29 30 SARS-CoV-2 is constantly evolving. Prior studies have focused on high case-density locations, such 31 as the Northern and Western metropolitan areas in the U.S. This study demonstrates continued 32 SARS-CoV-2 evolution in a suburban Southern U.S. region by high-density amplicon sequencing of 33 symptomatic cases. 57% of strains carried the spike D614G variant. The presence of D614G was 34 associated with a higher genome copy number and its prevalence expanded with time. Four strains 35 carried a deletion in a predicted stem loop of the 3' untranslated region. The data are consistent with 36 community spread within the local population and the larger continental U.S. No strain had mutations 37 in the target sites used in common diagnostic assays. The data instill confidence in the sensitivity of 38 current tests and validate "testing by sequencing" as a new option to uncover cases, particularly those 39 not conforming to the standard clinical presentation of COVID-19. This study contributes to the 40 understanding of COVID-19 by providing an extensive set of genomes from a non-urban setting and 41 further informs vaccine design by defining D614G as a dominant and emergent SARS-CoV-2 isolate 42 in the U.S.

Background Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists. Methods We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare. Results We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality. Conclusions When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

Highlights d NGS of SARS-CoV-2 from a rural/suburban area shows local spread as an epidemic driver d The D614G spike mutant is observed in >50% of cases d Deletion in the 3 0 UTR of SARS-CoV-2 is identified d Targeted NGS has 100% specificity and is as sensitive as qPCR

Kaposi Sarcoma-associated herpesvirus (KSHV) is a carcinogenic double-stranded DNA virus and the etiological agent of Kaposi’s Sarcoma (KS), primary effusion lymphoma (PEL), and multicentric Castleman’s Disease (MCD). To prevent premature apoptosis and support its replication cycle, KSHV expresses a series of open reading frames (ORFs) that regulate signaling by the p53 tumor suppressor protein. Here we describe a novel viral inhibitor of p53 encoded by KSHV ORF45 and identify its mechanism of action. ORF45 binds to p53 and prevents its interactions with USP7, a p53 deubiquitinase. This results in decreased accumulation, localization of p53 to the cytoplasm, and diminished transcriptional activity. IMPORTANCE Unlike in other cancers, the tumor suppressor protein p53 is rarely mutated in Kaposi Sarcoma (KS). Rather, Kaposi Sarcoma-associated herpesvirus (KSHV) inactivates p53 through multiple viral proteins. One possible therapeutic approach to KS is the activation of p53, which would result in apoptosis and tumor regression. In this regard, it is important to understand all the mechanisms used by KSHV to modulate p53 signaling. This work describes a novel inhibitor of p53 signaling and a potential drug target, ORF45, and identifies the mechanisms of its action.

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