major difference between PTSD under ongoing threat and PTSD after ended trauma is the fact that the former is characterized by a continuous and probably unavoidable stressful and traumatic environment that fuels the PTSD. Particularly, a recent meta-analysis suggested that early administration of hydrocortisone after a traumatic event is effective in the prevention of PTSD (Sijbrandij, Kleiboer, Bisson, Barbui, & Cuijpers, This review presents the limited evidence on PTSD under ongoing threat and underscores that the findings are sparse and do not provide a clear image of the differences between PTSD under ongoing threat and PTSD after ended trauma. Further research may disentangle these differences and explore the substantially understudied population of individuals with PTSD under ongoing threat. It would be beneficial for future research to directly compare the neurobiology and neuroendocrinology of individuals with PTSD after ended trauma and PTSD under ongoing threat in order to draw reliable conclusions. Furthermore, it is crucial to take into account several covariates such as comorbidity, history of childhood abuse and methodological limitations in order to unravel the independent effect of PTSD. There is also a great need for randomized controlled trials that will investigate whether and how we could provide effective treatment for PTSD under ongoing threat. By revealing the similarities and differences between PTSD after ended trauma and PTSD under ongoing threat, we will be able to shed light on the different manifestations of PTSD and explain some of the inconsistent findings in brain patterns and HPA functioning in PTSD. Overall, this review underscores that the findings on PTSD under ongoing threat are limited, inconsistent, and with methodological limitations and urges future studies to focus on this line of research in order to understand the characteristics of PTSD under ongoing threat and draw more definite conclusions.


While the Millennium Development Goals  focused primarily on poverty reduction, hunger and infectious diseases, the proposed Sustainable Development Goals (SDGs) and targets pay more attention to nutrition and non-communicable diseases (NCDs). One of the 169 proposed targets of the SDGs is to reduce premature deaths from NCDs by one third; another is to end malnutrition in all its forms. Nutrition-related NCDs (NR-NCDs) stand at the intersection between malnutrition and NCDs. Driven in large part by remarkable transformations of food systems, they are rapidly increasing in most low and middle income countries (LMICs). The transformation to modern food systems began in the period following World War II with policies designed to meet a very different set of nutritional and food needs, and continued with globalization in the 1990s onwards. Another type of food systems transformation will be needed to shift towards a healthier and more sustainable diet – as will meeting many of the other SDGs. The process will be complex but is necessary. Communities concerned with NCDs and with malnutrition need to work more closely together to demand food systems change. TheNutrition was also given short shrift in the MDGs with reference only to underweight. In the SDGs, there is a now a target (2.2) to end malnutrition in all its forms under Goal 2 (Box 1). This commentary focuses on the intersection between these health concerns – nutrition-related NCDs (NR-NCDs) – and what needs to be done to move towards achieving both the NCD and nutrition targets.The world has been moving headlong towards an unhealthy and equally unsustainable pattern of food production and consumption for decades. Often termed the “nutrition transition”, these changes have taken hold more recently – but more rapidly – in low and middle income countries (LMICs). As widely reported on elsewhere, e.g. , the nutDiets are not all that have changed. Concurrently there have been remarkable declines in physical activity at work and home and in transport and leisure, as modern technology has rapidly shifted into all sectors of life globally . As a reHow to change? One important focus of action needs to be the global food system  includes some relevant targets, transforming the food system will take multiple actions at multiple levels, from local level innovations to enhancing food access for vulnerable groups to the restructuring of global level governance of agriculture, food, nutrition and health.One action that academics and civil society can take to further a political environment more amenable to these changes is to engage with colleagues concerned with different forms of malnutrition, including NR-NCDs. We need greater unity across malnutrition in all its forms. We know that factors such as high quality diets for pregnant women, breastfeeding, appropriate complementary foods, healthy, nutritious foods in infancy and beyond, access to good healthcare and hygienic environments, are needed to address both under-nutrition and NR-NCDs . We knowGoal 1: End poverty in all its forms everywhereGoal 2: End hunger, achieve food security and improved nutrition and promote sustainable agricultureGoal 3: Ensure healthy lives and promote well-being for all at all agesGoal 4: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for allGoal 5: Achieve gender equality and empower all women and girlsGoal 6: Ensure availability and sustainable management of water and sanitation for allGoal 7: Ensure access to affordable, reliable, sustainable and modern energy for allGal 8: Promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for allGoal 9: Build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovationGoal 10: Reduce inequality within and among countriesGoal 11: Make cities and human settlements inclusive, safe, resilient and sustainableGoal 12: Ensure sustainable consumption and production patternsGoal 13: Take urgent action to combat climate change and its impacts*Goal 14: Conserve and sustainably use the oceans, seas and marine resources for sustainable developmentGoal 15: Protect, restore and promote sustainable use of terrestrial ecosystems, sustainably manage forests, combat desertification, and halt and reverse land degradation and halt biodiversity lossGoal 16: Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levelsGoal 17: Strengthen the means of implementation and revitalize the global partnership for sustainable developmentSource: * taking into account ongoing World Trade Organization (WTO) negotiations and WTO Doha Development Agenda and Hong Kong Ministerial MandateTo eradicate extreme poverty and hungerTo achieve universal primary educationTo promote gender equalityTo reduce child mortalityTo improve maternal healthTo combat HIV/AIDS, malaria, and other diseasesTo ensure environmental sustainabilityTo develop a global partnership for developmentSource:


Health promotion by and with Aboriginal and Torres Strait Islander (hereafter Indigenous) Australians is critically important given a wide gap in health parity compared to other Australians. The development and implementation of step-by-step guides, instruments, packages, frameworks or resources has provided a feasible and low-resource strategy for strengthening evidence-informed health promotion practice. Yet there has been little assessment of where and how these tools are implemented or their effectiveness. This paper reviews the characteristics, implementation and effects of Indigenous health promotion tools.Indigenous health promotion tools were identified through a systematic literature search including a prior scoping study, eight databases, references of other reviews and the authors’ knowledge (n = 1494). Documents in the peer reviewed and grey literature were included if they described or evaluated tools designed, recommended or used for strengthening Indigenous Australian health promotion. Eligible publications were entered into an Excel spreadsheet and documented tools classified according to their characteristics, implementation and effects. Quality was appraised using the Dictionary for Effective Public Health Practice Project (EPHPP) and Critical Appraisal Skills Program (CASP) tools for quantitative and qualitative studies respectively.The review found that Indigenous health promotion tools were widely available. Of 74 publications that met inclusion criteria, sixty (81%) documented tools developed specifically for the Indigenous Australian population. All tools had been developed in reference to evidence; but only 22/74 (30%) publications specified intended or actual implementation, and only 11/74 (15%) publications evaluated impacts of the implemented tools. Impacts included health, environmental, community, organisational and health care improvements. The quality of impact evaluations was strong for only five (7%) studies.The small number and generally moderate quality of implementation and evaluation studies means that little is known about how tools work to strengthen Indigenous health promotion practice. The findings suggest that rather than continuing to invest in tool development, practitioners, policy makers and researchers could evaluate the implementation and effects of existing tools and publish the results. There is a need for long-term investment in research to review the current use of health promotion tools and the factors that are likely to enhance their implementation. There is considerable scope for improvements in the implementation of health promotion efforts targeting Aboriginal and Torres Strait Islander (hereafter Indigenous) individuals, families, organisations and communities. Health promotion, defined as the process of enabling people to increase control over the determinants of health and thereby improve their health , is critIndigenous perceptions of health recognise a holistic view encompassing physical, mental and spiritual health as well as individual and community levels. Pat Anderson, the Chairperson of Australia’s Indigenous health research centre, the Lowitja Institute, recently argued that the breadth of health promotion efforts needed to be expanded. She stated: “attempts to prevent physical health issues are not enough from our perspective – prevention needs to operate across all these other domains as well. Our holistic conception of health is powerfully supported by the theory of the social determinants of health” . In 2002The demand for use of proven evidence-based strategies to improve Indigenous health has led government and non-government organisations to invest considerably in the development and implementation of tools. Health promotion tools were defined as structured step-by-step guides, instruments, packages, frameworks or resources which are designed for enabling practitioners and organisations to plan, implement or evaluate a health program or improve an existing one. Tools include guidelines, practice models or frameworks, training packages/manuals, toolkits, resource kits, action packs, screening tools, audit tools, handbooks, measurement tools, checklists and networks. Given the limited availability and often short-term nature of health promotion grant funding, the development and implementation of such tools has provided a feasible and low-resource strategy for strengthening Indigenous health promotion approaches, and the internet provides an easily accessible and time-efficient means of disseminating the developed tools. Yet there has been little assessment of the characteristics of such tools, whether or how they meet the priorities and needs of Indigenous Australian contexts, how they are implemented to improve Indigenous health promotion practice and outcomes, and whether they assist in supporting improved health promotion practice or outcomes.In order to optimise the potential of tools to contribute to Indigenous health promotion, it is important to develop an understanding of how to effectively deliver promising or proven tools across the wide diversity of Indigenous health promotion settings . With thPublications were identified and classified using a process that was consistent with Cochrane methods for systematic searches . First aDocuments were included in the review if they described or evaluated Indigenous-specific or non-Indigenous specific tools  that were designed, recommended or used to plan, implement or evaluate an Indigenous Australian health promotion program. The potential of non-Indigenous specific tools to contribute to Indigenous Australian health promotion was determined by: 1) the inclusion of the tool in Wise et al.’s  study; 2A search strategy, summarised in Figure A keyword search of the 1494 publications was conducted using the terms: tool*, training*, resource*, guide*, instrument*, package*, framework*, model*, manual*, toolkit*, kit*, pack*, handbook*, checklist* or network*. Publications were excluded that: 1) did not meet our definition of a health promotion tool (n = 1198); 2) were not relevant to Indigenous Australian health promotion (n = 174); 3) did not describe or evaluate the tool (n = 6); and 4) were duplicates (n = 42). Abstracts or executive summaries of the remaining 74 publications were searched by one author (JM) to classify the characteristics of the publications, with data entered into an Excel spread sheet.The tools were categorised according to their general characteristics: 1) Indigenous-specific or not; 2) tool type; 3) Ottawa Charter strategy focus ; 4) IndSuccessful implementation of a health promotion tool or program requires three elements as characterised in the Promoting Action on Research Implementation in Health Services (PARiHS) framework: evidence of its potential effectiveness; consideration of the organisational, community and broader context in which it is to be implemented; and the methods by which its delivery will be facilitated . PARiHS Evidence was considered to be the form of knowledge that was implemented through tools. Evidence was derived from research, clinical expertise, and/or local and Indigenous knowledge from clients ,17. The To determine the effectiveness of tools for Indigenous health promotion improvement, impact evaluation studies were categorised by: 1) effects; 2) study quality; and 3) publication type. The methodological quality of quantitative studies was assessed using the Dictionary for Effective Public Health Practice Project (EPHPP) tool . SectionThe review found 74 publications that described or evaluated tools designed to enhance Indigenous health promotion practice. They included 60/74 (81%) Indigenous Australian-specific tools; five non-Indigenous specific tools that were tailored for Indigenous Australians, nine tools that were non-Indigenous specific and not tailored, and one Canadian Indigenous tool. Figure The focus of tools was also diverse with regard to the five health promotion strategies outlined in the Ottawa Charter Figure . HoweverAlmost all publications documenting Indigenous-Australian-specific tools (57/60 or 95%) incorporated some description of Indigenous principles or ethical guidelines which informed their development or implementation. Most commonly reported were the principles of cultural competence, community engagement and empowerment, partnerships, holism, best practice, capacity development, and sustainability. Less commonly cited were the principles of incremental change; communication; community leadership; social and kinship relations; safety; harmony with country, equity, lawfulness, use of pictures, use of Aboriginal language, simplicity, prompt response, consensus, enhancing current investments, and fun/passion/sharing.The three most common health issues which together accounted for 38% of the tools, were mental health and alcohol and drug issues 11/74 or 15%); healthy lifestyle/chronic disease prevention (11/74 or 15%); and nutrition (6/74 or 8%). But the health issues were more notable for their diversity than similarity. In addition was documentation of tools to strengthen Indigenous environmental health/drinking water; physical activity; tobacco control; maternal and child health; women’s health; social and emotional wellbeing; men’s health, child injury, sexual health, ear health, musculoskeletal health, remote health and dementia/cognitive impairment.As shown in Figure  or 15%; The three elements of the PARiHS framework were examined for each health promotion tool. These three elements  are considered in turn.Hearteningly, all health promotion tools were developed, adapted, or updated in reference to evidence. The type of evidence consulted varied from research and clinical expertise to community preference. While it is critical that Indigenous knowledge was incorporated into the design of tools, only 52/74 (70%) publications specified that community members were consulted or collaboratively involved in developing or adapting tools. Other commonly mentioned sources of evidence for tool development were reviews of the literature (15/74 or 20%) or consultation with health practitioners (12/74 or 16%).Evidence was important in the development and implementation of tools because it improved users’ confidence in the utility of the tool and their willingness to apply it to improve health. The value of evidence was illustrated by Davidson et al.’s  evaluatiFurther, the impacts of tool implementation were evaluated in only 11/74 (15%) studies. In the remaining 63/74 (85%) publications, the studies described or evaluated the process of implementation of tools. Process evaluations found that screening and measurement tools were validated, reliable and culturally appropriate; guides were updated, supported by staff and/or implemented; and training packages were feasible, relevant, culturally acceptable, likely to be cost effective and/or accredited. However, the dearth of impact evaluation studies means that there is little evidence for whether tools work to improve Indigenous health promotion.Overall, the reviewed studies identified a huge diversity of geographical and organisational contexts, and individual practitioners involved in Indigenous health promotion Table . The impAs shown in Table The most common intended organisational settings for the use of tools were primary health care and community-based organisations. As well, tools were designed for specific use in health promotion projects, by policy makers, within research projects, within the alcohol and other drug sector, in the mental health sector and for use by a training organisation. The diversity of organisational contexts within which Indigenous health promotion tools were implemented is both a strength and challenge within health promotion. The holistic Aboriginal view of health promotion requires coordinated, inter-sectoral partnerships – with leadership from Aboriginal community controlled health bodies as well as government and non-government sectors . HoweverConsistent with the diverse organisational contexts, individual tool implementers were also diverse. They included primary health care workers, community members; health promotion officers; policy makers, board members and managers; community/welfare workers; specialist health practitioners; and Indigenous academics.The importance of facilitation was illustrated by Hunter, Brown and McCulloch  who founEighteen of the 74 (24%) studies described barriers to implementation including the lack of public availability of the tool; effort, motivation and capacity of workforce required to apply the tool, and lack of funding. Implementation was facilitated by the simplicity, attractiveness, relevance and availability of the tools themselves, and also by partnerships and networks, recommendations by Indigenous and health leaders, health practitioner confidence, skills and knowledge; supportive environments; pilot programs; and requirements or incentives. Recommendations or guidance relevant to implementation were provided in 26/74 (35%) publications as predominantly general statements such as a need to explore ways of making tools available to other health professionals.The impacts of tools were evaluated in only 11/74 (15%) publications. Table The studies provide diverse examples of tool implementation, suggesting that facilitating evidence-informed tools is feasible in community organisations and groups, primary health care services, training organisations and specialist alcohol rehabilitation and other services. The delivery of tools by Indigenous community members, Indigenous health workers and other health professionals, expert mental health and alcohol and other drug advisors, government trainers, and research partnerships suggested that facilitation by diverse individuals was also feasible. Facilitated processes were more commonly effective than passive dissemination methods.The documented health, environmental, community, organisational and health care improvements from the eleven impact evaluation studies were promising, suggesting that the implementation of tools can be an effective strategy for strengthening evidence-informed Indigenous health promotion practice. The health impacts of tool implementation comprised improvements in birth weight, reductions in body weight and waist/hip circumferences and lower depression levels, partner drinking and relationship violence. For example, D’Espaignet et al.  found siConsistent with the health promotion strategy of creating supportive environments, improvements in physical infrastructure and housing, and water management were found. Moran’s  qualitatThe use of tools also impacted community and organisational processes such as a changing discourse around sexual health, change in men’s personal development and growth and in their response to family responsibilities, and shifts in organisational culture and group cohesion. Whiteside et al.  establisFinally, health care impacts as a result of tool implementation included a willingness by primary health practitioners to engage with alcohol-related problems; collaboration, skill development, cultural competence and access to mentorship and expertise; and increased knowledge, skills and confidence to implement smoking brief intervention. The distribution of a clinical guideline  positively influenced willingness to engage with alcohol-related problems as part of primary clinical care . DavidsoThe quality of evaluation studies, measured using EPHPP (for quantitative studies) and CASP  quality assessment tools, however, was strong for only five of the studies  declare that they have no competing interests.JM and KT made substantial contributions to the conception and design, JM acquired the data and JM and RB analysed and interpreted data. All authors critically revised drafts of the manuscript and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/712/prepubProtocol for Lowitja tools review.Click here for filePRISMA Checklist.Click here for fileSpreadsheet.Click here for file


The study objective was to identify and describe the process, resources and expertise required for the revision of accreditation standards, and report outcomes arising from such activities.Secondary document analysis of materials from an accreditation standards development agency. The Royal Australian College of General Practitioners’ (RACGP) documents, minutes and reports related to the revision of the accreditation standards were examined.The RACGP revision of the accreditation standards was conducted over a 12 month period and comprised six phases with multiple tasks, including: review methodology planning; review of the evidence base and each standard; new material development; constructing field trial methodology; drafting, trialling and refining new standards; and production of new standards. Over 100 individuals participated, with an additional 30 providing periodic input and feedback. Participants were drawn from healthcare professional associations, primary healthcare services, accreditation agencies, government agencies and public health organisations. Their expertise spanned: project management; standards development and writing; primary healthcare practice; quality and safety improvement methodologies; accreditation implementation and surveying; and research. The review and development process was shaped by five issues: project expectations; resource and time requirements; a collaborative approach; stakeholder engagement; and the product produced. The RACGP evaluation was that participants were positive about their experience, the standards produced and considered them relevant for the sector.The revision of accreditation standards requires considerable resources and expertise, drawn from a broad range of stakeholders. Collaborative, inclusive processes that engage key stakeholders helps promote greater industry acceptance of the standards. Government, quality improvement and accreditation agencies frequently engage in the development or revision of clinical and organisational standards. These are significant tasks that utilise considerable human and financial resources . DiffereStandards for General Practice (4th Edition) developed and revised by The Royal Australian College of General Practitioners (RACGP), which are used for accrediting general practice nationally. Through implementing an instrumental case study [The aim of this study was to identify and describe the process, resources and expertise required for, and to report evaluation outcomes from, a revision of a set of healthcare accreditation standards. The standards and associated revision activities under examination concern the se study ,9 of these study . Previouse study ,11.The Accreditation Collaborative for the Conduct of Research, Evaluation and Designated Investigations through Teamwork (ACCREDIT) was funded across 2011–15 to investigate health service accreditation in Australia . The colStandards for General Practice [http://www.racgp.org.au/your-practice/standards/standards4thedition/).Australia has over 7,100 general practices in which more than 23,500 doctors work. There were 125 million consultation services provided during 2010–11, costed at A$5.3 billion through the Medicare Benefits Scheme [Practice . The staAn expert group was formed by UNSW researchers and RACGP staff. During 2012, they collaboratively conducted a study with three stages. First, informed by the accreditation and evaluation literatures, the expert group purpose-designed an analysis framework with seven categories including: phase, task, objective, time frame, components, people involved and National Expert Committee – Standards for General Practice (NEC-SGP) involvement. The role of the NEC-SGP includes developing and maintaining standards for general practices, and ensuring that the standards reflect quality practice and are independent of government policies and initiatives. The NEC-SGP comprises experts in standards development with professional backgrounds including general practitioners, practice nurses and managers, and a consumer representative. Since 2011 the NEC-SGP is known as the National Standing Committee – Standards for General Practice. Second, using the framework, thematic analysis  of RACGPThe analysis framework facilitated the identification of a standards review process comprising six sequential and overlapping phases with multiple components Table . The sixOver 100 individuals substantively participated in the review process, with an additional 30 providing periodic input and feedback. Participants were drawn from general practice stakeholders, including: healthcare professional associations; primary healthcare services; accreditation agencies; government agencies; and public health organisations. Their expertise spanned the fields of: project management; standards development and writing; primary healthcare practice; quality and safety improvement methodologies; accreditation implementation and surveying; and research methodologies.The review and development process was shaped by five factors. First, identifying and delivering upon the requirements of the RACGP, and stakeholders associated with the standards, was reported as necessary for the credibility of the product. Second, identifying and communicating resource and time restrictions to participants, and observers within the sector, was required to enable the review to be completed as expected. Managing expectations and employing an effective communication strategy reinforced a collaborative approach and facilitated broad stakeholder engagement with the review; these being the third and fourth issues identified as essential for a positive development process leading to the acceptance of revised standards. Finally, the review project had to deliver a well structured, clearly written, evidence based, high quality document that was consistent with previous editions. One significant improvement suggestion emerged from the evaluation: a majority of participants agreed that consideration could be given to altering the standards revision process to conduct periodic reviews and progressive updates.This study provides the first case-study evidence about processes invoked for the development and revision of accreditation standards , and layThe project was completed through the combined efforts, or distributed leadership , of moreThe revision of accreditation standards requires collaboration from a diverse range of professionals, with considerable resources and expertise. The collaborative, inclusive process employed engaged stakeholders and promoted the acceptance of the revised standards by the sector.