A Mixed-Methods Exploration of Competencies and Professional Development Needs Among Chief Certified Registered Nurse Anesthetists.

This project sought to explore the experiences, self-perceived preparation, professional development needs, and preferred learning methods of certified registered nurse anesthetists (CRNAs) in a management role. A sample of 10 current chief CRNAs responded to a demographics survey and participated in one-on-one interviews using a 14-question, semi-structured interview framework modified from a previous study. Interview responses were deidentified and qualitatively analyzed for common themes by two content experts and one qualitative analysis expert. Results suggest that CRNAs entering the management field feel somewhat unprepared to perform the administrative tasks associated with their role. Qualitative analysis of interview responses elicited multiple key themes including interpersonal communication and handling crucial conversations, time and organizational management skills, team building and motivation, and financial management skills. Themes related to preferred learning methods of chief CRNAs included mentorship, peer networking, and experiential learning to obtain the required knowledge and skills for the role. The authors recommend incorporating each of the identified themes to guide development of CRNA management-specific educational programs. Establishing such a program will serve to better prepare aspiring CRNA managers and further develop the knowledge and skillset of current chief CRNAs.

Challenges for Nurse Anesthetists Reentering Practice Following Substance Use Disorder Treatment.

Substance use disorder (SUD) is a persistent, relapsing condition that is present in approximately 10% of anesthesia providers, who, compared with other healthcare providers, face a greater risk of developing an SUD by virtue of constant access to medications. The ability of certified registered nurse anesthesiologists (CRNAs) to obtain or maintain employment after treatment for SUD treatment is not well documented. The purpose of this qualitative study was to explore challenges encountered by CRNAs in recovery as they attempt to reenter practice following SUD treatment. The phenomenon was explored through multiple-case study, using qualitative semistructured interviews with participants in four cases: CRNAs in recovery, CRNA colleagues, CRNA employers, and professional health program employees. Thirty-six participants conveyed their perspectives about challenges that CRNAs in recovery face upon reentry into practice following SUD treatment. The Worker Well-Being conceptual model was used to guide this study. The study revealed that more SUD education is a key facilitator for reentry, risk of relapse was a major concern, and stigma was the most significant barrier for CRNAs in recovery. Stigma persists as a considerable barrier in many facets of SUD, contributing to an increase in shame associated with having the disease.

Implementation of a Spaced Learning Program for Educating CRNAs on a Scalpel-Bougie Cricothyrotomy Procedure for Emergency Front of Neck Access.

Certified registered nurse anesthetists (CRNAs) who are responsible for airway management, may lack adequate continuing education for emergency front of neck access (EFONA), an advanced skill necessary in situations when a patient cannot be intubated and cannot be oxygenated (CICO). The purpose of this study was to improve CRNA knowledge and confidence when performing a scalpel-bougie cricothyrotomy for EFONA in a CICO event through the implementation of a spaced learning intervention. Thirteen CRNAs at a 160-bed community hospital participated in a 3-week educational intervention. Week 1: online preintervention survey followed by an educational video. Week 2: video review and skills component practiced on a cricothyrotomy trainer. Week 3: skills component practiced on a cricothyrotomy trainer followed by postintervention survey. This was a single-arm study and Wilcoxon sign ranked tests and a paired t-test were utilized to monitor for change in CRNA knowledge, confidence, and skill in performing EFONA. Implementation of a 3-week spaced learning program for educating CRNAs to perform a scalpel-bougie cricothyrotomy significantly increased CRNA knowledge, confidence, and skill when performing EFONA. Utilizing a spaced learning program may therefore improve provider skills, resulting in optimized patient care during a CICO event, leading to improved patient safety and outcomes.

Analysis of nitrogen source assimilation in industrial strains of Aspergillus oryzae.

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

A Nurse Anesthesiology Mentorship Program: An Evidence-Based Project for Implementation.

Transitioning from the role of student to the professional certified registered nurse anesthetist (CRNA), as well as a CRNA transitioning to a new job can be very difficult because of uncertainty in the new environment when compounded by a lack of social support. A formal mentorship program was developed and organized by CRNA leadership to help retain and engage new employees and ensure that they assimilate to the new culture while effectively gaining institutional knowledge and clinical skills. The mentorship program consisted of structured meetings that included the newly hired cohort of CRNAs, matched mentors, and CRNA leadership at regular intervals to foster a sense of community and professional growth. The working definition of the mentorship process for this project was described as the following: a mentor, defined as an experienced CRNA, not a direct manager, meets with the mentee, a newly hired CRNA, on a regular basis following a predetermined timeline to assess and meet the mentee's goals, to provide resources, including networking, and to provide guidance for the mentee to make the best decisions for their professional and personal growth. The purpose of this project was to explain the potential benefits of implementing a formal mentorship program for recruiting, on-boarding, and retaining CRNAs.

An Evaluation of Commercial Payer Reimbursement and Contracting Factors for Physician Anesthesiologists and Certified Registered Nurse Anesthetists for Services Performed in 2019.

We sought to establish commercial rate benchmarks specific to certified registered nurse anesthetist (CRNA) anesthesia delivery models (QZ), quantify any payer disparities discovered between CRNAs and anesthesiologists, and determine payer alignment with nondiscrimination provisions of the Affordable Care Act (ACA). The Lewin Group administered the exploratory, descriptive study of QZ billing practices by surveying a targeted cross-section of 345 CRNAs known for QZ billing. Forty-one respondents reported information from 1,089 CRNAs and 351,920 cases with 127,888 commercial claims billed under 144 unique commercial contracts as performed in 2019. There was a 24% payer disparity in rates negotiated reported between anesthesia providers: CRNAs overall average of $58.62; $55.33-$64.57, compared with anesthesiologist average of $77.01 overall; $73.79-$80.76. Other findings included QZ payment adjustments, denials for reimbursement, and exclusion from plan participation. The study found disparities in rate and discriminatory payer practices specific to CRNA contracting and reimbursement, which suggests payer misalignment with nondiscrimination provisions of the ACA.

The Intersectional Impact of Cost-Related Non-Adherence and Depression: A Cross-Sectional Analysis of the Canadian Community Health Survey by Sex, Race, and Indigeneity.

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

Cognitive Preference and Clinical Experience: The Relationship Between Student Nurse Anesthetists' and Certified Registered Nurse Anesthetists' Thinking Styles.

This study examined the relationship between cognitive preference and clinical experience in student registered nurse anesthetists (SRNAs) and certified registered nurse anesthetists (CRNAs). Survey data was collected from enrolled SRNAs and practicing CRNAs via an email link distributive through a network sampling technique. Participants completed the Rational Experiential Inventory (REI-40), which assesses individuals' preference, ability, and engagement with rational and experiential cognitive styles. Data analysis revealed that SRNAs and CRNAs have the ability and engagement preference for rational decision-making. Furthermore, there was no statistical significance in years of clinical experience to cognitive preference, nor was there a statistically significant difference between SRNA and CRNA REI-40 Inventory results. Based on these findings, the dominant cognitive preference is rational cognition and experiential thinking preference remains constant with increased experience. This knowledge contributes to our understanding of CRNAs' decision-making related to cognitive processes and provides insight into SRNA clinical education and CRNA continuing development.

Practice Model Trends in Medicare Payments Across States and Regions.

Anesthesia delivery models have long been shaped by workforce trends, state and federal regulations, economic incentives driven by reimbursement, and the normative preferences of provider and facility organizations. In recent years, there has been a significant shift toward greater use of more efficient certified registered nurse anesthetist (CRNA)-oriented delivery models observed at the national level Medicare data. However, given the wide range of these factors across states and regions, this shift has likely occurred at an uneven pace. This study analyzes the influence of provider workforce composition and CRNA scope of practice (SOP) regulations on usage of competing types of anesthesia delivery models, including anesthesiologist alone, care team, and undirected CRNA models. Results show that over the period from 2010-2019, anesthesia delivery models utilized under Medicare Part B have become increasingly oriented around the use of CRNAs. However, increases in the care team vs undirected CRNA model are highly uneven and inconsistent across states, even after adjusting for workforce and SOP. Speculation on additional normative or organization-driven reasons for persistent use of inefficient delivery models in some places is offered.

A Qualitative Description of CRNA Clinical Coordinators' and Student Registered Nurse Anesthetists' Perceptions of Clinical Readiness.

The transition from classroom academic environment to clinical patient-focused learning is a celebrated milestone, yet it is a source of stress and anxiety for student registered nurse anesthetists (SRNAs). In nurse anesthesia education, limited information exists on perceptions of clinical readiness, either from the certified registered nurse anesthetist (CRNA) clinical educators' or the SRNAs' experiences. The purpose of this study was to explore the perceptions of CRNA clinical coordinators and SRNAs regarding clinical readiness as the students transition from classroom to clinical training. A qualitative descriptive design from a postpositivist philosophical mindset was utilized and a semistructured interview guide and content analysis methodology described by Graneheim and Lundman was used. Seventeen participants were interviewed. Four themes emerged from the analysis of the CRNA clinical coordinators' perceptions: 1) going in with good attitudes and professionalism, 2) the expectation of clinical readiness, 3) mental preparedness, and 4) solid simulation experiences. Additionally, four themes emerged from the content analysis of students' perception: 1) expectations of readiness is higher than anticipated, 2) transitional orientation/adjuncts for preparedness, 3) sound didactic training, and 4) simulation and the effects of COVID-19. While prioritization is different, educators and SRNAs value knowledge, skills (including simulated), and positive attitudes as measures of clinical readiness.

Assessing CRNA Knowledge of Local Anesthetic Systemic Toxicity Treatment.

Local anesthetic systemic toxicity (LAST) is a rare life-threatening adverse event. Due to the potential for devastating patient outcomes, it is crucial for anesthesia providers to understand appropriate LAST management. The primary aim of this study was to assess certified registered nurse anesthetist (CRNA) knowledge of the 2020 American Society of Regional Anesthesia and Pain Medicine (ASRA) LAST treatment guidelines. The secondary aim was to determine whether there was a relationship between the frequency of CRNAs' exposure to perioperative local anesthetic use and their knowledge level. A quantitative descriptive study and national American Association of Nurse Anesthetists electronic survey solicited practicing CRNAs. Survey findings revealed knowledge scores averaging 47.3% among 184 respondents. Almost all (97.8%) recognized the importance of early lipid emulsion administration. Over half (54.3%) were unaware of the recommended epinephrine dosing during LAST. No relationship was found between knowledge level and CRNAs' exposure to local anesthetics. Those who reported having immediate access to written or electronic guidelines in the event of LAST had significantly higher knowledge scores than those without access (P = .049). Implementing cognitive aids may help bridge knowledge gaps identified in this study and ensure critical steps are not missed. Further studies examining the use of cognitive aids to improve CRNA knowledge of LAST management may be beneficial in the future.

California Certified Registered Nurse Anesthetist Workforce Study.

BACKGROUND: Nurse anesthesia in California has been instrumental in shaping Certified Registered Nurse Anesthetist (CRNA) practice nationally, but to date, no workforce data has been published on this group of Advanced Practice Registered Nurses. PURPOSE: The purpose of this workforce study was to explore the demographic information, education, and practice patterns of CRNAs working in California. METHODS: Survey methodology was conducted to gather workforce data from a sample of licensed CRNAs working in California. DISCUSSION: California CRNAs provide anesthesia services in very diverse settings among different anesthesia delivery models, including independent practice. CRNAs practice in a majority of California counties and are the sole anesthesia providers for four underserved counties. CONCLUSION: The CRNA workforce in California is comparatively young, highly educated, and desires more education. CRNAs improve access to care for California patients; however, more ethnically diverse CRNAs and CRNAs with Non-Surgical Pain Management Certification are needed.

Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol.

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

The impact of prescription drug insurance on cost related non-adherence to medications in Canada: A Heckman sample selection approach.

Unlike some other high-income counties, Canada does not provide universal prescription drug coverage. The various extent of coverage may left some Canadians vulnerable to cost-related non-adherence (CRNA) to medications. Using data from the 2015 national cycle of the Canadian Community Health Survey, we examine the impact of having private and public drug coverage on mitigating the risk of CRNA with a logit model and a Heckman selection model. CRNA was only observed in respondents who had prescriptions to fill, and respondents did not randomly make decisions on whether to get a prescription. This results in a classic sample selection problem. We found a higher estimated probability of reporting CRNA for uninsured respondents from the Heckman selection model than from the logit model. Respondents with government coverage only had a slightly higher probability of reporting CRNA relative to respondents with private coverage. These findings suggest that, without accounting for sample selection, the risk of not having drug insurance coverage is likely to be underestimated. Moreover, despite covering a less healthy cohort of respondents, the government insurance plans reduce risk of CRNA to a comparable level with private insurance.

Cost-related prescription non-adherence and patient-reported outcomes in systemic lupus erythematosus: The Michigan Lupus Epidemiology & Surveillance program.

OBJECTIVES: Medication access and adherence play key roles in determining patient outcomes. We investigated whether cost-related non-adherence (CRNA) to prescription medications was associated with worse patient-reported outcomes in a population-based systemic lupus erythematosus (SLE) cohort. METHODS: Sociodemographic and prescription data were collected by structured interviews in 2014-2015 from patients meeting SLE criteria in the established Michigan Lupus Epidemiology & Surveillance (MILES) Cohort. We examined the associations between CRNA and potential confounders such as sociodemographics and health insurance coverage, and outcome measures of SLE activity and damage using multivariable linear regression. RESULTS: 462 SLE participants completed the study visit: 430 (93.1%) female, 208 (45%) Black, and mean age 53.3 years. 100 (21.6%) participants with SLE reported CRNA in the preceding 12 months. After adjusting for covariates, CRNA was associated with both higher levels of current SLE disease activity [SLAQ: ß coeff 2.7 (95% CI 1.3, 4.1), p < 0.001] and damage [LDIQ ß coeff 1.4 (95% CI 0.5, 2.4), p = 0.003]. Race, health insurance status, and fulfilling Fibromyalgia (FM) Survey Criteria were independently associated with both higher (worse) SLAQ and LDIQ scores; female sex was further associated with higher SLAQ scores. CONCLUSION: Patients with SLE who reported CRNA in the previous 12 months had significantly worse self-reported current disease activity and damage scores compared to those not reporting CRNA. Raising awareness and addressing barriers or concerns related to financial implications and accessibility issues in care plans may help to improve these outcomes.

Toward a Molecular Mechanism of Complementary RNA Duplexes Denaturation.

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

Synthesis and properties of a novel modified nucleic acid, 2'-N-methanesulfonyl-2'-amino-locked nucleic acid.

2'-Amino-locked nucleic acid has a functionalizable nitrogen atom at the 2'-position of its furanose ring that can provide desired properties to a nucleic acid as a scaffold. In this study, we synthesized a novel nucleic acid, 2'-N-methanesulfonyl-2'-amino-locked nucleic acid (ALNA[Ms]) and conducted comparative studies on the physical and pharmacological properties of the ALNA[Ms] and on conventional nucleic acids, such as 2'-methylamino-LNA (ALNA[Me]), which is a classical 2'-amino-LNA derivative, and also on 2',4'-BNA/LNA (LNA). ALNA[Ms] oligomers exhibited binding affinities for the complementary RNA strand that are similar to those of conventional nucleic acids. Four types of ALNA[Ms] nucleosides exhibited no genotoxicity in bacterial reverse mutation assays. The knockdown abilities of Malat1 RNA using the Matat1 antisense oligonucleotide (ASO) containing ALNA[Ms] were higher than those of ALNA[Me] and were closer to those of LNA. Furthermore, the ASO containing ALNA[Ms] showed different tissue tropism from that containing LNA. ALNA[Ms] exhibited biological activities that were distinct from conventional constrained nucleic acids, suggesting the possibility that ALNA[Ms] can serve as novel modified nucleic acids in oligonucleotide therapeutics.

The utility of zebrafish cardiac arrhythmia model to predict the pathogenicity of KCNQ1 variants.

Genetic testing for inherited arrhythmias and discriminating pathogenic or benign variants from variants of unknown significance (VUS) is essential for gene-based medicine. KCNQ1 is a causative gene of type 1 long QT syndrome (LQTS), and approximately 30% of the variants found in type 1 LQTS are classified as VUS. We studied the role of zebrafish cardiac arrhythmia model in determining the clinical significance of KCNQ1 variants. We generated homozygous kcnq1 deletion zebrafish (kcnq1del/del) using the CRISPR/Cas9 and expressed human Kv7.1/MinK channels in kcnq1del/del embryos. We dissected the hearts from the thorax at 48 h post-fertilization and measured the transmembrane potential of the ventricle in the zebrafish heart. Action potential duration was calculated as the time interval between peak maximum upstroke velocity and 90% repolarization (APD90). The APD90 of kcnq1del/del embryos was 280 ± 47 ms, which was significantly shortened by injecting KCNQ1 wild-type (WT) cRNA and KCNE1 cRNA (168 ± 26 ms, P < 0.01 vs. kcnq1del/del). A study of two pathogenic variants (S277L and T587M) and one VUS (R451Q) associated with clinically definite LQTS showed that the APD90 of kcnq1del/del embryos with these mutant Kv7.1/MinK channels was significantly longer than that of Kv7.1 WT/MinK channels. Given the functional results of the zebrafish model, R451Q could be reevaluated physiologically from VUS to likely pathogenic. In conclusion, functional analysis using in vivo zebrafish cardiac arrhythmia model can be useful for determining the pathogenicity of loss-of-function variants in patients with LQTS.

Effect of temperature and IRF-9 gene-knockout on dynamics of vRNA, cRNA, and mRNA of viral hemorrhagic septicemia virus (VHSV).

The replication of viral hemorrhagic septicemia virus (VHSV) in appropriate host cells depends on environmental factors and the host cell's immunity. The dynamics of each VHSV RNA strand (vRNA, cRNA, and mRNA) in different conditions can provide a clue on the viral replication strategies, which can be a base for the development of efficient control measures. As VHSV is known to be sensitive to temperature and type I interferon (IFN) responses, in this study, we analyzed the effect of temperature difference (15 °C and 20 °C) and IRF-9 gene knockout on the dynamics of the three VHSV RNA strands in Epithelioma papulosum cyprini (EPC) cells using a strand-specific RT-qPCR. The tagged primers designed in this study successfully worked to quantify the three strands of VHSV. In the results of the temperature effect, the higher speed in viral mRNA transcription and the significantly higher (more than 10 times at 12-36 h) copy number of cRNA at 20 °C compared to those at 15 °C suggested the positive effect of high temperature on VHSV replication. In the results of the IRF-9 gene knockout effect, although IRF-9 gene knockout did not bring a dramatic effect on VHSV replication compared to the temperature effect, the increase of mRNA in IRF-9 KO cells was faster than normal EPC cells, which was reflected in the copy numbers of cRNA and vRNA. The IRF-9 gene knockout effect was not dramatic even in the replication of rVHSV-ΔNV-eGFP that harbors eGFP gene ORF instead of NV gene ORF. These results suggest that VHSV may be highly susceptible to pre-activated type I IFN responses but not highly susceptible to post-infection-mediated type I IFN responses or lowered type I IFN before infection. In both experiments of temperature effect and IRF-9 gene knockout effect, the copy number of cRNA never exceeded the copy number of vRNA at all assay times, suggesting that the binding efficiency of the RNP complex to the 3' end of cRNA might be lower than that to the 3' end of vRNA. Further research is needed to elucidate the regulatory mechanism that limits the amount of cRNA at an appropriate level during VHSV replication.

Avian Influenza A Virus Polymerase Can Utilize Human ANP32 Proteins To Support cRNA but Not vRNA Synthesis.

Host restriction limits the emergence of novel pandemic strains from the influenza A virus avian reservoir. For efficient replication in mammalian cells, the avian influenza RNA-dependent RNA polymerase must adapt to use human orthologues of the host factor ANP32, which lack a 33-amino-acid insertion relative to avian ANP32A. Here, we find that influenza polymerase requires ANP32 proteins to support both steps of genome replication: cRNA and vRNA synthesis. However, avian strains are only restricted in vRNA synthesis in human cells. Therefore, avian influenza polymerase can use human ANP32 orthologues to support cRNA synthesis, without acquiring mammalian adaptations. This implies a fundamental difference in the mechanism by which ANP32 proteins support cRNA versus vRNA synthesis. IMPORTANCE To infect humans and cause a pandemic, avian influenza must first adapt to use human versions of the proteins the virus hijacks for replication, instead of the avian orthologues found in bird cells. One critical host protein is ANP32. Understanding the details of how host proteins such as ANP32 support viral activity may allow the design of new antiviral strategies that disrupt these interactions. Here, we use cells that lack ANP32 to unambiguously demonstrate ANP32 is needed for both steps of influenza genome replication. Unexpectedly, however, we found that avian influenza can use human ANP32 proteins for the first step of replication, to copy a complementary strand, without adaptation but can only utilize avian ANP32 for the second step of replication that generates new genomes. This suggests ANP32 may have a distinct role in supporting the second step of replication, and it is this activity that is specifically blocked when avian influenza infects human cells.