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Introduction: The University of Iowa Hospitals and Clinics (UIHC) serves as the main referral center for Iowa and has seen increased delivery volumes following many hospital closures across the state. Maternal characteristics are also shifting as pre-pregnancy obesity of reproductive-age women is increasing nationally and in Iowa; average maternal age at first delivery has also increased over time. The aim of the current study was to characterize the outcomes of the delivering population at UIHC over a one-year period to better understand the population we serve, as well as compare our population to state and national delivering populations. Methods: This study is a secondary analysis of a pre-existing prospectively gathered database related to COVID-19 in pregnancy. The current study included all pregnant patients who delivered or underwent procedures for a spontaneous or induced second-trimester abortion on the labor and delivery unit at UIHC between May 1, 2020, and April 30, 2021. Demographic and clinical data including maternal characteristics, delivery information, maternal complications, and neonatal outcomes were obtained from the electronic medical record and double entered in a Research Electronic Data Capture (REDCap) database. Continuous and categorical variables were summarized using medians and ranges. Results: The median maternal age among the 2497 delivering patients was 30 (IQR 26, 33). The median pre-delivery body mass index (BMI) was 32 (IQR 28, 37), which included 439 patients (17.6%) with BMI >40 at time of delivery. 1769 (70.8%) patients listed White as their self-defined race and 2275 (91.0%) listed English as their preferred language. 23% had hypertensive disease of pregnancy. The patients delivered a total of 2603 neonates, with 907 (34.8%) born by cesarean section. 18.7% of deliveries were preterm and 16.6% of neonates had low birth weight. Discussion: The delivering population at UIHC has a high rate of obesity and preeclampsia, both of which place patients at higher risk for other obstetric complications. The cesarean section rate was significantly higher than the national rate of 31.8% (p=0.0017). Understanding common complications in our changing population will better equip providers to care for these patients; providing these data also creates a resource for other researchers.

Objective This study aimed to estimate the prevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) among pregnant patients at the time of delivery in a rural Midwest tertiary care hospital and to examine demographics, clinical factors, and maternal and neonatal outcomes associated with SARS-CoV-2 infection during pregnancy. Study Design This prospective cohort study included all delivering patients between May 1 and September 22, 2020 at the University of Iowa Hospitals and Clinics. Plasma SARS-CoV-2 antibody testing was performed. SARS-CoV-2 viral reverse-transcription polymerase chain reaction (RT-PCR) results and maternal and neonatal outcomes were collected from the electronic medical record. Data were analyzed using univariate statistical methods with clustering for multiple births. Results In total, 1,000 patients delivered between May 1 and September 22, 2020. Fifty-eight (5.8%) were SARS-CoV-2 antibody positive. Twenty-three also tested viral positive during pregnancy. Three of 1,000 (0.3%) were viral positive on admission but antibody negative. The median age was 30 years (interquartile range [IQR]: 26–33 years) and body mass index was 31.75 kg/m2 (IQR 27.7–37.5 kg/m2). The cesarean delivery rate was 34.0%. The study population was primarily white (71.6%); however, 41.0% of SARS-CoV-2 infected patients identified as Black, 18.0% as Hispanic/Latino, 3.3% as Native Hawaiian/Pacific Islander, and only 27.9% as White (p Conclusion In this largely rural Midwest population, 6.1% of delivering patients had evidence of past or current SARS-CoV-2 infection. Rates of SARS-CoV-2 during pregnancy were higher among racial and ethnic minorities and patients without private insurance. The SARS-CoV-2 infected patients and their neonates were not found to be at increased risk for adverse outcomes. Key Points

Epstein-Barr virus (EBV) is the cause of infectious mononucleosis, which disproportionately affects university students. This population has the potential to benefit from a prophylactic EBV vaccine trial. Our objectives were to determine EBV infection status and associated demographic/lifestyle factors among first year undergraduate university students at the beginning and end of first year. EBV infection status was assessed by testing for circulating IgG class antibodies against EBV viral capsid antigen. Of 198 starting students; 56.1% were positive for EBV antibodies with a higher rate in women (64.8%) than men (41.1%); p=0.002. A history of deep kissing was associated with a higher rate of EBV antibody positivity. On follow-up 8 months later at the end of freshman year, 22.4% had acquired EBV antibodies for a primary infection incidence of 33.6/100 person years. These findings indicate that our first year undergraduate population contains sufficient EBV-naïve subjects for a prophylactic vaccine trial.

Objective: To determine if ABO blood group, age, body mass index (BMI), or symptomatic COVID-19 infection are associated with COVID-19 antibody response in unvaccinated COVID-19 antibody positive pregnant women at time of delivery. Methods: At the time of delivery, 2,499 consecutive pregnant women were tested for ABO blood group and antibodies to both the spike protein and nucleocapsid protein of the COVID-19 virus. The DiaSorin assay was used for antibody to spike protein analysis and the Roche assay for antibody to nucleocapsid protein. Gamma regression models with a log link were used to compare antibody signals, with blood group, age, and BMI as the predictors. Results: 260 (10.4%) of 2,499 women who had not been vaccinated for COVID-19, were positive for both spike and nucleocapsid protein antibodies to COVID-19. The mean signal for COVID-19 nucleocapsid antibody was significantly lower for blood group AB (p=0.028) compared with blood group O. A relationship between blood group and presence of symptomatic COVID-19 was detected (p = 0.028), with asymptomatic individuals having blood group B at a higher rate than the symptomatic individuals do. No other significant pairwise differences between blood groups were detected. There was no significant difference in signal level of antibodies to COVID-19 spike protein between any of the blood groups. Mean signals for antibodies to spike and nucleocapsid proteins were significantly higher in older women (p=0.001 for spike protein antibody and p=0.002 for nucleocapsid antibody). Significantly higher signal levels of antibody to spike and nucleocapsid proteins were found in women with class 2/3 obesity (p=0.022 and p=0.003, respectively). Conclusions: Pregnant women of AB blood group had lower antibody signal to nucleocapsid protein compared to the O blood group, and women of older age and greater BMI had higher antibody signal to COVID-19 spike and nucleocapsid proteins. There was a significant association between women with blood group B and asymptomatic infections.

The spike protein of SARS-CoV-2 is arranged as a trimer on the virus surface, composed of three S1 and three S2 subunits. Infected and vaccinated individuals generate antibodies against spike, which can neutralize the virus. Most antibodies target the receptor-binding domain (RBD) and N-terminal domain (NTD) of S1; however, antibodies against other regions of spike have also been isolated. The variation between infected individuals in domain specificity of the antibodies and in their relative neutralization efficacy is still poorly characterized. To this end, we tested serum and plasma samples from 85 COVID-19 convalescent subjects using 7 immunoassays that employ different domains, subunits and oligomeric forms of spike to capture the antibodies. Samples were also tested for their neutralization of pseudovirus containing SARS-CoV-2 spike and of replication-competent SARS-CoV-2. We observed strong correlations between the levels of NTD- and RBD-specific antibodies, with a fixed ratio of each type to all anti-spike antibodies. The relative potency of the response (defined as the measured neutralization efficacy relative to the total level of spike-targeting antibodies) also exhibited limited variation between subjects, and was not associated with the overall amount of anti-spike antibodies produced. Accordingly, the ability of immunoassays that use RBD, NTD and different forms of S1 or S1/S2 as capture antigens to estimate the neutralizing efficacy of convalescent samples was largely similar. These studies suggest that host-to-host variation in the polyclonal response elicited against SARS-CoV-2 spike is primarily limited to the quantity of antibodies generated rather than their domain specificity or relative neutralization potency.IMPORTANCEInfection by SARS-CoV-2 elicits antibodies against various domains of the spike protein, including the RBD, NTD and S2. Different infected individuals generate vastly different amounts of anti-spike antibodies. By contrast, as we show here, there is a remarkable similarity in the properties of the antibodies produced. Different individuals generate the same proportions of antibodies against each domain of the spike protein. Furthermore, the relationship between the amount of anti-spike antibodies produced and their neutralization efficacy of SARS-CoV-2 is highly conserved. Therefore, the observed variation in the neutralizing activity of the antibody response in COVID-19 convalescent subjects is caused by differences in the amounts of antibodies rather than their recognition properties or relative antiviral activity. These findings suggest that COVID-19 vaccine strategies that focus on enhancing the overall level of the antibodies will likely elicit a more uniformly efficacious protective response.

Objective: To determine the association between body mass index (BMI) and hypertension in the healthy weight group (BMI: >18.5-18 years old) seen since 2015 at either the family medicine clinic or general internal medicine clinics were obtained from the electronic health record using ICD-10 codes for hypertension. This analysis was implemented on the 14,443 of these patients whose BMI values were between 18.5 and

Background and ObjectivesVaccination has been shown to stimulate remarkably high antibody levels in donors who have recovered from COVID-19. Our objective was to examine patient antibody responses following COVID-19 Convalescent Plasma (CCP) transfusion and compare responses to CCP from vaccinated and nonvaccinated donors.Materials and methodsPlasma samples were obtained from 25 recipients of CCP and COVID-19 antibody levels measured before and after CCP treatment. Factors that effect antibody levels were examined.ResultsIn the 21 patients who received CCP from nonvaccinated donors, only modest increases in antibody levels were observed. Patients who received two units were more likely to seroconvert than those receiving just one unit. The strongest predictor of changes in patient antibody level was the CCP dose. Using patient plasma volume and donor antibody level, the post-transfusion antibody level could be predicted with remarkable accuracy. In contrast, the 4 patients who received CCP from vaccinated donors all had dramatic increases in antibody levels following transfusion of a single unit. In this subset of recipients, antibody levels observed after transfusion of CCP were comparable to those seen in donors who had fully recovered from COVID-19.ConclusionIf available, CCP from vaccinated donors with very high antibody levels should be used. CCP from vaccinated donors increases patient antibody levels much more than 1 or 2 units of CCP from unvaccinated donors.

Maternal obesity has been linked to adverse outcomes for mothers and their offspring, including, but not limited to gestational hypertension (gHTN), gestational diabetes (GDM), pre-eclampsia, fetal macrosomia, and emergency cesarean section. Recent investigations have also shown that obesity, as defined by a body mass index (BMI) ≥ 30, especially severe obesity (BMI ≥ 40), is a risk factor for both hospitalization and death from COVID-19.The objective of this study is to determine the prevalence and association of maternal obesity at delivery with adverse antenatal, intrapartum, and neonatal outcomes in a cohort of consecutive delivering patients at a tertiary care center in Iowa from May to September 2020. A secondary objective is to determine if maternal obesity has any relationship to past or current COVID-19 infection status at the time of delivery. This is a secondary analysis of a prospective cohort study to analyze obstetric outcomes among COVID-19 infected and uninfected patients.We conducted a prospective cohort study using demographic and clinical data obtained from the electronic medical record. Excess plasma was collected from routine blood samples obtained at delivery admission to determine the seroprevalence of COVID-19 antibody using the DiaSorin and Roche antibody assays. Frequency variables were each calculated separately, and a comparison of maternal and neonatal outcomes was conducted using the generalized linear mixed modeling (GLMM) framework to account for varying distributions (normal and binary).1001 women delivered during the study period and 89.7% met criteria for being overweight or obese; 17.9% met criteria for severe obesity. Women with obesity had 49.8% lower odds of possessing private insurance, and women with severe obesity were less than half as likely to plan to breastfeed at the time of discharge. Women with obesity of any kind had a significantly increased odds of GDM and gHTN, and an increased risk of an infant with macrosomia, hypoglycemia, and NICU admission. No significant association was found between BMI and COVID-19 infection or disease severity.This study provides insight into obstetric complications facing women with obesity, especially those with severe obesity. This report serves to highlight potential challenges, such as insurance status and labor complications, that impact women of high BMI to a greater degree when compared to their normal-weight counterparts.

Objectives: Determine the prevalence of obesity in an adult patient population at an academic health center, and determine the association between body mass index (BMI) with type 2 diabetes, hypertension, coronary stent placement, joint replacement, and spinal fusion procedures stratified by age and sex. Methods: Patient age, sex, BMI, and disease conditions/procedures for 51,435 adult patients seen since 2015 at either the family medicine clinic or general internal medicine clinic were obtained from the electronic health record using ICD-10 codes. A logistic regression analysis was performed with and without adjusting for the impact of age and sex. Odds ratios were calculated using both the adjusted and unadjusted models. Results: The percentage of patients with a BMI in the healthy weight range, overweight range, and obesity categories was 28.5%, 31.3%, and 40.2%, respectively. The percent of adult patients with obesity steadily increased with age and peaked in the 49-54 age group at 49.5% for women and 46.9% for men, and then decreased with age. The odds ratios (both adjusted and unadjusted) indicated that individuals with greater BMI measurements are at significantly greater risk of type 2 diabetes (odds ratio 1.096), hypertension (odds ratio 1.097), coronary stent (odds ratio 1.051), and joint replacement (odds ratio 1.051), while no statistically significant relationship between spinal fusion and BMI was identified (odds ratio 1.014). Conclusions: Our findings support the increasingly high prevalence of obesity in American society, the significant associations of obesity with chronic conditions and surgical/medical procedures, and the need for effective prevention and treatment interventions.

Hormone therapy (HT) for vasomotor and genitourinary symptoms associated with menopause has been an effective treatment for relief of these symptoms and the prevention of bone loss and fracture, but does entail potential risks for which our understanding continually evolves with additional studies. Risks of HT are likely to be minimized if started within 10 years of menopause onset. HT, types of HT, dose, route of application, and duration of use should be individualized taking into account age, personal health risks, time since menopause, and individual preferences and quality of life issues to minimize risks and maximize benefits

Purpose: United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores are frequently used to evaluate applicants to residency programs. Recent literature questions the value of USMLE scores for evaluation of residency applicants, in part due to a lack of evidence supporting a relationship with clinical performance. This study explored the relationship between USMLE scores and medical students' clinical performance, as measured by the count of honors grades received in core clinical clerkships. Methods: USMLE Step 1 and Step 2 CK scores and number of honors grades per student in seven core clinical clerkships were obtained from 1,511 medical students who graduated in 2013-2017 from two medical schools. The relationships between variables were analyzed using correlation coefficients, independent-samples t-tests, and hierarchical multiple regression. Results: Count of honors grades correlated with both Step 1 (R=0.480, P

Aim: To compare prevalence and disease severity of Severe Acute Respiratory Syndrome Coronavirus 2 (COVID-19) among multiparous and nulliparous pregnant patients at a rural Midwest tertiary care hospital; parity used as a surrogate for having additional children, assessing if exposure to other coronaviruses is protective for COVID-19. Methods: Retrospective cohort study included all patients who delivered at the University of Iowa between May 1, 2020 and September 22, 2020. Reverse transcriptase polymerase chain reaction and plasma antibody testing for COVID-19 were performed on women at the time of delivery. Demographics and outcome information were obtained from the electronic medical record. Adjusted odds ratio estimates for COVID-19 risk factors were obtained through the generalized linear modeling framework. Results: In 1,001 delivering patients, 6.2% tested positive for COVID-19 by either viral or antibody tests. Comparing infection rates by parity strata revealed no significant distinctions, with 5.4% of nulliparous women and 6.7% of multiparous women positive by either test (p=0.41). Odds of COVID-19 infection decreased by 6.2% for each year of maternal age (p=0.02). Conclusion: No significant associations were found between parity and prevalence or severity of COVID-19 infection in this population. Increasing maternal age and decreased COVID-19 frequency demonstrated a significant association.

Background While molecular techniques remain the gold standard for diagnosis of acute SARS-CoV-2 infection, serological tests have the unique potential to ascertain how much of the population has been exposed to the COVID-19 pathogen. There have been limited published studies to date documenting the performance of SARS-CoV-2 antibody assays. Methods We compared the DiaSorin Liaison SARS-CoV-2 S1/S2 IgG and Roche Diagnostics Elecsys Anti-SARS-CoV-2 assays using 228 samples spanning patients with positive PCR for SARS-CoV-2, patients with compatible symptoms but negative PCR, pre-COVID specimens, and potential cross-reactives. Results Both assays detected antibodies in 18/19 samples collected at least one week after a positive PCR result. Neither method consistently detected antibodies in specimens collected within one week of a positive PCR result (sensitivity < 50%), but antibodies were detected by only Roche in four samples in this time frame. Using 139 pre-COVID and 35 PCR-negative samples, the Roche and DiaSorin assays demonstrated specificities of 100.0% and 98.9%, respectively. Neither assay demonstrated cross-reactivity from other coronaviruses (229E, HKU1, NL63, OC43), respiratory pathogens (adenovirus, metapneumovirus, rhinovirus/enterovirus), or antibodies to other viruses (HIV, EBV, CMV, HBV, HCV, HAV). Discussion Overall, the qualitative interpretations afforded by the Roche and DiaSorin assays agreed for 97% of samples evaluated. Minor discrepancies in sensitivity and specificity were observed between methods, with the differences in specificity more clinically significant for our low-prevalence population. For the DiaSorin assay, all disagreements with the Roche assay occurred in samples with quantitative signals near the cut-off determining positivity.

Total NIH funding dollars have increased from 2009-2018. We questioned whether this growth has occurred proportionately around the country and throughout allopathic medical schools. Therefore, we compared the trend in NIH grant funding from 2009 to 2018 for United States allopathic medical schools among historically top-funded schools, private and public schools, and by region of the country. Changes in both unadjusted and real funding dollars over time revealed a significant difference. Region was the only significant factor for mean percent change in funding from 2009-2018, with the Western region showing a 33.79% increase in purchasing power. The Northeastern region showed a -6.64% decrease in purchasing power while the Central and Southern regions reported changes of 2.46% and -6.08%, respectively. The mean percent increases were more proportional and nonsignificant in the public vs. private institutions comparison, at -3.41% and 4.75%, respectively. Likewise, the top-funded institutions vs. other institutions comparisons demonstrated modest, nonsignificant differences. However, although the relative changes might be proportional, the absolute increases evidence a pattern of growing cumulative advantage that favor the highest-funded institutions and private institutions. The potential consequences of this disproportionate increase include health science education, biomedical research, and patient access disparities in large parts of the country. The NIH and the scientific community should explore potential solutions in its funding models.

It has been reported that some mutations in the genome of hepatitis B virus (HBV) may predict the outcome of the virus infection. However, evolutionary data derived from long-term longitudinal analysis of entire HBV genomes using next generation sequencing (NGS) remain rare. In this study, serum samples were collected from asymptomatic hepatitis B surface antigen (HBsAg) carriers from a long-term prospective cohort. The entire HBV genome was amplified by polymerase chain reaction (PCR) and sequenced using NGS. Twenty-eight time series serum samples from nine subjects were successfully analysed. The Shannon entropy (Sn) ranged from 0 to 0.89, with a median value of 0.76, and the genetic diversity (D) ranged from 0 to 0.013, with a median value of 0.004. Intrahost HBV viral evolutionary rates ranged from 2.39E-04 to 3.11E-03. Double mutations at nt1762(A → T) and 1764(G → A) and a stop mutation at nt1896(G → A) were seen in all sequences from subject BO129 in 2007. However, in 2019, most sequences were wild type at these positions. Deletions between nt 2920-3040 were seen in all sequences from subject TS115 in 2007 and 2013 but these were not present in 2004 or 2019. Some sequences from subject CC246 had predicted escape substitutions (T123N, G145R) in the surface protein in 2004, 2013 and 2019 but none of the sequences from 2007 had these changes. In conclusion, HBV mutations may revert to wild type in natural infection. Clinicians should be wary of predicting long-term prognoses on the basis of the presence of mutations.

Jacqueline L Gauer,1 J Brooks Jackson2 1Office of Medical Education, 2Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA Introduction: Medical schools worldwide are faced with the challenge of selecting from among many qualified applicants. One factor that might help admissions committees identify future exceptional medical students is scores on standardized entrance exams. The purpose of this study was to determine the association between scores on the most commonly used standardized medical school entrance exam in the USA, the Medical College Admission Test (MCAT), and election to the US medical honors society, Alpha Omega Alpha (AOA).Method: MCAT scores and AOA membership data were analyzed for all the students pursuing Doctor of Medicine degrees at the University of Minnesota Medical School and who graduated between 2012–2016 (n=1,309).Results: An independent-samples t-test found a significant difference (t=6.132, p

The HIV Network for Prevention Trials (HIVNET) 012 trial showed that NVP resistance (NVPR) emerged in some women and children after the administration of single-dose nevirapine (SD-NVP). We tested whether K103N-containing human immunodeficiency virus (HIV)-1 variants persisted in women and infants 1 year or more after the administration of SD-NVP.We analyzed samples from 9 women and 5 infants in HIVNET 012 who had NVPR 6-8 weeks after the administration of SD-NVP. Samples were analyzed with the ViroSeq system and with 2 sensitive resistance assays, LigAmp and TyHRT.ViroSeq detected the K103N mutation in 8 of 9 women and in 2 of 5 infants. LigAmp detected the K103N mutation at low levels in 8 of 9 women and in 4 of 5 infants. K103N was not detected by ViroSeq 12-24 months after the administration of SD-NVP but was detected by LigAmp in 3 of 9 women and in 1 of 5 infants. K103N was also detected in those samples by use of the TyHRT assay.K103N-containing variants persist in some women and infants for 1 year or more after the administration of SD-NVP. Sensitive resistance assays may provide new insight into the impact of antiretroviral drug exposure on HIV-1 evolution.

Introduction : The purpose of this study was to determine the associations and predictive values of Medical College Admission Test (MCAT) component and composite scores prior to 2015 with U.S. Medical Licensure Exam (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores, with a focus on whether students scoring low on the MCAT were particularly likely to continue to score low on the USMLE exams. Method : Multiple linear regression, correlation, and chi-square analyses were performed to determine the relationship between MCAT component and composite scores and USMLE Step 1 and Step 2 CK scores from five graduating classes (2011–2015) at the University of Minnesota Medical School ( N =1,065). Results : The multiple linear regression analyses were both significant ( p

Purpose: United States Medical Licensing Examination (USMLE) Step 1 and Step 2 Clinical Knowledge (CK) scores are frequently used to evaluate applicants to residency programs. Recent literature questions the value of USMLE scores for evaluation of residency applicants, in part due to a lack of evidence supporting a relationship with clinical performance. This study explored the relationship between USMLE scores and medical students’ clinical performance, as measured by the count of honors grades received in core clinical clerkships. Methods: USMLE Step 1 and Step 2 CK scores and number of honors grades per student in seven core clinical clerkships were obtained from 1,511 medical students who graduated in 2013–2017 from two medical schools. The relationships between variables were analyzed using correlation coefficients, independent-samples t-tests, and hierarchical multiple regression. Results: Count of honors grades correlated with both Step 1 (R=0.480, P

Significance This study defines clinical indications for using telomere length (TL) measurement as a diagnostic tool in a hospital setting. It shows that, in contrast to other methods, TL measurement by flow cytometry and FISH (flowFISH) can be standardized, and has reproducible and definable upper and lower normal boundaries. In telomerase mutation carriers and carriers of other mutant telomere maintenance genes, TL had prognostic value, correlating with the age of onset of short telomere syndrome phenotypes, as well as the predominant complication. In a prospective study, TL results were actionable in one-fourth of cases with idiopathic bone marrow failure affecting the stem cell donor choice and/or treatment regimen. The data show that, for targeted clinical indications, and in a hospital setting, TL measurement by flowFISH informs patient care decisions., Telomere length (TL) predicts the onset of cellular senescence in vitro but the diagnostic utility of TL measurement in clinical settings is not fully known. We tested the value of TL measurement by flow cytometry and FISH (flowFISH) in patients with mutations in telomerase and telomere maintenance genes. TL had a discrete and reproducible normal range with definable upper and lower boundaries. While TL above the 50th age-adjusted percentile had a 100% negative predictive value for clinically relevant mutations, the lower threshold in mutation carriers was age-dependent, and adult mutation carriers often overlapped with the lowest decile of controls. The extent of telomere shortening correlated with the age at diagnosis as well as the short telomere syndrome phenotype. Extremely short TL caused bone marrow failure and immunodeficiency in children and young adults, while milder defects manifested as pulmonary fibrosis-emphysema in adults. We prospectively examined whether TL altered treatment decisions for newly diagnosed idiopathic bone marrow failure patients and found abnormally short TL enriched for patients with mutations in some inherited bone marrow failure genes, such as RUNX1, in addition to telomerase and telomere maintenance genes. The result was actionable, altering the choice of treatment regimen and/or hematopoietic stem cell donor in one-fourth of the cases (9 of 38, 24%). We conclude that TL measurement by flowFISH, when used for targeted clinical indications and in limited settings, can influence treatment decisions in ways that improve outcome.

The mechanisms that drive T cell aging are not understood. We report that children and adult telomerase mutation carriers with short telomere length (TL) develop a T cell immunodeficiency that can manifest in the absence of bone marrow failure and causes life-threatening opportunistic infections. Mutation carriers shared T cell-aging phenotypes seen in adults 5 decades older, including depleted naive T cells, increased apoptosis, and restricted T cell repertoire. T cell receptor excision circles (TRECs) were also undetectable or low, suggesting that newborn screening may identify individuals with germline telomere maintenance defects. Telomerase-null mice with short TL showed defects throughout T cell development, including increased apoptosis of stimulated thymocytes, their intrathymic precursors, in addition to depleted hematopoietic reserves. When we examined the transcriptional programs of T cells from telomerase mutation carriers, we found they diverged from older adults with normal TL. Short telomere T cells upregulated DNA damage and intrinsic apoptosis pathways, while older adult T cells upregulated extrinsic apoptosis pathways and programmed cell death 1 (PD-1) expression. T cells from mice with short TL also showed an active DNA-damage response, in contrast with old WT mice, despite their shared propensity to apoptosis. Our data suggest there are TL-dependent and TL-independent mechanisms that differentially contribute to distinct molecular programs of T cell apoptosis with aging.

Very short telomere length (TL) provokes cellular senescence in vitro, but the clinical utility of TL measurement in a hospital-based setting has not been determined. We tested the diagnostic and prognostic value of TL measurement by flow cytometry and fluorescence in situ hybridization (flowFISH) in individuals with mutations in telomerase and telomere maintenance genes, and examined prospectively whether TL altered treatment decisions for patients with bone marrow failure. TL had a definable normal range across populations with discrete lower and upper boundaries. TL above the 50th age-adjusted percentile had a 100% negative predictive value for clinically relevant mutations in telomere maintenance genes, but the lower threshold for diagnosis was age-dependent. The extent of deviation from the age-adjusted median correlated with the age at diagnosis of a telomere syndrome as well as the predominant complication. Mild short telomere defects manifested in adults as pulmonary fibrosis-emphysema, while severely short TL manifested in children as bone marrow failure and immunodeficiency. Among 38 newly diagnosed patients with bone marrow failure, TL shorter than the 1st age-adjusted percentile enriched for patients with germline mutations in inherited bone marrow failure genes, such as RUNX1, in addition to telomere maintenance genes. The TL result modified the hematopoietic stem cell donor choice and/or treatment regimen in one-fourth of the cases (9 of 38,24%). TL testing by flowFISH has diagnostic and predictive value in definable clinical settings. In patients with bone marrow failure, it altered treatment decisions for a significant subset.

BACKGROUND Injection opioid use plays a significant role in the transmission of HIV infection in many communities and several regions of the world. Access to evidence-based treatments for opioid use disorders is extremely limited. METHODS HIV Prevention Trials Network 058 (HPTN 058) was a randomized controlled trial designed to compare the impact of 2 medication-assisted treatment (MAT) strategies on HIV incidence or death among opioid-dependent people who inject drugs (PWID). HIV-negative opioid-dependent PWID were recruited from 4 communities in Thailand and China with historically high prevalence of HIV among PWID. A total of 1251 participants were randomly assigned to either (1) a 1-year intervention consisting of 2 opportunities for a 15-day detoxification with buprenorphine/naloxone (BUP/NX) combined with up to 21 sessions of behavioral drug and risk counseling [short-term medication-assisted treatment (ST-MAT)] or (2) thrice-weekly dosing for 48 weeks with BUP/NX and up to 21 counseling sessions [long-term medication-assisted treatment (LT-MAT)] followed by dose tapering. All participants were followed for 52 weeks after treatment completion to assess durability of impact. RESULTS Although the study was stopped early due to lower than expected occurrence of the primary end points, sufficient data were available to assess the impact of the interventions on drug use and injection-related risk behavior. At week 26, 22% of ST-MAT participants had negative urinalyses for opioids compared with 57% in the LT-MAT (P < 0.001). Differences disappeared in the year after treatment: at week 78, 35% in ST-MAT and 32% in the LT-MAT had negative urinalyses. Injection-related risk behaviors were significantly reduced in both groups after randomization. CONCLUSIONS Participants receiving BUP/NX 3 times weekly were more likely to reduce opioid injection while on active treatment. Both treatment strategies were considered safe and associated with reductions in injection-related risk behavior. These data support the use of thrice-weekly BUP/NX as a way to reduce exposure to HIV risk. Continued access to BUP/NX may be required to sustain reductions in opioid use.

Objectives: To describe key characteristics (laboratory quality, test volumes, and complexity) of clinical laboratories in Kampala, Uganda (population ~1.7 million). Methods: Cross-sectional survey using a standard questionnaire to document laboratory type and quality, as well as test menus and volumes. Quality was based on the World Health Organization–Africa Region checklist. Results: Of the 954 laboratories identified (a density of one laboratory per 1,781 persons), 779 (82%) performed only simple kit tests or light microscope examinations. The 95% (907/954) of laboratories for whom volumes were obtained performed an average aggregate of 13,189 tests daily, for a test utilization rate of around 2 tests per individual per year. Laboratories could be segregated into eight groups based on quality, test volume, and complexity. However, 90% of the testing was performed by just two groups: (1) low-volume (≤100 tests daily), low-quality laboratories performing simple tests or (2) high-volume (>100 tests daily), high-quality laboratories. Each of these two groups did 45% of the daily testing volume (90% combined). Conclusions: Clinical laboratory density in Kampala (1/1,781 persons) is high, approaching that in the United States (1/1,347 persons). Low-volume/low-quality and high-volume/high-quality laboratories do 90% of the daily aggregate testing. Quality improvement (QI) schemes for Africa must be appropriate to low-volume laboratories as well as to the large laboratories that have been the focus of previous QI efforts.

Background Buprenorphine/naloxone (BUP/NX), an effective treatment for opioid dependence, has been implicated in hepatic toxicity. However, as persons taking BUP/NX have multiple hepatic risk factors, comparative data are needed to quantify the risk of hepatoxicity with BUP/NX. Methods We compared rates of alanine aminotransferase (ALT) elevation ≥ grade 3 (ALT ≥ 5.1 times the upper limit of normal) and graded bilirubin elevations in HIV-negative opioid injectors randomized to long-term (52 weeks) or short-term (18 days) medication assisted treatment (LT-MAT and ST-MAT, respectively) with BUP/NX in a multisite trial conducted in China and Thailand. ALT and bilirubin were measured at baseline, 12, 26, 40 and 52 weeks, times temporally remote from BUP/NX exposure in the ST-MAT participants. Results Among1036 subjects with at least one laboratory follow-up measurement, 76 (7%) participants experienced ALT elevation ≥ grade 3. In an intent-to-treat analysis, the risk of ALT events was similar in participants randomized to LT-MAT compared with ST-MAT (adjusted hazard ratio 1.25, 95% confidence interval 0.79 to 1.98). This finding was supported by an as-treated analysis, in which actual exposure to BUP/NX was considered. Hepatitis C seroconversion during follow-up was strongly associated with ALT events. Bilirubin elevations ≥ grade 2 occurred in 2% of subjects, with no significant difference between arms. Conclusions Over 52-week follow-up, the risk of hepatotoxicity was similar in opioid injectors receiving brief and prolonged treatment with BUP/NX. These data suggest that most hepatotoxic events observed during treatment with BUP/NX are due to other factors.

Envelope protein gp120 of human immunodeficiency virus (HIV) is armored with a dense glycan shield, which plays critical roles in envelope folding, immune-evasion, infectivity, and immunogenicity. Site-specific glycosylation profiling of recombinant gp120 is very challenging. Therefore, glycoproteomic analysis of native viral gp120 is still formidable to date. This challenge promoted us to employ a Q-Exactive mass spectrometer to identify low abundant glycopeptides from virion-associated gp120. To search the HCD-MS data for glycopeptides, a novel spectral-aligning strategy was developed. This strategy depends on the observation that glycopeptides and the corresponding deglycosylated peptides share very similar MS/MS pattern in terms of b- and y-ions that do not contain the site of glycosylation. Moreover, glycopeptides with an identical peptide backbone show nearly resembling spectra regardless of the attached glycan structures. For the recombinant gp120, this "copy-paste" spectral pattern of glycopeptides facilitated identification of 2224 spectra using only 18 spectral templates, and after precursor mass correction, 1268 (57%) spectra were assigned to 460 unique glycopeptides accommodating 19 N-linked and one O-linked glycosylation sites (glycosites). Strikingly, we were able to observe five N- and one O-linked glycosites in native gp120. We further revealed that except for Asn276 in the C2 region, glycans were processed to contain both high mannose and hybrid/complex glycans; an additional four N-linked glycosites were decorated with high mannose type. Core 1 O-linked glycan Gal1GalNAc1 was seen for the O-linked glycosite at Thr499. This direct observation of site-specific glycosylation of virion-derived gp120 has implications in HIV glycobiology and vaccine design.

Objective Maternal-to-child-transmission of HIV-1 infection remains a significant cause of HIV-1 infection despite successful prevention strategies. Testing protective HIV-1 vaccines remains a critical priority. The immunogenicity of ALVAC-HIV vCP1521 (ALVAC) in infants born to HIV-1-infected women in Uganda was evaluated in the first pediatric HIV-1 vaccine study in Africa. Design HIV Prevention Trials Network 027 was a randomized, double-blind, placebo-controlled phase I trial to evaluate the safety and immunogenicity of ALVAC in 60 infants born to HIV-1-infected mothers with CD4 counts of >500 cells per microliter, which were randomized to the ALVAC vaccine or placebo. ALVAC-HIV vCP1521 is an attenuated recombinant canarypox virus expressing HIV-1 clade E env, clade B gag, and protease gene products. Methods Infants were vaccinated at birth and 4, 8, and 12 weeks of age with ALVAC or placebo. Cellular and humoral immune responses were evaluated using interferon-γ enzyme-linked immunosorbent spot, carboxyfluorescein diacetate succinimidyl ester proliferation, intracellular cytokine staining, and binding and neutralizing antibody assays. Fisher exact test was used to compare positive responses between the study arms. Results Low levels of antigen-specific CD4 and CD8 T-cell responses (intracellular cytokine assay) were detected at 24 months (CD4-6/36 vaccine vs. 1/9 placebo; CD8-5/36 vaccine vs. 0/9 placebo) of age. There was a nonsignificant trend toward higher cellular immune response rates in vaccine recipients compared with placebo. There were minimal binding antibody responses and no neutralizing antibodies detected. Conclusions HIV-1-exposed infants are capable of generating low levels of cellular immune responses to ALVAC vaccine, similar to responses seen in adults.

HIV elite suppressors (ES) or controllers are individuals achieving control of viremia by their natural immunological mechanisms without highly active antiretroviral therapy (HAART). Study of the mechanisms responsible for the immunological suppression of viremia in ES may lead to the detection of individuals with ES and the effective control of HIV infection. We hypothesize that plasma glycoproteins play essential roles in the immune system of ES since plasma proteins are critical and highly relevant in anti-viral immunity and most plasma proteins are glycoproteins. To examine glycoproteins associated with ES, plasma samples from ES individuals (n=20), and from individuals on HAART (n=20), with AIDS (n=20), and no HIV infection (n=10) were analyzed by quantitative glycoproteomics. We found that a number of glycoproteins changed between ES versus HAART, AIDS and HIV- individuals. In sharp contrast, the level of plasma glycoproteins in the HAART cohort showed fewer changes compared with AIDS and HIV- individuals. These results showed that although both ES and HAART effectively suppress viremia, ES appeared to profoundly affect immunologically relevant glycoproteins in plasma as consequence of or support for anti-viral immunity. Bioinformatic analysis revealed that altered proteins in ES plasma were mainly associated with inflammation. This analysis suggests that overlapping, while distinguishable, glycoprotein profiles for inflammation and immune activation appeared to be present between ES and non-ES (HAART+AIDS) cohorts, indicating different triggers for inflammation and immune activation between natural and treatment-related viral suppression.

Background. In resource-limited settings, mothers infected with human immunodeficiency virus type 1 (HIV-1) face a difficult choice: breastfeed their infants but risk transmitting HIV-1 or not breastfeed their infants and risk the infants dying of other infectious diseases or malnutrition. Recent results from observational studies and randomized clinical trials indicate daily administration of nevirapine to the infant can prevent breast-milk HIV-1 transmission. Methods. Data from 5396 mother-infant pairs who participated in 5 randomized trials where the infant was HIV-1 negative at birth were pooled to estimate the efficacy of infant nevirapine prophylaxis to prevent breast-milk HIV-1 transmission. Four daily regimens were compared: nevirapine for 6 weeks, 14 weeks, or 28 weeks, or nevirapine plus zidovudine for 14 weeks. Results. The estimated 28-week risk of HIV-1 transmission was 5.8% (95% confidence interval [CI], 4.3%–7.9%) for the 6-week nevirapine regimen, 3.7% (95% CI, 2.5%–5.4%) for the 14-week nevirapine regimen, 4.8% (95% CI, 3.5%–6.7%) for the 14-week nevirapine plus zidovudine regimen, and 1.8% (95% CI, 1.0%–3.1%) for the 28-week nevirapine regimen (log-rank test for trend, P

Background Buprenorphine/naloxone (BUP/NX) is not licenced for use in China or Thailand and there was little clinical experience with this drug combination in these countries at the inception of HIV Prevention Trial Network (HPTN) 058, a randomized trial comparing risk reduction counselling combined with either short-term or long-term medication assisted treatment with BUP/NX to prevent HIV infection and death amongst opioid-dependent injectors. Methods We conducted a safety phase that included the first 50 subjects enrolled at each of the three initial study sites ( N =150). Clinical and laboratory assessments were conducted at baseline and weekly for the first 4 weeks. Changes in laboratory parameters were estimated with random effects models. Results BUP/NX was well tolerated by study subjects and opioid withdrawal scores decreased substantially during the 3-day induction. Two participants experienced grade 3 clinical adverse events, which were categorized as probably not related to the study drug. Grade 2 or 3 increases in alanine aminotransferase (ALT) occurred in 25 (17%) subjects. The magnitude of ALT increase over 4-week follow-up was strongly associated with baseline ALT elevation. Conclusions In Chinese and Thai opioid-dependent injectors, we found BUP/NX to be effective in reducing opioid withdrawal symptoms and safe during short-term use. ALT increases were observed over 4-week-follow-up, which are consistent with reports from Western populations. Long-term safety and efficacy evaluations are indicated.

In developed countries, the majority of medical decisions are made on the basis of quality laboratory testing according to established standards and enforced regulations. With the large investments of global health initiatives into resource-limited settings in sub-Saharan Africa, there is an opportunity to establish quality laboratory testing by overcoming barriers such as physical infrastructure, quality management plans according to external standards, and human resource capacity building. Strengthening laboratories could change the paradigm from empiric, algorithm-based clinical care to care based on accessible test-based accurate diagnoses. * SSA : sub-Saharan Africa MDGs : Millennium Development Goals TB : tuberculosis RLS : resource-limited settings UNGASS : United Nations General Assembly Special Session HC : health centers CPHL : Central Public Health Laboratories DST : Direct Sensitivity Testing NTCL : National TB Central Laboratory DBS : Dried Blood Spots JCRC : Joint Clinical Research Centre IDI : Infectious Diseases Institute HR : human resource ISO : International Organization for Standardization GCLP : Good Clinical Laboratory Practices CLSI : Clinical and Laboratory Standards Institute CDC : Centers for Disease Control and Prevention WHO-AFRO : World Health Organization-Africa Regional Office SLMTA : Strengthening Laboratory Management Toward Accreditation MU-JHU/IDI : Makerere University-Johns Hopkins University at the Infectious Diseases Institute CAP : College of American Pathologists COQ : cost of quality EQA : external quality assurance NGO : non-governmental organization

BACKGROUND This phase III, randomized, clinical trial compared single-dose nevirapine (sdNVP) plus HIV hyperimmune globulin (HIVIGLOB) with sdNVP alone for preventing maternal-to-child transmission of HIV. Primary objectives were to determine rates of HIV infection among infants and to assess the safety of HIVIGLOB in combination with sdNVP in HIV-infected Ugandan pregnant women and their infants. METHODS Mother-infant pairs were randomized to receive 200 mg of nevirapine to women in labor and 2 mg/kg NVP to newborns within 72 hours after birth (sdNVP arm) or to receive sdNVP plus a single intravenous 240-mL dose of HIVIGLOB given to women at 36- to 38-week gestation and a single intravenous 24-mL dose to newborns within 18 hours of birth (HIVIGLOB/sdNVP arm). Risk of HIV infection was determined using Kaplan-Meier and risk ratio estimates at birth, 2, 6, 14 weeks, 6, and 12 months of age. RESULTS Intent-to-treat analysis included 198 HIVIGLOB/sdNVP and 294 sdNVP mother-infant pairs. At 6 months of age, the primary endpoint, there was no statistically significant difference in HIV transmission in the HIVIGLOB/sdNVP arm vs. the sdNVP arm [18.7% vs. 15.0%; risk ratio = 1.240 (95% confidence interval: 0.833 to 1.846); P = 0.290]. Similarly, the proportion of serious adverse events in the HIVIGLOB/sdNVP and sdNVP arms, respectively, for mothers (18.9% vs. 19.3%; P = 0.91) and infants (62.6% vs. 59.5%; P = 0.51) was not significantly different. CONCLUSIONS Giving mother-infant pairs an infusion of peripartum HIV hyperimmune globulin in addition to sdNVP for preventing maternal-to-child transmission was as safe as sdNVP alone but was no more effective than sdNVP alone in preventing HIV transmission.

BACKGROUND: The global human immunodeficiency virus (HIV)-1 epidemic is becoming increasingly diverse and complex. Molecular epidemiologic characteristics were studied for HIV-1–infected blood donors from five Chinese regions to determine genotype diversity and drug resistance mutations (DRMs) profile. STUDY DESIGN AND METHODS: HIV-1 confirmed-reactive serum samples were collected from 172 blood donors from five blood centers during 2007 to 2010. HIV-1 Pol including whole protease and partial reverse transcriptase genes was amplified, sequenced, and analyzed for the subtype determination and drug resistance profile description. RESULT: A total of 113 amplified sequences including 82 from Kunming blood center and 31 from four other blood centers had the following genotype characteristics: G (0.9%), B (2.7%), circulating recombinant form (CRF) 01_AE (32.7%), CRF07_BC (22.1%), and CRF08_BC (41.6%). Female donors represent 45.1% of all cases and 63.9% cases with DRMs. The prevalence of samples with potential low or higher resistance among Chinese blood donors is 4.4%. CONCLUSION: HIV-1 infection in Chinese blood donors is genetically diverse and the subtype distribution reflects that from the high-risk populations. Our results support continuous molecular epidemiologic surveillance for HIV-1 in blood donors as a part of a comprehensive HIV control program.

HIV viruses are usually genetically homogeneous shortly after infection, and become more heterogeneous over time. We developed a high-resolution melting (HRM) assay to analyze HIV diversity without sequencing. Plasma samples from the HIVNET 012 trial were obtained from nine Ugandan mother–infant pairs. DNA amplified from the HIV gag region was analyzed to determine the number of degrees over which the DNA melted (HRM score). HRM gag DNA was also cloned and sequenced (50 clones/mother; 20 clones/infant). The median HRM score for infants (4.3, range 4.2–5.3) was higher than that for control plasmids (3.4, range 3.2–3.8, p

Health care decision makers often have a limited understanding of the costs associated with quality improvement efforts. However, such information is vital for managers to make appropriate operational and financial decisions to ensure high quality health care services. We used the Cost of Quality (COQ) model to estimate the cost of quality-related activities at the Makerere University-Johns Hopkins University (MU-JHU) Laboratory in Uganda. Using data collected from January 1, 2007–December 31, 2007, we allocated the direct costs associated with quality-related activities in the laboratory across COQ’s cost categories: prevention, appraisal, internal failures, and external failures. We found that approximately 94% of total COQ was spent on costs of “good quality” (prevention and appraisal), while 6% was spent on costs of “poor quality” (internal and external failures). The high percentage of COQ spent on prevention and appraisal activities is consistent with efforts to ensure high quality laboratory results. Future studies should try to link COQ to health outcomes and quantify “hidden” failure costs. This CE update introduces the Cost of Quality (COQ) model and illustrates how it can be applied to a clinical laboratory setting to help managers and executives make more informed decisions about spending on quality-related activities. We begin with an overview of the COQ concept and its 4 main cost categories, followed by an illustration of how the model can be applied in a medical laboratory setting. We then discuss some of the advantages and limitations of this methodology and provide suggestions for future research. * COQ : Cost of Quality MU-JHU : Makerere University-Johns Hopkins University IOM : Institute of Medicine P-A-F : prevention-appraisal-failure CAP : College of American Pathology PCR : polymerase chain reaction QA : quality assurance LIS : laboratory Information System EQA : External Quality Assurance CSC : Customer Service Concern PM : preventive maintenance QC : Quality Control PIR : Process Improvements Reports GLP : good laboratory practices GAAP : generally accepted accounting principles