The advances in high-throughput sequencing (HTS) technologies and bioinformatic tools have provided new opportunities for virus and viroid discovery and diagnostics. Hence, new sequences of viral origin are being discovered and published at a previously unseen rate. Therefore, a collective effort was undertaken to write and propose a framework for prioritizing the biological characterization steps needed after discovering a new plant virus to evaluate its impact at different levels. Even though the proposed approach was widely used, a revision of these guidelines was prepared to consider virus discovery and characterization trends and integrate novel approaches and tools recently published or under development. This updated framework is more adapted to the current rate of virus discovery and provides an improved prioritization for filling knowledge and data gaps. It consists of four distinct steps adapted to include a multi-stakeholder feedback loop. Key improvements include better prioritization and organization of the various steps, earlier data sharing among researchers and involved stakeholders, public database screening, and exploitation of genomic information to predict biological properties. Advances in high-throughput sequencing (HTS) technologies and bioinformatic analyses have created new opportunities for the discovery and unbiased diagnosis of plant viruses and viroids (together referred to hereafter as viruses) . This exA collective framework was published in 2017 to address the difficulties in assessing risks that these novel detections might pose. The framework aimed to suggest guidelines for researchers, policymakers, plant health authorities, and plant inspection services. It proposed an approach for prioritizing the biological characterization steps for newly identified plant viruses and evaluating their impact at biosecurity, commercial, regulatory and scientific levels . The firThis framework was widely used to guide the characterization of newly identified plant viruses. However, recent reviews have shown that there is rarely a follow-up after the first report of novel viruses except for viruses that cause an immediate and obvious threat to production. Another publication by Rivarez et al. analyzed 53 published discovery and post-discovery studies on novel tomato viruses for the 2011–2020 period. It assessed how the framework by Massart et al. was fulfilled after the initial discovery . In mostPoaceae was performed. The analysis is summarized in Poaceae infecting viruses respectively, while for fruit tree viruses, they were mentioned in only 18 and 11% of cases and for tomato viruses in approximately 30 and 40%, respectively.Here, a similar analysis for 28 publications reporting 42 novel viruses identified by HTS in These three studies exemplify the exponential growth in plant viruses’ discovery due to HTS and the scarcity of biological characterization efforts for the identified novel viruses. The probable reasons for such an observation are the extended time and resources required for characterization experiments, including host range testing, large-scale surveys, and the technical difficulty of working with novel viruses for which little or no information is available. Nevertheless, there are some exceptions. For example, chestnut mosaic virus (ChMV) was identified by HTS technologies in symptomatic plants and was proposed as the potential causal agent of chestnut mosaic disease (ChMD). After obtaining a complete genome sequence from two chestnut disease sources, the genomes of ChMV were used to determine the phylogenetic relationships with other badnaviruses. New isolates were identified from publicly available chestnut HTS data. Incidence and genetic variability of ChMV were studied using samples from France and Italy . AnotherData on the geographic distribution, incidence, severity, symptomatology, host range, transmission mode, and genetic diversity of these novel viruses are necessary to support a proper risk assessment. Therefore, the previous framework is revised here to adapt it to the current rate of virus discovery through HTS, and add clarity on the prioritization of knowledge gaps . FurtherData-driven virus discovery through scanning of large public sequencing datasets is a major recent development. Re-examining existing datasets for the presence of known and novel viruses has become accessible for virologists, through new web-based platforms like SerratusIn a short timeframe, these revolutionary high-throughput sequencing and data-driven approaches have extended the need to reconsider and adapt the current framework through a multi-stakeholder consultation. We thus propose an improved and adapted framework for plant health stakeholders, which could include researchers, policymakers, plant health authorities [also referred to as National Plant Protection Organizations (NPPOs)], plant inspection services, funding bodies, grower associations, technical extension services, seed traders, and breeding companies. It details the prioritization process to be followed for novel plant viruses and viroids identified by HTS technologies or datamining of HTS datasets.1.Importantly, international guidelines were proposed to improve the reliability of data generation by HTS technologies and their analysis by bioinformatics pipelines. These guidelines are generic and do not depend on the plant pest or pathogen being detected, sequencing protocol, or platform. These guidelines are advised to be implemented when applying HTS tests to detect viruses, whatever protocol is selected .In selected cases, the complete genome sequence is not obtained because of insufficient coverage (low read numbers), which can also depend on the library preparation protocol , double-stranded RNA (dsRNA), small interfering RNA (siRNA), and total DNA with or without rolling circle amplification (RCA))  and the Closteroviridae, ICTV advises using RdRp, CP and HSP70h (70 kDA heat shock protein homolog) amino acid sequences to distinguish viral species  to evaluate if the assembled sequence belongs to a recognized species or to a new one. Even if the assembled genome lacks the UTRs or still has some gaps, the taxonomical position can still often be predicted . Further species .Partitiviridae includes viruses that can infect plants, fungi, or protozoa  could also help in verifying the taxonomic assignment of the virus. It is possible that generic primers are not available or fail to amplify the novel virus, which can be because there are mismatches between the primer and the sequence to amplify, meaning that there will be a need to develop a more specific diagnostic tool that can detect the novel virus . The obtTenuivirus have almost complementary 3′ and 5′ genome ends  for caulimoviruses or endogenous geminivirus-like (EGV) elements for geminiviruses) and/or as episomal forms that are contagious and can cause pathogenic infections . However, one should keep in mind that extrapolating the biological properties of a novel virus based on the viruses in the same taxa is associated with significant uncertainties.2Tm-2 confers resistance against several tobamoviruses in tomatoes, but it does not protect against the newly discovered tomato brown rugose fruit virus (ToBRFV)  the putative modes of vertical and horizontal transmission and candidate vectors, if any, to assess the potential spread of the disease ; (ii) th(ToBRFV) .Tenuivirus are transmitted by a particular planthopper species, except maize yellow stripe virus (MYSV) that is transmitted by leafhoppers (Geminiviridae can be transmitted by whiteflies (Begomovirus genus), by leafhoppers , by aphids (genus Capulavirus), or by treehoppers (genera Topocuvirus and Grablovirus)  . Differelovirus) , althouglovirus) .The information gathered from this bibliographical research will assist in elaborating possible epidemiological scenarios and hypotheses, from which further investigation on the host and vector range can be defined. This information can also help in formulating provisional tentative control measures included in the first notification to regulatory authorities, risk managers and other stakeholders. However, as mentioned before, this information is extrapolated from that of related viruses and should therefore be treated with caution.2.2.At this stage and to assist the risk assessment process, as much information as possible, whenever possible, should be collected regarding the original sample (or pool of samples) where the novel virus was detected. This includes the plant species and cultivar, sample accession number, description of the symptoms observed at the time of sampling, plant tissue collected, the viral status of the neighboring plants (if known either by onsite testing or from previous records), the incidence in the affected crop, other crops affected, recent meteorological conditions, sample collection date, geographical origin of the sample with specific map coordinates, and growth conditions of the plants . Collect2.3.Communication between stakeholders and the scientific community is essential for a quick decision-making process. Pre-publication data sharing between research groups that independently detected the novel virus is highly encouraged, because it can provide valuable information on the presence, distribution, host range, and impact of the novel virus . For exa2.4.In animal virology, many publications used machine learning approaches on databases of genomic features and biological properties from known viruses to predict the taxonomy or key biological properties of new viruses, such as host range and vector. Most of these approaches focus on nucleotide features like CG bias, CpG bias, di-codon, or dinucleotide bias . For exaRecent research used an original approach to identify new proteomic features potentially involved in plant virus-vector transmission, i.e., intrinsically disordered proteins/regions, and to understand how their biophysical properties and regulation might arise from these interactions . As a reThis opens a new focus for predicting the biological properties of the new plant virus from in-depth structural and functional analyses of protein sequences.Nevertheless, interpreting all these features and results should still currently be done with much caution, given the uncertainty attached to such predictions and the sometimes limited accuracy of these databases. In the future, integrating these powerful emerging approaches to the framework could represent a significant step toward gathering relevant biological predictions from a genomic sequence. Therefore, it might ultimately support regulatory and phytosanitary decisions linked to discovering novel viruses.2.5.Valuable information can be gained by screening public databases of HTS data, such as the SRA of GenBankThe recent development of a practical and user-friendly web-based interface called Serratus  represenThe palmID search tool allows finding the palmprint sequence within the provided RdRp and match it, with a minimal threshold of pairwise identity, to palmprint sequences in the palmprint database. The palmprint OTU is necessary to avoid heavy computational requirements, although it lowers the confidence in the results, thus only giving hints to the presence of the target virus, which needs further validation. Thus, the sequencing reads of the identified SRA dataset should be reanalyzed using existing bioinformatic approaches to confirm the presence of the virus of interest. Nevertheless, Serratus has some limitations, mainly when the virus of interest is not detected from public SRA datasets. Even in case of detection, the verification step (assembly and mapping) is time-consuming and a computational burden, and sometimes inefficient, depending for example on virus representation and on sample identity . Another limitation is the potential misassignment of the host, in particular when the new finding involves a metagenomic dataset with unexpected virome content . In addition, metadata information such as the host or the country of origin of the sequenced material should also be investigated, keeping in mind that the metadata may not be accurate. If biological material is still available, contacting the authors may allow the confirmation of the detection. It should be stressed that there could also be some implications for trade and related policies when relying on SRA mining for reporting the detection of pathogens in a country where it is not currently known to be present. In such a case, the conduct of confirmatory tests in the wet lab should be encouraged and given a very high priority. The ethics of reporting the presence of a pathogen in a territory without prior notification to its NPPO should also be considered. Whenever possible, it is advised to contact the dataset’s original authors and notify the country’s NPPO before the publication of a new country record.2.6.Based on the studies described in steps 2.1 to 2.5, researchers should have a better idea of whether a newly identified virus might threaten plant health and whether the new finding(s) should be reported to other stakeholders. However, it is crucial not to overburden relevant stakeholders with non-relevant information that might raise unnecessary concerns. For example, the detection of a plant virus, belonging to a family of pathogenic viruses with high horizontal transmission rates, on a sample of a critical crop should be communicated as soon as possible to the NPPO. In contrast, detecting a partitiviridae in an asymptomatic wild plant has lower significance and, therefore, priority. The participation of plant virology experts is therefore crucial at this stage to support well-informed decision making. As mentioned before, when a virus is considered a potential threat to plant health, researchers should report the finding to the relevant NPPO, engage in discussions with risk managers and assist them in efforts to determine if the novel virus should be considered a priority, and whether immediate action  or specific management measures  should be taken and to evaluate whether further research is needed. Given the potential impact of the management decision taken by the NPPO, the uncertainties associated with the discovery of the novel virus and its potential impacts should be highlighted in a transparent fashion.Further on, if the NPPO analysis confirms the potential threat following consultations, the main challenge for scientists is to efficiently characterize the biological properties through short, mid- and long-term strategies. This is while creating appropriate communication channels with the regulatory authorities and other stakeholders including grower associations, technical extension centers, or seed companies .3.3.1.After the first notification to the regulatory agencies, if a novel virus is considered a priority or has potential risks, further evaluation of the association between symptoms and virus presence must be carried out via field surveys or greenhouse assays. Field surveys and greenhouse assays can provide helpful information regarding symptomatology, infectivity, causal association, virus genetic diversity, geographic distribution, incidence, host range, transmission mode, and disease severity, as discussed in step 4. Nevertheless, at this stage, it is essential to focus the survey’s aim and assays on the symptom(s) causation issue if the novel virus is considered a priority. These efforts should not be hindered by those toward the completion of previous steps, since obtaining a complete genome sequence might be time-consuming and could delay the needed surveys or assay actions.In conventional plant pathology approaches, when trying to establish a causal association between a disease and a pathogen, causation is demonstrated by isolating the putative pathogenic agent and subjecting it to the experimental demonstration of Koch’s postulates . NeverthIn recent years, there has been an ongoing discussion among researchers to find possible alternative and systematic approaches that overcome the limitations of Koch’s postulates in plant virology . These e3.2.Surveys at small- and/or large scales allow a better understanding of the key factors associated with a disease. These epidemiological field surveys should include both symptomatic and asymptomatic plants since an asymptomatic individual could be in the incubation or latent phase at the time of sampling. In field surveys, caution should be taken in generating and analyzing data on the virus variability to ensure that the viral populations in crops and weeds are sufficiently similar to support the hypothesis of the role of weeds as a potential reservoir. Neighboring plants from the same or different species that present similar symptoms may also be tested for presence or absence of the novel virus, without the need for viral enrichment extraction protocols, and instead using commercial extraction kits or even crude extracts . Because3.3.Greenhouse assays are commonly used to assess symptom causality and symptomatology. Since mixed infection can occur in the source material, working on single viral species during greenhouse assays is essential. In many cases, particularly with graft inoculation, these techniques cannot separate viruses in a mixed infection. One solution to this limitation is the use of infectious clones during the biological characterization of the virus as proposed in the previous framework . Neverth3.4.ad hoc meetings with relevant plant health authorities. A meeting between the involved parties can be organized to analyze the new information obtained since the last notification (step 2.3), to assess the status of the novel virus as a pest, and if it needs to be regulated  and greenhouse assays. As shown in It is possible that despite the efforts described in step 3, causation issues were not solved. In that case, further field surveys or greenhouse assays informed by the partial or negative outcome of the early efforts can be envisioned to fill the remaining data gaps on disease causation. This is necessary to assess the priority status of novel viruses and demonstrate their role in disease development. Once the association between presence/absence of the virus and symptoms in the host is confirmed, the aim is to determine the severity of the disease symptoms on host plant species and to estimate the potential yield and economic losses due to said disease, which can be done by (i) surveys to assess the impact on infected plants , and ii. For praIt is also essential to study the potential spread of the virus and its geographic distribution, to assess the situation’s urgency and the measures to be taken, particularly when considering the need to restrict plant commodities’ circulation. For this, large-scale field surveys  are necessary, as well as collecting symptomatic and asymptomatic plants and test them with the diagnostic protocols designed in step 1 or with generic tests such as HTS, to better determine the presence of mixed infections. Ideally, this large-scale evaluation could be supported by a network of collaboration with other stakeholders  that could facilitate the exchange of samples.Whenever possible, sampling of geographically and phylogenetically related wild and domesticated plant species should be considered to expand the knowledge of the potential host range, study its prevalence and identify potential reservoirs, since earlier efforts may have provided incomplete information . HoweverAccounting for the genetic variability of a viral population when designing the experiments is essential to improve the inclusiveness of detection tests and study the origin, dynamics, evolution, and phylogenetic relationships of the novel virus . This diKnowing the primary transmission mechanism of a virus is advised to properly design a successful greenhouse assay, as well as to evaluate risks and design an efficient disease/pest management strategy. Although difficult to accomplish, from a risk assessment perspective it is important to know about all transmission mechanisms as it can influence the fitness of the novel virus, selection pressures driving resistance and tolerance genes in the host, and viral population structure .5.Poaceae, highlighted the need for a revision of the previous characterization framework. Conducting similar systematic reviews in other crops might give additional insights on what is the current landscape on plant virus characterization after a first identification in an HTS dataset. Essentially, this revision emphasizes adapting a progressive feedback approach during the risk evaluation process, highlights the growing importance of database mining, proposes as a keystone the disease causal association, and underlines the importance and benefits of data and effort sharing, as well as the advantages to collaborate with other researchers. It is worth noting that this is not a substitution for any decision-support scheme for a pest risk analysis or pest categorization but a complementary document, especially useful for cases where the virus is considered as non-priority or where communication with plant health authorities may be more limited. Researchers may be overwhelmed with the number of findings in HTS datasets, or have a lack of resources and time, so this revision serves as an outline of the prioritization steps to go further than the genomic and molecular characterization of a novel virus, which will produce more useful and practical information for plant health authorities and producers/grower associations. In the long term, advances in artificial intelligence, machine learning technologies and bioinformatic tools will facilitate the process of characterization of a novel virus and reduce the resources and time needed. For example, SRA mining tools have the potential to complement conventional global surveys although a discussion around the technical and ethical considerations of using such methods should be held between the scientific community and stakeholders. Similar to the aim of the previous framework, this work should be regularly adapted by authorities to help rationalize and accelerate decisions on the most relevant actions at the different stages of virus discovery and characterization. In addition, this characterization framework can also be adapted for different countries not only for plant viruses but also for animal viruses and even other pathogens.The recent reviews of The original contributions presented in the study are included in the article/NF, MK, AyM, MRi, JR, FS, CoT, MA, NB, TC, AF, YH, DK, ArM, FP, MRa, and SM wrote the first draft. NF did the later work to expand and improve the text. MB, IS, RT, ChT, TW, and SM revised the text. All authors contributed to the article and approved the submitted version.This work was supported by the European Union’s Horizon 2020 Research and Innovation Program under grant agreement no. 773139 (VALITEST) and under the Marie Skłodowska-Curie grant agreement no. 813542 (INEXTVIR), by the CGIAR Genbank platform and by the Germplasm Health Unit (GHU) improvement initiative.AF was employed by Fera Science Ltd. AyM and YH were employed by Abiopep S.L.The remaining 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Person-centered care responsive to individual preferences, needs, and values is recognized as an important aspect of high-quality health care, and patient empowerment is increasingly viewed as a central core value of person-centered care. Web-based interventions aimed at empowerment report a beneficial effect on patient empowerment and physical activity; however, there is limited information available on barriers, facilitators, and user experiences. A recent review of the effect of digital self-management support tools suggests a beneficial effect on the quality of life in patients with cancer. On the basis of an overall philosophy of empowerment, guided self-determination is a person-centered intervention that uses preparatory reflection sheets to help achieve focused communication between patients and nurses. The intervention was adapted into a digital version called digitally assisted guided self-determination (DA-GSD) hosted by the Sundhed DK website that can be delivered face-to-face, via video, or by the combination of the 2 methods.We aimed to investigate the experiences of nurses, nurse managers, and patients of using DA-GSD in 2 oncology departments and 1 gynecology department over a 5-year implementation period from 2018 to 2022.This qualitative study was inspired by action research comprising the responses of 17 patients to an open-ended question on their experience of specific aspects of DA-GSD in a web questionnaire, 14 qualitative semistructured interviews with nurses and patients who initially completed the web questionnaire, and transcripts of meetings held between the researchers and nurses during the implementation of the intervention. The thematic analysis of all data was done using NVivo .The analysis generated 2 main themes and 7 subthemes that reflect conflicting perspectives and greater acceptability of the intervention among the nurses over time owing to better familiarity with the increasingly mature technology. The first theme was the different experiences and perspectives of nurses and patients concerning barriers to using DA-GSD and comprised 4 subthemes: conflicting perspectives on the ability of patients to engage with DA-GSD and how to provide it, conflicting perspectives on DA-GSD as a threat to the nurse-patient relationship, functionality of DA-GSD and available technical equipment, and data security. The other theme was what influenced the increased acceptability of DA-GSD among the nurses over time and comprised 3 subthemes: a re-evaluation of the nurse-patient relationship; improved functionality of DA-GSD; and supervision, experience, patient feedback, and a global pandemic.The nurses experienced more barriers to DA-GSD than the patients did. Acceptance of the intervention increased over time among the nurses in keeping with the intervention’s improved functionality, additional guidance, and positive experiences, combined with patients finding it useful. Our findings emphasize the importance of supporting and training nurses if new technologies are to be implemented successfully. Person-centered care that is responsive to individual preferences, needs, and values is recognized as an important aspect of high-quality health care ,2, and pA 2013 systematic review investigating the effect of web-based interventions aimed at increasing patient empowerment and physical activity in chronic conditions assessed the relevance of the interventions for cancer survivors . The autEmpowerment is the underlying philosophy of guided self-determination (GSD), in which the overall goal is to support patients’ development of life skills to improve their self-management of chronic conditions ,8. A ranMethods section.To increase access to health care, digitalizing and incorporating the option of using video conversations in person-centered interventions is of great importance. From 2016 to 2017, the Danish National Health Portal (DNHP), Sundhed DK , developDA-GSD was implemented in 2018 at 3 hospital departments in Denmark treating women with cancer and endometriosis. Documenting the maturation of the technology when switching from an analog to a digital version that uses not only face-to-face but also video conversations is important in terms of successfully developing future interventions. Other aspects that are important to examine and document include barriers and facilitators, user experience, and identification and fulfillment of the individual’s need for support in the digital environment. This paper reports on the implementation process with the aim of exploring the experiences of nurses, nurse managers, and patients with DA-GSD over a 5-year period from 2018 to 2022.Inspired by action research , this quThe study was conducted from 2018 to 2022 at 3 different departments at a university hospital in Copenhagen, Denmark, that were implementing DA-GSD: a gynecology department surgically treating patients with gynecological cancers as well as women with endometriosis as of 2020, an oncology department treating patients with various cancer diagnoses, and an oncology rehabilitation unit counseling patients with a variety of cancer diagnoses.DA-GSD is based on the analog version of GSD ,8, in whDA-GSD was developed from 2016 to 2017 by the DNHP Sundhed DK website  in an agThroughout the process of converting the traditional analog reflection sheets into a digital version for patients and HCPs, a service design methodology was used , which iThe partnership established among the HCPs; patients; and cross-functional team of the Sundhed DK website , which cHCPs used their secure work digital ID to access DA-GSD via the DNHP Sundhed DK website  to creatThe content of the digital reflection sheets was the same as that of the analog sheets, but their functions had changed. Some digitalized sheets were interactive and responsive to mobile devices. One of the analog sheets asks the patients to draw a picture of their experience of living with their disease, whereas the corresponding digital version permits the users to upload images to illustrate their experience. Finally, the problem-solving analog sheets, which comprised 4 pages on feelings, observations, goals, and actions concerning a specific problem, were now completed digitally and could be condensed into 1 page summarizing all 4 aspects to support problem-solving.DA-GSD allowed nurses and patients to collaborate on the digital sheets in a face-to-face meeting to discuss them on a shared computer screen, via videoconference and screen sharing, or by using a combination of the 2 approaches .Pexip , which wIn the autumn 2020, video consultation using VDX was introduced , which iThere were different inclusion criteria for nurses with managerial responsibility and the other nurses. Inclusion criteria for the former were: managerial responsibility for staff who were implementing DA-GSD, and not necessarily possessing certification in GSD or DA-GSD, or in facilitating them. Inclusion criteria for the latter were: being certified in GSD  and in fA total of 10 nurses with a median range of 40 to 49 years of age with 4 to 37 years (median 26.5 years) of nursing experience participated from the 3 departments. Of the 10 nurses, 5 (50%) nurses had a master’s degree and 3 (30%) had managerial responsibility, 1 of whom facilitated GSD, whereas the remaining 2 nurses facilitated the implementation of GSD in their department. Nurses had generally conducted 10 GSD conversations on average, but the number ranged from 5 to >100, as shown in Nurses and patients were recruited between 2018 and 2022. The participating nurses and nurse managers were recruited by the first author (MLO). The patients were included continuously by the participating GSD nurses. We did not register patients who declined to participate in the study.Semistructured interviews with 10 nurses were conducted during the initial implementation of DA-GSD. One nurse who participated throughout the entire study was interviewed twice, once at the beginning and again in 2022. The interview guide for nurses focused on their experience of using DA-GSD and covered functionality, the perceived need for DA-GSD, favorability of the surrounding circumstances, barriers, challenges, need for support, their role in facilitating DA-GSD, and data security. During the 5-year implementation period, MLO and a project assistant held regular implementation meetings with the nurses regarding their current experiences and challenges. Interviews and meetings were audio recorded, transcribed, and included as data. Knowledge from these meetings, specifically regarding the functionality of DA-GSD, was continuously reported back to Sundhed DK website  to proviThe included patients reported their sociodemographic details before their first DA-GSD conversation. After the last DA-GSD conversation, all patients were asked to complete a web-based questionnaire that contained an open-ended question about their overall experience with the digital reflection sheets. These answers were included in the data. Individual semistructured interviews were conducted with a convenience sample  comprisiAll participants received oral and written information and were given time to consider their participation before providing written informed consent. The study was conducted in accordance with the Declaration of Helsinki and was registered with the Danish Data Protection Agency . Ethics approval was not legally required.The data were analyzed thematically by following a 5-step process . First, A total of 10 nurses and 17 patients were included from 2018 to 2022. Of the 17 patients, 12 (71%) patients received DA-GSD via face-to-face conversations, 3 (18%) via video only, and 2 (12%) via a combination of face-to-face and video conversations .There were 2 main themes, one on conflicting perspectives that contained 4 subthemes and the other on the development of DA-GSD over time that comprised 3 subthemes .Different experiences and perspectives of nurses and patients concerning barriers to using digitally assisted guided self-determination (DA-GSD)Conflicting perspectives on the ability of patients to engage with DA-GSD and how to provide itConflicting perspectives on DA-GSD as a threat to the nurse-patient relationshipFunctionality of DA-GSD and available technical equipmentData securityWhat influenced the increased acceptability of DA-GSD among the nurses over timeRe-evaluation of the nurse-patient relationshipImproved functionality of DA-GSDSupervision, experience, patient feedback, and a global pandemicThis theme comprises 4 subthemes describing aspects that some users experienced as barriers to using DA-GSD and about which they, in several cases, had opposing perspectives. Many of the barriers that most nurses described were not reflected in the patients’ experiences.In general, the nurses were positive about technology and GSD being digitalized, but they had many deliberations about the patients’ prerequisites for participating in DA-GSD, especially during the beginning of the implementation process. This involved, for example, concerns about age, digital skills, cognitive function, fatigue, and the level of digital literacy. They appeared to protect the patients from the challenges they expected to arise from DA-GSD. Only 2 nurses experienced DA-GSD as easy to use from the outset, and they were younger or positively motivated by the unpredictability of their work tasks:I think it’s super exciting and it’s modern. And that’s how it’s going to be; it’s part of technological development that we also start doing things like this...and that everything shouldn’t be in paper form, and it’s clearly aimed at a target group that is younger and thus comfortable with all this...I have a concern that it may exclude someone who does not have strong [digital] literacy because they’re not safe inside that world.Nurse 3As expected by the nurses in the beginning, many patients said that DA-GSD was challenging in terms of their memory, fatigue, and sometimes the length of the reflection sheets. Furthermore, using the save feature (a flashing heart in the middle of the screen) was a lengthy and challenging process that made filling out the digital sheets difficult, in addition to the fact that they did not always work as intended, and the video feature had a complicated log-in process. Nevertheless, they did not mind overall and were generally highly positive about DA-GSD throughout the whole process, and they felt that the intervention fulfilled an unmet need.During the implementation process, nurses’ assumptions or understanding of patients’ digital skills were sometimes not in agreement with patients’ actual experiences and skill levels. In one case, a nurse described how she included a patient who she felt did not have the skills to participate:I felt that I...twisted the arm of someone [patient] who was not very digitally literate and who chose to say, well, I want that, because I want these conversations with you [the nurse] so much...That was a big challenge I just gave her.Nurse 3This did not fully align with the patient’s experience, which the patient described as not only challenging but also good and successful:I hadn’t visited Sundhed.dk [DNHP] before...but I got in and found all the sheets. I was so happy. Because my memory does not work as well as it should, I find it difficult to remember.Patient 1, oncologyOther patients said the following about DA-GSD: “works great,” “I could easily figure it out,” and “I’m used to logging in and checking test answers and stuff like that.” In general, their descriptions of the benefits overshone the challenges they experienced. One woman was especially excited about digitalized sheets that facilitated the problem-solving process:It was visual somehow, wasn’t it...? It was pretty good...I remember thinking while I was answering the questions, I thought: “It can’t be connected. It just doesn’t add up”...and then it was presented on that page ...“It does add up! ”, it’s like a SWOT  analysis, in reality.Patient 3, oncologyInitially, the Pexip video feature was somewhat cumbersome for nurses and patients. Moreover, because they felt responsible for the technical functionality of DA-GSD, including the video feature, they were concerned when the patients requested video conversations:As a professional, I’m a little bit worried about the technology...in terms of whether it causes any problems and whether it can...make it difficult to have a conversation.Nurse 2A pattern emerged throughout the implementation period that involved the nurses trying to screen the patients’ digital skills to ensure that they could manage the challenges involved in using DA-GSD:It has to be a patient who really understands IT and is not afraid of it and who is completely ready for it...Nurse 7Although the patients described difficulties in getting the video feature to work, being challenged was not the dominant narrative that emerged when they were interviewed regarding the video conversations. Their focus was primarily on the benefits of the conversation:I felt like I really got something out of it when we finished the hour-long videoconference, and I had some tasks to work on for the next time a fortnight later. And I actually looked forward to having that conversation again, because there were some things I was looking forward to talking about.Patient 2, oncologyImportantly, this quote is from the time when the intervention had just begun and Pexip provided the first video feature, which was even more difficult to install for this patient as she used an Apple computer. Nevertheless, the patient described using the video feature as crucial to her because she would otherwise have been unable to participate:If I had to show up [in person], I wouldn’t have come.Patient 2, oncologyShe lived far away and did not have the strength or money to pay for a long trip.Initially, during the commencement of the implementation, most nurses were concerned that DA-GSD would negatively affect or be a threat to their relationship with the patients. This sense of uneasiness was reflected in both face-to-face conversations using digital sheets on a shared PC and video conversations that involved collaborating on the sheets with screen sharing:The thing about constantly having to look at a screen [face-to-face conversations with reflection sheets on a shared screen]. I really like making eye contact with people. And there’s also something about keeping an eye on reactions and (...). You can get a little preoccupied with a screen like that, so (...) maybe I could also see such a barrier in relation to the conversation itself, how...so it might be a slightly different conversation. I don’t know, it’s not certain.Nurse 3In relation to the video conversations, their considerations focused on their ability to comfort the patients:If you have to do that video...that slightly close contact you have with the patient when you normally sit next to each other and can hand them a handkerchief and bring them a glass of water...you don’t have that option long distance, so it could well be a bit negative to have them further away.Nurse manager 8Although the nurses with managerial responsibilities also hesitated about the quality of the relationship via video conversations, all the nurses  recognized that video conversations were better than no access to health care for patients living far away:Well, I think I have a foot in two camps because..., for me, communication is when you sit and have eye contact, and you can sense each other, and you sit across from each other, and you’re just people sitting and having a conversation. And I know that well, we can’t keep doing that because patients, especially here with us, come from far away , and I think it would be a shame if those patients were prevented from having conversations because of the distance is a barrier.Nurse manager 5The nurses shared feedback during the regular implementation meetings. They discussed patients who wanted to do video conversations, and if they agreed that it was a good idea, they would recommend that the first conversation take place face-to-face at the hospital to help establish the relationship. This approach aligned with patients who combined face-to-face and video conversations. The nurses felt that the initial face-to-face conversation added value and believed that it was the reason video conversations were experienced positively subsequently.In general, the patients experienced no deterioration in their relationship with the nurses when using DA-GSD with both types of conversations. By contrast, some saw video conversations as an advantage:...when you’re sitting in the comfort of your own home, you can open up a little more than if you sat and were met head-on. I’ve built up a...a minor phobia of doctors...and then you can say that this [video conversation] is way better because there’s that kind of barrier somehow (...) I have to say, so I think it has worked.Patient 2, endometriosisDuring the data analysis, it became clear that many of the initial challenges patients experienced early in the study and the ones the nurses discussed at the implementation meetings disappeared over time, that is, patients did not mention them later in the implementation process. One possible reason for this is that DA-GSD and the video features were continuously adjusted during the study period based on feedback from the intervention , accelerPatients included early in the study found that the save feature in the digital sheets, a flashing heart in the middle of the screen, was an annoying hindrance “...and then suddenly that heart appeared, almost as if it had to update something” . This issue continued for quite some time:Sometimes, if you wrote it quickly, it couldn’t keep up...then the heart blinked...in the end, I gave up and wrote everything down by hand.Patient 4, oncologyEarly in the study, the complicated setup of the Pexip video feature and its instability were perceived as challenges:...how do we do it now [use video]...and it never worked out and then suddenly it crashed when I finally had to having a video conversation. The system didn’t work...Nurse 7Neither the nurses nor the patients described having trouble logging in to the DNHP on Sundhed DK website  with theIn addition to the challenges concerning functionality, the nurses lacked the technical equipment needed to conduct video conversations, making them even more skeptical about video conversations:Well, yes...[pause], secondly, it’s at least important that all departments have a computer with a camera. And the desktop computers don’t have that, at least the way things are in the department right now. I’ve been thinking about it lately...In any case, we must have access to a computer equipped with a camera...Nurse 2Almost all patients felt completely safe about having sensitive data hosted at DNHP Sundhed DK website :I feel very comfortable with that. I was a little surprised that it [this question] was asked at all.Patient 3, endometriosisI think there’s so much other data about me that is digital.Patient 2, endometriosisThere were only a few who had thought about whether unauthorized individuals could gain access to and see data or whether data could be leaked:Actually, I feel completely unworried, and yet, I know very well that everything can be leaked in the end. It’s not because I have something to hide, but whether I fully trust that it won’t get leaked one day, I don’t know if I do...Patient 4, oncologyThis was somewhat in contrast to what most nurses felt, who did not consider data security an issue when using the DNHP, Sundhed DK website :I don’t think that’s a problem, we already have data there, right?Nurse 9Several patients wanted other HCPs besides nurses to be able to see their data and the challenges they were collaborating on with the nurses during their DA-GSD conversations:Others should be able to see the data so that you don’t have to explain yourself so many times...that they [the completed reflection sheets] would become part of your medical record, perhaps...so the doctor can also see how the person is actually doing.Patient 1, endometriosisBoth patients with endometriosis and cancer thought that data of this nature should be accessible to the multidisciplinary team surrounding the patient:I want the doctors to be able to see it, so they can see how I feel!Patient 1, oncologyAs the nurses gained more experience using DA-GSD, their concerns about whether the nurse-patient relationship might deteriorate disappeared, regardless of how the intervention was provided. The following quote is about face-to-face meetings, which include sharing digital reflection sheets:It’s going really well. During the conversation, we sit opposite each other and occasionally look at the screen. I don’t see it as a problem that the computer screen becomes part of the conversation. I don’t see it affecting the relationship between me and the patientNurse at endometriosis implementation meeting 2019One nurse who had used DA-GSD continuously throughout the implementation process was interviewed twice, once at the beginning and once toward the end of the implementation period. Her experiences also illustrated the general increase in recognizing that the relationship remained intact. Despite her concerns regarding the nurse-patient relationship at the beginning of the study, using videos for DA-GSD became a tool that she offered to every patient by the end of the study period. At that point, she did not worry about or even consider its effect on forming a relationship and stated the following at her follow-up interview:I actually had someone [patient] the other day who I had to book [for DA-GSD], and then I asked what she preferred...she was from XXX [less than 20 kilometers away], but she wanted video.Nurse manager 8A common pattern was that the nurses saw a trusting relationship developing with patients when they used DA-GSD:You get closer to the patient, I think...and when I meet her, it’s a big hug in the hallway and she feels very attached to me.Nurse 7Over time, the nurses experienced that the functionality of DA-GSD matured, for example, the annoying blinking heart that served as the save feature completely disappeared:After Sundhed.dk ran DA-GSD again, they [the patients] don’t find that it [DA-GSD] freezes anymore. It’s not something that the patients complain about.Nurse at endometriosis implementation meeting 2019The improved functionality coincided with the nurses describing that they were increasingly unconcerned about whether patients requested the analog version or DA-GSD:Now I have tried both the digital one and what was printed out [analog GSD], and I think that the digital one just works really well. It’s easy for the patients to fill in and I don’t have to think about whether I have to print something out...it’s easy to log in to Sundhed.dk and...well, I’m comfortable with that. I actually don’t think of it as being anything special at all.Nurse 10The final video feature at DNHP Sundhed DK website  also appWe had to try it once to see if it worked [video conversations]...it worked. We continued with it...and it worked fine.Patient 2, endometriosisAt the end of the implementation process, the digital reflection sheets were prioritized over the analog ones, and the nurses viewed video conversations as an excellent supplementary resource to offer patients whom they would otherwise have been unable to reach and support owing to long distances:It’s a great extension of the method, isn’t it?...and also a resource, I think. Another tool we can have on the shelf, which might serve...? People who live far away.Nurse 9Notably, the statements supporting the mature, well-functioning version of the DA-GSD were made by patients and nurses who used it toward the end of the implementation process.At the beginning of the implementation process, the nurses had various preferences about how they would like to be taught about DA-GSD: “...for me it would be really nice with a little summary [of DA-GSD]” (nurse 7). Although written instructions were sufficient for some nurses, others wanted one of the researchers to join them in the beginning. Written instructions were drawn up and adjusted on an ongoing basis, and individual needs for instruction were met as much as possible. In addition, guidelines for the video conversations were prepared jointly with the intervention partners who provided the video features. In addition, tips and tricks that were presented at meetings were drawn up in writing and covered issues such as those concerning the physical and confidential setting of a video conversation, location in relation to the camera, and the use of headsets to optimize the sound. During the meetings inspired by action research, the nurses gave one another feedback and shared experiences about the challenges they encountered and how they approached them.During the implementation process, the nurses became more comfortable with DA-GSD, owing to its improved functionality, ongoing instruction, the support provided by the researchers, and an increase in confidence arising from their own experiences and those of their colleagues. On the basis of their own experiences, they began to emphasize the advantages of the digital version over the analog version. Several nurses emphasized the advantage of being able to safely store reflection sheets on the web so that it could be easily retrieved by all parties in relevant contexts before and after the conversations:The electronic GSD is perceived as much better than the analogue one. Patients won’t lose the sheets, and you can easily find what you’ve talked about. As an HCP, you can easily look at the sheets again, if necessary.Endometriosis implementation meeting 2019As described earlier, the nurses felt technically challenged, especially at the beginning of the implementation process. They felt professional responsibility for the DA-GSD’s functionality when offering it to patients. Their evaluation of DA-GSD was positively affected by patients who apparently embraced the intervention and described it as useful and supportive, despite technical challenges:It’s the best sessions I’ve ever attended, and I’ve attended a heck of a lot.Patient 4, oncologySome of the positive benefits of DA-GSD that the patients described were that they were being seen as a whole person, as it enabled them to exchange knowledge with an HCP familiar with their disease and receive support for successful self-management.Positive patient feedback about DA-GSD video conversations also appeared to influence the nurses’ attitudes toward the use of video:I think it worked quite well and, for me, it’s been a good opportunity to do it digitally.Patient 2, endometriosisI have tested that [DA-GSD] with some patients...they liked it...they think it made sense...now it’s young women I’ve had, and they use digital tools—without generalizing—very easily, yes. So, exactly for that patient group, because they are young women, I think it works fine. At least those are the ones I’ve done it with.Nurse 10In March 2020, the COVID-19 pandemic changed the delivery of health care worldwide and also affected how the nurses experienced the usefulness of DA-GSD using video instead of face-to-face conversations:An interesting observation was that, during video conversations, they saw the whole patient and could see the subtleties of their body language. When they meet face-to-face, only the eyes are visible [owing to the use of masks during the COVID-19 pandemic].Report from endometriosis implementation meeting 2020For other patients, using personal protective equipment during the pandemic meant that a video conversation was preferable to meeting face-to-face. Interestingly, they focused primarily on interpreting the nonverbal language:I actually almost think that, with this corona, it’s been easier over video because you can see each other, instead of sitting with masks and shields and all that, so in that way, it’s actually been better.Patient 4, endometriosisThe nurses agreed that the pandemic quickly made collaboration via video more common among both patients and HCPs. The pandemic also resulted in the provision of additional technical equipment for video conversations in departments:In relation to facilities for video conversations in the outpatient clinic, there are also some new resources that were not there before the pandemic, for instance, video and computers that allow you to facilitate video conversations...We have three computers that are equipped with cameras...and then I found out that this, a portable camera that you can take with you, also works.Follow-up interview, nurse manager 8This study aimed to investigate the experiences of nurses, nurse managers, and patients with DA-GSD in a long-term implementation process. Our results show that nurses and nurse managers were more concerned about using DA-GSD and the various ways of using it than the patients. The nurses’ doubts regarding the ability of patients to use DA-GSD, as well as their concerns about it having a negative impact on the nurse-patient relationship, were baseless. Although DA-GSD did not always work optimally, the patients embraced the intervention and found it useful and rewarding. The improved functionality, nurses’ own experience with using DA-GSD, and patients’ positive feedback seemed to affect the acceptability of DA-GSD over time among the nurses. Of note, the global pandemic required rapid implementation of video consultations in health care worldwide, which likely also played an important role in its acceptability. In contrast to the nurses, only a few patients had concerns about data security..The nurses and patients had conflicting perspectives on the ability of patients to engage with DA-GSD. Our study showed that the nurses’ concerns about patient characteristics that would be a barrier to using DA-GSD and would prevent them from benefiting from the intervention were unfounded, although other studies have found that they were warranted . A previThe nurses in our study felt responsible for the functionality of the technology and ensuring that the individual patients had the necessary digital skills before engaging in DA-GSD. A scoping review on the role of nurses and the skills needed to master technology and digital solutions  found thIn our study, the patients embraced DA-GSD and found it useful, which is in line with a review of web-based psychosocial interventions for cancer survivors  that fouNurses’ expectations and concerns about DA-GSD affecting the nurse-patient relationship were a central aspect in our findings. According to the person-centered practice framework, the relationship is important  and the , such as motivation, accessibility, and trust; (2) environmental and organizational, such as financial, political, and organizational structures; and (3) technical, such as services and design that do not suit user needs. These findings are in accordance with ours in which the nurses lacked motivation to initiate video conversations in the beginning because the initial Pexip video feature did not meet their needs for functionality, turning its functionality into a personal and technical barrier. Interestingly, the patients did not experience the technical barriers to the same degree as the nurses, perhaps because the benefits of DA-GSD outweighed the technical challenges and the nurses felt a great deal of professional responsibility toward its functionality. A study on patient rounds with relatives consulted on video also found that the nurses felt a huge responsibility for the technical setup and organizing it [Our study found that 2 barriers to implementation were DA-GSD’s functionality and a lack of technical equipment, which is in line with a systematic review of the barriers and facilitators of eHealth services  that ideizing it . Other sizing it ,27. Orgaizing it .GSD was previously digitalized in an eHealth intervention targeting patients with type 2 diabetes in Norway -31 and aVarious factors may have affected our data, analyses, and findings. First, the oncology patient group provided feedback on the newly developed version of the DA-GSD and the endometriosis patient group did so on a more mature version, which may have negatively affected the experience of the former group. Second, the patients with cancer were older and perhaps more cognitively affected because of their diagnosis and treatment than the patients with endometriosis, who were younger, of childbearing age, and especially challenged by pain, making the comparison of their technological skills difficult. Third, in March 2020, the COVID-19 pandemic affected treatments, priorities, and the development of technology in the Danish health care system, although video consultations were quickly implemented to reduce the spread of COVID-19. These circumstances likely accelerated the implementation of the DA-GSD video feature. Fourth, the prospective use of a systematic evaluation tool, such as nonadoption, abandonment, scale-up, spread, and sustainability-complexity assessment tool, from the beginning of the research project may have amplified the attention given to the complex social and political aspects of the implementation process . Fifth, One of the strengths of this study is that it examines the perspectives of both nurses and patients regarding DA-GSD. Another strength is the longer-time perspective of 5 years. Moreover, several researchers participated in the analysis and interpretation of results, which enhances their reliability.In this study, the nurses experienced more barriers to DA-GSD than the patients. The acceptance of DA-GSD increased over time among the nurses once DA-GSD’s functionality improved, they had received guidance, and had had their own positive experiences, combined with the fact that the patients found DA-GSD useful and beneficial. Our findings emphasize the importance of focusing on supporting and teaching nurses if new technologies are to be implemented successfully.


Juglans ailanthifolia) between squirrel-only and squirrel-mouse sites in natural forests of Hokkaido, Japan, and found that the SDE from the red squirrel (Sciurus vulgaris), considered a primary seed disperser, was altered by an alternative seed disperser species, the Japanese wood mouse (Apodemus speciosus). Seed removal rates at the squirrel-mouse site were significantly higher than those at the squirrel-only site, and both dispersed seeds and seedlings were less aggregated, with a strongly repulsive relationship with adult conspecific trees at the squirrel-mouse site. Seedlings established themselves at a location with fewer medium-sized trees (< 10 cm DBH) at the squirrel-mouse site. These results suggest that the interactive effect of the rodent species affects the SDE of Japanese walnut.The effects of seed dispersers on plant fitness  have been evaluated based on the number (quantity) and recruitment probability  of dispersed seeds. Although seeds of most zoochorous species are dispersed by two or more animal species, which may interact with each other, SDE has often been studied assuming a one-plant and one-animal species system. We compared the SDE of Japanese walnut ( Seed dispersers may increase plant fitness by conveying seeds from a mother tree and depositing them in microhabitats favourable for survival or growth4. The seed dispersal effectiveness (SDE) is estimated as the product of the number of seeds dispersed (quantity) and the probability of recruitment of each dispersed seed 4. The microhabitat of dispersed seeds and its spatial pattern have been the focus of previous studies on the qualitative component of SDE5. This is because spatial aggregation of seeds (seedlings) leads to sibling competition and reduces the reproductive probability of each individual6. Moreover, seeds and seedlings that settle near a conspecific adult tree are likely to be attacked by distance- or density-responsive pests and pathogens8.Animals play an important role as seed dispersers in the regeneration of many plant species10. Typically, their SDE has been independently evaluated for individual plant species and seed disperser species11. Even when focusing on two or more animal species, SDE has been investigated as an independent pairwise plant-animal system without considering the interaction between seed dispersers. SDE calculated for isolated species might be inaccurate because multiple disperser species may interact with each other to affect seed fate under natural conditions13. For example, rodents affect the fate of seeds that are dispersed by dung beetles. Beetles disperse seeds in dung deposits after endozoochory in warm temperate and tropical regions14. Dung beetles bury dung with seeds under the ground to prevent competitors such as rodents and other beetles from using the seeds. Although many of these seeds can survive until germination, rodents often remove and consume them when dung is not buried deeply15. However, few studies have evaluated SDE considering the effects of multiple species of seed dispersers (but see refs. 17 for exceptions).The seeds of most zoochorous species are dispersed by more than one animal speciesJuglans ailanthifolia) produces a very hard seed shell. After walnut seeds drop to the ground, the red squirrel (Sciurus vulgaris) and the Japanese wood mouse (Apodemus speciosus) disperse walnut seeds and hoard them under the ground in Hokkaido, Japan20. Red squirrels store each seed separately in the litter layer on the ground (scatter hoarding)19. Wood mice also carry out scatter hoarding in the litter layer and occasionally store two or more seeds in the same burrows (larder hoarding)18. Wood mice are known to find seeds buried by red squirrels and steal them when both species coexist21. Therefore, the SDE of red squirrels on the Japanese walnut may vary depending on the presence of wood mice.The Japanese walnut  to determine how the different combinations of seed dispersers affect the quantitative component of SDE; (2) to elucidate how the qualitative component of SDE, including the spatial distribution pattern of dispersed seeds and current-year seedlings , varies depending on the different combinations of dispersers; and (3) to show how microhabitat characteristics of walnut seedlings differ between habitats with different combinations of dispersers. We tracked the dispersal of magnet-attached walnut seeds to compare the spatial distribution pattern  and removal rates of walnut seeds between the habitats in which both red squirrels and wood mice were present (the squirrel-mouse site) and those where only squirrels were present (the squirrel-only site). We also observed the dispersal of walnut seeds in a habitat without dispersers. Furthermore, we investigated the spatial distribution pattern of current-year seedlings and compared the microhabitat characteristics of seedlings between the squirrel-mouse and squirrel-only sites. In this study, we were not able to assess SDE from the wood mouse alone at a mouse-only site because we could not exclude red squirrels in the wild.p < 0.001; Fig. At the squirrel-mouse site, 198 (99%) out of 200 placed magnet-attached walnut seeds were relocated from the initial position. Seventeen (8.6%) of the relocated seeds were dispersed, three (1.5%) were eaten by mice, 59 (29.8%) were found with only the magnet intact , and 119 (60.1%) were not found. At the squirrel-only site, 51 (25.5%) out of 200 placed magnet-attached seeds were relocated from the initial position. Five (9.8%) of the relocated seeds were dispersed, 44 (86.3%) were found with only the magnet intact, and two (3.9%) were not found. The removal rates of magnet-attached seeds (the percentage of relocated seeds) were significantly higher at the squirrel-mouse site than at the squirrel-only site (chi-square test: p =0.023) and control site  , followed by those at the squirrel-only site  and control sites (p < 0.001) , followed by those at the squirrel-only (Mann‒Whitney U test: 01) Fig. .Figure 3p < 0.001; Fig. Spatial relationships between the adult walnut trees and the current-year seedlings were also significantly different between the squirrel-mouse and squirrel-only sites. The spatial-association index R* was larger at the squirrel-mouse site than at the squirrel-only site  at the squirrel-mouse site, although it was not dependent on any variable for microhabitats at the squirrel-only site (Table 0 cm DBH 22) at the squirrel-mouse site was much lower than that of wood mice  was unlikely to be below the density of the arboreal squirrels in the forest of Sila Grande Mountain  and Hachioji City (Japan25), where these squirrels contributed to the seed dispersal of walnut species; Italian squirrels: 0.44 to 0.61 individuals/ha, Japanese squirrels: 0.06 to 0.13 individuals/ha.The removal rates of walnut seeds were significantly higher at the squirrel-mouse site than at the squirrel-only site Fig. . Further20 is much lower than that of red squirrels (17.4 m)19. Therefore, if there was no interaction between wood mice and red squirrels, then dispersed walnut seeds would aggregate more clearly at the squirrel-mouse site than at the squirrel-only site. However, dispersed walnut seeds were less aggregated at the squirrel-mouse site  was likely shorter than that of retrievals by mice (often occurring more than 3 weeks after caching20). Furthermore, the current-year walnut seedlings also exhibited less of a repulsive relationship with adult conspecific trees at the squirrel-mouse site than at the squirrel-only site  m20 is m29, significant differences were detected in our results .The sample sizes of the aggregation index R and the spatial-association index R* greatly varied across study sites Figs. , 3. Alth31, while wood mice prefer a closed habitat in which the light availability is low and the coverage of the understorey and tree density are high33. Therefore, if there was no interaction between wood mice and red squirrels, then walnut seedlings in the current year would tend to be established in a closed habitat characterized by low light availability, a high density of trees, and high understorey coverage at the squirrel-mouse site compared to the squirrel-only site. However, seedlings tended to be established in a more open habitat at the squirrel-mouse site than at the squirrel-only site. This is because many seedlings were established at the microhabitat with fewer medium-sized walnut trees (< 10 cm DBH) at the squirrel-mouse site, whereas they did not exhibit such a pattern at the squirrel-only site  was few at the squirrel-mouse site.The results of this study suggest that the interaction between red squirrels and wood mice, in which mice may retrieve seeds from the caches of squirrels and consume them20. However, both quantitative and qualitative components of SDE are context-dependent and vary with various conditions35. Therefore, it cannot be logically ruled out that the results observed at the squirrel-mouse site were simply due to seed dispersal by wood mice rather than the interactive effect with red squirrels. The second limitation is that factors other than the combinations of seed dispersers may have influenced the results. For example, it is known that seed disperser density affects the fate of seeds38. However, there was no significant difference in the hit rates of camera traps for red squirrels between the squirrel-mouse and squirrel-only sites  at the squirrel-mouse site, whereas they did not show any preference for microhabitat characteristics at the squirrel-only site. The results of this study suggest that the interactive effect of seed dispersers may affect plant fitness through the qualitative component of SDE and indicate that SDE, which has been evaluated in one plant species and one seed disperser species systemJuglans ailanthifolia) is a deciduous tree species (height: up to approx. 20 m) and common in Hokkaido, Japan. It often occurs in early successional habitats, especially in flat or mild slope areas of riparian forests40. Walnut seeds have extremely hard shells protecting embryos measuring 1.5 to 4.3 cm in shell length and 4.3 to 14.8 g in fresh weight41. They drop to the ground in autumn, October to early November, as the primary means of dispersal and then are conveyed by the limited species of vertebrates from their natal site as the secondary means of dispersal42. Japanese walnut seeds were identified using a field guide because they have highly characteristic morphology and are straightforward to identify.The Japanese walnut (Sciurus vulgaris) and the Japanese wood mouse (Apodemus speciosus)19. The body weight of red squirrels is 350 to 456 g, while that of wood mice is 20 to 60 g43. Both species contribute to walnut seed dispersal, but each has a different hoarding behaviour that may affect walnut fitness. Although both red squirrels and wood mice carry out scatter hoarding, wood mice occasionally also carry out larder hoarding19. Some scatter-hoarded seeds are not retrieved and can germinate. The germination rate of larder-hoarded seeds decreases with increasing hoarding depth (80% at 50 mm to 13% at 300 mm in depth44). Squirrels can hoard walnut seeds relatively far from the source tree than wood mice . The survival rates of dispersed walnut seeds and seedlings are generally lower near the source tree and increase rapidly with increasing distance from the source tree45. Therefore, the natural dispersal of Japanese walnuts is thought to be primarily performed by red squirrels.In Hokkaido, walnut seeds are consumed primarily by two species of rodents: the red squirrel , northern Hokkaido, Japan  had both red squirrels and wood mice and consisted of mixed deciduous forests (8.6 ha and 41.2 ha) on the shore of the lake. At both squirrel-mouse sites, the dominant canopy trees were Acer mono, Quercus crispula, and Kalopanax septemlobus, and the understorey was dominated by Senecio cannabifolius and Sasa veitchii.Other investigations were conducted at three sites in mixed forests near Lake Toya , southwestern Hokkaido, Japan, with the intervals between neighbouring sites ranging from 5.1 to 8.8 km  to 3 (for the squirrel-only site) 1.0-ha square plots whose centre was located on an adult walnut tree under which walnut seeds with bite marks showing vertebrate eating were observed Fig. d. The in2 sheet-shaped seed trap at each control site from the end of September to October 2018. At each site, the understorey within a 15 m radius from the walnut tree was removed with a grass cutter, and a seed trap was placed on the ground whose centre was located on the walnut tree. The seed trap was divided into 100 grids (2 × 2 m = 4 m2) to facilitate measuring the location of walnut seeds. We surrounded the periphery of each seed trap with a 1.0 m high net to prevent any terrestrial vertebrates from intruding into the seed trap. The angles of the slopes in the traps vary between 0.98° and 7.22° (mean ± SD: 3.39 ± 2.05°).To investigate walnut seed dispersal by gravity, we measured the location of seeds dropping from the source tree using a 400-mx and y coordinates in each grid with a measuring tape.After placing seed traps, we searched for walnut seeds dropped from the central walnut tree inside the seed trap every five days until we could not find any new seeds and measured their 41). We selected 400 average-sized seeds for experiments  to facilitate measuring the location of dispersed seeds  inside the 13 grids  the number of large-sized trees (> 10 cm DBH) within 5 m; (2) the number of medium-sized trees (< 10 cm DBH) within 2 m; (3) the slope angles; (4) the understorey coverage; and (5) the percentage of canopy cover (light availability). To test the selectivity of seedlings with respect to microhabitat characteristics, we also measured the above five variables at the centre of each grid as representative characteristics of the entire study area. The understorey coverage was estimated by the Braun-Blanquet scale based on the eight abundance classes: 0, r, +, 1, 2, 3, 4 and 5 corresponding to the absence of the understorey, negligible cover, less than 0.1% cover, between 0.1 and 5% cover, between 5 and 25% cover, between 25 and 50% cover, between 50 and 75% cover, and more than 75% cover, respectively48. To determine the percentage of canopy cover, we took hemispherical photographs and calculated canopy cover using the CanopOn 2 program (http://takenaka-akio.org/etc/canopon2/index.html).We quantitively evaluated the microhabitat characteristics of current-year walnut seedlings at the squirrel-mouse and squirrel-only sites. For every seedling, we measured a series of variables that were selected based on their potential importance for seed fates based on the results of previous studiesTo test the difference in the removal rates of magnet-attached walnut seeds between the squirrel-mouse and squirrel-only sites, the Chi-square test of independence was applied.49 for each plot. The aggregation index R is based on the measurement of nearest neighbour distances for each individual and provides an indication of whether the observed distribution has a clumped or uniform distribution compared to the expected random pattern. To assess the spatial relationship between the adult walnut trees and the current-year seedlings, dispersed magnet-attached seeds or gravity dispersed seeds, we used the spatial-association index R*50. The spatial-association index R* is based on the measurement of the nearest neighbour distance from points of one type to the other type and provides an indication of whether two distributions have an attractive or repulsive spatial relationship compared to an independent spatial association. We also used Ripley’s L(r) function and the cross-type Ripley’s L(r) function as complementary tests for the aggregation index R and the spatial-association index R*, respectively  using the aggregation index R51, to calculate the aggregation index R and the spatial-association index R* based on the x- and y-coordinates of each adult walnut tree, current-year seedling, dispersed magnet-attached seed and gravity dispersed seed for all plots. Regarding the aggregation index R and the spatial-association index R*, the Mann‒Whitney U test with Holm correction was used to test for significant differences among the squirrel-mouse, squirrel-only and control sites .We used spatstat, an R package for spatial point pattern analysis52 with binomial error structure and logit-link function for each of the squirrel-mouse and squirrel-only sites, in which the dependent variable was whether the point was the location of current-year seedlings or the centre of each grid inside the study site (the occurrence of the seedlings), and the independent variables were the number of large-sized trees (> 10 cm DBH), the number of medium-sized trees (< 10 cm DBH), angles of the slope, understorey coverage, and light availability. GAM was used, rather than a more conventional linear modelling approach, because the expected relationships are likely to be nonlinear. Some independent variables were significantly different between the squirrel-mouse and the squirrel-only sites, and therefore, we fitted the GAM to each site separately. Among the independent variables, the number of medium-sized trees at the squirrel-only site had fewer unique covariate combinations than the specified maximum degrees of freedom. Thus, we used a linear function for this variable instead of a smooth function in the model. The variance inflation factor (VIF) was assessed to determine the potential multicollinearity among the independent variables for each site53. The VIF among the independent variables ranged from 1.04 to 1.56, indicating negligible multicollinearity among the independent variables.To test the effects of microhabitat characteristics on the occurrence of current-year walnut seedlings, we fitted a generalized additive model (GAM)The field research in the Nakagawa Experimental Forest was permitted by the Nakagawa Experimental Forest of the Field Science Center for Northern Biosphere of Hokkaido University. Permission to perform the study, including permission to collect seeds and catch small mammals at Lake Toya, was issued by the Shiribeshi District Forest Office of the Forestry Agency and the Iburi Subprefecture of the Hokkaido Government (18-0114). All methods employed in this study were performed in accordance with the institutional, national and international guidelines and regulations.Supplementary Information.


Paramyxoviridae, which include several highly contagious viruses with zoonotic potential. In this case report we describe the detection of FeMV in archived brain tissue of a 2‐month‐old Bengal cat with nonsuppurative encephalitis from the year 2011 in Switzerland by high‐throughput sequencing (HTS). Our metagenomics approach was able to obtain a full‐length sequence covering the entire FeMV genome. Phylogenetic analysis showed that our FeMV strain clustered within FeMV genotype 1. We were able to detect FeMV RNA by in situ hybridization (ISH) in brain sections with inflammatory lesions and demonstrated its potential neurotropism and association with encephalitis. Our results provide further insight into this recently discovered morbillivirus and encourage further investigations into the pathogenesis and epidemiology of associated diseases in cats and potentially other species.Feline morbillivirus (FeMV) is a recently discovered morbillivirus of the family  Ffusion glycoproteinFeMVfeline morbillivirusFFPEformalin‐fixed and paraffin embeddedHTShigh‐throughput sequencingISHin situ hybridizationNnucleoproteinPphosphoprotein1Morbillivirus of the family Paramyxoviridae includes various viruses responsible for highly contagious diseases in humans and animals, such as measles virus, rinderpest virus and canine distemper virus.The genus 2In 2011, a 2‐month‐old female Bengal cat was admitted to a veterinary practice in the Canton of Ticino, Switzerland. The kitten was underweight and received initial medical treatment including an antiparasitic, antibiotics and corticosteroids. In the following days however, the neurological condition of the kitten rapidly deteriorated with apathy, stupor, anisocoria and aggressive behavior. None of the siblings nor the queen was sick. Because of lack of improvement, the kitten was euthanized, and the brain was removed and submitted to the Division of Neurological Sciences of the Vetsuisse Faculty of Bern for further neuropathological investigations. Histopathology identified an unusually mild lymphocytic inflammation of the brain associated with neuronal degeneration and necrosis consistent with an acute viral infection. Lesions were most prominent in the thalamus, basal ganglia, hippocampus, and brainstem. We also observed inclusion bodies in the soma of neurons. We performed further etiologic investigations by immunohistochemistry  as well as reverse transcription PCR (rustrela virus and Borna disease virus 1 [in 2022]) and all were negative  using a probe targeting the nucleoprotein (N) gene of FeMV and detected an abundance of FeMV RNA in the soma of neurons and astrocytes Figure . Notably3Morbilliviruses are a major threat to human and animal health and some have a high potential for cross species transmission.Authors declare no conflict of interest.Authors declare no off‐label use of antimicrobials.Authors declare no IACUC approval was needed. Owners of the animals of which tissue samples were used retrospectively in this study provided informed consent for the use of these materials for research purposes.Authors declare human ethics approval was not needed for this study.Data S1: Supporting Information.Click here for additional data file.Figure S1: Phylogenetic analysis of FeMV strains based on a partial nucleotide segment of the large polymerase protein (L). Representative FeMV strains were obtained from NCBI GenBank with corresponding accession numbers shown in brackets. Colors indicate the genotypes  and clades  of FeMV strains.Click here for additional data file.Table S1: Primers and probes used for orthobornavirus and rustrela virus (RusV) RNA detection.Click here for additional data file.Table S2: Whole genome comparison between the discovered feline morbillivirus (FeMV) strain Locarno/CH2011 and the FeMV reference strain and FeMV strain “SS1.”Click here for additional data file.


Preserve fertility in these patients is of major interest. It is demonstrated that hysteroscopic resection of focal well-differentiated endometrioid adenocarcinoma, followed by progestins achieve a complete response rate of 95.3%. Recently, fertility-sparing treatment was proposed also in case of moderately differentiated endometrioid tumors, with a relatively high remission rate.To show a new hysteroscopic approach, in case of fertility-sparing treatment of diffuse endometrial G2 endometrioid adenocarcinoma.Stepwise demonstration of the technique with narrated video footage for the fertility- sparing management of diffuse endometrial G2 endometrioid adenocarcinoma, combining the use of a 15 Fr bipolar miniresectoscope and ‘three-steps’ resection technique  with a Tissue Removal Device (TRD) .negative hysteroscopic assessment and endometrial biopsies at three and six months.Normal endometrial cavity and negative biopsiesCombined hysteroscopic technique, in case of diffuse endometrial G2 endometrioid adenocarcinoma, followed by double progestin therapy (Levonorgestrel releasing Intrauterine Device + Megestrole Acetate 160 mg/ daily), may be associated with higher complete response rate; the use of TRD to complete the resection near tubal ostia may reduce risk of post-operative intrauterine adhesions and improve reproductive outcomes.A novel, fertility-sparing surgical approach for diffuse endometrial G2 endometroid adenocarcinoma. To show a new hysteroscopic approach, combining the use of a 15 Fr bipolar miniresectoscope  with a Tissue Removal Device (TRD)  followed by double progestin therapy (Levonorgestrel releasing Intrauterine Device + Megestrole Acetate 160 mg/daily), for fertility-sparing treatment of diffuse endometrial G2 endometrioid adenocarcinoma, stage I at preoperative imaging assessment.4% of women diagnosed with EC are younger than 40 years old, and 70% of these women are nulliparous . PreservThe hysteroscopic resection technique, the so- called “three steps” technique, was firstly described by Mazzon et al.  to treatComplete surgical resection of endometrial cancer prior to starting progestin therapy seems to improve the complete response rate. Although results are encouraging, patients who are candidates for fertility-sparing treatment must be referred to specialised centres, using well-defined protocols and close follow-up .A 38-year-old patient was referred to our oncological centre with a histological diagnosis of moderately differentiated (G2) endometrial endometrioid adenocarcinoma. She strongly wanted to preserve her fertility. Preoperative imaging  showed a disease limited to the endometrium, with diffuse pathological endometrial tissue limited to the endometrial basal layer. There was no suspicious of ovarian pathology and no evidence of cervical extension and/or pelvic or para-aortic lymphadenopathies leading to a diagnosis of radiological stage I endometrial cancer. After adequate counselling, a fertility-sparing approach was agreed.This is a stepwise demonstration of a step-by- step hysteroscopic procedure for the fertility- sparing management of diffuse endometrial G2 endometrioid adenocarcinoma with narrated video footage.The patient underwent the hysteroscopic procedure in an outpatient setting under conscious sedation (Level 3(b) pain management, as achieved with i.v. midazolam 10 milligrams and fentanyl 100 micrograms) . HysteroA 15 Fr Miniresectoscope was used to remove the main lesions according to the so called “three steps” technique, described by At the end of the procedure, all the diffuse pathological tissue was removed. No complications were documented, and patient was discharged 3 hours after the procedure. The estimated blood loss was 20mL.Double progestin therapy was then administered, through a levonorgestrel-releasing intrauterine device and oral megestrol acetate 160 mg/daily.A three and six months hysteroscopic control showed a normal uterine cavity with negative endometrial biopsies.Combined hysteroscopic resection with 15Fr bipolar miniresectoscope and TRD allowed a complete resection of the pathological tissue in case of diffuse endometrial G2 endometrioid adenocarcinoma.The demonstrated hysteroscopic technique requires advanced surgical skills and it ought to be performed in a specialised oncological referral centre. Conservative management of moderate- high grade disease should be considered with caution, given that there are few studies and limited numbers of cases of fertility-sparing treatment in these patients .According to the more recent guidelines, fertility-sparing treatment should be considered only in case of atypical endometrial hyperplasia or grade 1 endometrioid carcinoma without myometrial invasion . In thesThe hysteroscopic surgical techniques described to treat these women vary according to the diffusion of the lesions inside the uterine cavity. Mazzon et al.  firstly In light of these studies, we proposed a new hysteroscopic approach to treat diffuse endometrial G2 endometrioid adenocarcinoma. A 15 Fr bipolar miniresectoscope was used to remove the main lesions according to the Mazzon “three steps” technique  and a TRAlthough this result is encouraging, patients who are candidates for this approach ought to be referred to specialised centres which use well-defined protocols, offer detailed counselling regarding the possible risks and ensure close follow-up .Combined hysteroscopic resection with 15 Fr bipolar miniresectoscope and TRD, in the case of diffuse endometrial G2 endometrioid adenocarcinoma, followed by the administration of double progestin therapy , may be associated with a higher complete response rate. Complete resection of the tumour, even in difficult areas, is made possible using a TRD, which reduces the use of electrosurgery and the subsequent risk of post-operative intrauterine adhesions. This could lead to better reproductive outcomes in these patients. Further studies are needed to refine the indications and the surgical technique.https://vimeo.com/762169020/130a2b6bca