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Certified registered nurse anesthetists (CRNAs) who are responsible for airway management, may lack adequate continuing education for emergency front of neck access (EFONA), an advanced skill necessary in situations when a patient cannot be intubated and cannot be oxygenated (CICO). The purpose of this study was to improve CRNA knowledge and confidence when performing a scalpel-bougie cricothyrotomy for EFONA in a CICO event through the implementation of a spaced learning intervention. Thirteen CRNAs at a 160-bed community hospital participated in a 3-week educational intervention. Week 1: online preintervention survey followed by an educational video. Week 2: video review and skills component practiced on a cricothyrotomy trainer. Week 3: skills component practiced on a cricothyrotomy trainer followed by postintervention survey. This was a single-arm study and Wilcoxon sign ranked tests and a paired t-test were utilized to monitor for change in CRNA knowledge, confidence, and skill in performing EFONA. Implementation of a 3-week spaced learning program for educating CRNAs to perform a scalpel-bougie cricothyrotomy significantly increased CRNA knowledge, confidence, and skill when performing EFONA. Utilizing a spaced learning program may therefore improve provider skills, resulting in optimized patient care during a CICO event, leading to improved patient safety and outcomes., Competing Interests: Name: Antoinette T. Padula, DNP, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Joy Elwell, DNP, FNP-BC, APRN, CNE, FAAN, FAANP Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Maria Madonick, DNAP, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Michael Wilhelm, DNP, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Don Boyd, PhD, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None, (Copyright © by the American Association of Nurse Anesthetists.)

This project sought to explore the experiences, self-perceived preparation, professional development needs, and preferred learning methods of certified registered nurse anesthetists (CRNAs) in a management role. A sample of 10 current chief CRNAs responded to a demographics survey and participated in one-on-one interviews using a 14-question, semi-structured interview framework modified from a previous study. Interview responses were deidentified and qualitatively analyzed for common themes by two content experts and one qualitative analysis expert. Results suggest that CRNAs entering the management field feel somewhat unprepared to perform the administrative tasks associated with their role. Qualitative analysis of interview responses elicited multiple key themes including interpersonal communication and handling crucial conversations, time and organizational management skills, team building and motivation, and financial management skills. Themes related to preferred learning methods of chief CRNAs included mentorship, peer networking, and experiential learning to obtain the required knowledge and skills for the role. The authors recommend incorporating each of the identified themes to guide development of CRNA management-specific educational programs. Establishing such a program will serve to better prepare aspiring CRNA managers and further develop the knowledge and skillset of current chief CRNAs., Competing Interests: Name: Austin L. Cole, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. He is the corresponding author for this article. Disclosures: None. Name: Virginia C. Simmons, DNP, CRNA, CHSE-A, FAANA, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Barbara S. Turner, PhD, RN, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Robert Whitehurst, MSN, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Denise H. Tola, DNP, CRNA, CHSE Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None, (Copyright © by the American Association of Nurse Anesthetists.)

Nitrogen source assimilation is important for the biological functions of fungi, and its pathway has been deeply studied. Aspergillus oryzae mutants defective in nitrogen source assimilation are known to grow poorly on Czapek-Dox (CD) medium. In this study, we found an industrial strain of A. oryzae that grew very poorly on a CD medium containing sodium nitrate as a nitrogen source. We used media with various nitrogen components to examine the steps affecting the nitrogen source assimilation pathway of this strain. The strain grew well on the CD medium supplied with nitrite salt or ammonium salt, suggesting that the strain was defective in nitrate assimilation step. To ascertain the gene causing the defect of nitrate assimilation, a gene expression vector harboring either niaD or crnA of A. oryzae RIB40 was introduced into the industrial strain. The industrial strain containing the crnA vector recovered its growth. This is the first report that a mutation of crnA causes poor growth on CD medium in an industrial strain of A. oryzae, and crnA can be used as a transformation marker for crnA deficient strains., (Copyright © 2024 The Society for Biotechnology, Japan. Published by Elsevier B.V. All rights reserved.)

Substance use disorder (SUD) is a persistent, relapsing condition that is present in approximately 10% of anesthesia providers, who, compared with other healthcare providers, face a greater risk of developing an SUD by virtue of constant access to medications. The ability of certified registered nurse anesthesiologists (CRNAs) to obtain or maintain employment after treatment for SUD treatment is not well documented. The purpose of this qualitative study was to explore challenges encountered by CRNAs in recovery as they attempt to reenter practice following SUD treatment. The phenomenon was explored through multiple-case study, using qualitative semistructured interviews with participants in four cases: CRNAs in recovery, CRNA colleagues, CRNA employers, and professional health program employees. Thirty-six participants conveyed their perspectives about challenges that CRNAs in recovery face upon reentry into practice following SUD treatment. The Worker Well-Being conceptual model was used to guide this study. The study revealed that more SUD education is a key facilitator for reentry, risk of relapse was a major concern, and stigma was the most significant barrier for CRNAs in recovery. Stigma persists as a considerable barrier in many facets of SUD, contributing to an increase in shame associated with having the disease., Competing Interests: Name: T’Anya Carter, PhD, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Nancy Wingo, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Susan McMullan, PhD, CRNA, CNE, CHSE, FAANA, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Gwen Childs, PhD, RN, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Bernadette Roche, EdD, CRNA, FAANA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Lisa J. Merlo, PhD, MPE Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Karen Heaton, PhD, COHN-S, FNP-BC, FAAN, FAAOHN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Disclosure statements are available upon request., (Copyright © by the American Association of Nurse Anesthetists.)

We evaluated the relationship between cost-related non-adherence (CRNA) and depressive symptoms. Pooling data from the 2015, 2016, 2018, and 2019 annual Canadian Community Health Survey, we analyzed the relationship between CRNA and moderate to severe depressive symptoms, assessed by the Patient Health Questionnaire (PHQ-9). Among the sample, 4.9% experienced CRNA and 6.8% experienced moderate to severe depressive symptoms. Respondents who reported CRNA had 1.51 (95% confidence interval [CI], 1.51-1.52) greater odds of experiencing moderate to severe depressive symptoms. Stratified analysis by sex and race showed the association between CRNA and depressive symptoms was greatest among racialized males (aOR: 1.83, 95% CI: 1.81- 1.85). Stratified analysis by sex and Indigeneity showed this association was greatest for Indigenous males (aOR: 2.16, 95% CI: 2.10-2.22). Forgoing prescribed medications due to cost is associated with more severe depressive symptoms among Canadians, particularly racialized and Indigenous males., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We sought to establish commercial rate benchmarks specific to certified registered nurse anesthetist (CRNA) anesthesia delivery models (QZ), quantify any payer disparities discovered between CRNAs and anesthesiologists, and determine payer alignment with nondiscrimination provisions of the Affordable Care Act (ACA). The Lewin Group administered the exploratory, descriptive study of QZ billing practices by surveying a targeted cross-section of 345 CRNAs known for QZ billing. Forty-one respondents reported information from 1,089 CRNAs and 351,920 cases with 127,888 commercial claims billed under 144 unique commercial contracts as performed in 2019. There was a 24% payer disparity in rates negotiated reported between anesthesia providers: CRNAs overall average of $58.62; $55.33-$64.57, compared with anesthesiologist average of $77.01 overall; $73.79-$80.76. Other findings included QZ payment adjustments, denials for reimbursement, and exclusion from plan participation. The study found disparities in rate and discriminatory payer practices specific to CRNA contracting and reimbursement, which suggests payer misalignment with nondiscrimination provisions of the ACA., Competing Interests: Name: Jean M. Covillo, DNAP, CRNA, APRN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Maria Sallie Poepsel, PhD, CRNA, APRN, FAANA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: B. Jeanie Skibiski, DNAP, MHA, CRNA, CPPS, FAANA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. She is the corresponding author of this article. Disclosures: None. The American Association of Nurse Anesthetists Foundation supported this work through a grant to Missouri State University School of Anesthesia., (Copyright © by the American Association of Nurse Anesthetists.)

Transitioning from the role of student to the professional certified registered nurse anesthetist (CRNA), as well as a CRNA transitioning to a new job can be very difficult because of uncertainty in the new environment when compounded by a lack of social support. A formal mentorship program was developed and organized by CRNA leadership to help retain and engage new employees and ensure that they assimilate to the new culture while effectively gaining institutional knowledge and clinical skills. The mentorship program consisted of structured meetings that included the newly hired cohort of CRNAs, matched mentors, and CRNA leadership at regular intervals to foster a sense of community and professional growth. The working definition of the mentorship process for this project was described as the following: a mentor, defined as an experienced CRNA, not a direct manager, meets with the mentee, a newly hired CRNA, on a regular basis following a predetermined timeline to assess and meet the mentee's goals, to provide resources, including networking, and to provide guidance for the mentee to make the best decisions for their professional and personal growth. The purpose of this project was to explain the potential benefits of implementing a formal mentorship program for recruiting, on-boarding, and retaining CRNAs., Competing Interests: Name: Shelly Anderson, MBA, MSNA, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

Purpose: The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements., Design: This quality improvement project was conducted using a pre- and postimplementation design., Methods: Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU)., Findings: Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%., Conclusions: Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes., (Copyright © 2023 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

This study examined the relationship between cognitive preference and clinical experience in student registered nurse anesthetists (SRNAs) and certified registered nurse anesthetists (CRNAs). Survey data was collected from enrolled SRNAs and practicing CRNAs via an email link distributive through a network sampling technique. Participants completed the Rational Experiential Inventory (REI-40), which assesses individuals' preference, ability, and engagement with rational and experiential cognitive styles. Data analysis revealed that SRNAs and CRNAs have the ability and engagement preference for rational decision-making. Furthermore, there was no statistical significance in years of clinical experience to cognitive preference, nor was there a statistically significant difference between SRNA and CRNA REI-40 Inventory results. Based on these findings, the dominant cognitive preference is rational cognition and experiential thinking preference remains constant with increased experience. This knowledge contributes to our understanding of CRNAs' decision-making related to cognitive processes and provides insight into SRNA clinical education and CRNA continuing development., Competing Interests: Name: Thomas A. Diller, PhD, MSN, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Lisa Haddad, PhD, RN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Sharon E. Bigger, Ph.D, MA, RN, CHPN, CNE Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Teresa Carnevale, PhD, RN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Linda Hill, DNSc, DNP, CRNA, FAANA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Vallire Hooper, PhD, RN, CPAN, FASPAN, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None, (Copyright © by the American Association of Nurse Anesthetists.)

Background: Nurse anesthesia in California has been instrumental in shaping Certified Registered Nurse Anesthetist (CRNA) practice nationally, but to date, no workforce data has been published on this group of Advanced Practice Registered Nurses., Purpose: The purpose of this workforce study was to explore the demographic information, education, and practice patterns of CRNAs working in California., Methods: Survey methodology was conducted to gather workforce data from a sample of licensed CRNAs working in California., Discussion: California CRNAs provide anesthesia services in very diverse settings among different anesthesia delivery models, including independent practice. CRNAs practice in a majority of California counties and are the sole anesthesia providers for four underserved counties., Conclusion: The CRNA workforce in California is comparatively young, highly educated, and desires more education. CRNAs improve access to care for California patients; however, more ethnically diverse CRNAs and CRNAs with Non-Surgical Pain Management Certification are needed., Competing Interests: Declaration of Competing Interest Sarah E. Giron and Sandra K. Bordi do not have any conflicts of interest as it pertains to this study. The authors have no affiliations with or involvement in any organization or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Anesthesia delivery models have long been shaped by workforce trends, state and federal regulations, economic incentives driven by reimbursement, and the normative preferences of provider and facility organizations. In recent years, there has been a significant shift toward greater use of more efficient certified registered nurse anesthetist (CRNA)-oriented delivery models observed at the national level Medicare data. However, given the wide range of these factors across states and regions, this shift has likely occurred at an uneven pace. This study analyzes the influence of provider workforce composition and CRNA scope of practice (SOP) regulations on usage of competing types of anesthesia delivery models, including anesthesiologist alone, care team, and undirected CRNA models. Results show that over the period from 2010-2019, anesthesia delivery models utilized under Medicare Part B have become increasingly oriented around the use of CRNAs. However, increases in the care team vs undirected CRNA model are highly uneven and inconsistent across states, even after adjusting for workforce and SOP. Speculation on additional normative or organization-driven reasons for persistent use of inefficient delivery models in some places is offered., Competing Interests: Name: Ruby L. Hoyem, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Lorraine Jordan, PhD, CRNA, CAE, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Valentina V. Lukyanova, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Trinidad Legaspi, JD, LLM Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access ( P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future., Competing Interests: Name: Lapio Tkach, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Laura Baillie, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Jamison Newby, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Crystal O'Guin, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Carrie Bowman Dalley, PhD, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Nancy Crowell, PhD Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None Name: Ladan Eshkevari, PhD, CRNA, LAc, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; she is the senior and corresponding author of this article. Disclosures: None. The authors did not discuss off-label use within the article. Disclosure statements are available upon request., (Copyright © by the American Association of Nurse Anesthetists.)

The transition from classroom academic environment to clinical patient-focused learning is a celebrated milestone, yet it is a source of stress and anxiety for student registered nurse anesthetists (SRNAs). In nurse anesthesia education, limited information exists on perceptions of clinical readiness, either from the certified registered nurse anesthetist (CRNA) clinical educators' or the SRNAs' experiences. The purpose of this study was to explore the perceptions of CRNA clinical coordinators and SRNAs regarding clinical readiness as the students transition from classroom to clinical training. A qualitative descriptive design from a postpositivist philosophical mindset was utilized and a semistructured interview guide and content analysis methodology described by Graneheim and Lundman was used. Seventeen participants were interviewed. Four themes emerged from the analysis of the CRNA clinical coordinators' perceptions: 1) going in with good attitudes and professionalism, 2) the expectation of clinical readiness, 3) mental preparedness, and 4) solid simulation experiences. Additionally, four themes emerged from the content analysis of students' perception: 1) expectations of readiness is higher than anticipated, 2) transitional orientation/adjuncts for preparedness, 3) sound didactic training, and 4) simulation and the effects of COVID-19. While prioritization is different, educators and SRNAs value knowledge, skills (including simulated), and positive attitudes as measures of clinical readiness., Competing Interests: Name: Tito D. Tubog, PhD, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Scott K. Shaffer, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Terri D. Kane, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Jennifer D. Hestand, EdD, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

Unlike some other high-income counties, Canada does not provide universal prescription drug coverage. The various extent of coverage may left some Canadians vulnerable to cost-related non-adherence (CRNA) to medications. Using data from the 2015 national cycle of the Canadian Community Health Survey, we examine the impact of having private and public drug coverage on mitigating the risk of CRNA with a logit model and a Heckman selection model. CRNA was only observed in respondents who had prescriptions to fill, and respondents did not randomly make decisions on whether to get a prescription. This results in a classic sample selection problem. We found a higher estimated probability of reporting CRNA for uninsured respondents from the Heckman selection model than from the logit model. Respondents with government coverage only had a slightly higher probability of reporting CRNA relative to respondents with private coverage. These findings suggest that, without accounting for sample selection, the risk of not having drug insurance coverage is likely to be underestimated. Moreover, despite covering a less healthy cohort of respondents, the government insurance plans reduce risk of CRNA to a comparable level with private insurance., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Zhang, Laporte. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

RNA duplexes are relatively rare but play very important biological roles. As an end-product of template-based RNA replication, they also have key implications for hypothetical primitive forms of life. Unless they are specifically separated by enzymes, these duplexes denature upon a temperature increase. However, mechanistic and kinetic aspects of RNA (and DNA) duplex thermal denaturation remain unclear at the microscopic level. We propose an in silico strategy that probes the thermal denaturation of RNA duplexes and allows for an extensive conformational space exploration along a wide temperature range with atomistic precision. We show that this approach first accounts for the strong sequence and length dependence of the duplexes melting temperature, reproducing the trends seen in the experiments and predicted by nearest-neighbor models. The simulations are then instrumental at providing a molecular picture of the temperature-induced strand separation. The textbook canonical "all-or-nothing" two-state model, very much inspired by the protein folding mechanism, can be nuanced. We demonstrate that a temperature increase leads to significantly distorted but stable structures with extensive base-fraying at the extremities, and that the fully formed duplexes typically do not form around melting. The duplex separation therefore appears as much more gradual than commonly thought.

2'-Amino-locked nucleic acid has a functionalizable nitrogen atom at the 2'-position of its furanose ring that can provide desired properties to a nucleic acid as a scaffold. In this study, we synthesized a novel nucleic acid, 2'-N-methanesulfonyl-2'-amino-locked nucleic acid (ALNA[Ms]) and conducted comparative studies on the physical and pharmacological properties of the ALNA[Ms] and on conventional nucleic acids, such as 2'-methylamino-LNA (ALNA[Me]), which is a classical 2'-amino-LNA derivative, and also on 2',4'-BNA/LNA (LNA). ALNA[Ms] oligomers exhibited binding affinities for the complementary RNA strand that are similar to those of conventional nucleic acids. Four types of ALNA[Ms] nucleosides exhibited no genotoxicity in bacterial reverse mutation assays. The knockdown abilities of Malat1 RNA using the Matat1 antisense oligonucleotide (ASO) containing ALNA[Ms] were higher than those of ALNA[Me] and were closer to those of LNA. Furthermore, the ASO containing ALNA[Ms] showed different tissue tropism from that containing LNA. ALNA[Ms] exhibited biological activities that were distinct from conventional constrained nucleic acids, suggesting the possibility that ALNA[Ms] can serve as novel modified nucleic acids in oligonucleotide therapeutics., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Genetic testing for inherited arrhythmias and discriminating pathogenic or benign variants from variants of unknown significance (VUS) is essential for gene-based medicine. KCNQ1 is a causative gene of type 1 long QT syndrome (LQTS), and approximately 30% of the variants found in type 1 LQTS are classified as VUS. We studied the role of zebrafish cardiac arrhythmia model in determining the clinical significance of KCNQ1 variants. We generated homozygous kcnq1 deletion zebrafish (kcnq1 del/del ) using the CRISPR/Cas9 and expressed human Kv7.1/MinK channels in kcnq1 del/del embryos. We dissected the hearts from the thorax at 48 h post-fertilization and measured the transmembrane potential of the ventricle in the zebrafish heart. Action potential duration was calculated as the time interval between peak maximum upstroke velocity and 90% repolarization (APD90). The APD90 of kcnq1 del/del embryos was 280 ± 47 ms, which was significantly shortened by injecting KCNQ1 wild-type (WT) cRNA and KCNE1 cRNA (168 ± 26 ms, P < 0.01 vs. kcnq1 del/del ). A study of two pathogenic variants (S277L and T587M) and one VUS (R451Q) associated with clinically definite LQTS showed that the APD90 of kcnq1 del/del embryos with these mutant Kv7.1/MinK channels was significantly longer than that of Kv7.1 WT/MinK channels. Given the functional results of the zebrafish model, R451Q could be reevaluated physiologically from VUS to likely pathogenic. In conclusion, functional analysis using in vivo zebrafish cardiac arrhythmia model can be useful for determining the pathogenicity of loss-of-function variants in patients with LQTS., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The replication of viral hemorrhagic septicemia virus (VHSV) in appropriate host cells depends on environmental factors and the host cell's immunity. The dynamics of each VHSV RNA strand (vRNA, cRNA, and mRNA) in different conditions can provide a clue on the viral replication strategies, which can be a base for the development of efficient control measures. As VHSV is known to be sensitive to temperature and type I interferon (IFN) responses, in this study, we analyzed the effect of temperature difference (15 °C and 20 °C) and IRF-9 gene knockout on the dynamics of the three VHSV RNA strands in Epithelioma papulosum cyprini (EPC) cells using a strand-specific RT-qPCR. The tagged primers designed in this study successfully worked to quantify the three strands of VHSV. In the results of the temperature effect, the higher speed in viral mRNA transcription and the significantly higher (more than 10 times at 12-36 h) copy number of cRNA at 20 °C compared to those at 15 °C suggested the positive effect of high temperature on VHSV replication. In the results of the IRF-9 gene knockout effect, although IRF-9 gene knockout did not bring a dramatic effect on VHSV replication compared to the temperature effect, the increase of mRNA in IRF-9 KO cells was faster than normal EPC cells, which was reflected in the copy numbers of cRNA and vRNA. The IRF-9 gene knockout effect was not dramatic even in the replication of rVHSV-ΔNV-eGFP that harbors eGFP gene ORF instead of NV gene ORF. These results suggest that VHSV may be highly susceptible to pre-activated type I IFN responses but not highly susceptible to post-infection-mediated type I IFN responses or lowered type I IFN before infection. In both experiments of temperature effect and IRF-9 gene knockout effect, the copy number of cRNA never exceeded the copy number of vRNA at all assay times, suggesting that the binding efficiency of the RNP complex to the 3' end of cRNA might be lower than that to the 3' end of vRNA. Further research is needed to elucidate the regulatory mechanism that limits the amount of cRNA at an appropriate level during VHSV replication., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

The clinical learning environment is essential for student registered nurse anesthetists (SRNAs) to develop intricate clinical knowledge and acquire proficiency in technical skills required for anesthetic care. The perioperative experience of an SRNA can differ greatly based on the program, preceptor, hospital rotation, or geographic location. This literature review synthesizes the historical and current state of certified registered nurse anesthetist (CRNA)/SRNA preceptorship in the clinical setting. Themes analyzed include the current CRNA/SRNA learning and teaching environment, student perceptions of effective CRNA preceptors, evaluation tools and feedback practices, and overall CRNA preceptor preparedness as well as the availability and effectiveness of preceptor training programs. We compare their findings to best practices seen in the United States Air Force (USAF) pilot training program because of its similar "high stakes" learning environment and utilization of a preceptor teaching model. Actionable recommendations, based on CRNA preceptorship data, preceptorship theory, and the USAF pilot training model are presented in the effort to improve preceptor transfer of knowledge and SRNA clinical competence., Competing Interests: Name: Logan MacLean, CRNA, DNP Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Julie Fairman, RN, PhD, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: Current funding: RWJF Future of Nursing Scholars Program., (Copyright © by the American Association of Nurse Anesthetists.)

Boron cluster-conjugated antisense oligonucleotides (B-ASOs) have already been developed as therapeutic agents with "two faces", namely as potential antisense inhibitors of gene expression and as boron carriers for boron neutron capture therapy (BNCT). The previously observed high antisense activity of some B-ASOs targeting the epidermal growth factor receptor (EGFR) could not be rationally assigned to the positioning of the boron cluster unit: 1,2-dicarba- closo -dodecaborane (0), [(3,3'-Iron-1,2,1',2'-dicarbollide) (1-), FESAN], and dodecaborate (2-) in the ASO chain and its structure or charge. For further understanding of this observation, we performed systematic studies on the efficiency of RNase H against a series of B-ASOs models. The results of kinetic analysis showed that pyrimidine-enriched B-ASO oligomers activated RNase H more efficiently than non-modified ASO. The presence of a single FESAN unit at a specific position of the B-ASO increased the kinetics of enzymatic hydrolysis of complementary RNA more than 30-fold compared with unmodified duplex ASO/RNA. Moreover, the rate of RNA hydrolysis enhanced with the increase in the negative charge of the boron cluster in the B-ASO chain. In conclusion, a "smart" strategy using ASOs conjugated with boron clusters is a milestone for the development of more efficient antisense therapeutic nucleic acids as inhibitors of gene expression.

The insect nicotinic acetylcholine receptor (nAChR) is a pentameric channel protein and also a target for neonicotinoids. There are few reported studies on the molecular interactions of Leptinotarsa decemlineata nAChRs with neonicotinoids. In this study, we analyzed the response of acetylcholine and neonicotinoids (thiamethoxam [TMX], imidacloprid [IMI], and clothianidin [CLO]) on hybrid receptors constructed by nAChR α1 and α8 subunits of L. decemlineata (Ldα1 and Ldα8) co-expressed with rat β2 subunit (rβ2) at different capped RNA (cRNA) ratios in Xenopus oocytes. In addition, we evaluated the expression changes of Ldα1 and Ldα8 after median lethal dose of TMX treatment for 72 h by quantitative polymerase chain reaction (qPCR). The resulting functional nAChRs Ldα1/rβ2 and Ldα1/Ldα8/rβ2 showed different pharmacological characteristics. The neonicotinoids tested showed lower agonist affinity on Ldα1/Ldα8/rβ2 compared to Ldα1/rβ2 at same ratios of subunit cRNAs. The sensitivities of neonicotinoids tested for Ldα1/rβ2 and Ldα1/Ldα8/rβ2 at cRNA ratios of 5:1, 1:1 and 5:5:1, 1:1:1, respectively, were lower than those for nAChRs at ratios of 1:5 and 1:1:5, respectively, whereas the values of maximum response (I max ) varied. For Ldα1/Ldα8/rβ2, a reduction of Lda8 cRNA resulted in increased sensitivity to IMI and decreased sensitivity to TMX. The expression of Ldα1 and Ldα8 significantly decreased in adults by 82.12% and 47.02%, respectively, while Ldα8 was significantly upregulated by 2.44 times in 4th instar larvae after exposure to TMX. We infer that Ldα1 and Ldα8 together play an important role in the sensitivity of L. decemlineata to neonicotinoids., (© 2022 Institute of Zoology, Chinese Academy of Sciences.)

COVID-19 has a strong hold on New York City, and it has similar effects on other areas of the country. As COVID-19 strains healthcare systems and the certified registered nurse anesthetists (CRNAs) who work within them, optimization of CRNA organizational climate promotes transformation of care delivery and may positively impact provider and patient outcomes. This article describes one healthcare system's newly refined processes for managing the surge of COVID-19 patients. It also describes the novel contributions of CRNAs to all aspects of care provision from supply and resource management to management of patients in critical care environments, to refinement of intubation and airway management for this patient population. Lessons learned during this pandemic from two facilities within this healthcare system are described. When a healthcare system's culture respects and encourages collaboration and innovation, dynamic changes can be implemented effectively during times of crises. Also, critically helpful is when CRNA organizational climate promotes equal partnerships with physicians, and administration values the CRNA contributions to care. In this case, collaboration of all stakeholders promoted best practices and improved care provision. Lessons learned may be applied to facilities where the COVID-19 surge is occurring., Competing Interests: Name: Donald Boyd, PhD, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author; he is the principal author of this article Disclosures: None. Name: Margaret Meenan, MS, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

Some of the emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants are less susceptible to neutralization with post-vaccine sera and monoclonal antibodies targeting the viral spike glycoprotein. This raises concerns of disease control, transmissibility, and severity. Numerous substitutions have been identified to increase viral fitness within the nucleocapsid and nonstructural proteins, in addition to spike mutations. Therefore, we sought to generate infectious viruses carrying only the variant-specific spike mutations in an identical backbone to evaluate the impact of spike and non-spike mutations in the virus life cycle. We used en passant mutagenesis to generate recombinant viruses carrying spike mutations of B.1 and B.1.617.2 variants using SARS-CoV-2- bacterial artificial chromosome (BAC). Neutralization assays using clinical sera yielded comparable results between recombinant viruses and corresponding clinical isolates. Non-spike mutations for both variants neither seemed to effect neutralization efficiencies with monoclonal antibodies nor the response to treatment with inhibitors. However, live-cell imaging and microscopy revealed differences, such as persisting syncytia and pronounced cytopathic effect formation, as well as their progression between BAC-derived viruses and clinical isolates in human lung epithelial cell lines and primary bronchial epithelial cells. Complementary RNA analyses further suggested a potential role of non-spike mutations in infection kinetics.

Purpose: This study estimates the frequency of uninsurance for prescription drugs and cost-related medication nonadherence (CRNA) among lesbian, gay, and bisexual (LGB) persons in Canada, compared with the heterosexual population. Methods: Logistic regression was used to quantify associations between sexual orientation, insurance status, and CRNA within the national probability-based Canadian Community Health Survey, 2015-2016. This sample included 98,413 individuals aged 15-80 years, including 2803 LGB individuals. Results: From our sample of Canadians, 22.2% of LGB respondents reported being uninsured for prescription drugs, compared with 20.0% of heterosexual persons (unadjusted odds ratio [UOR] 1.14, 95% confidence interval [CI] 0.97-1.35). LGB individuals had more than twice the odds of reporting CRNA compared with heterosexual individuals (UOR 2.48, 95% CI 1.99-3.10). This disparity was most pronounced among bisexual respondents, who had over three times the odds of reporting CRNA in comparison to heterosexual respondents (UOR 3.45, 95% CI 2.65-4.51). The odds ratio (OR) for CRNA comparing bisexual with heterosexual individuals remained statistically significant after adjustment for race/ethnicity, gender/sex, and age (OR 2.67, 95% CI 1.97-3.61) and was further attenuated with adjustment for partnership status, employment status, income, educational attainment, prescription drug insurance status, general health status, and immigration status (OR 2.09, 95% CI 1.51-2.89). Conclusion: LGB Canadians reported more CRNA but comparable prescription drug insurance frequencies to heterosexual persons. Factors pertaining to medication access (e.g., income, partnership status) and health needs appear to be the most important contributors to disparities.

The purpose of this study was to evaluate certified registered nurse anesthetist (CRNA) current pediatric atropine dosing practices. Emphasis was placed on rationale for dosing and knowledge regarding current literature and guidelines. An electronic survey was deployed by the American Association of Nurse Anesthetists (AANA)'s survey department to a total of 2,905 CRNAs who are current AANA members. The survey was completed by 98 CRNAs, of which 67 selected that they do not administer anesthesia to pediatric patients weighing less than 5 kg and were excluded from further survey participation. The responses from the remaining 31 CRNAs were utilized for data analysis (n = 31). Approximately two thirds of participants (64.5%) were unaware of available guidelines pertaining to pediatric dosing of atropine within the last 5 years. A statistically significant difference existed when analyzing whether awareness of guidelines was associated with knowledge of the correct American Heart Association recommended pediatric atropine dose. Providers who were aware of guidelines reported the correct dose 100% of the time, whereas those unaware of guidelines reported the correct dose only 65% of the time ( P = .03). Variability in clinical practices and sources guiding practice should be addressed to avoid potential overdosing in the vulnerable neonatal population., Competing Interests: Name: Anna Thai, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and editing of the manuscript to justify inclusion as an author. Disclosures: None. Name: Chelsea Varner, DNAP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and editing of the manuscript to justify inclusion as an author. Disclosures: None. Name: Crystal O'Guin, DNP, CRNA Contribution: This author made significant contributions to the conception, synthesis, writing, and editing of the manuscript to justify inclusion as an author. Disclosures: None. Name: Kumudhini Hendrix, MD Contribution: This author made significant contributions to the conception, synthesis, writing, and editing of the manuscript to justify inclusion as an author. Disclosures: None. Name: Ladan Eshkevari, PhD, CRNA, FAAN Contribution: This author made significant contributions to the conception, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author and is the senior author of the article. Disclosures: None., (Copyright © by the American Association of Nurse Anesthetists.)

Introduction: Operating room (OR) management plays a pivotal role in the healthcare system due to the high cash flow it yields. Enhancing communication in the OR, which is the common root problem for delays, might improve OR efficiency and revenues for healthcare. This study aims to evaluate the impact of an OR relay strategy on turnover time (TOT)., Methods: A quality improvement project was conducted. In the intervention group, a certified registered nurse anaesthetist (CRNA) remained outside of the OR, coordinating the steps to get the next patient ready. This CRNA communicated with the anaesthesia providers within the OR via a Microsoft Team chat. The TOT for the control group was recorded from the electronic anaesthesia record system., Results/data Analysis: Analysis of 636 turnovers was performed with non-parametric tests. The OR relay strategy decreased TOT for most ORs, with statistically significant results for three of the ORs and the overall ORs system. A decreased in variability between TOTs was evidenced for the overall OR and the majority of the ORs evaluated individually., Conclusion: The OR relay strategy has a positive impact on TOT., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)