There are multiple educational programs for individuals to become registered nurses (RNs), and the transition from an associate degree or diploma to a Bachelor of Science in Nursing (BSN) degree is vital to healthcare. This study examined the factors contributing to delayed completion or withdrawal from online RN-BSN nursing programs from students’ perspectives.N = 26).Thematic content analyses were conducted on qualitative data obtained from semi-structured interviews (Complex factors contributed to delayed completion of online RN-BSN programs, including student-, institutional-, and faculty-related factors.This study validated and extends previous studies without delineating students in fully online programs from hybrid and face-to-face programs. Students, faculty, and institutions all have a role to play in facilitating on-time program completion. Recognizing and mitigating the barriers that delay on-time program completion is required to foster nurses to obtain a BSN degree.The online version contains supplementary material available at 10.1186/s12912-021-00574-7. Unlike many other health professional programs with standardized educational requirements for entry to practice, nursing has multiple educational programs for registered nurses (RNs): hospital or diploma school programs, a two-year junior college or associate degree (AD) program, and a four-year baccalaureate or university program leading to a Bachelor of Science in Nursing (BSN) degree. In a December 1965 position statement, the American Nurses Association (ANA) declared that education for professional nurses should take place in institutions of learning within the education general system of. The ANA then recommended that a baccalaureate degree become the entry educational requirement for nursing practice, while AD education in nursing be recognized as the beginning of technical nursing practice . This reDecades later, the American Association of Colleges of Nursing (AACN)  recommenGranting the goal of 80% BSN-prepared nurses by 2020 was not reached, tremendous progress has been made with 57% achieved in 2019. Prior to 1965, hospital-based diploma programs were responsible for the education of approximately 80% of nurses . AlthougDespite the ongoing controversy about the entry points into professional nursing, it is agreed that there is a need to increase the number of BSN-prepared nurses in the U.S. This led to the RN–BSN program as a bridge to promote less-educated nurses’ upward career mobility. Many states in the U.S. have adopted legislation to increase the number BSN-prepared nurses; e.g., New York’s “BSN in 10 Law” requires future nurses graduating from an AD or diploma nursing program to obtain BSN qualification within 10 years of their initial RN license . The “BSThere are several formats for online RN–BSN programs: 8-week term/semester, 7-week term/semester, 10-week term/semester, and 15−/16-week term/semester. Online programs are designed for working nurses to control their time, offer students flexibility, and provide 24-h access to course materials. However, there may be challenges present that prolong or hinder degree completion. Not only is the on-time completion rate of RN–BSN programs important for meeting IOM recommendation, it is vital for nursing program’s accreditation. Therefore, it is critical to understand the factors that contribute to delayed completion or failure to complete RN–BSN programs from students’ perspectives.Significant literature exists regarding the barriers related to returning for completion of RN–BSN education , 43, 49.RN–BSN programs are bridge programs that should build upon nurses’ prior education and experience  and provThe purpose of this descriptive qualitative study were a) to elucidate the factors contributing to delayed completion or withdrawal from online RN–BSN programs from students’ perspectives to determine ways to alleviate said barriers; b) to answer two important questions: i) What factors led to the decision to return to school for an online RN–BSN Program? ii) What were the most important factors online RN-BSN students considered before choosing which school to attend?This study employed a descriptive qualitative design using semi-structured interviews conducted virtually via telephone and WebEx. Permission to conduct this study was granted by the Central Michigan University Institutional Review Board (IRB). An IRB approved informed consent to participate in an interview form with detailed information about the study was emailed to participants who contacted the researcher for more information. Prior to each interview, the consent form was reviewed with participants who then provided verbal consent to participate as part of the audio recording. Pseudonyms which were used for data collection, analysis, and presentation of the findings were assigned to each participant to ensure confidentiality.Recruitment began by inviting participants from a convenience sample of individuals known to the author via emails, LinkedIn, and Facebook. The author sent emails to colleagues in different institutions requesting that they post the flyers and forward emails to their students. Snowball sampling was used to identify other potential participants by asking participants to forward recruitment flyers to their peers and students. This recruitment strategy resulted in participants from seven U.S. states.A four-question screening form was used to determine prospective participants’ eligibility. Any individual meeting the eligibility criteria was contacted by telephone and invited to participate in a 30–45-min interview. Inclusion criteria were being an RN and currently enrolled in or having completed an online RN–BSN program that has taken/took more than 2 years to complete. Students who have not been in an online RN—BSN programs longer than 2 years, are in face-to-face or hybrid programs, or in prelicensure BSN program were excluded from the study. Participation was voluntary, participants can withdraw at any time from the study and were not compensated for their participation.Participants’ demographic information was collected using a short IRB approved demographic data collection form developed by the researcher for this study, including age, sex, ethnicity, number of years as a nurse, setting of primary practice, and number of years in the RN–BSN program. Twenty-six  nurses participated. Their experience as an RN ranged 5–23 years (Table Data were collected via telephone and WebEx interviews. Each interview lasted around 35–45 (maximum = 56 min). Six follow-up interviews lasting approximately 9–13 min were completed to verify previously collected information. Three participants agreed to participate in a conference call with the researcher after data analyses to be debriefed on the findings. All interviews were audio-recorded using an encrypted password-protected digital audio recorder to protect participants’ privacy. All audio recordings were professionally transcribed within 24 to 48 h of completion. The transcripts were reviewed for accuracy against the audio recording; when real names were used, they were removed to maintain confidentiality.Semi-structured interview questions Table  were devThematic content analyses for generating category systems  was condThe first stage of data analysis began soon after the interviews were completed. The researcher listened to the audio recordings, made notes, and added observations made during the interviews. Then, transcripts were reread to verify the accuracy of the audio recordings, and codes were assigned to the segments, per content analysis , 32. TheCreswell  suggesteThe key findings are shown in Table The findings of the study are discussed in two parts to answer three important research questions. First, the findings in response to two major questions i) What factors led to the decision to return to school for an online RN–BSN Program? ii) What were the most important factors online RN-BSN students considered before choosing which school to attend?. Second, the rest of the findings are discussed under the three major themes elucidated in Table My job required it;” “I wanted to work in a big hospital, [and] having BSN increases my chances of getting in;” and I always wanted to become a nurse practitioner someday—so I have to start somewhere.” Pauline stated,“I have been a nurse for over 15 years; the only reason I returned to school was because I love where I work. I did not want to have to find another job. I was given five years to get the BSN; so, I am using the whole five years.”Hannah, who has been a nurse for 21 years stated,“I was happy with my job until my hospital decided to go Magnet … I had no intention of going back to school. I tried to find a new job; but no one will pay me what I was making at my current job. So, I went back to school.”Some participants went back to school for personal reasons. For Izzy it was to earn the respect of her peers: “I have been a good nurse for years; then, all of a sudden, I wasn’t good enough because I don’t have a piece of paper with BSN on it … I wasn’t mentally prepared for it; but I am doing it.”The most common response to the above question was, ““I went to nursing school because I needed a career change and stability. I was laid off from my financial job a few years ago. I knew that a BSN was important for that security; but I am in no hurry to get there.”The least frequent reason given for returning to school was plans to go to graduate school (n = 2). Zumar stated, “I have been going to school for as long as I can remember … I was in no hurry … I plan to go to grad school after I complete the BSN.”Another reason was for financial stability and job security. Fernanda stated,online would be easy. Many did not account for the discipline and level of time management required to be successful in an online environment. Izzy stated, “I really thought that going online will be really easy—less work than face-to-face since I don’t have to take the time to go to class. Boy, was I wrong! It is way too much work.” Chidi chose a program because she heard from her colleagues that online learning is easier, students can work and complete the assignment at their own pace.When participants were asked about the most important factors considered when making school and program choices, their responses varied. Some thought completing the RN–BSN program “I was convinced by one of my colleagues to attend the same school he was attending … He made it seem easy … manageable. He promised to help me with technical issues.” Gina explained, “… My colleagues told me the program had no exams or quizzes. I hated those when I was doing my ASN [Associate of Science in Nursing].”Peer recommendation was the second most common reason cited by participants as influencing their program choices. Tamara explained, “I chose my program because of the cost. You pay one flat amount of money for all your nursing classes. For $10,000, I can complete 32 credits.” Fuschia chose a program that offered a tuition lock from enrollment till completion if completed within six years. She stated, “It was perfect because I needed to take my time and not worry about tuition or fee increases.”Two of the most significant consideration for schools and programs were cost and consideration for prior education. For some participants, being offered a flat tuition for all the RN–BSN core courses was important; for others, paying the same tuition from the time of enrollment till graduation was important. Danny, who completed an online program in four years, said, . She applied to three programs before making a final decision: “My program took most of my previous credits. I had over 130 credits before I finished my ASN program. The program with the most generous credit transfer was the most logical choice for me.”Brandy’s choice was based on the school that had the most generous transfer policy based on her previous learningWithin the context of the interviews, participants described several factors that contributed to delayed completion or withdrawal from online RN–BSN programs: student-, organizational/institutional-, and faculty-related factors.Student-related factors included participants’ ability to navigate many responsibilities outside of work and school. These included financial constraints, competing responsibilities such as family and work schedule, poor study habits/writing skills and technology challenges, and poor time management.“I returned to school at the age of later in life to get an associate degree in nursing. That was my end goal … Between my partner and I, we owe over $130,000.00 in student loan [s]. We make a little over that a year. Why would I want to take on more debt if I can complete the program in seven years with little out-of-pocket expense and the tuition reimbursement offered by my employer?”Although many participants received some financial assistance from their employers for educational advancement, they felt that it was inadequate to pursue the degree full-time. Some programs also expect the students to pay their tuition within a time frame after course registration. Andy stated,“Once you register for the course you have a few weeks to pay … If you don’t pay, they begin to charge you late fees … Sometimes it can take up to six weeks to get the approval for reimbursement after you successfully complete the course. I have other responsibilities like rent and food.”The same sentiment was echoed by Ayesha, “My job offers $2000.00 for tuition after the fact. It will be nice if the money is given at the beginning of the semester, instead of weeks after the course is completed.”Almost all participants agreed that BSN education is important, and many reported that getting the degree will offer more job security. However, they also reported financial limitations as a barrier. Six participants who held previous bachelor’s degree did not qualify for federal financial aid. Three participants stated that their current income disqualified them from regular financial aid. Many participants stated that they did not want to incur more students’ loans for nursing education. Two participants stated that they had children in college and were more concerned with their children’s education than their own. For example, Yara stated,“There isn’t much scholarship out there … the few that I looked at when I first started the program weren’t worth the time or energy.”Scholarships were available to help alleviate the financial burden. However, many participants were not aware of the scholarships or did not apply for various reasons. Yara laughed and stated, “A few scholarships, I thought were worth applying for; but the requirement was like completing a tax return … If I picked [up] 24 extra hours a week at my job, I will make that money in less than four weeks and I will not have to face the shame and disappointment that comes when I get rejected.”Ayesha compared the scholarship application to filing a tax return:Many participants had several competing personal responsibilities. All but three participants have children. Some had two or more jobs. Students’ motivation to complete the program was also affected by the value they placed on their educational achievement over other aspects of their lives. For most participants, when family and work responsibilities collided with schoolwork responsibilities, the schoolwork was relegated to the bottom of their priority list.their families. Eze stated,“I really want to someday get graduate nursing education; but I have to financially support most of my family here and in my country. If they have any problem, I have to drop my course or withdraw from the program to take care of it. Their wellbeing is my priority.”Helga reported having two jobs to manage family and school financial responsibilities. “I have no choice but to work two jobs … I will complete the BSN at some point; but keeping my job and family is more important right now.” Frances discussed how pregnancy got in the way of completing the program, “I got pregnant and figured I will take the time off and return after the baby. Before I knew it, two years has passed.” Unger reported quitting school to keep her family together,“Advancing nursing education is not a priority within my family structure. I don’t really have the support of [my] family with nursing school or choosing to return for the BSN … That’s what made me determined to complete the process; but I had to be realistic. I did not want to rock the family boat too much. So, I take it very slow.”Family support is an essential factor of students’ academic success . HoweverI thought that going online would be easier; but it requires a lot of discipline and self-motivation. I just found all the requirements and self-direction daunting.” Some participants reported the intensity of written communication and paper writing required in online education versus face-to-face as a barrier. Zumar reported, “writing papers makes me very anxious and we had a lot of that.” While Judah explained, “There is just too much writing in the program. I was not prepared for that. It takes too much time, especially for someone like me who does not enjoy writing.”Another factor was students’ approach to learning and the strategies they used to accomplish the tasks related to their education. Students whose motivation for returning to school are extrinsic are more likely to delay completion than those whose intension are more intrinsic . The stu“I just had such [a] difficult time finding the right information for the assignments.” This was echoed by Alice, “… It was not until my very last course that I [was] able to connect with the writing center and librarian for help.”Poor information literacy skills also contributed to the challenges some students faced. Faculty and programs sometimes assume that because students are in RN–BSN programs they are equipped to find evidenced-based information and incorporate them into their work. For some participants, this caused anxiety and undue stress that led to delayed program completion. Lucky stated, “I dropped my first course after the third week because I kept missing assignments. I did not know how to access the course requirements.” Hannah stated, “I failed a course because I was not able to use the collaboration function on the course to do my group project. I was ashamed to ask for help and frustrated.”For some students the RN–BSN program was their first foray into online learning. For these students, navigating the online learning environment was difficult. Although, some programs have learning management platform tutorials and orientations, it was not mandatory. Chidi stated, “I felt like I was always playing catch up with the assignments. It was very stressful; so, I couldn’t do it full-time.” From some participants, it was clear that they underestimated the time commitment required to manage online education. Tamara, who chose the program because her friends made it seem easy, stated,“I have friends and colleagues who completed the RN–BSN program in record time. They made it seem so easy. I thought it would be the same for me … [but] I lack structure … misjudged the time commitment. I have three young children … I just did not manage my time well.”Poor time management was a significant factor that challenged participants, especially those enrolled in programs with shorter semester time frames of seven to 8 weeks. Andy commented, Organizational- and institutional-related factors include availability of support , deceptive marketing strategies, credit transfer issues/disregard for prior learning, lack of incentive for educational advancement, and curriculum factors.“I signed up for online education so that I can complete the program on my own schedule; yet, the program requires that we meet at a set time once or twice a week.”Lack of institutional financial support was raised by the participants, including those whose employers offered tuition reimbursement. Financial support included limited or no scholarships for RN–BSN students or cumbersome scholarship application requirements. Crystal, who withdrew from her program, stated,“The scholarships for RN to BSN were very few; there [was] just too much competition. I was not going to spend time applying to something that I have very little chance of getting. I would rather spend that time writing my paper or picking up extra shift to pay for it myself.”Some participants described the requirements for the application of available scholarship as “not worth the time.” Others reported that getting assistance with the scholarship application would be helpful. Andy reported, “I was overwhelmed with the requirements of some of the scholarships, that I did not even consider applying … It will be nice to have help.” This was echoed by Lucia, “I wished there was someone to help with scholarship applications. The college website had a list of scholarships … but they did not offer any assistance with that.”Although many programs have academic support in place for students, some students did not know how to access them or that the support was tailored more for traditional students than for online students. Ivan stated that having mandatory online meetings defeated the whole purpose of online learning.generic advising,” meaning that the advisors lacked knowledge about the program and the curriculum, including institutional resources. Alice stated,“It will be nice if you have someone to help you navigate all those classes and program requirements after they take your money … If you needed assistance with something, it took days to get meaningful response from anyone.”Lack of academic advising and coaching was also something that frustrated participants. One participant called it ““What they sell you is not really what you get when you start the program” This sentiment was echoed by Lucia, “The person I spoke with in admissions told me they will accept all my credits … that was not true … I felt deceived.”Another institutional factor was the lack of transparency in marketing regarding actual program requirements and cost, as well as credit transfers. Twelve participants felt that some programs were not transparent enough in their marketing. Eze explained, “I thought that because we (the ASN program) had [an] articulation agreement with the school, all my credits [would] be accepted; but they were not. I still have to complete 15 more credits plus the BSN courses … I did not know this until I started the program. That meant more money and time.”A few participants also reported that their employers pushed some programs over others because of some type of agreement; however, these did not consider their prior learning. Eze wished for “more options for testing out of some of the courses.” Programs did not offer more efficient methods of assessing prior learning where available. Hannah explained, “By the time I complete the portfolio required for the evaluation of prior learning, I would have completed two courses … it just was too much.”Many participants were not aware of all the requirements prior to enrolling in the programs. Diana stated,“too many unnecessary prerequisite courses and strict progression plans,” caused delays and frustrations. Some felt like they could not take a semester break and be able to pick up from where they left off.Another important factor the participants discussed was related to the program curriculum. These included prerequisite courses and stringent program progression plans. What Ivan described as “I make a decent amount of money without the BSN; so why should I be in a hurry to get that. Moreover, I can run circles around a lot of the nurses who graduate with BSN.”Although almost all participants agreed that BSN education is important, they also reported that there is very little financial or career incentive to be in a rush to complete the programs. Alice stated, “… You get very little tuition reimbursement, $1,000.00 a year. The people who went back to school had nothing to show for it but the BSN behind their names … I spent over $15,000.00 for [my] BSN diploma, just to get measly $25.00 added to my pay every two weeks.”Ayesha described the only incentive to returning to school saying, “I am doing it so that I can remain at the same hospital and not lose my seniority.”Some others talked about their employers not offering any financial incentive for getting the BSN. Fuschia said,Several faculty-related factors contributed to delayed program completion or withdrawal. For some students, it was vital that faculty engaged in consistent, positive, and emotional teacher–student interactions. Perceived poor faculty support contributed to program delay and withdrawal. The subthemes included faculty feedback, faculty support/flexibility, and faculty communication.Lucia stated, “When you are struggling to do your best … and the faculty feedback is rude and judgmental, it makes you question your abilities.” Alice described her experience with faculty feedback during her first course, “Some faculty feedback was really discouraging. I already feel bad about a lot of things and I did not have the energy to deal with some of the offensive feedback about my work.” Cherry echoed this sentiment, “Some of the comments on my paper made me feel like … stupid … Demeaning faculty comments are not useful. You ask a question about something and you don’t hear back … when you do, it is flippant and disrespectful.”When students lacked self-confidence and perceived that faculty members did not care about them it negatively impacted their program progression. “I had a course in the summer semester. I was hoping to catch up; but with my children at home it was challenging going to work, finding childcare, and completing my assignments. I tried to do my schoolwork at night. I asked the faculty for [an] extension on a paper; but she refused … Rather than get an F, I dropped the course.”This sentiment was echoed by Helga, “Sometimes faculty are unrelenting and too strict—they fail to recognize that life happens to students outside of school.”Along with feedback issues, some participants also mentioned the lack of flexibility as a barrier. Especially, when family-related factors were accompanied by lack of flexibility from faculty it led to students dropping the course or sometimes withdrawing from the program. Unger stated,“My program did whatever they could to support the students. In fact, the program director called me when I failed to turn in assignments and did not return emails from the faculty. She wanted to know if there was anything, they can do to help me complete the course I was registered for.”“The program faculty are very supportive; but they can’t solve my financial problems or do anything about all the general education classes required by the university.”Eze stated, The above experience was contradicted by five participants, who reported that their programs and the faculty were very flexible and accommodating to students’ needs. Brandy reported,“were virtually absent—often taking over 72 hours to respond to questions or emails without any explanation or apologies for the delay.” Another source of frustration for some students was receiving poor grades without reasonable feedback concerning the grade. Helga stated,“If you have to wait 48 hours or more for the faculty [to respond to an email], it makes it tough to stay on top of your class work, especially if you are already having a difficult time staying on track.”According to Danny, his program “had a lot of part-time teachers; so, we were not a priority. Some of the teachers had no patience, and they took too long getting back to you.” Gina stated, “Some faculty were unreasonable with the amount of work that they expected the students to complete every week. The workload was simply unrealistic.”Poor communication was also described by participants, including not responding to students’ questions, lack of or very late response to emails, lack of clear expectations, and diverse policies across courses. Some participants described difficulties in communicating with faculty who This study elucidated the complex factors that contributed to the delayed completion of online RN–BSN programs from students’ perspectives. The findings validate and extend those of previous studies without delineating students in fully online programs from hybrid and face-to-face programs. Students’ reasons for returning to school for RN-BSN program are similar to previous cited reasons such as pressure from employers and employer hiring practices resulting from the popularity of Magnet recognition programs job security and advancement , 11, 39.At the time of this study, only four participants had withdrawn from their programs. One on them (Cherry) was planning to return, and three were unsure. In making the decision to return to school and choosing a program, cost was the single most important consideration and barrier reported by participants. Other students’ experiences with the programs was another significant consideration for students when deciding where to go. Previous studies indicated that nurses who had dependent children or relatives or who worked full-time or multiple jobs had greater barriers returning to school for BSN education than did their counterparts , 33, 48), 4833, 4Previously cited barriers included finances and having the time to balance family, work, and school responsibilities , 48, 49.Institutional related factors reported by participants included limited financial support from employers in the form of tuition reimbursement, this was also reported in previous studies , 48. AltAlso noted was a lack of transparency concerning program requirements and overall cost. This lack of transparency has not been reported in previous studies. This often resulted in prolonged program completion time and increased cost for the students. However, Robbins and Hoke  noted thNurses returning to school for their BSN degree are interested in finding RN–BSN programs that will respect employer and familial demands on their time and recognize the education and experience they have already acquired . HoweverUnlike prior studies , 40, 49,Some participants reported faculty-related factors that contributed to delayed completion. Faculty flexibility was reported as supportive, while lack of flexibility posed challenges, extended delayed response to emails and inquiries from the faculty or advisor let to frustrations and contributed to delayed program completion. Constructive faculty feedback aimed at encouraging professional growth increased students’ confidence and fostered persistence in the program. Lack of support and poor communication were reported as barrier to program completion in prior studies , 29, 47.This study had some limitations. Participants may have perceived the delayed completion or withdrawal from the program as a failure, which may have influenced how they responded to some questions. The descriptive research design and small sample size also limits the generalizability of the findings. However, the perceptions of these students cannot be disregarded when exploring factors contributing to delayed program completion or developing support programs to encourage the return to school and the completion of program of study.The current study focused on the perception of students enrolled in online RN–BSN programs. The results are significant because they provided detailed information exclusively from the perspectives of online RN–BSN students nurses from various institutions across the U.S. Institutions could use this information when addressing the challenges contributing to delayed completion or withdrawal from their RN–BSN programs. The findings also inform those who advocate for additional funding to support online RN–BSN programs.Effective online teaching is inherently different from face-to-face teaching. Nurse educators need to be skilled in online teaching provision, including integrating online learning resources without overwhelming the students and without being too rigid in the structure. Providing flexibility and unrestricted access to course materials, which allows students to complete their work on time, is required. Institutions have a responsibility to support their educators in the enhancement of quality online education. Institutions should provide online educators with the resources and necessary training required to be successful in online learning environment.Employers can incentivize their nurses to complete BSN programs by expanding their roles to include participation in unit and institution-wide committees, leadership roles, and other activities that challenge them to practice beyond their current levels. Academic institutions could facilitate on-time program completion by increasing support services for online learners. Assistance with scholarship applications may alleviate students’ financial burdens.Students, faculty members, and institutions all have a role to play in facilitating on-time program completion. Program stakeholders need to be cognizant of the factors that affect students’ program completion. Faculty were perceived as both a challenge and as a support system; thus, it is critical to determine this distinction. Mitigating the barriers to on-time completion of RN–BSN programs will foster timely completion and off-set program withdrawals.Future researchers should investigate the challenges of online RN–BSN programs from faculty and academic nurse leaders’ perspectives. Study should also investigate what nurse education leaders are doing to mitigate student attrition and to facilitate on-time completion. Future studies can explore what incentives employers are offering non-BSN nurses to return to school. To foster nurses’ motivation to obtain their BSN, it is imperative that stakeholders recognize the barriers that prevent nurses from returning to school and delay program completion and to implement feasible strategies to address them. The current findings can be used to develop strategies to facilitate smooth transition and ultimate on-time completion.Additional file 1. IRB approved Demographic data collection form.


PLOS Biology reveals that unrelated parasites have evolved effectors that specifically suppress the function of helper nucleotide-binding leucine-rich repeats (NLRs), explaining the complex plant–parasite coevolutionary dynamics.Parasites target the plant immune system for successful colonization. A new study in  For successful colonization, parasites need to target the plant immune system. This Primer explores a new study in PLOS Biology which reveal that unrelated parasites have evolved effectors which specifically suppress the function of helper NLRs, explaining the complex plant-parasite coevolutionary dynamics. Plants have evolved a robust innate immune system to defend against a large number of parasites present in their ecological niche . The plaThe plant genome encodes a large number of NLRs ,3. The NPseudomonas syringae bacteria, but NLR Rpi-blb2 only requires NRC4 to confer resistance to potato blight caused by the oomycete pathogen Phytophthora infestans [Potato virus X (PVX). Given that some helper NLRs are points of convergence in downstream signaling of multiple upstream sensor NLRs, they would be ideal targets for parasite effectors to overcome NLR-mediated ETI.The Solanaceae-specific NRC family is required for the function of a large number of CC-type sensor NLRs that confer resistance to a diverse array of parasites ,5. An emPLOS Biology, the Kamoun group [Nicotiana benthamiana plants. Among these effectors, SS15, from the cyst nematode Globodera rostochiensis, and AVRcap1b, from the potato late blight oomycete pathogen P. infestans, showed strong suppression of the cell death triggered by autoimmune mutants of NRC2 and NRC3, but not NRC4. This demonstrated that these 2 effectors act specifically at the level of the NRC2 and NRC3 helpers or their downstream pathways, independent of their upstream sensor NLR partners. In agreement with these findings, these 2 effectors can suppress sensor NLR, Rx-mediated cell death in response to PVX only if NRC4 is silenced.In this issue of un group  provide in vitro and in planta assays, the Kamoun group [Using a combination of yeast two-hybrid (Y2H), un group  revealedThe findings by Derevnina and colleagues  provide Additional studies are needed to understand the mechanisms by which SS15 and AVRcap1b interfere with helper NLRs function. How does SS15 binding to the NB-ARC domain of NRC2 and NRC3 suppress cell death? Since there is no evidence so far for direct interaction between NRCs and corresponding sensor NLR partners, does SS15 binding interfere with downstream signaling steps that are required for cell death execution? Recent studies uncovered that the activated sensor NLR, ZAR1, and the helper-NLRs, NRG1, and ADR1 function as cation channels that promote calcium influx leading to HR cell death ,9. Since


Social accountability is often put forward as a strategy to promote health rights, but we lack a programmatic evidence base on if, when, and how social accountability strategies can be used to promote access to quality Sexual and Reproductive Health (SRH) care for stigmatized populations and/or stigmatized issues. In this Commentary, we discuss the potential advantages and disadvantages of social accountability strategies in promoting the availability of a full range of SRH services for excluded and historically oppressed populations. We accomplish this by describing four programs that sought to promote access to quality SRH care for stigmatized populations and/or stigmatized services. Program implementers faced similar challenges, including stigma and harmful gender norms among providers and communities, and lack of clear guidance, authority, and knowledge of Sexual and Reproductive Health and Rights (SRHR) entitlements at local level. To overcome these challenges, the programs employed several strategies, including linking their strategies to legal accountability, budgetary expenditures, or other institutionalized processes; taking steps to ensure inclusion, including through consultation with excluded or stigmatized groups throughout the program design and implementation process; specific outreach and support to integrating marginalized groups into program activities; and the creation of separate spaces to ensure confidentiality and safety. The program experiences described here suggest some general principles for ensuring that social accountability efforts are inclusive both in terms of populations and issues addressed. Further empirical research can test and further flesh out these principles, and deepen our understanding of context. Activists, Non-Governmental Organizations (NGOs), and donors point to social accountability as one key approach to improve the realization of Sexual and Reproductive Health and Rights (SRHR) related rights and goals. Broadly defined, social accountability refers to “ongoing and collective effort[s] to hold public officials to account for the provision of public goods which are existing state obligations” . This paSocial accountability programs typically entail community actors assessing government performance against an agreed set of standards; a deliberative consensus building or priority setting element, wherein community members use these data to discuss and identify priorities; two-way dialogue between communities and the health system about these priorities; and follow up to ensure that these priorities are addressed. For example, a community group may compile a scorecard delineating key elements of the government maternal health strategy, assess gaps at their local health facilities, and, through a deliberative process, decide which gaps they wish to discuss with the government; or, jointly agree on budget priorities in a participatory budgeting or budget monitoring process –4. DelibFew studies on social accountability for SRHR assess the inclusiveness of the social accountability process or the extent to which the outcomes favor equity, though some programs have gender or age specific groupings in order to encourage participation among marginalized people –13. One In addition to challenges in ensuring inclusion and equity in social accountability efforts generally, efforts regarding SRHR are shaped by the politicization, social mores, and stigma attached to SRHR in particular –15. In tThese social, political, and law and policy factors may shape which SRH issues are addressed in social accountability efforts. Given that most social accountability efforts aim to promote the realization of rights enshrined in national laws and policy, advocacy for SRHR that are enshrined in international human rights law but not national systems may be limited in many social accountability projects. The social norms and values of program implementers, participants, and likely respondents, such as health providers, may also influence which elements of SRHR are ultimately chosen as the focus of social accountability efforts. For example, a 2004 review of community participation in 18 World Bank-supported health reform projects in Asia found evidence suggesting that community participation translated into gains in maternal health and family planning services, but less – if any – impact on more stigmatized areas, such as Sexually Transmitted Infections (STIs), abortion services, and health services for violence survivors . SimilarWe describe how four programs aimed to promote inclusion and equity, and navigated the stigma and politicization relating to SRHR in particular. The programs discussed were selected based on their stated intent to apply social accountability strategies to SRHR. The program successes and challenges presented were chosen following discussions among the authors; the content of each section is derived from the authors’ own program management experiences, as well as from internal and external evaluations. While we justify our statements with examples, this paper is in the style of a practice reflection or commentary, rather than a research study. Thus, the findings and principles we present are intended as hypotheses for further consideration by program implementers and exploration by researchers with expertise and engagement in social accountability and/or SRHR; we argue for fuller programmatic and research engagement with the topic. We also expect that this paper will contribute to broader discussions within the social accountability field about promoting inclusion.Table In the programs we discuss, common challenges emerged that are similar to those encountered in other social accountability programs, including financing and budgetary constraints; risk of social and physical harm perpetrated by household members, community members, or health system actors who are threatened by the issues being raised and/or by the individuals mobilizing to raise them; and, inability to meaningfully address issues that are perceived to be beyond the authority of the program participants. Rather than focus on these more common challenges, we explore challenges that have particular relevance to ensuring comprehensive SRHR below.All of the programs aimed to address stigma among providers, but, deeply embedded norms and beliefs about gender, reproduction, and sexuality posed a challenge. For example, youth engaged with the SAHAJ program in Gujarat, India, found it relatively easy to engage with the health system on issues related to nutrition, and they successfully ensured regular hemoglobin testing for adolescent girls to identify iron deficiency, as well as consistent access to weekly iron folic acid supplementation and take-home rations. However, they found it more difficult to communicate successfully to decision-makers and providers regarding adolescent sexual health, in part because providers seemingly held stigmatizing attitudes about adolescent sexuality and lacked knowledge of the public health evidence base in this area. For example, recent SAHAJ research found that a Community Health Worker (CHW) threatened to report a woman seeking information about abortion to her in-laws, and some CHWs expressed a desire to “control” young women who putatively exhibited sexuality in the “way they walk” .Concerns about poor access to comprehensive abortion and post-abortion care services and information were raised during the program scoping of the CARE International in Uganda and Center for Reproductive Rights (CRR) program addressing refugee and host population women and girls in Northern Uganda. However, these issues have not come up in the Community Council or reported to the Ombudsperson. The program team speculates that this may be due to stigma about abortion among providers and communities.Thus, irrespective of the anti-discrimination legislation in force or what entitlements are enshrined in law and policy, values and norms relating to SRHR may shape what issues are addressed as part of social accountability efforts, as well as if and how providers and governments respond. This is an unsurprising conclusion; shifting social norms that reflect longstanding social hierarchies entails a long process of contestation and debate ; while aGovernment responsiveness is challenged in contexts where local level providers and officials lack clarity, knowledge, or resources to fulfill their responsibilities. Lack of capacity undermines many social accountability efforts, but it is possible that this challenge is greater for stigmatized issues and populations.Nepal has recently decentralized its health system, and local governments have the authority and responsibility to manage health service budgets and service provision, including safe abortion services. In this new context, local governments were more responsive to community members and local NGOs assessing abortion service delivery as part of a social accountability program run by Ipas Nepal and local partners in two rural districts. Despite this, local Ministry of Health staff tasked with managing service delivery at the local level sometimes lacked the information and capacity required to fulfill their responsibilities. The Ministry of Health had instituted accountability mechanisms – such as a citizens’ charter and health facility operation and management committees, but awareness of these mechanisms within communities was poor. An Ipas program evaluation revealed that knowledge of these mechanisms increased significantly in the areas where the social accountability program is being implemented as compared to a control, but still, 38% of community members did not know about these mechanisms in program areas; the percentage was even higher in comparison districts at 62%.SAHAJ has realized that some front-line service providers in program districts in India lack important knowledge or skills regarding adolescents’ sexuality related concerns, including menstruation; SAHAJ team members have thus begun to train them on adolescent SRHR issues. Building on this, peer leaders have used the training as a basis to identify what they feel is lacking in service delivery, including support for boys seeking advice on nocturnal emissions and STIs.Limited knowledge of the application of human rights standards and principles was a key feature among stakeholders in the Northern Uganda CARE/CRR program. At the onset of the program, few refugee and host women and girls understood their access to SRH services as entitlements, or experiences of discrimination as violations that require accountability and access to effective remedies. Lack of clarity and knowledge about entitlements were particularly stark for stigmatized issues such as adolescent access to contraception and access to comprehensive post-abortion care regardless of the legal status of abortion.None of the programs we represent explicitly sought to ascertain whether or not local level authority and knowledge regarding SRHR entitlements differed from those regarding other entitlements. Nonetheless, our experience suggests that this may be the case, particularly for stigmatized issues. Explicit attention to addressing this frontline knowledge gap may be especially important for social accountability efforts addressing SRHR.The implementers of these programs raised many factors for success that are commonly identified in the peer reviewed research on social accountability, such as garnering support for a social accountability program from the communities involved, health system actors, and local politicians. In addition to these findings that are ubiquitous in the literature, we highlight two broad groupings of strategies below that our programs employ that are especially relevant to comprehensive SRHR for all.Social accountability efforts have grappled with key questions about how to make sure that duty bearers respond –26. GrouIn Northern Uganda, integrating legal accountability strategies at all stages of program consultation, design, implementation, and monitoring provided the program duty-bearers and rights holders with a clear rationale for the program and clarified their respective SRHR responsibilities and entitlements. This was accomplished through an accessible and ongoing translation of the complementary bodies of law that apply in humanitarian settings  and thosSimilarly, in India, SAHAJ has used existing government policies and norms as the framework for community-led research in order to spur governmental responsiveness. Program participants documented service availability and quality, using the resultant data to point out gaps in the operationalization of governmental programs. For example, recent SAHAJ research described the prevalence of poor knowledge about contraception amongst working class urban young women, despite concerted government efforts to increase access . In addiLocal NGOs working with Ipas in Nepal promoted the implementation of comprehensive SRH programs by engaging directly in the budget process. They approached local government bodies to advocate for the inclusion of safe abortion services in the budget, and to institutionalize this inclusion. As a result, the local health system had the resources to meet their obligation to ensure access to free comprehensive abortion care. The governments used the funds allocated in the budget to train service providers; to raise awareness about SRH entitlements among girls by providing sessions on reproductive health and rights - including abortion - in schools; and to directly fund abortion services.In Zambia, the Ipas and local partners’ social accountability program seeking to address barriers to contraception access among youth in the Copperbelt Province utilized Neighborhood Health Committees. Neighborhood Health Committees are pre-existing quasi-governmental structures that include health providers, community health workers, and community members, including youth and individuals participating in local Safe Motherhood Action Groups. Youth participants in the social accountability program appreciated that this structure offered access to Ministry of Health representatives and service providers. Moreover, youth advocates advocated for improved access to contraception through frameworks that the Ministry had committed to, namely evidence-based public health and Ministry commitments regarding contraception. The program complemented this approach with strategic engagement with other Ministry of Health actors, namely designated Adolescent Focal Points in health facilities and central level officials.Reliance on existing state obligations is a defining feature of social accountability. In the case of individuals and SRHR issues that are subject to stigma or discrimination, reference to these obligations might be particularly important, perhaps because they can be used to communicate government priorities to previously unaware providers, or because they can deflect blame or lessen space for discretion, e.g. “I am just following the rules.” Similarly, social accountability programs successfully pushing for the integration of SRHR into existing state processes can confer legitimacy and sustainability to the services concerned. In brief, despite the fact that government policies and programs and public sector employee behaviors are shaped by wider social norms, in many contexts, formal rules and processes may allow for activities that prioritize public health evidence rather than restrictive social norms. This strategy would not work in cases where laws, policies, and institutional processes themselves exclude services or populations, such as laws that criminalize LGBT populations or restrict abortion.In contrast to approaches that engage communities as geographically defined (e.g. residents of a particular village), the programs described here focused on particularly marginalized groups, such as adolescents, or made special efforts to engage these groups. There has been limited research on this approach to social accountability, but the existing research suggests that social accountability programs could be more rights-based by ensuring that each component of the program, such as information gathering, mobilization, and engagement, takes explicit steps to support participation of excluded groups .The CARE Uganda/CRR program in Northern Uganda includes a specific adolescent representative on the program established Community Council; this person has raised several adolescent specific concerns, including menstrual hygiene kit inaccessibility for refugee girls, and discrimination and stigma experienced by pregnant adolescents when seeking antenatal care at the health center. The adolescent representative also established an adolescent specific solidarity group to discuss concerns that the broader Community Council should address. This separate space for dialogue and sharing accurate SRH information helped participants to feel more comfortable discussing intimate issues, and helped to protect adolescent participants’ privacy and confidentiality, making it less likely that they would experience reprisals for raising stigmatized SRHR questions.Youth were involved from the program design stage in Zambia, influencing the social accountability program priorities and outcomes. They identified community score card indicators for success, as well as the scoring procedures, and included youth-friendly services in the score card. According to an internal midline assessment, the program has contributed to increased knowledge of youth and parents regarding available contraceptive services, the establishment of youth-friendly corners in health facilities, commitments from the Ministry of Health to provide transportation for adolescents to the clinic, improved availability of contraceptive options at facilities, and longer service hours in facilities. Importantly, the groups of adolescents from the four facilities who participated in the program educated both service providers and policymakers about adolescents’ needs and challenges.In Nepal, the community score card program included standalone, confidential meetings with women who had recently obtained abortions. Identified by local civil society organizations, these women discussed the quality of care received, including the behavior of health providers, overall treatment by the health service, and availability of medication abortion and sanitation facilities at the point of care.The SAHAJ program included outreach to sexual minority youth and adolescents – and then, once these groups felt comfortable, integrating them into their more general youth social accountability work. This has expanded other youths’ awareness of exclusion and expanded solidarity, culminating in the 2019 Pride March, when there was a large turnout of new allies.In sum, the programs took three main approaches to inclusion: (1) consultation with excluded or stigmatized groups throughout the program design and implementation process, (2) specific outreach and support to integrating marginalized groups into program activities, and (3) the creation of separate spaces to ensure confidentiality and safety, safeguarding emotional, social, and physical security. These efforts fostered environments where existing power hierarchies can be transgressed, and create the conditions for the inclusion of historically excluded people and SRH issues into social accountability efforts.Realization of the right to sexual and reproductive health requires providing comprehensive, high quality information and services to all people, especially those who are excluded. While a robust evidence base on if, when, and how social accountability strategies can be used to promote this goal is lacking, the program experiences described here suggest some general principles for ensuring that social accountability efforts are inclusive both in terms of populations and issues addressed. First, in the context of stigma and discrimination, it is perhaps even more important than for programs addressing less stigmatized issues and people, that efforts rely on legal and other formalized commitments, obligations, and rationales. Invoking these formal commitments may create space to surface unacknowledged persons and issues, making them issues of acceptable public concern. Second, inclusion should be built into the program, and permeate all stages of implementation. Depending on the context, this may require creating specific processes for excluded groups. Further empirical research can test and further flesh out these principles and hypotheses, and deepen our understanding of context.


Websites are an important source of information for fellowship applicants, as they can influence ongoing interest and potential program selection.This study aims to evaluate the current state of colorectal fellowship websites.This cross-sectional study evaluates the quantity and quality of information available on websites of colorectal fellowship programs verified by the Accreditation Council for Graduate Medical Education in 2019.P=.46).A total of 63 colorectal fellowships were included for evaluation. Websites were surveyed for content items that previous studies have found to be influential to program applicants. The 58 (91%) programs with a functional website were evaluated using an information index  and an interactive index . Programs had a median total score of 27.8 (IQR 21.5-34.5) of 79. The median score for the interactive index was 7.5 of 15 and for the information index was 20 of 64. The median scores for website application, education, personnel, and benefits or life considerations were 5, 5.5, 3.3, and 4 of 13, 24, 13, and 14, respectively. There was no difference in total score between programs in different geographical regions (Currently, colorectal surgery fellowship program websites do not provide enough content for applicants to make informed decisions. All training programs, regardless of specialty, should evaluate and improve their digital footprint to ensure their websites are accessible and provide the information desired by applicants. Residency and fellowship training program websites often serve as a first impression and vital source of information for applicants. It is a resource for training programs to attract highly competitive applicants and for applicants to identify best fit programs.As early as 1998, program websites were found to influence nearly three-quarters of emergency medicine applicants . In 2011Colorectal surgery is a popular field. The number of applicants to colorectal surgery fellowship programs increases with each passing year. The application and recruitment process is time-consuming and costly for both programs and applicants. Well-maintained program websites can facilitate this process for both parties, enabling programs and applicants in finding their best match. Colorectal training websites, however, have not been previously evaluated.The aim of this study is to evaluate the accessibility, content, and design of colorectal fellowship websites.A cross-sectional review of Accreditation Council for Graduate Medical Education (ACGME)–approved colorectal fellowship program websites was conducted using a validated assessment tool with two single-blinded reviewers .A list of colorectal fellowship training programs within the United States was obtained from the ACGME program list in September 2019 . The ACGEach program website was evaluated by two independent reviewers who were blinded to the other’s scores. A validated website assessment tool was used, including an interactive index and an information index . The intReviewers were given detailed definitions of each scoring criteria and trained using a sample of 10 general surgery residency websites of various quality. Interrater correlation coefficient for total score was 0.94 (95% CI 0.91-0.97). Rater agreement was 81% and weighted Kappa was 0.74. If there was disagreement between two reviewers regarding accessibility or content items in the information index, it was reviewed, and consensus was reached. For design, organization, and user-friendliness, the average score of two raters was used as the final score.Continuous variables were reported as median (IQR) values. Categorical variables were reported as count (percentage) values. An analysis of programs based on four main geographic locations, as defined by the United States Census Bureau , was performed using a Kruskal-Wallis test for continuous variables and chi-square for categorical variables. Association between two continuous variables was assessed by Kendall correlation coefficient. Statistical analysis was performed in RStudio version 1.2.5001 .All data reviewed was open to the public, and there was no contact with fellowship staff; thus, no institutional review board review, ethics approval, or informed consent was necessary.P=.46). There was no correlation between age of the program and total score (P=.38). No program had a Facebook profile or Instagram account to promote their fellowship.There was a total of 63 ACGME-accredited colorectal fellowship programs in the United States. Of 63 programs, 5 (9%) did not have a functional website (in spite of being established prior to 2012) and thus were excluded from analysis. Of the 58 programs with a functional website, the median total score was 27.8 (IQR 21.5-34.5) of 79. When stratified by geographic location, there were 21 programs in the Northeast, 18 in the Midwest, 17 in the South, and 7 in the West. There was no significant difference in the total score of programs in different geographic regions within the United States (Programs scored a median of 7.5 (IQR 6.0-10.0) of 15.0 for the interactive index, including design , organization , user-friendliness  and accessibility . For accessibility, the ACGME website provided a website link for 53 of 58 (91%) programs. Of those 53 programs with links, only 85% (n=45) of those links were functional, and only 31% (n=14) of the functional links led directly to the colorectal fellowship webpage; the remaining functional links led to a general departmental page.Programs scored a median of 20.0 (IQR 14.1-24.5) of 64 possible points for the information index content items. When further broken down, the median score (IQR) was 5.0 (4.0-6.5) of 13.0 for application information, 5.5 (3.1-9.0) of 24.0 for education information, 3.3 (2.5-5.0) of 13.0 for personnel information, and 4.0 (1.6-6.8) of 14.0 for benefits information. Over one-third (20/58) of programs received less than 16 points, while only 2 (3.4%) programs received 32 points or more for the presence of the information index content items.Only 59% (34/58) of the functional fellowship websites disclosed the number of fellowship positions available . AlthougMost of the 58 colorectal fellowship websites provided faculty listings , information on the education of their faculty , and dedicated faculty profiles . However, 28% (n=16) of faculty listings and 33% (n=19) of faculty profiles were on the general departmental website without a direct link from the specific fellowship website. Only 34% (n=20) of websites listed the current fellows and 33% (n=19) listed information on their alumni. Contact information for faculty , fellows , and alumni  was rarely reported publicly on the websites.Most  of the 58 programs provided a list of conferences and didactic education, with 55% (n=32) of programs reporting frequency of these conferences. Journal club was mentioned by 64% (n=37) of programs. Although research requirements or opportunities were listed for 67% (n=39) of the programs, a description of the research or potential research support resources were only available for 33% (n=19) of the programs; past research projects were listed on 17% (n=10) of the sites. Only 33% (n=19) of programs provided operative caseload of the fellows, while an additional 9% (n=5) listed examples of operations without case volume. Colonoscopy volume or time allocated to endoscopy was provided by 45% (n=26) of the program websites and anorectal physiology was mentioned by 52% (n=30) of the programs. Half of the programs had information regarding expectations on national or regional meeting attendance by fellows. Only 1 (2%) program provided any information regarding the colorectal board performance of prior fellows.Most  of the 58 websites provided some information regarding employment benefits or practice location lifestyle. Benefits , vacation policy , and salary  were the three most common benefit or lifestyle content items provided by programs. Debt management , work hours , and a sample contract  were the three least common benefit or lifestyle content items reported by programs. About one-third of the websites that provided benefit or lifestyle information had to be found on the associated GME page via search.Colorectal fellowship programs have lagged in embracing program websites as a recruitment tool despite the ubiquitous use of program websites throughout the application process ,4. A totThis study has several limitations. This is a cross-sectional study. It is possible that program websites were altered after data collection. However, data was collected from September to November 2019. This period of time encompasses the fellowship application season and should reflect what applicants were able to access in the 2019 application cycle. Additionally, no survey of colorectal fellowship applicants was performed to identify what that particular pool of applicants finds important on program websites. This information was inferred from the literature where studies have been performed for other specialties. However, each applicant likely has their own perception on what information is considered valuable. Thus, it would benefit both the programs and applicants for these websites to be as comprehensive as possible. Information was evaluated as being either present or absent, but it could not be verified if the information was current and accurate. Lastly, we were not able to evaluate changes in program websites over a period of time, as this was a cross-sectional study performed in 2019.In this study, it was unexpectedly found that 5 of 63 (9%) colorectal fellowship programs did not have an accessible website. In the current era, all programs should have a functional website. Studies from other specialties have revealed an absence of program websites for less than 1% of radiology programs to as high as 30% of pediatric orthopedic surgery programs -11,13,14Program websites should not merely exist but should be easily accessible and user-friendly. One-fifth of the links provided on the ACGME webpage were not functional, and only a quarter led directly to the fellowship website. Programs should check and update links on the ACGME website and other major program listing sites on an annual basis. Additionally, applicants value ease of navigation more than the presence of individual content items . In thissensitive topic not discussed during an interview [Only a quarter of the content items we evaluated were presented by half or more programs. Information regarding application process; current faculty, residents, or alumni; and training information are highly valued by applicants ,3,5. Intnterview ,10,16. TAlthough this analysis is limited to colorectal fellowships, it serves as an alarm that current training program websites are not meeting the needs of applicants. Although the program websites of some specialties have been reviewed and showed similar deficiency in quality, there exists a gap in many specialties where program websites have not been reviewed. Thus, all training programs, regardless of specialties, should maintain a program website that is updated before each application cycle. Direct links to the program website should be updated on all major listings such as the ACGME program list, FRIEDA, or the Electronic Residency Application Service. Information available on the departmental webpage or GME webpage should be connected to the fellowship program website via a direct link. Programs should optimize the design, organization, and usability of their websites by grouping information (when appropriate), using hyperlinks to lead applicants to the departmental webpage or GME webpage, and separating content in a way that maintains easy navigation between pages. Future studies that survey applicants of different specialties or subspecialties on their specific needs will further clarify the important content to include that may be unique to each specialty. Guidelines from GME or professional societies would also provide guidance for individual programs in the development of a high-quality program website.This study found the overall quality of colorectal fellowship program websites to be poor. Colorectal fellowship programs need to increase the amount of information available and improve the usability of their websites. Absent or poorly designed fellowship websites can negatively impact the application and recruitment process for both applicants and fellowship programs, as both seek to find the best fit for the program.


The PF sows received unique daily blends of two isocaloric diets , whereas CON sows received a static blend throughout gestation to achieve 0.56% SID Lys. After weaning, sows were re-bred and entered the same feeding program as in the previous pregnancy for two subsequent pregnancy cycles . Sows on the PF program received 97%, 105%, and 118% (average over three pregnancy cycles) of dietary energy and 67%, 79%, and 106% of SID Lys intakes compared to CON between days 5 and 37, 38 and 72, and 73 and 108 of gestation, respectively. Estimated N (26.1%) retention did not differ between gestation feeding programs in any pregnancy, but excess N excretion was less  for PF vs. CON sows. Regardless of pregnancy cycle, sows that received the PF program had greater ADG between days 38 and 72  and between days 73 and 108  of gestation, and greater loin depth gain between days 63 and 110 of gestation , but BW (235.1 kg) and backfat (17.8 mm) and loin (70.5 mm) depths on day 110 of gestation did not differ. The number of piglets born alive, stillborn, and mummified, and litter birth weight (16.5 kg) did not differ in any pregnancy cycle, nor did piglet ADG during lactation (250 g/d) and piglet BW (6.7 kg) at weaning. Sows that received the PF program during gestation had lower ADFI during lactation . Therefore, using feeding programs that precisely match estimated daily energy and Lys requirements for gestating sows provides the opportunity to reduce N losses to the environment and reduce lactation feed usage, without negatively affecting sow reproductive and lactation performance.The objective of the current study was to determine the effects of precisely meeting estimated daily energy and Lys requirements for gestating sows over three consecutive pregnancies on sow reproductive and lactation performance. A total of 105 sows  were randomly assigned to a precision (PF;  The nutrient and energy requirements for gestating sows are not constant throughout the gestation period or across parities. For example, the estimated Lys requirement for a sow in the first reproductive cycle increases by 200% between days 0 and 114 of gestation, whereas the estimated energy requirement increases by 45% within the same timeframe . FurtherThe sow is adept at buffering moderate nutrient and energy deficiencies and excesses in the diet e.g., . HoweverTherefore, the aim of the current study was to determine the long-term effects of precisely meeting estimated daily Lys and energy requirements for individual sows on each day of gestation across three consecutive pregnancies on reproductive and lactation performance.The experimental protocol was approved by the University of Guelph Animal Care Committee and followed Canadian Council on Animal Care guidelines . Sow genetics were distributed equally between treatments and sows were randomly bred with either Yorkshire, Landrace, or Duroc semen. The ESF [modified according to One hundred five sows  were placed into one of four pens equipped with ESF 5 ± 3 d after breeding over five breeding batches (blocks). Sows were randomly assigned to one of two gestation feeding programs in the first gestation cycle: precision feeding (PF) or standard feeding  on days 5 ± 3, 62 ± 3, and 110 ± 1 of gestation and 3 d after weaning by a trained technician using a portable ultrasound machine with a 140 mm linear probe .g at room temperature for 15 min. Serum was aliquoted into microcentrifuge tubes and stored at −20 °C until further analysis. Serum from a subset of 20 sows (n = 10 per treatment) from each of three subsequent gestation cycles were analyzed at the University of Guelph Animal Health Laboratories  using a Cobas 6000 c501 biochemistry analyzer  to determine serum concentrations of glucose, urea, beta-hydroxybutyric acid (BHBA), and non-esterified fatty acids (NEFA).On days 5 ± 3 and 108 ± 1 of gestation, 10 mL of blood were collected from each sow via sub-orbital sinus puncture into serum tubes . Blood samples were centrifuged at 3000 × Immediately after birth and before first suckle, up to two piglets per sow were sacrificed for determination of physical and chemical body composition. Body weight and individual organ weights  were collected. The organs and carcass were combined per pig in a plastic bag and frozen at −20 °C until further analysis .Representative feed subsamples for the HP and LP diets were collected monthly (to include each batch of feed) and compiled into 3.5-mo intervals for analysis. Samples were ground and sent to SGS  and analyzed for dry matter (method 930.15), crude protein (method 990.03), and calcium and phosphorus  with individual sow as the experimental unit. The model included the fixed effects of gestation feeding program treatment , pregnancy number (PREG), and their interaction; initial reproductive cycle (INTPARITY) was used as a covariate and the repeated measures option was employed. The random effects of block, treatment nested within block, and sow nested within treatment were included. Piglet performance during the lactation period (after cross-fostering) was analyzed with the additional covariate of post-fostering litter size. Sow serum concentrations for BHBA, glucose, and NEFA were log transformed prior to analysis and back transformed for presentation of results. Pre-planned contrasts were constructed to compare treatments within pregnancy cycle. A The analyzed and calculated nutrient contents were comparable for both the high and low protein gestation diets, as well as the commercial lactation diet . The onlP-values are presented in the tables for the reader’s information. Initial and final sow body weights and ADG between gestation days 5 and 37 were not influenced by gestation feeding program for any of the three pregnancies (P < 0.05) where sows that received the PF program had greater ADG in pregnancies 2 and 3 than sows that received the CON program , whereas gestation feeding program did not affect ADG in pregnancy 1. Between gestation days 73 and 108, sows that received the PF program tended (P = 0.063) to have greater ADG than those that received the CON program; in pregnancy 1 only, sows fed the PF program had greater ADG than those fed the CON program . Generally, backfat and loin depth values, along with changes in backfat and loin depths over gestation, were not influenced by gestation feeding program in any of the pregnancies. However, the loin depth gain between days 63 and 110 of gestation was greater for sows that received the PF versus the CON program (P < 0.05); in pregnancy 3, sows fed the PF program had greater loin depth gain than those fed the CON program . The costs for the HP and LP diet usage per sow were less and greater, respectively, for sows that received the PF versus the CON program (P < 0.001 and P < 0.001). In pregnancies 1, 2, and 3, sows fed the PF program had lower feed cost associated with feeding the HP diet  and greater feed cost associated with feeding the LP diet . Cumulative feed cost (HP + LP) over the gestation period was greater for sows that received the PF vs. the CON program (P < 0.05). In pregnancies 1 and 2, cumulative feed cost tended to be  and was , respectively, greater for sows fed the PF vs. CON feeding program, but in pregnancy 3, cumulative gestation feed cost was not different between the feeding programs.The main effect of pregnancy is not mentioned in the results section since some variation in sows from different pregnancies was expected; the main effect gnancies . BetweenP = 0.071). Serum glucose tended to be influenced by the interactive effect of gestation feeding program and pregnancy (P = 0.059) where PF sows had greater serum glucose concentration on day 108 of gestation in pregnancy 2 (P < 0.05), whereas no differences in sercum glucose between gestation feeding programs were observed for pregnancies 1 or 3.The serum concentrations for BHBA and urea were not influenced by gestation feeding program in any pregnancy on either day 5  or day 108  of gestation . The serP = 0.092). Piglet BW, liver, and large intestine mass, and relative gastrointestinal tract weight (% of BW) at birth were not influenced by gestation feeding program in any pregnancy (P < 0.01), such that piglets from sows that received the PF program had greater stomach mass in pregnancy 3  but stomach masses were not different between feeding programs in pregnancies 1 or 2. Piglets from sows that received the PF program tended to have greater small intestine mass than piglets from sows that received the CON program in pregnancy 2 only . The protein content in piglet carcasses was less for sows that received the PF vs. the CON program (P < 0.05), which was especially evident in pregnancy 3 . The piglet ash and fat contents were not influenced by gestation feeding program in any pregnancy but the water content was greater for piglets from sows that received the PF vs. the CON program (P < 0.05).The number of piglets born alive, piglet birth weight, the variation in piglet birth weights before and after cross-fostering, litter birth weight, and the number of stillbirths were not influenced by gestation feeding program in any pregnancy . The numregnancy . Piglet P < 0.01). In pregnancy 1, the litter size for sows that received the PF program tended to be smaller than the litter size for CON-fed sows , whereas litter size was greater in pregnancies 2 and 3 for sows that received the PF program , such that the variation was greater for piglets from sows that received the PF program in pregnancy 1 , was less in pregnancy 2 , and not different in pregnancy 3 vs. piglets from sows that received the CON program. There was an interactive effect of feeding program and pregnancy on sow BW change over lactation (P < 0.05). In pregnancy 2, sows that received the PF program tended to lose less BW than sows that received the CON feeding program , but no differences in sow BW loss between feeding programs were observed in pregnancies 1 and 3. Changes in backfat and loin depths over lactation and re-breeding interval were not influenced by gestation feeding program in any pregnancy. Average daily feed intake and cumulative feed cost during lactation were less for sows that received the PF versus CON program (P < 0.01), which was especially apparent in pregnancy 2 .There was an interactive effect of sow feeding program and pregnancy on the number of piglets per litter after cross-fostering (P = 0.050), such that sows that received the PF program had lower excretion of excess N in pregnancies 2 and 3 vs. sows that received the CON program , whereas there was no difference in excess N in pregnancy 1. Overall, sows that received the PF program had lower amounts of excess N compared to sows that received the CON program (P < 0.01). Sows that received the PF program had greater excretion of excess P compared to sows that received the CON program (P < 0.01), particularly in pregnancies 2 and 3 .Estimated N and P retentions were not influenced by gestation feeding program in any pregnancy . There wThe purpose of the current study was to examine the long-term effects of closely meeting the dynamic estimated Lys and energy requirements for individual sows during gestation across three consecutive pregnancies on sow reproductive and lactation performance. Using the PF program, sows gained the same overall amount of BW during gestation, but with greater BW gain occurring after day 38 of gestation versus sows that received a static quantity and composition of gestation diet (CON). This, combined with positive and greater loin depth gains after day 63 of gestation and 7 and 2× (average over three pregnancies) lower day 108 fasted serum BHBA and NEFA concentrations, respectively, indicates that the dynamic and increasing SID Lys:NE ratio provided throughout gestation for the PF program, supplied adequate amounts of both Lys and energy to support maternal protein deposition and minimize lipid mobilization. However, since there were no differences in piglet birth weights, piglet ADG (indicator of sow milk production), re-breeding intervals, and sow retention, it appeared there were no negative long-term implications for CON-fed sows. In modeled scenarios, it has been demonstrated that a static SID Lys supply of 11 g/d throughout gestation resulted in maternal protein and lipid mobilization in late gestation, while providing 13.5 g/d SID Lys was above estimated requirements for both gilts and sows . FurtherSows that received the PF program during gestation consumed less lactation diet in the subsequent lactation period vs. those that received the CON program. Since overall sow BW change and piglet ADG during lactation were not different between sows from the two gestation feeding programs, sows that received the PF program during gestation were presumably more efficient at utilizing dietary nutrients and energy for milk production. This occurred despite PF sows unintentionally tending to have larger litter sizes than CON sows after cross-fostering. During lactation, when feed intake is no longer restricted, sows attempt to compensate for nutrient and energy deficiencies experienced in gestation by increasing feed intake . Thus, sIn the current study, there were minimal differences in litter characteristics and piglet physical and chemical composition at birth from sows that received the PF and CON gestation feeding programs. Piglets from sows that received the PF program in gestation, however, had greater variation in BW within litters at weaning in pregnancy cycle 1, less variation in pregnancy cycle 2, and no difference in variation in pregnancy cycle 3, despite no differences in BW variation within litters at birth or after cross-fostering. Variation in BW at weaning can be linked to poor lactation output ; howeverOverall, gestation feeding program had no obvious effect on sow retention throughout the study, although the number of sows enrolled was relatively small. Nearly equal numbers of sows were removed from the study for: lameness , reproductive failure , illness , savaging piglets , death with unknown cause , and incompatibility with the ESF system . It is interesting to note that 30% more CON sows were removed from the study due to reproductive failure compared to PF sows, with the most common reproductive issues being failure to enter estrus after weaning, failure to conceive after insemination, and miscarriage. The reproductive issue of failing to return to estrus is typically due to low BW at the time of breeding, which is caused by BW loss during lactation and poor adipose and protein reserves at weaning . In the The cumulative feed cost during gestation was greater for sows that received the PF vs. CON feeding program, which was largely driven by greater feed allowance  to meet estimated daily energy requirements. Considering the reduction in feed intake (and cost) during lactation for sows that received the PF program, the relative difference in feed cost per entire reproductive cycle was small (i.e. ~ $0.25 per sow in pregnancies 1 and 2). Conversely, in pregnancy 3, the sum of gestation and lactation feed costs per sow were $1.24 less for sows on the PF gestation feeding program. As sows mature, the estimated daily energy requirements increase slightly to account for greater maintenance needs, but AA requirements decrease as maternal protein retention approaches zero (once losses from the previous lactation are recuperated; Using feeding programs that precisely match estimated daily energy and Lys requirements for gestating sows provides the opportunity to reduce nitrogen losses to the environment and reduce lactation feed usage, without negatively affecting sow reproductive and lactation performance. Based on the conditions of the current study with the genetics used across three consecutive gestation cycles, there appeared to be no ill effects for sows that received a static amount of energy and Lys throughout gestation and across parities. Although there were no notable differences in piglet characteristics from the time of birth to weaning, it is not known if precisely meeting estimated energy and Lys requirements throughout gestation will influence offspring post-weaning growth performance. Depending on commodity prices and individual farm factors, implementing a precision feeding program in gestation could be a means to reduce gestation and lactation feed costs. Future studies should examine the impact of precision feeding gestating sows in commercial scenarios using modern, hyper-prolific sow genetics.


Major advances in molecular profiling for available targeted treatments and immunotherapy for lung cancer have significantly increased the complexity of tissue-based diagnostics. Endobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNA) are commonly performed for diagnostic biopsies and lymph node staging. EBUS-TBNA has increasingly become one of the main sources of tumor cells for molecular analyses. As a result, there is a growing need for high quality EBUS-TBNA samples with adequate cellularity. This has increased the technical demands of the procedure and has created additional challenges, many of which are not addressed in the current EBUS guidelines. This review provides an overview of current evidence on the technical aspects of EBUS-TBNA in light of comprehensive sample processing for personalized lung cancer management. These include sonographic lymph node characterization, optimal needle choice, suction biopsy technique, and the role of rapid on-site evaluation. Attention to these technical details will be important to maximize the throughput of EBUS-TBNA biopsies for molecular testing. Linear endobronchial ultrasound (EBUS) is a well-established diagnostic tool for the workup and staging of lung cancer ,2. The dEndobronchial ultrasound-guided transbronchial needle aspirations (EBUS-TBNAs) are becoming one of the main sources for tissue-based biomarker analysis. Time is of the essence for the management of lung cancer, and there should be a close partnership between the pulmonary, surgical, and medical specialties responsible for the management of lung cancer. Ideally, EBUS samples can be simultaneously sent by the practitioner for diagnosis, staging, and molecular analysis so that these data will be available to the medical oncologist at the first visit rather than being ordered post hoc, further delaying therapeutic decision making. To accomplish these goals, there is a growing need for high quality EBUS-TBNA tissue samples, which has created additional challenges and has increased technical demands, many of which are not reflected in the current EBUS guidelines. In this review, we sought to review technical aspects of EBUS as they relate to lung cancer diagnostics and treatment in the current era of personalized cancer care.The identification and characterization of lymph nodes by EBUS is the first step in the selection of lymph nodes for biopsy, which is paramount considering the importance of accurate mediastinal staging. Ultrasonographic features to distinguish potentially metastatic lymph nodes from likely benign lymph nodes were first described by Fujiwara and colleagues in 2010 . They reWhile the most widely used ultrasonographic features to distinguish malignant from benign lymph nodes remains the size (short axis of >1 cm), smaller lymph nodes may still harbor malignancy. A systematic sampling of mediastinal, hilar, and interlobar lymph nodes should therefore be performed even in light of false negative rates of radiologic and nuclear staging ,23. For Thoughtful procedural planning and the flexibility to adapt available biopsy techniques is needed to satisfy increasing tissue demands for EBUS-TBNA. A suggested workflow is illustrated in ® needle (Medi-Globe) and in the Acquire Pulmonary® needle . All other needle types have a rounded or beveled single-point needle tip.The needle choice is the next important technical consideration because it may affect quality of the EBUS-TBNA biopsy samples. EBUS needles are now available from several manufacturers , and they are also available in various sizes . The earThe needle size and number of needle passes are both related factors that may determine the tissue yield of the EBUS-TBNA biopsies. Current recommendations of three needle passes to be performed for optimal diagnostic yield were derived from a study by Lee at al. published in 2008, which used the 22G EBUS-TBNA needle from Olympus. At that time, the main focus of EBUS-TBNAs was to provide the best possible diagnostic yield when comparisons to the previously established mediastinoscopy were underway and when molecular testing was still in its infancy ,26. In tThe CHEST guidelines from 2016 recommended a minimum of three needle passes with a 21G or 22G needle and additional samples for molecular analysis. However, as demonstrated by Ortaköylü and colleagues, more than 40% of EBUS-TBNA samples may be insufficient for pathological work up . TherefoA recently introduced technique using transbronchial mediastinal cryobiopsy using a channel created with a TBNA needle, similar to the previously described needle forceps technique, may be used in selected patients to yield additional tissue .Current guidelines leave the decision of whether suction should be applied during EBUS-TBNA sampling up to the bronchoscopist. While the use of suction may cause bleeding and potentially increased tissue damage, it may also result in the aspiration of more cells, particularly in lymph nodes with liquified consistencies. The existing evidence on the benefits of suction are limited to studies that are focused on the ability to secure the diagnosis as opposed to tissue yield ,37. CasaA further technical consideration that may affect the quality of EBUS-TBNA samples is the use of a rapid on-site evaluation (ROSE). The first randomized study to test the impact of ROSE on the diagnostic yield of EBUS-TBNAs was performed by Oki and colleagues. A total of 108 patients receiving EBUS-TBNA for suspected lung cancer were randomized for the additional use of ROSE during their EBUS procedure. Since a sample-size calculation had not been conducted and since the difference between the diagnostic yields of the two groups was small (sensitivity: 88% versus 86%), the authors admitted that this study was underpowered . FurtherMost larger studies on this topic have been retrospective in nature. Nakajima and colleagues analyzed 965 lymph node samples of 438 patients obtained via EBUS-TBNA. Eighty-four lymph nodes (8.7%) were determined to be insufficient for definitive diagnosis by final cytologic evaluation, the non-diagnostic sampling rate was 4.0%, and the rate of false-negative ROSE results was 5.7%. The concordance rate for staging between ROSE and final pathologic diagnosis was 94.3% . AnotherChoi et al. demonstrated that the adequacy of ROSE from EBUS-TBNA samples could be significantly increased when an algorithm with the following four criteria was implemented: (1) ≥3 punctures per lymph node, (2) the presence of tumor cells, (3) the presence of microscopic anthracotic pigments (MAP), and (4) lymph node (LD) density of ≥40 cells/field  in smears. On permanent tissue histology, a core tissue size ≥ 2 cm, MAP, and LD ≥ 40 cells/field in smears were significantly related to adequate results. The diagnostic sensitivity of the specimen was increased from 64.7% using a core size ≥ 2 cm as the only criterion to 97% using all four criteria, while the lymph node density >40 cells/field only increased the adequacy by 2% (95% compared to 97%) . The stuEGFR and KRAS testing by next-generation sequencing (NGS), followed by ALK testing (FISH) for EGFR and KRAS wild-type disease. ROSE was associated with a higher percentage of patients for whom the institution’s clinical protocol for lung cancer genotyping was completed  and a decrease in the number of samples that could only be used for diagnostic purposes  [More recently, the impact of ROSE on molecular workup has been demonstrated in several studies. In addition to the qualitative assessment for establishing cytologic diagnostic, ROSE may also allow for a quantitative evaluation of the percentage of tumor cells in the smear to gauge suitability for molecular testing. As such, Yarmus and colleagues reported that 95.3% of EBUS-TBNA samples were sufficient for KRAS, EGFR by polymerase chain reaction (PCR), and/or ALK mutation analyses via fluorescence in situ hybridazition (FISH) when four passes were sampled with a 21G needle in the presence of ROSE . Trisoli = 0.05) . These dIn the current era of personalized pulmonary oncology and immunotherapies, the necessary amount of tumor DNA and lymphocytes for thorough evaluation via next-generation sequencing (NGS) to detect multiple genes and PD-L1 immunostaining have likely increased beyond what is typically achieved with four sample passes with a 21G needle. The input DNA requirement for NGS analysis varies by testing platform but ranges between 10 ng for Ion Torrent PGM  for the detection of 50 genes and 250 ng for Illumina MiSeq  platforms for the detection of 48 genes . DependiImmunohistochemical staining with anti-PD-L1 antibodies has become an integral part of EBUS-TBNA pathology workup in lung cancer patients. Single-agent immunotherapy with the anti-PD-1 drug pembrolizumab has been approved by the FDA for the front-line treatment of patients with advanced EGFR/ALK wild-type NSCLC whose tumors have ph nodes . The conG needle . EBUS-TBG needle ,53. YoshG needle . With reG needle .While EBUS-TBNA has been established and widely adopted in clinical practice, there is an ongoing need for high-quality research. Randomized-controlled prospective trials are crucial to define the benefits of technical advancements such as navigational techniques, new robotic platforms, needle designs, and new refinements in cytopathological processing. Study designs need to reflect the increasing demands of lung cancer precision diagnostics by shifting the primary focus from diagnostic yield to cellular quality and quantity. Implementation research will help to further enhance procedural techniques and lead to the widespread adoption of best practices.The role of EBUS-TBNA in the management of lung cancer has evolved from a primarily diagnostic and staging modality to also serve as an effective vehicle for molecular testing for the growing number of actionable genetic alterations and for the testing of diagnostic and/or predictive biomarkers. It enables concurrent diagnosis, staging, and molecular analysis, speeding up therapeutic decision-making. The lymphocyte and tumor cell amounts of EBUS-TBNAs matter for molecular work-up and PD-L1 staining can best be estimated when ROSE is used. Because NGS panels differ between institutions, the amount of required DNA varies as well. In general, an addition two to three sample passes with the use if a 21G needle or using an even larger needle design should be considered to optimize the throughput of EBUS-TBNA samples for comprehensive molecular testing, especially when PD-L1 staining is added. The use of suction may also additionally increase the amount of sampled material. Further studies on EBUS-TBNA are needed to establish universal protocols that maximize the yield of cytology material for molecular workup while maintaining the established reliable diagnostic workflow.