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BACKGROUND: Driving is a complex task requiring multiple cognitive domains and the musculoskeletal system. Cognitive dysfunction is associated with driving impairment. Dialysis patients are known to have a high prevalence of cognitive impairment and other comorbidities, and may be at risk of driving impairment. No Australian guidelines address driving safety in dialysis patients. AIMS: To estimate the proportion of dialysis patients who were driving and those at risk of driving impairment, and to investigate the agreement between objective and subjective markers of risk. METHODS: This single-centre study involved dialysis patients voluntarily completing two questionnaires relating to risk of driving impairment; the first questionnaire focussed on objective markers, and the second questionnaire focussed on subjective markers. Risk of driving impairment was established using pre-determined criteria, and the agreement between objective and subjective markers was estimated using Cohen kappa. RESULTS: A total of 44.8% (99/221) of patients participated; 76.8% (76/99) of participants were driving, and 76.3% (58/76) of drivers were at risk of driving impairment. Factors associated with at-risk driving included post dialysis dizziness, leg weakness or numbness, falling asleep while driving and hypoglycaemia. Sixteen patients reported collisions since commencing dialysis. The questionnaires displayed slight agreement (Cohen kappa = 0.20) between objective and subjective markers. CONCLUSIONS: Dialysis patients are at risk of driving impairment based on self-reported questionnaire responses. Discrepancies between patients' perceptions and objective markers were apparent. Further research into appropriate risk assessments, as well as development of guidelines to aid in determining driving safety in dialysis patients, is needed.

Patients with anorexia nervosa (AN) may experience life-threatening malnutrition-related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high-level evidence.To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN.MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia.The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high-calorie refeeding and micronutrient supplementation.The evidence supports high-calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence-based health care.

The management of chronic kidney disease is complex. With disease management being the responsibility of parents in the paediatric renal clinic, the responsibility is gradually shifted to adolescents and young adults during the transition to adult care. This multi-perspective qualitative study aimed to explore the experiences of adolescents and young adults, their parents and health professionals to gain an insight into transitional care. Focussing on the transition process and transfer to adult care, 18 adolescents and young adults and eight mothers participated in individual semi-structured interviews. Additionally, three focus groups were conducted with 20 multidisciplinary health professionals. Data were transcribed verbatim and analysed thematically. Similar responses from adolescents and young adults and mothers included the reluctance to leave the paediatric health service. Mothers found the transition to adult care more challenging than the adolescents and young adults. While health professionals acknowledged that engaging adolescents and young adults in their own care was challenging, they believed parents had an important role in facilitating their child’s independence. This study highlights that health professionals in both paediatric and adult health services need to work collaboratively. However, importantly, health professionals need to be mindful that parents require an equal amount of engagement as adolescents and young adults, if not more, to mitigate parental barriers in achieving a successful transfer.

Factors related to the ‘typical university experience,’ such as high levels of perceived stress and a lack of sleep, negatively affect student mental health. The present study analyzes mental healt...

Background Glycolysis is altered in various kidney diseases, but little is known about glycolysis in pre-eclampsia, a multi-system disorder with major pathological effects on the kidney. Urinary exosomes provide a non-invasive alternative for studying changes in kidney metabolism. This study aims to characterise the expression and phosphorylation of isozymes of the key glycolytic regulatory protein, 6-phosphofructokinase-2-kinase/fructose-2,6-bisphosphatase (PFK-2/FBPase-2), in urinary exosomes of subjects with pre-eclampsia (PE), compared to normotensive non-pregnant (NC) and normotensive pregnant (NP) controls. Methods A cross-sectional study of NC (n = 19), NP (n = 23) and PE (n = 29) subjects was performed. Exosomes were isolated from urine samples by differential ultracentrifugation, and then analyzed by Western blot and densitometry for expression of PFK-2/FBPase-2 isozymes (PFKFB2, PFKFB3 and PFKFB4) and phosphorylation of PFKFB2 at residues Ser483 and Ser466 and PFKFB3 at Ser461. Results PFKFB2 expression was increased 4.7-fold in PE compared to NP (p

Aim The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends the incorporation of a new risk calculator that quantifies the end stage kidney disease (ESKD) risk based on a composite profile of risk factors in living kidney donor candidates (LKDCs). We compared the ESKD risk estimates in previously declined versus accepted LKDCs to evaluate the predictive capacity and potential impact of this tool. Methods Baseline 15-year and lifetime ESKD risk estimates without donation were calculated using the risk calculator for LKDCs assessed from two centres between 2007 and 2015. LKDC suitability based on the proposed KDIGO and the existing Caring for Australasians with Renal Impairment (KHA-CARI) national guidelines was compared. Results Median 15-year ESKD risk was 0.14% (IQR 0.09-0.31%) in declined LKDCs (n = 59) versus 0.10% (0.07-0.14%) in accepted LKDCs (n = 89) (P 1%. This risk calculator appears to complement but not replace clinical evaluation.

Introduction The low FODMAP diet is known to be effective in improving symptoms in approx. 70% of those with Rome criteria IBS. Whilst the majority of IBS patients are young adults, there is a cohort of patients over the age of 45 with IBS who may benefit from similar interventions. In January 2017, the dietetic-led refractory IBS (RIBS) Service in Gloucestershire expanded its direct access inclusion criteria to allow GP referral of patients >45 years with negative GI investigation within the previous 5 years and no change in symptoms. Consultant referrals following negative investigation in this age group are also accepted. Methods This is a retrospective analysis of data collected during patient consultations. Patients over 45 years referred to the RIBS service by GP or consultant were assessed and provided with detailed advice on a low FODMAP diet by a specialist dietitian, to be followed for 6 weeks. An 11 point symptom evaluation was completed before and after dietary manipulation and total scores were calculated. Typical bowel frequency and stool consistency were recorded, along with responses to a global symptom question ‘do you currently have satisfactory relief of your gut symptoms?’ Results 107 patients>45 years of age have completed treatment within the RIBS service (82% with diarrhoea or mixed symptom predominance). Individual and total symptom scores demonstrate an average reduction in severity of almost 50% after following a FODMAP exclusion diet (figure 1), with mean total symptom score before treatment 60.9 (range 27–89/110) reducing to 36.0 after treatment (range 11–89/110). Sixty-seven percent (72/107) of patients reported satisfactory relief of their gut symptoms following dietary restriction (figure 2). Direct-access patients who did not respond to treatment were discussed within a consultant-led MDT, with further advice, clinician review or investigation arranged as appropriate. No known cases of IBD or cancer have been missed to date using this pathway of care. Conclusions Treatment within a dietetic-led, direct-access service with an appropriate, policed care pathway and MDT support is a safe and clinically effective management strategy for patients over the age of 45 with diagnosed IBS symptoms. The pathway provides an important adjunct to ‘straight to test’ referral protocols for GP’s in those over 45 with stable symptoms and previously negative colonoscopy, diverting these patients from unnecessary specialist review and costly further investigation.

Living kidney donors (LKD) for paediatric kidney transplant recipients (KTR) have a heightened motivation to donate for emotional reasons and the clear health benefits to the KTR. We hypothesized that the cohort of LKD for paediatric KTR (LKD-P) includes motivated young parents with a higher lifetime end-stage kidney disease (ESKD) risk compared to adult KTR (LKD-A). Data from the Australia and New Zealand Dialysis and Transplant LKD Registry (2004-2015) was analysed to compare baseline characteristics and predonation ESKD risk in LKD-P (n = 315) versus LKD-A (n = 3448). LKD-P were younger (median age 42 vs. 50 years; P < 0.001) and had a marginally higher lifetime ESKD risk (median 0.44% vs. 0.40%; P < 0.01), with a similar proportion of LKD exceeding 1% risk threshold (5.4% vs. 5.6%; P = NS). Compared to grandparents as LKD-P, parents (median age 41 vs. 59 years; P < 0.001) had a higher lifetime ESKD (0.44% vs. 0.25%; P < 0.001). Although unique benefits to paediatric KTR justify the minor increase in lifetime ESKD risk in young parents, carefully selected grandparents are an alternative LKD-P option, allowing parents to donate for subsequent transplants.

Obesity is an independent risk factor for chronic kidney disease (CKD). The mechanisms linking obesity and CKD include systemic changes such as high blood pressure and hyperglycemia, and intrarenal effects relating to lipid accumulation. Normal lipid metabolism is integral to renal physiology and disturbances of renal lipid and energy metabolism are increasingly being linked with kidney disease. AMP-activated protein kinase (AMPK) and acetyl-CoA carboxylase (ACC) are important regulators of fatty acid oxidation, which is frequently abnormal in the kidney with CKD. A high fat diet reduces renal AMPK activity, thereby contributing to reduced fatty acid oxidation and energy imbalance, and treatments to activate AMPK are beneficial in animal models of obesity-related CKD. Studies have found that the specific cell types affected by excessive lipid accumulation are proximal tubular cells, podocytes, and mesangial cells. Targeting disturbances of renal energy metabolism is a promising approach to addressing the current epidemic of obesity-related kidney disease.

The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends the incorporation of a new risk calculator that quantifies the end-stage kidney disease (ESKD) risk based on a composite profile of risk factors in living kidney donor candidates (LKDC). We compared the ESKD risk estimates in previously declined versus accepted LKDC to evaluate the predictive capacity and potential impact of this tool.Baseline 15 year and lifetime ESKD risk estimates without donation were calculated using the risk calculator for LKDC assessed from two centres between 2007 and 2015. LKDC suitability based on the proposed KDIGO and the existing Caring for Australasians with Renal Impairment national guidelines was compared.Median 15 year ESKD risk was 0.14% (IQR 0.09-0.31%) in declined LKDC (n=59) versus 0.10% (0.07-0.14%) in accepted LKDC (n=89) (P0.001). Lifetime risk was similar: 0.39% (0.23-0.80%) versus 0.35% (0.22-0.56%), respectively; however, declined LKDC had a higher 98% risk percentile value (8.19% vs 1.02%) and were more likely to exceed a 1% ESKD risk threshold (15% vs 1%; P0.01). The calculator captured reasons for declining donation in only 39% of LKDC; 46.9% of LKDC with Caring for Australasians with Renal Impairment contraindications were reclassified as having an acceptable (≤1%) lifetime risk and no KDIGO contraindications, primarily related to a lower pre-donation glomerular filtration rate or controlled hypertension with obesity.Declined LKDC had a higher 15 year but similar lifetime ESKD risk. However, the calculator successfully differentiated declined LKDC with a lifetime risk1%. This risk calculator appears to complement but not replace clinical evaluation.

Objective Patient narratives, or stories, are an effective means of educating patients because they increase personal relevance and may reduce counter-arguing. However, such stories must seamlessly combine evidenced-based health information while being true to real patient experiences. The purpose of this paper is to describe the process of developing an educational intervention using African-American patients’ success stories controlling hypertension. Methods We identified a process to address stories development challenges. Results (1) To help identify story tellers, we conducted a literature review and subsequently streamlined the process of storyteller identification through screening and telephone interviews. (2) To better elicit stories, we consulted with experts in storytelling and incorporated principles from theater. (3) To select stories, we used intervention mapping to map the intervention to theory and key clinical concepts, and also engaged members of the target community to ensure scientific criteria and maintain authenticity. Conclusion Using personal narratives as intervention requires weaving together science, theory and clinically sound content, while still being true to the art of storytelling. Through a careful process of identifying storytellers and story selection and drawing upon theater arts, creating stories for intervention can be streamlined while meeting the goals of authenticity and scientific soundness.

Interpersonal violence is associated with numerous adverse health outcomes, including posttraumatic stress disorder (PTSD), other anxiety disorders, depression, substance abuse disorders, and other psychiatric comorbidities (Brady, Killeen, Brewerton, & Lucerini, 2000; Breslau, Davis, Andreski, & Peterson, 1991; Jordan, Campbell, & Follingstad, 2010; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Resnick, Acierno, & Kilpatrick, 1997; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993; Schnurr & Jankowski, 1999). For example, a recent study documented substantial associations between four types of interpersonal violence exposure—physical assault by an intimate partner, rape, other sexual assault, and stalking—and psychopathology among a nationally representative sample of Australian women. Women exposed to one or more of these forms of interpersonal violence were 2.6 to 11 times more likely than nonexposed women to meet criteria for a mood, anxiety, or substance use disorder in their lifetime. The associations between other types of stressful life events and psychopathology were considerably smaller. Unfortunately, in studies to date, the category of interpersonal violence has often been construed narrowly, including only experiences such as physical assault by an intimate partner, rape, other sexual assault, and stalking. Thus, less is known about the mental health impact of a broad array of different types of interpersonal violence. Also, although the link between these frequently studied forms of interpersonal violence and psychiatric morbidity is well-documented among women (Basile, Arias, Desai, & Thompson, 2004; Campbell, Greeson, Bybee, & Raja, 2008; Rees et al., 2011; Smith et al., 2011), fewer studies have focused on their prevalence and mental health impact among men. This study examines gender differences in population rates of a comprehensive set of interpersonal violence exposures in a national sample of U.S. women and men and investigates gender as a moderator of the associations between interpersonal violence exposure and lifetime mental disorders and suicide attempts using a comprehensive array of diagnostic mental health outcomes. Several studies suggest that the rates of exposure to interpersonal violence vary markedly by gender. For example, women are more likely than men to be the victims of rape, sexual assault, and stalking, and men are more likely than women to be physically assaulted and threatened with a weapon (Black et al., 2011; Kessler et al., 1995; Tolin & Foa, 2006). Because of these differences in prevalence of exposure, research on health consequences associated with certain types of interpersonal violence—for example, rape, sexual assault, and intimate partner violence—has understandably tended to focus on the effects of violence perpetrated against women in isolation from the effects of violence perpetrated against men (Campbell et al., 2008). However, although these exposures are less common among men than women, sexual assault and intimate partner violence among men also represents a significant social problem in the United States (Black et al., 2011; Carbone-Lopez, Kruttschnitt, & Macmillan, 2006; Coker et al., 2002; Saunders, 2002; Tolin & Foa, 2006; Whitaker, Haileyesus, Swahn, & Saltzman, 2007). For instance, the National Intimate Partner and Sexual Violence Survey found that at least one in five U.S. men have experienced sexual violence victimization during their lifetime, and one in seven have experienced severe physical violence by an intimate partner (Black et al., 2011), and such experiences are associated with elevated mental health symptoms (Black et al., 2011; Coker et al., 2002). Although women are often overrepresented in the literature examining the impact of rape, sexual assault, and stalking, the aforementioned studies suggest that men are legitimate victims of these forms of interpersonal violence as well. This highlights the need for research to understand the scope of a broad range of interpersonal violence experiences among men, including any ways in which health effects of interpersonal violence may be similar or different for women and men. The few studies that have examined the impact of interpersonal violence by gender have resulted in inconsistent findings (Dube et al., 2005; Kessler et al., 1995; Kimerling et al., 2010). Kessler and colleagues (Kessler et al., 1995) found that although women were nine times more likely to experience rape than men, the conditional probability of PTSD associated with rape was similar for women and men. Similarly, a study of HMO members found that although men reported slightly lower levels of childhood sexual abuse than women (16% vs. 25%, respectively), the association between child sexual abuse and mental health problems was consistent across genders (Dube et al., 2005). Conversely, other findings suggest that there may be gender differences in health outcomes as a function of the specific type of interpersonal violence. For example, Kessler et al. (1995) found that women were about four times more likely to report sexual molestation in childhood than men, and the conditional probability of PTSD associated with molestation was considerably higher for women than for men. Additionally, several studies with military populations suggest that exposure to sexual violence may have more serious mental health consequences for men than for women (Kang, Dalager, Mahan, & Ishii, 2005; Shipherd, Pineles, Gradus, & Resick, 2009; Street, Gradus, Stafford, & Kelly, 2007; Vogt, Pless, King, & King, 2005). Thus, it remains unclear whether the mental health effects of specific types of interpersonal violence differ for women and men. There are theoretical reasons to expect that the associations between interpersonal violence and mental health outcomes vary for women and men. Gender differences exist in terms of risk for a variety of psychiatric conditions, including mood, anxiety, substance use disorders, eating disorders, and attempted suicide (APA, 2000; Kessler, Chiu, Demler, Merikangas, & Walters, 2005; Moscicki, 1994). Stressful life events, such as interpersonal violence exposure, are known risk factors for psychiatric problems (Bradley et al., 2008; Jordan et al., 2010; Kessler et al., 1995). Moreover, gender differences in the prevalence and types of interpersonal violence exposure, such as women’s higher risk for rape and intimate partner violence, have been theorized to account, in part, for women’s greater risk for some mental health conditions (Herman, 1992; Kimerling, Ouimette, & Weitlauf, 2007). However, despite such research and theory, gender has yet to be explicitly examined as a moderator of the association between interpersonal violence and mental health outcomes in a large population-based sample. Understanding gender differences in the prevalence of different types of interpersonal violence exposure among women and men, and determining whether gender moderates the associations between interpersonal violence and mental health outcomes, is critical for developing targeted programs aimed at preventing health problems among all interpersonal violence victims. We addressed this gap in the literature in the current report using data from a U.S. national probability sample. First, we examined gender differences in the prevalence of a wide range of interpersonal violence exposures (i.e., physical assault by an intimate partner, rape, other sexual assault, stalking, physical assault, mugging, childhood physical abuse, kidnapping, and witnessing interparental violence). Second, we investigated the associations between the nine forms of interpersonal violence and lifetime mental health diagnoses and a history of attempted suicide after rigorous adjustment for potential cofounding variables. Third, we tested gender as a moderator of the association between interpersonal violence with lifetime mental health diagnoses and a history of attempted suicide in women and men to determine whether the associations between interpersonal violence and morbidity vary by gender.

SUMMARY A 105-year-old woman developed pemphigus foliaceus. She had been on fosinopril, an angiotensin-converting enzyme inhibitor (ACE inhibitor) for 4 years. Anti-intercellular cement substance antibodies were positive with titre > 160. She died during admission of an unrelated illness. A 57-year-old man developed pemphigus vulgaris after 11 months treatment with quinapril. At 14 months after developing pemphigus, this man continues on prednisone and azathioprine. We speculate that these are cases of ACE-inhibitor-related pemphigus and we review ACE-inhibitor-related pemphigus.

We report a case of photoallergic contact dermatitis to two sunscreen agents, methoxycinnamate and oxybenzone, occurring in a 6-year-old Asian boy.

We report on our experience with sunscreen allergy between 1992 and 1999 and also review the international literature on sunscreen allergy. There were a total of 21 allergic reactions to sunscreen chemicals observed in 19 patients over the 8 years. There were nine positive photopatch reactions to oxybenzone, eight to butyl methoxy dibenzoylmethane, three to methoxycinnamate and one to benzophenone. No positive reactions were observed to para aminobenzoic acid. Six patients also had positive patch tests to components of the sunscreen base. In our experience, sunscreen chemicals are the most common cause of photoallergic contact dermatitis.

Salt reabsorption is the major energy-requiring process in the kidney, and AMP-activated protein kinase (AMPK) is an important regulator of cellular metabolism. Mice with targeted deletion of the β1-subunit of AMPK (AMPK-β1−/− mice) had significantly increased urinary Na+ excretion on a normal salt diet. This was associated with reduced expression of the β-subunit of the epithelial Na+ channel (ENaC) and increased subapical tubular expression of kidney-specific Na+-K+-2Cl− cotransporter 2 (NKCC2) in the medullary thick ascending limb of Henle. AMPK-β1−/− mice fed a salt-deficient diet were able to conserve Na+, but renin secretion increased 180% compared with control mice. Cyclooxygenase-2 mRNA also increased in the kidney cortex, indicating greater signaling through the macula densa tubular salt-sensing pathway. To determine whether the increase in renin secretion was due to a change in regulation of fatty acid metabolism by AMPK, mice with a mutation of the inhibitory AMPK phosphosite in acetyl-CoA carboxylase 1 [ACC1-knockin (KI)S79A mice] were examined. ACC1-KIS79A mice on a normal salt diet had no increase in salt loss or renin secretion, and expression of NKCC2, Na+-Cl− cotransporter, and ENaC-β were similar to those in control mice. When mice were placed on a salt-deficient diet, however, renin secretion and cortical expression of cyclooxygenase-2 mRNA increased significantly in ACC1-KIS79A mice compared with control mice. In summary, our data suggest that renin synthesis and secretion are regulated by AMPK and coupled to metabolism by phosphorylation of ACC1.

The energy-sensing kinase AMP-activated protein kinase (AMPK) is associated with the sodium-potassium-chloride cotransporter NKCC2 in the kidney and phosphorylates it on a regulatory site in vitro. To identify a potential role for AMPK in salt sensing at the macula densa, we have used the murine macula densa cell line MMDD1. In this cell line, AMPK was rapidly activated by isosmolar low-salt conditions. In contrast to the known salt-sensing pathway in the macula densa, AMPK activation occurred in the presence of either low sodium or low chloride and was unaffected by inhibition of NKCC2 with bumetanide. Assays using recombinant AMPK demonstrated activation of an upstream kinase by isosmolar low salt. The specific calcium/calmodulin-dependent kinase kinase inhibitor STO-609 failed to suppress AMPK activation, suggesting that it was not part of the signal pathway. AMPK activation was associated with increased phosphorylation of the specific substrate acetyl-CoA carboxylase (ACC) at Ser79, as well as increased NKCC2 phosphorylation at Ser126. AMPK activation due to low salt concentrations was inhibited by an adenovirus construct encoding a kinase dead mutant of AMPK, leading to reduced ACC Ser79and NKCC2 Ser126phosphorylation. This work demonstrates that AMPK activation in macula densa-like cells occurs via isosmolar changes in sodium or chloride concentration, leading to phosphorylation of ACC and NKCC2. Phosphorylation of these substrates in vivo is predicted to increase intracellular chloride and so reduce the effect of salt restriction on tubuloglomerular feedback and renin secretion.

The renal-specific NKCC2 (Na+–K+–2Cl− co-transporter 2) is regulated by changes in phosphorylation state, however, the phosphorylation sites and kinases responsible have not been fully elucidated. In the present study, we demonstrate that the metabolic sensing kinase AMPK (AMP-activated protein kinase) phosphorylates NKCC2 on Ser126in vitro. Co-precipitation experiments indicated that there is a physical association between AMPK and the N-terminal cytoplasmic domain of NKCC2. Activation of AMPK in the MMDD1 (mouse macula densa-derived 1) cell line resulted in an increase in Ser126 phosphorylation in situ, suggesting that AMPK may phosphorylate NKCC2 in vivo. The functional significance of Ser126 phosphorylation was examined by mutating the serine residue to an alanine residue resulting in a marked reduction in co-transporter activity when exogenously expressed in Xenopus laevis oocytes under isotonic conditions. Under hypertonic conditions no significant change of activity was observed. Therefore the present study identifies a novel phosphorylation site that maintains NKCC2-mediated transport under isotonic or basal conditions. Moreover, the metabolic-sensing kinase, AMPK, is able to phosphorylate this site, potentially linking the cellular energy state with changes in co-transporter activity.

Background The introduction of evidence-based programs and practices into healthcare settings has been the subject of an increasing amount of research in recent years. While a number of studies have examined initial implementation efforts, less research has been conducted to determine what happens beyond that point. There is increasing recognition that the extent to which new programs are sustained is influenced by many different factors and that more needs to be known about just what these factors are and how they interact. To understand the current state of the research literature on sustainability, our team took stock of what is currently known in this area and identified areas in which further research would be particularly helpful. This paper reviews the methods that have been used, the types of outcomes that have been measured and reported, findings from studies that reported long-term implementation outcomes, and factors that have been identified as potential influences on the sustained use of new practices, programs, or interventions. We conclude with recommendations and considerations for future research. Methods Two coders identified 125 studies on sustainability that met eligibility criteria. An initial coding scheme was developed based on constructs identified in previous literature on implementation. Additional codes were generated deductively. Related constructs among factors were identified by consensus and collapsed under the general categories. Studies that described the extent to which programs or innovations were sustained were also categorized and summarized. Results Although "sustainability" was the term most commonly used in the literature to refer to what happened after initial implementation, not all the studies that were reviewed actually presented working definitions of the term. Most study designs were retrospective and naturalistic. Approximately half of the studies relied on self-reports to assess sustainability or elements that influence sustainability. Approximately half employed quantitative methodologies, and the remainder employed qualitative or mixed methodologies. Few studies that investigated sustainability outcomes employed rigorous methods of evaluation (e.g., objective evaluation, judgement of implementation quality or fidelity). Among those that did, a small number reported full sustainment or high fidelity. Very little research has examined the extent, nature, or impact of adaptations to the interventions or programs once implemented. Influences on sustainability included organizational context, capacity, processes, and factors related to the new program or practice themselves. Conclusions Clearer definitions and research that is guided by the conceptual literature on sustainability are critical to the development of the research in the area. Further efforts to characterize the phenomenon and the factors that influence it will enhance the quality of future research. Careful consideration must also be given to interactions among influences at multiple levels, as well as issues such as fidelity, modification, and changes in implementation over time. While prospective and experimental designs are needed, there is also an important role for qualitative research in efforts to understand the phenomenon, refine hypotheses, and develop strategies to promote sustainment.