SARS-CoV-2 viral load is associated with risk of transmission to household and community contacts.

BACKGROUND: Factors that lead to successful SARS-CoV-2 transmission are still not well described. We investigated the association between a case's viral load and the risk of transmission to contacts in the context of other exposure-related factors. METHODS: Data were generated through routine testing and contact tracing at a large university. Case viral loads were obtained from cycle threshold values associated with a positive polymerase chain reaction test result from October 1, 2020 to April 15, 2021. Cases were included if they had at least one contact who tested 3-14 days after the exposure. Case-contact pairs were formed by linking index cases with contacts. Chi-square tests were used to evaluate differences in proportions of contacts testing positive. Generalized estimating equation models with a log link were used to evaluate whether viral load and other exposure-related factors were associated with a contact testing positive. RESULTS: Median viral load among the 212 cases included in the study was 5.6 (1.8-10.4) log10 RNA copies per mL of saliva. Among 365 contacts, 70 (19%) tested positive following their exposure; 36 (51%) were exposed to a case that was asymptomatic or pre-symptomatic on the day of exposure. The proportion of contacts that tested positive increased monotonically with index case viral load (12%, 23% and 25% corresponding to < 5, 5-8 and > 8 log10 copies per mL, respectively; X2 = 7.18, df = 2, p = 0.03). Adjusting for cough, time between test and exposure, and physical contact, the risk of transmission to a close contact was significantly associated with viral load (RR = 1.27, 95% CI 1.22-1.32). CONCLUSIONS: Further research is needed to understand whether these relationships persist for newer variants. For those variants whose transmission advantage is mediated through a high viral load, public health measures could be scaled accordingly. Index cases with higher viral loads could be prioritized for contact tracing and recommendations to quarantine contacts could be made according to the likelihood of transmission based on risk factors such as viral load.

One-step generation of a targeted knock-in calf using the CRISPR-Cas9 system in bovine zygotes.

BACKGROUND: The homologous recombination (HR) pathway is largely inactive in early embryos prior to the first cell division, making it difficult to achieve targeted gene knock-ins. The homology-mediated end joining (HMEJ)-based strategy has been shown to increase knock-in efficiency relative to HR, non-homologous end joining (NHEJ), and microhomology-mediated end joining (MMEJ) strategies in non-dividing cells. RESULTS: By introducing gRNA/Cas9 ribonucleoprotein complex and a HMEJ-based donor template with 1 kb homology arms flanked by the H11 safe harbor locus gRNA target site, knock-in rates of 40% of a 5.1 kb bovine sex-determining region Y (SRY)-green fluorescent protein (GFP) template were achieved in Bos taurus zygotes. Embryos that developed to the blastocyst stage were screened for GFP, and nine were transferred to recipient cows resulting in a live phenotypically normal bull calf. Genomic analyses revealed no wildtype sequence at the H11 target site, but rather a 26 bp insertion allele, and a complex 38 kb knock-in allele with seven copies of the SRY-GFP template and a single copy of the donor plasmid backbone. An additional minor 18 kb allele was detected that looks to be a derivative of the 38 kb allele resulting from the deletion of an inverted repeat of four copies of the SRY-GFP template. CONCLUSION: The allelic heterogeneity in this biallelic knock-in calf appears to have resulted from a combination of homology directed repair, homology independent targeted insertion by blunt-end ligation, NHEJ, and rearrangement following editing of the gRNA target site in the donor template. This study illustrates the potential to produce targeted gene knock-in animals by direct cytoplasmic injection of bovine embryos with gRNA/Cas9, although further optimization is required to ensure a precise single-copy gene integration event.

Screening Programs for SARS-CoV-2 Infections on a University Campus - Austin, Texas, September 30-November 30, 2020.

Colleges and universities in the United States have relied on various measures during the COVID-19 pandemic to prevent transmission of SARS-CoV-2, the virus that causes COVID-19, including implementing testing programs (1-3). These programs have permitted a safer return to campus for students by identifying infected persons and temporarily isolating them from the campus population (2,3). The University of Texas at Austin (UT Austin) implemented COVID-19 prevention measures in Fall 2020* including the following testing programs: clinic-based diagnostic testing, voluntary community screening, and targeted screening (testing of specific student populations in situations of increased transmission risk). During September 30-November 30, 2020, UT Austin students participated in tests for SARS-CoV-2, which resulted in the detection of 401 unique student cases of COVID-19 from among 32,401 tests conducted.† Among students who participated in one targeted screening program for students attending campus events, 18 (37.5%) of 48 infected students were asymptomatic at the time of their positive test result compared with 45 (23%) of 195 students identified through community testing and nine (5.8%) of 158 students identified through clinic-based testing. Targeted screening also identified a different population of students than did clinic-based and community testing programs. Infected students tested through targeted screening were more likely to be non-Hispanic White persons (chi square = 20.42; p<0.03), less likely to engage in public health measures, and more likely to have had interactions in settings where the risk for SARS-CoV-2 transmission is higher, such as restaurants, gyms, and residence halls. In addition to clinic-based SARS-CoV-2 testing at colleges and universities, complementary testing programs such as community and targeted screening might enhance efforts to identify and control SARS-CoV-2 transmission, especially among asymptomatic persons and disproportionately affected populations that might not otherwise be reached.

Improved first trimester maternal iodine status with preconception supplementation: The Women First Trial.

Maternal iodine (I) status is critical in embryonic and foetal development. We examined the effect of preconception iodine supplementation on maternal iodine status and on birth outcomes. Non-pregnant women in Guatemala, India and Pakistan (n ~ 100 per arm per site) were randomized ≥ 3 months prior to conception to one of three intervention arms: a multimicronutrient-fortified lipid-based nutrient supplement containing 250-µg I per day started immediately after randomization (Arm 1), the same supplement started at ~12 weeks gestation (Arm 2) and no intervention supplement (Arm 3). Urinary I (µg/L) to creatinine (mg/dl) ratios (I/Cr) were determined at 12 weeks for Arm 1 versus Arm 2 (before supplement started) and 34 weeks for all arms. Generalized linear models were used to assess the relationship of I/Cr with arm and with newborn anthropometry. At 12 weeks gestation, adjusted mean I/Cr (µg/g) for all sites combined was significantly higher for Arm 1 versus Arm 2: (203 [95% CI: 189, 217] vs. 163 [95% CI: 152, 175], p < 0.0001). Overall adjusted prevalence of I/Cr < 150 µg/g was also lower in Arm 1 versus Arm 2: 32% (95% CI: 26%, 38%) versus 43% (95% CI: 37%, 49%) (p = 0.0052). At 34 weeks, adjusted mean I/Cr for Arm 1 (235, 95% CI: 220, 252) and Arm 2 (254, 95% CI: 238, 272) did not differ significantly but were significantly higher than Arm 3 (200, 95% CI: 184, 218) (p < 0.0001). Nominally significant positive associations were observed between I/Cr at 12 weeks and birth length and head circumference z-scores (p = 0.028 and p = 0.005, respectively). These findings support the importance of first trimester iodine status and suggest need for preconception supplementation beyond salt iodization alone.

FGF4 retrogene on CFA12 is responsible for chondrodystrophy and intervertebral disc disease in dogs.

Chondrodystrophy in dogs is defined by dysplastic, shortened long bones and premature degeneration and calcification of intervertebral discs. Independent genome-wide association analyses for skeletal dysplasia (short limbs) within a single breed (PBonferroni = 0.01) and intervertebral disc disease (IVDD) across breeds (PBonferroni = 4.0 × 10-10) both identified a significant association to the same region on CFA12. Whole genome sequencing identified a highly expressed FGF4 retrogene within this shared region. The FGF4 retrogene segregated with limb length and had an odds ratio of 51.23 (95% CI = 46.69, 56.20) for IVDD. Long bone length in dogs is a unique example of multiple disease-causing retrocopies of the same parental gene in a mammalian species. FGF signaling abnormalities have been associated with skeletal dysplasia in humans, and our findings present opportunities for both selective elimination of a medically and financially devastating disease in dogs and further understanding of the ever-growing complexity of retrogene biology.

Transition to Office-based Obstetric and Gynecologic Procedures: Safety, Technical, and Financial Considerations.

Office-based surgery is increasingly desired by patients and providers due to ease of access, overall efficiency, reimbursement, and satisfaction. The adoption of office-based surgery requires careful consideration of safety, efficacy, cost, and feasibility within a providers practice. This article reviews the currently available data regarding patient and provider satisfaction as well as practical considerations of staffing, equipment, and supplies. To aid the practitioner, issues of office-based anesthesia and safety with references to currently available national guidelines and protocols are provided. Included is a brief review of billing, coding, and reimbursement. Technical procedural aspects with information and recommendations are summarized.

Effective strategies in improving operating room case delays and cancellations at an academic medical center.

BACKGROUND: Traditionally, the operating room (OR) in an academic medical center has faced numerous challenges to effective clinical productivity, including additional missions of teaching and research. Level 1 trauma poses more challenges related to the need for additional specialized personnel in anesthesia, surgery, and nursing. The present investigation explores lessons learned in efficiency, teamwork, and data evaluation at a level 1 academic teaching facility. METHODS: The months of July 2012, July 2013, and July 2014 were selected for this study. Multiple strategies were implemented through the Operating Room Committee during this time in an effort to reduce the number of OR delays and cancellations. RESULTS: Case cancellations decreased significantly over the three-year period, while delays remained relatively stable. In July 2012, 15.0% of cases were cancelled and 10.2% were delayed. Cancellations decreased to 6.3% in 2013 and to 5.9% in 2014. The total number of cases completed per month increased each year throughout the study, from 577 in 2012 to 649 in 2013 to 842 in 2014. CONCLUSION: These results are remarkable in comparison to the greater-than 20% cancellation rate recorded in 2005 when the current OR leadership team first assessed OR efficiency. An increase in the number of cases completed per month likely can be attributed to a reduction in the number of case cancellations. Increased efficiency allows for more operations to be performed, leading to increased profitability and an increased ability of hospitals to continue caring for patients. We advocate the implementation of a comprehensive multidisciplinary strategy for sustained improvement in OR efficiency and utilization.

To err is human; to provide safe, quality, and cost-effective hysterectomy is divine!

Approximately 500,000 hysterectomies are performed each year in the United States despite the existence of numerous nondefinitive alternatives. Gaining an understanding of the relationship between quality, safety, and cost is critical to gynecologists performing this procedure. Analysis of quality measures includes important process measures such as time-out procedures, the Surgical Care Improvement Project, Peer Review, and Credentialing. Databases, such as the National Surgical Quality Improvement Program, are also available for review of quality. Safety is evaluated by analyzing outcomes including complications, route of procedure, and patient satisfaction. The cost of hysterectomy is impacted by continuous quality and safety improvements.

Current insights into equine neuroaxonal dystrophy/equine degenerative myeloencephalopathy.

Equine neuroaxonal dystrophy/equine degenerative myeloencephalopathy (eNAD/EDM) is an inherited neurodegenerative disease associated with vitamin E deficiency in the first year of life. It is the second most common cause of spinal ataxia in horses euthanized for neurologic disease. Equine NAD/EDM is characterized by neurologic signs including a symmetric proprioceptive ataxia (> grade 2/5) and a wide-base stance at rest. There are currently no antemortem tests for eNAD/EDM in any breed. Conclusive diagnosis requires postmortem histologic evaluation of the brainstem and spinal cord at necropsy. Research studies on antemortem biomarkers and genetic testing are ongoing. The development of a genetic test for eNAD/EDM would have widespread impact, even if it were breed specific. Currently, the best approach to eNAD/EDM is to focus on preventing cases by providing pregnant mares and foals with access to pasture. Alternatively, dams' diets can be supplemented with high doses of water-soluble RRR-α-tocopherol during the last trimester of gestation, with continued supplementation of foals through the first two years of life. It is important to measure horses' baseline serum vitamin E levels prior to supplementing. While considered generally safe, oversupplementation of vitamin E is possible and can lead to coagulopathies.

Placental abruption and fetal demise secondary to placental metastases from unknown primary: a case report.

BACKGROUND: Although maternal malignancy is relatively common, maternal metastases to the products of conception remains a rare event. There is no available literature that describes the incidence of placental metastases as a cause of abruption and fetal death. importanc CASE: We present an unusual case of placental abruption and disseminated intravascular coagulation leading to fetal demise secondary to placental metastases of unknown origin. CONCLUSION: In our case placental abruption likely resulted from metastases to the intervillous space.

Contributions, Aspirations, and Challenges of Academic Specialist Divisions in Obstetrics and Gynecology.

Shortly after its inception, the Society for Academic Specialists in General Obstetrics and Gynecology recognized that no data described the composition and faculty activities of "academic generalist divisions." Consequently, in 2018, the Society for Academic Specialists in General Obstetrics and Gynecology appointed a presidential task force and conducted the current surveys of chairs and division directors and key informant interviews to understand the composition and faculty activities in divisions of academic specialists in departments of obstetrics and gynecology and propose criteria for excellence in each mission area to guide development of divisions. In 2014, with Society for Academic Specialists in General Obstetrics and Gynecology's guidance, these divisions were referred to as academic specialists divisions and the faculty within as academic specialists to emphasize that they provide specialized women's health care in academic settings. The divisions comprised approximately 30% of departments' full-time faculty (median 12). In 27% of the departments, these divisions contributed more than half of departmental revenue, and 49% contributed 26-50%. Nearly 90% of divisions provided a sizeable proportion of the department's total teaching efforts. Compensation relied more on clinical productivity than on seniority, quality, academic contributions, or academic rank. Subsequently, five performance domains were identified to help divisions define divisional excellence: clinical, education, research, service & advocacy, and academic environment. Furthermore, excellent divisions were characterized as those with outstanding clinicians and educators who emphasize scholarly productivity. Although academic specialists contribute significantly to their departments' financial, clinical, and educational productivity, many have limited opportunities for scholarly activity. Achieving divisional excellence likely will depend on the ability to recruit and retain faculty with career expectations that align with the division's prioritized performance domains.

Harnessing endogenous repair mechanisms for targeted gene knock-in of bovine embryos.

Introducing useful traits into livestock breeding programs through gene knock-ins has proven challenging. Typically, targeted insertions have been performed in cell lines, followed by somatic cell nuclear transfer cloning, which can be inefficient. An alternative is to introduce genome editing reagents and a homologous recombination (HR) donor template into embryos to trigger homology directed repair (HDR). However, the HR pathway is primarily restricted to actively dividing cells (S/G2-phase) and its efficiency for the introduction of large DNA sequences in zygotes is low. The homology-mediated end joining (HMEJ) approach has been shown to improve knock-in efficiency in non-dividing cells and to harness HDR after direct injection of embryos. The knock-in efficiency for a 1.8 kb gene was contrasted when combining microinjection of a gRNA/Cas9 ribonucleoprotein complex with a traditional HR donor template or an HMEJ template in bovine zygotes. The HMEJ template resulted in a significantly higher rate of gene knock-in as compared to the HR template (37.0% and 13.8%; P < 0.05). Additionally, more than a third of the knock-in embryos (36.9%) were non-mosaic. This approach will facilitate the one-step introduction of gene constructs at a specific location of the bovine genome and contribute to the next generation of elite cattle.

Evaluation of mutation rates, mosaicism and off target mutations when injecting Cas9 mRNA or protein for genome editing of bovine embryos.

The CRISPR/Cas9 genome editing tool has the potential to improve the livestock breeding industry by allowing for the introduction of desirable traits. Although an efficient and targeted tool, the CRISPR/Cas9 system can have some drawbacks, including off-target mutations and mosaicism, particularly when used in developing embryos. Here, we introduced genome editing reagents into single-cell bovine embryos to compare the effect of Cas9 mRNA and protein on the mutation efficiency, level of mosaicism, and evaluate potential off-target mutations utilizing next generation sequencing. We designed guide-RNAs targeting three loci (POLLED, H11, and ZFX) in the bovine genome and saw a significantly higher rate of mutation in embryos injected with Cas9 protein (84.2%) vs. Cas9 mRNA (68.5%). In addition, the level of mosaicism was higher in embryos injected with Cas9 mRNA (100%) compared to those injected with Cas9 protein (94.2%), with little to no unintended off-target mutations detected. This study demonstrated that the use of gRNA/Cas9 ribonucleoprotein complex resulted in a high editing efficiency at three different loci in bovine embryos and decreased levels of mosaicism relative to Cas9 mRNA. Additional optimization will be required to further reduce mosaicism to levels that make single-step embryo editing in cattle commercially feasible.

Genomic and phenotypic analyses of six offspring of a genome-edited hornless bull.

Genome editing followed by reproductive cloning was previously used to produce two hornless dairy bulls. We crossed one genome-edited dairy bull, homozygous for the dominant PC Celtic POLLED allele, with horned cows (pp) and obtained six heterozygous (PCp) polled calves. The calves had no horns and were otherwise healthy and phenotypically unremarkable. We conducted whole-genome sequencing of all animals using an Illumina HiSeq4000 to achieve ~20× coverage. Bioinformatics analyses revealed the bull was a compound heterozygote, carrying one naturally occurring PC Celtic POLLED allele and an allele containing an additional introgression of the homology-directed repair donor plasmid along with the PC Celtic allele. These alleles segregated in the offspring of this bull, and inheritance of either allele produced polled calves. No other unintended genomic alterations were observed. These data can be used to inform conversations in the scientific community, with regulatory authorities and with the public around 'intentional genomic alterations' and future regulatory actions regarding genome-edited animals.

Author Correction: Genomic and phenotypic analyses of six offspring of a genome-edited hornless bull.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Canine fibroblast growth factor receptor 3 sequence is conserved across dogs of divergent skeletal size.

BACKGROUND: Fibroblast growth factor receptor 3 (FGFR3) is expressed in the growth plate of endochondral bones and serves as a negative regulator of linear bone elongation. Activating mutations severely limit bone growth, resulting in dwarfism, while inactivating mutations significantly enhance bone elongation and overall skeletal size. Domesticated dogs exhibit the greatest skeletal size diversity of any species and, given the regulatory role of FGFR3 on growth plate proliferation, we asked whether sequence differences in FGFR3 could account for some of the size differences. METHODS: All exons, the promoter region, and 60 bp of the 3' flanking region of the canine FGFR3 gene were sequenced for nine different dog breeds representing a spectrum of skeletal size. The resultant sequences were compared to the reference Boxer genome sequence. RESULTS: There was no variation in sequence for any FGFR3 exons, promoter region, or 3' flanking sequence across all breeds evaluated. CONCLUSION: The results suggest that, regardless of domestication selection pressure to develop breeds having extreme differences in skeletal size, the FGFR3 gene is conserved. This implies a critical role for this gene in normal skeletal integrity and indicates that other genes account for size variability in dogs.

SNPS in the promoter regions of the canine RMRP and SHOX genes are not associated with canine chondrodysplasia.

Canine chondrodysplasia is a heritable defect of endochondral ossification characterized by disproportionately short limbs. It is directly linked to significant health concerns, such as intervertebral disc disease. Some human skeletal dysplasias exhibit similar disproportionate dwarfisms and are associated with mutations in the RMRP and SHOX genes. These phenotypic similarities indicated RMRP and SHOX as candidate genes in dogs. They were sequenced in three chondrodysplastic and three normal-legged breeds. Single nucleotide polymorphisms in the promoter regions of both genes and in exon 2 of SHOX were found in affected and unaffected breeds, indicating that they are not associated with canine chondrodysplasia.

Developing Best Clinical Practices Through Outcomes Improvement: An Ongoing Quality Improvement Curriculum for Faculty and Residents.

Introduction: Practice patterns in clinical learning environments are an important predictor of the patient care quality that residents will deliver after training. The Accreditation Council for Graduate Medical Education (ACGME) Clinical Learning Environment Review Evaluation Committee reported that from 2012-2015, residents and fellows rarely engaged in quality improvement (QI) activities. A QI curriculum was created for OB-GYN faculty and trainees to develop and implement best practices and study the resulting improvement in patient outcomes. Methods: Educational leadership in the Dell Medical School Department of Women's Health designed a five-stage curriculum: (1) learning module describing the curriculum's rationale, (2) clinical practice proposal development, (3) implementation/data analysis for selected proposals, (4) dissemination of proposals and outcomes during a live forum, and (5) evaluation. PGY1 and PGY4 OB-GYN residents collaborated in dyads with selected faculty mentors to draft evidence-based proposals. Dyads identified suggested outcomes measures to be analyzed postimplementation. Remaining faculty analyzed outcomes from the previous year's proposals with PGY2 and PGY3 OB-GYN residents. Results: Forum participants, including faculty, residents, nursing staff, and private obstetrician-gynecologists, evaluated the activity. In 2017, 15 (35%) completed the evaluation. All respondents intended to change their practice based on findings. In addition, the 2016 ACGME survey indicated significant increases in faculty perception of resident QI from 58% in 2014-2015 to 89% in 2015-2016 (p = .01) and in collaboration in scholarly activity from 50% to 85% (p < .01). Discussion: This curriculum was effective in engaging OB-GYN faculty and residents in formalized problem-based learning to address QI.

A multi-institutional effort for temporary training of residents displaced by disaster: lessons from Katrina.

OBJECTIVE: This study was undertaken to describe a comprehensive, collaborative temporary residency training curriculum after disaster. STUDY DESIGN: The Texas Southeast Alliance was created in response to the Katrina Disaster by regional obstetric/gynecology programs. Principles were devised to guide development of a temporary training curriculum. Learning opportunities were identified and pooled. Affected program directors were contacted who expressed interest in the curriculum which had been approved by institutional officials and appropriate regulatory bodies. RESULTS: In total, 41 different training opportunities were made available to the Tulane residents. Twenty-four residents completed 92 rotations in total. Residents met weekly with their program director. Free psychiatric consultative services were provided through resident counseling services. Housing was facilitated wherever possible. CONCLUSION: Consolidation of resources by the Texas Southeast Alliance provided temporary training experiences for Tulane obstetric and gynecology residents displaced by Hurricane Katrina. Effective training can be maintained after disaster by coordinating institutional efforts and establishing governing principles.

Evaluation of FOXC2 as a candidate gene for chronic progressive lymphedema in draft horses.

Chronic progressive lymphedema (CPL) is a debilitating condition identified in Clydesdales, Shires and Belgian draft horses and results in progressive swelling of the lower legs associated with the development of thick skin folds, ulcerations, fibrosis and marked hyperkeratosis. The result is severe discomfort and recurrent secondary infection, often requiring euthanasia. Due to the delayed onset, many horses are bred prior to diagnosis. CPL has only been documented in three related draft horse breeds, suggesting a genetic cause. Determining the molecular basis would enable owners to test horses prior to breeding and facilitate the elimination of CPL. Mutations in the FOXC2 gene cause a comparable condition in humans, lymphedema-distichiasis. This gene was sequenced in affected and unaffected draft horses and a control horse. Four single nucleotide polymorphisms (SNPs) were identified in unaffected draft horses and the control horse, indicating that they were not associated with CPL. A fifth SNP was seen in a single affected draft horse and the control horse. Since it was not seen in all affected draft horses, this SNP is not associated with the CPL phenotype.