Abstract Background Subaortic stenosis (SAS) was a rare congenital heart disease of left ventricular outflow tract (LVOT), ranging from “isolated” lesions to “tunnel” or “diffuse” lesions. We conducted a retrospective study to describe the characteristics of patients with different lesions and analyze the risk factors for reoperation. Methods In this study, we examined a single-center retrospective cohort of SAS patients undergoing resection from 2010 to 2019. Patients were classified as simple lesion group (n = 37) or complex lesion group (n = 28). Demographics, perioperative findings, and clinical data were analyzed. Results The surgical effect of the two groups was significantly lower than that before the operation (p <0.05). The median age at operation was 6(3-11.8) years. There was no operative mortality. In complex lesion group, extracorporeal circulation time (CPB time), aortic cross clamp time (ACC time), mechanical ventilation time and ICU stay time were longer. The median follow-up period was 2.8 years (range 1-3.8), with two late death. Six patients (9.2%) required reoperation due to restenosis or severe aortic insufficiency. The freedom from reoperation rates at 5 years was 66.7% for simple lesion but only 52.3% for complex lesion (p = 0.036). Conclusions Although the lesions include many forms, subaortic stenosis resection was still satisfactory. However, the reoperation after initial surgical treatment was not infrequent, especially in patients with complex lesion.

Background: This study aims at better defining the profile of patients with a complicated versus non-complicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favourable/unfavourable hospital outcome. Methods: All patients treated with isolated tricuspid surgery from March 1997-January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit <4 days and/or postoperative length-of-stay <10days. Patients were therefore divided accordingly in two groups. Results: 172 patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p<0.001) and higher in-hospital mortality (13% vs 0%, p<0.001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics’ dose were predictors of complicated postoperative course. Conclusions: In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Introduction: Over-prescription of antimicrobials for patients is a major driver of bacterial resistance. The aim of the present study was to assess the knowledge, attitude and prescription in relation to antimicrobials among physicians in the Zhejiang province in China, and identify the determining factors. Methods: A total of 600 physicians in public county hospitals and township health institutions were surveyed cross-sectionally using a structured electronic questionnaire. Results: The questionnaire was completed by 580 physicians and accordingly, the response rate was 96.67%. The mean score of 11 terms related to antimicrobial knowledge was 6.81, and that an average of 32.1% of patients with upper respiratory tract infections (URIs) would be prescribed antimicrobials. Multivariate analysis indicated that young general practitioners with less training are more likely to contribute to high antimicrobial prescriptions (P<0.05). Older physicians with more trainings are more willing to provide patients with the correct knowledge regarding antimicrobials and less likely to prescribe antimicrobial s to URIs. The results of the correlation analysis showed that a positive connection was found between the doctor’s knowledge, attitude and prescription practice (P<0.05). Conclusion: Proper prescription of antimicrobials depends on adequate knowledge and regular training programs for physicians.

Background: Children with Sickle-Cell Anemia (SCA) are at high risk for obstructive sleep apnea (OSA). Screening for OSA is therefore recommended by current guidelines but no specific method described. The Pediatric Sleep Questionnaire (PSQ) is a validated detection tool for OSA in children. We assessed the utility of PSQ to screen for OSA in snoring children with SCA. Methods: A prospective study in children with SCA, aged 4 - 18 years. Subjects were assessed for snoring and PSQ administered at the same visit. All snoring children were then referred for polysomnography (PSG). Results: A total of 106 subjects were screened. Mean age was 10.5 years and 47.2% male. Snoring prevalence was 51/106 (48.1%). In the snoring group, OSA was detected in 83.9% (AHI ≥ 1.0/h) and 22.6% (AHI ≥ 5.0/h), respectively. Sensitivity and specificity of PSQ in snoring children was 46.2% and 20.0% (AHI ≥ 1.0/h), and 57.1% and 50.0% (AHI ≥ 5.0/h), respectively. Physician assessment of snoring had a high sensitivity of 70.3% but low specificity of 58.4% (AHI ≥1.0/h), and 87.5% and 41.5% (AHI ≥ 5.0/h), respectively. Conclusion: PSQ is a poor screening tool for detection of OSA in snoring children with SCA. Physician assessment of snoring however could be an initial approach prior to polysomnography.

Objective: to evaluate current practice and outcomes of pregnancy in women previously diagnosed with Budd-Chiari syndrome and/or portal vein thrombosis, with and without concomitant portal hypertension. Design and setting: multicentre retrospective cohort study between 2008-2021 Population: Women who conceived in the predefined period after the diagnosis of Budd-Chiari syndrome and/or portal vein thrombosis Methods and main outcome measures: We collected data on diagnosis and clinical features. The primary outcomes were maternal mortality and live birth rate. Secondary outcomes included maternal, neonatal and obstetric complications. Results: Forty-five women (12 Budd-Chiari syndrome, 33 portal vein thrombosis; 76 pregnancies) were included. Underlying prothrombotic disorders were present in 23 of 45 women (51%). Thirty-eight women (84%) received low-molecular-weight heparin during pregnancy. Of 45 first pregnancies, 11 (24%) ended in pregnancy loss and 34 (76%) resulted in live birth of which 27 at term age (79% of live births and 60% of pregnancies). No maternal deaths were observed, one woman developed pulmonary embolism during pregnancy and two women (4%) had variceal bleeding requiring intervention. Conclusions: The high number of term live births (79%) and lower than expected risk of pregnancy-related maternal and neonatal morbidity in our cohort suggest that Budd-Chiari syndrome and/or portal vein thrombosis should not be considered as an absolute contra-indication for pregnancy. Individualized, nuanced counselling and a multidisciplinary pregnancy surveillance approach are essential in this patient population.

Key Points • Transnasal Oesophagoscopy (TNO) is an approach to inspect the upper aerodigestive tract, especially in the head and neck cancer (HNCA) population that present with dysphagia. • Twenty-five (25) office-based TNO procedures were performed, with a same-day discharge rate of 96% (24/25) and no reported complications. • This case series is the first to compare preoperative and postoperative outcomes (EAT-10) following stricture dilatation using TNO in the UK. Our results show a statistically significant improvement in symptom severity (EAT-10 scores) (n=11, P=0.001). In the majority of these patients, strictures were due to post-radiation complications. Biopsy in 4/5 cases was sufficient for diagnosis/ruling out disease. Of these patients, 80% had a previous HNCA. • This study identifies the remit for a new ‘one-stop’ TNO service for suspected cancer referrals, of which a large proportion are patients with a previous HNCA. Surveillance, therapeutics and diagnostics can be achieved in a single visit. • Earlier staging or treatment may be achieved due to a fast turnover in clinic

Slope gradient and vegetation cover play key roles in soil erosion process. Exploring the effects of slope gradient and vegetation cover on runoff and sediment yielding characteristics is therefore of great importance for minimizing soil erosion. In this work, based on field scouring experiments on the riparian slopes of the lower Yellow River, China, variation in total runoff, accumulative runoff sediment concentration, erosion sediment yield, and sediment particle size composition under four slope gradients (5°, 10°, 15°, 20°) and three vegetation cover levels (0%, 15%, 30%) were analyzed. Runoff and sediment yield were greatly influenced by slope gradient at steep slope gradients (15° and 20°), while they were mainly affected by vegetation cover at medium slope gradients (5° and 10°). The main enriched particle size of the eroded sediment showed a trend of first increasing and then decreasing with the increasing slope gradient. There was an interaction between slope gradient and vegetation cover, the effect of vegetation cover on erosion sediment yield weakened gradually with increasing slope gradient (at medium slope gradients of 5° and 10°), while the effect of slope gradient increased at steep slope gradients (15° and 20°).

Mycorrhizal associations are essential for orchid germination and seedling establishment, and thus may constrain the distribution and abundance of orchids under natural conditions. Previous works have shown that germination and seedling establishment in several orchids often decline with increasing distance from adult plants, resulting in nonrandom spatial patterns of seedling establishment. In contrast, individuals of the fully mycoheterotrophic orchid Gastrodia confusoides often tend to have random spatial patterns of distribution within bamboo forests. Since G. confusoides is parasitic on litter-decaying fungi, its random spatial patterns of distribution may be due to highly scattered patterns of litter-decaying fungi within bamboo forests. To test this hypothesis, we first identified the main mycorrhizal fungi associating with developing seeds and adult plants using Miseq high-throughput sequencing. Next, we combined seed germination experiments with quantitative PCR (qPCR) analyses to investigate to what extent the abundance of mycorrhizal fungi affected spatial patterns of seed germination. Our results show that seed germination and subsequent growth to an adult stage in G. confusoides required a distinct switch in mycorrhizal partners, in which protocorms associated with a single Mycena fungus, while adults associated with a fungus from the genus Gymnopus. A strong, positive relationship was observed between germination and Mycena abundance in the litter, but not between germination and Gymnopus abundance. Fungal abundance was not significantly related to the distance from the adult plants, and consequently germination was also not significantly related to the distance from adult plants. Our results provide the first evidence that the spatial distribution and abundance of litter-decaying fungi are distributed randomly within the bamboo forest and independently from G. confusoides adults.

Cholesterol-rich arterial plaques characterize atherosclerosis, a significant cause of heart disease. Arterial plaques upregulate inflammatory cytokines secreted by the macrophages that finally become cholesterol-laden foam cells. Nutraceuticals have received attention over the years, demonstrating potential benefits towards treating and preventing cardiovascular diseases (CVD), including atherosclerosis. Curcumin, a potent polyphenol present in Curcuma longa, showed remarkable anti-atherosclerotic activity via anti-inflammatory and anti-oxidative properties. The bioavailability and low water solubility of curcumin limit its clinical translational purposes. These issues can be circumvented effectively by nano-drug delivery systems that can target atherosclerotic plaque sites. In this work, we chose to use curcumin and a natural bioenhancer called Bioperine (derived from Piper nigrum) inside a polymeric nano-drug delivery system for targeting atherosclerotic plaque sites. We selected two different ratios of curcumin: Bioperine to study its comparative effect on the inhibition of oxidized low-density lipoprotein (Ox-LDL) induced foam cell formation and investigated the therapeutic efficacy in THP-1 monocyte-derived macrophages via different in vitro cell studies. Our studies demonstrated that Bioperine administration alongside curcumin via PLGA nanoparticles (NPs) imparts a reduction in macrophage-mediated foam cell formation, relative cholesterol content, and the inflammatory pathways when administered as preventive medicine, highlighting the importance of natural-based compounds towards the therapeutic intervention against the atherosclerotic activity.

BJOG-20-2353.R2 What should we believe when systematic reviews disagree?For many years, uterine balloon tamponade (UBT) has been used to treat severe postpartum haemorrhage (PPH), despite a lack of randomised trials to demonstrate its effectiveness. With commercial devices being expensive, clinicians in low resource settings have made their own using 2 low-cost, widely available items (Foley catheters and condoms). Public health experts have been so confident of their benefit that large programmes have been set up to disseminate the necessary skills worldwide.Recently, however, the global maternal health community has been thrown into disarray when not one, but two randomised controlled efficacy trials suggested that outcomes with condom catheter UBTs were actuallyworse than normal care in low resource settings. The Cochrane meta-analysis concluded that “in [low resource] settings, balloon tamponade [should be] only introduced alongside multi‐system improvements in PPH care” (Kellie et al. Cochrane Database of Systematic Reviews 2020(7): CD013663).Systematic reviews may be the pinnacle of evidence-based medicine, but even they can differ in how to interpret evidence. And so, proponents of the condom catheter conducted their own systematic review with far wider inclusion criteria – they not only included the randomised trials but examined success rates from 15 non-randomised trials and 69 case series (Suarez et al. Am J Obstet Gynecol 2020;222(4):293.e1–e52). Furthermore, the primary outcome was the success rate of the technique (overall 86%) rather than the risk of morbidity and mortality compared to controls, as used in the Cochrane review. This is problematic, as reported ‘success rates’ without controls can be very difficult to interpret: in initial case series misoprostol showed similar success rates against life-threatening haemorrhage before RCTs eventually showed it to be less effective than oxytocin.A third version of the same review is published today by a WHO team (Pingray et al. BJOG 2021;XXX,XXX). This time they include only 4 high quality studies in which UBT was compared to standard care. With a composite maternal morbidity / mortality outcome, they found no evidence of benefit and concluded that “the effect … is unclear, as is the role of the type of device and the setting”. WHO studies are now underway to address this uncertainty.But why is this all so important? The difficulty comes because the World Health Organisation has been updating its guidance on PPH management, and had to declare a position on UBT. The recently-published guideline, drawn up by independent experts, accepts the validity of the RCTs but recognises that there is wide acceptability of the technique and that the evidence of harm is only for condom catheters and onlyin resource-poor settings. They put a high emphasis on minimising harm and conclude that UBTs should only be used in settings where there is already a good standard of care, including recourse to blood transfusion and surgery if needed (WHO. Geneva: World Health Organization; 2021).Until further studies are published, the debate will continue. But this episode shows how the choice of inclusion criteria and outcomes in systematic reviews are critical, both for their conclusions, and for global policy.

Is the patient choice the best choice?

Objectives To evaluate the benefits imparted by concurrent chemoradiotherapy (CCRT) and chemotherapy of any form to elderly head and neck cancer (HNC) patients in Ireland. Secondary outcomes included comparison of these benefits to the adult population and subgroup analysis by site. Design, setting, and participants A retrospective cohort study was conducted using 20 years of cancer registry data provided by the National Cancer Registry of Ireland. All HNC diagnosed from 1994-2014 were included. Cox multivariate regression analysis was applied to test for the benefits of CCRT and chemotherapy of any form in HNC. The primary outcome measures were cancer-specific and all-cause survival in months. Results Survival analysis showed an overall benefit to the use of CCRT in patients with advanced disease over 65 years, particularly when used for hypopharyngeal, oral cavity, oropharyngeal, and laryngeal malignancy, though the latter did not achieve statistical significance. Chemotherapy of any form conferred a survival benefit in elderly patients with hypopharyngeal, laryngeal, nasopharyngeal, and oropharyngeal cancer. Conclusion CCRT and chemotherapy of any form confer significant survival benefits to appropriately selected elderly HNC patients and should therefore not be withheld solely on the basis of age.

This paper deals with a homogeneous Dirichlet initial-boundary problem of parabolic equations with different space-time coefficients, $$u_t =\Delta u + t^{\sigma_1} u^{\alpha} + \langle x\rangle^{n} v^{p},\quad v_t =\Delta v + \langle x\rangle^{m} u^{q} + t^{\sigma_2} v^{\beta},$$ where the eight exponents are nonnegative constants and $\langle x\rangle$ is the Japanese brackets. We obtain the Fujita exponents of solutions, which are determined by the eight exponents and the dimension of the space domain. Moreover, simultaneous or non-simultaneous blow-up of the two components of blow-up solutions is discussed with or without conditions on the initial data.

Background. To analyze the clinical features of children with plastic bronchitis (PB) and identify the risk factors of multiple flexible fiberoptic bronchoscopy (FOB) therapy. Methods. Retrospective analysis was performed on 269 PB children from 2016 to 2019, 144 cases were in single FOB group, 125 cases were in the multiple FOB group. The clinical manifestations, laboratory datas, imaging findings and management were investigated. The different features were compared between the single FOB group and multiple FOB group. Results. A total of 269 PB children were collected with a mean age of 6.7 ± 2.8 years. 257 (95.5%) cases were diagnosed as Mycoplasma pneumonia (MP) infection. The mean duration of fever was 10.6 ± 3.7 days. All the patients presented with fever, and 62 (23.0%) suffered from hypoxemia, 144 (53.5%) had extrapulmonary complications. Higher levels of ESR, CRP, PCT, IL-6, LA, LDH, FER and D-dimer were observed. The proportion of pulmonary consolidation, segmental or lobar atelectasis, pleural effusion and pleural thickening were 97.4%, 46.5%, 47.9% and 63.2%, respectively. Furthermore, multivariate logistic regression analysis showed that N% >75.5%, LDH >598.5U/L, and D-dimmer>0.45mg/L were independent isk factors for multiple FOB therapy. Conclusions. MP is a significant pathogen of PB in children. Patients with PB are more likely to suffer from persistent fever, excessive inflammation and severe radiological findings. N% >75.5%, LDH >598.5U/L and D-dimmer > 0.45mg/L may be predictors of multiple FOB treatment.

Pulmonary cryptococcosis presents as various radiological manifestations depending on the immunological status of the host. The most common chest radiographic findings include single or multiple nodules. Herein, we present a rare case of pulmonary cryptococcosis in a patient with rheumatoid arthritis presenting as multiple cystic lesions that enlarged after treatment.

Landslides

In this paper, a modified weak Galerkin finite element method on Shishkin mesh has been developed and analyzed for the singularly perturbed convection-diffusion-reaction problems. The proposed method is based on the idea of replacing the standard gradient (derivative) and convection derivative by modified weak gradient (derivative) and modified weak convection derivative, respectively, over piecewise polynomials of degree $k\geq1$. The present method is parameter-free and has less degree of freedom compared to the weak Galerkin finite element method. Stability and convergence rate of $\mathcal {O}((N^{-1}\ln N)^k)$ in the energy norm are proved. The method is uniformly convergent, i.e., the results hold uniformly regardless of the value of the perturbation parameter. Numerical experiments confirm these theoretical findings on Shishkin meshes. The numerical examples are also carried out on B-S meshes to confirm the theoretical results. Moreover, the proposed method has the optimal order error estimates of $\mathcal {O}(N^{-(k+1)})$ in a discrete $L^2-$ norm and converges at superconvergence order of $\mathcal {O}((N^{-1}\ln N)^{2k})$ in the discrete $L_\infty-$ norm.

Background The origin distribution of right-ventricular-outflow-tract (RVOT) ventricular arrhythmias (VAs) remains unclear. There is limited data on the ablation effectiveness of the reversed U-curve method compared with the antegrade method. Objectives To investigate the origin distribution of RVOT-type VAs and compare the ablation effectiveness of the two methods. Method Consecutive patients who had idiopathic RVOT-type VAs were prospectively enrolled. After activation mapping, patients were randomly assigned to supravalvular strategy using the reversed U-curve or subvalvular strategy using the antegrade method. The primary outcome was initial ablation (IA) success, defining as the successful ablation within the first three attempts. Results 61 patients were enrolled from November 2018 to June 2020. Activation mapping revealed 34/61 (55.7%) of the earliest ventricular activating (EVA) sites were above the pulmonary valves (PVs). The IA success rate was 25/33(75.8%) in the patients assigned to supravalvular strategy as compared with 16/28(57.1%) in those assigned to subvalvular strategy (P=0.172). Logistic regression revealed a substantial and qualitative interaction between the EVA sites and IA strategies (Pinteraction<0.001). For multiple-comparison, either strategy had a remarkably higher IA success rate in treating its ipsilateral EVA sites than contralateral ones (P<0.0083). Conclusion Of the idiopathic RVOT-type VA origins, half were located above the PV. The two strategies did not differ in the primary outcomes. However, they complement locating the EVA sites and facilitate ipsilateral ablation, which produces a significantly higher IA success rate. (Chinese Clinical Trial Registry number, ChiCTR2000029331)

Climate change is considered as one of the biggest threats to coral reefs in the next 100 years. The most significant impact of climate change would be the rise in global seawater temperature. A critical turning point which determines the fate of coral reefs depends on how corals and their associated algae respond to the rise in seawater temperature. Symbiotic plasticity may help corals to survive such environmental threats. The zooxanthella Symbiodinium is classified into nine clades (A – I), six of which are known to be coral symbionts. As reaction to thermal stress, symbionts are lost to the host by several mechanisms. Physiological models on the importance of nitrogen fixing bacteria, i.e., diazotrophs, for bleached corals indicate that diazotrophically derived nitrogen either allows corals to better withstand bleaching, or increases bleaching by generating unbalanced nutrient requirements that lead to phosphorous starvation of the Symbiodinium. Reactive oxygen species (ROS) triggered by symbiosis operation of the damaged photosynthetic machinery causes leaks in the host cell, where they overpower cellular antioxidant mechanisms and potentially damage the host tissue. Both symbiotic partners, however, have significant adaptations for managing ROS to mitigate against cell damage as illustrated herein. Such extensive compile of literature in this review suggest that physiological host plasticity and/or symbiotic components clearly plays a significant role in response to thermal stress that may also vary between different species of corals, as many corals may contain specific ecotypes or clades of zooxanthellae which may vary in their ability to withstand thermal stress.

A document by Jie Xing, written on Authorea.

With regard to acquired melanosis of the conjunctiva, there is still neither a worldwide uniform nomenclature nor reliable data on how frequent this type of pigment disorder is. This is even more true for the estimation of the risk of progression into cancer as well as the clinical management of this entity. This short paper presents the current, partly contradictory scientific knowledge which is available.

Objective: Arterial stiffness refers to arterial wall rigidity, particularly in central vessels, and is an independent predictor of cardiovascular disease. 25-Hydroxy (OH) vitamin D has beneficial effects on blood pressure, vascular endothelial function, and arterial stiffness. Therefore, we aimed to elucidate the role of 25-OH vitamin D deficiency in arterial stiffness development and its relationship with arterial stiffness in healthy children. Methods: This study included 80 patients with low levels of 25-OH vitamin D and 40 healthy control. The study participants were then divided into three groups: group 1 consisted of patients with a deficient 25-OH D level of < 19.9 ng/mL, group 2 with an insufficient 25-OH D level between 20-29.9 ng/mL; group 3 were considered control group with a sufficient serum 25-OH vitamin D level of ≥30 ng/mL. Aortic strain, distensibility, stiffness index, and standard left ventricular measurements were calculated using M-mode echocardiographic data. Results: Left ventricular mass index (LVMI) and interventricular septal diastolic thickness (IVSTd) appeared to increase in group 1 compared to groups 2 and 3. Aortic strain and distensibility were significantly decreased in group 1, whereas aortic stiffness index and elastic modulus were significantly increased. The aortic stiffness index was negatively correlated with serum 25-OH vitamin D levels; however, aortic strain, aortic distensibility, and LVMI were positively correlated. Conclusions: Our study results revealed a significant relationship between 25-OH vitamin D levels indicative of a deficiency and aortic stiffness. We suggest that arterial stiffness may also occur in healthy children with a 25-OH vitamin D deficiency.

Objectives Possibility of reinfection with SARS-CoV-2 changes our view on herd immunity and vaccination, and can impact worldwide quarantine policies. We performed RT-PCR follow-up studies on recovered patients to assess possible development of reinfections and re-positivity. Method During a 6-month period, 202 PCR-confirmed recovering COVID-19 patients entered this study. Follow-up RT-PCR tests and symptoms assessment were performed one month after the initial Positive results. patients who tested negative were tested again one and three months later. The Serum IgG and IgM levels were measured in the last follow-up session. Results In the first two follow-up sessions, 82 patients continued their participation, of which four patients tasted positive. In the second follow-up 44 patients participated, three of whom tested positive. None of the patients who tested positive in the first and second follow-up session were symptomatic. In the last session, 32 patients were tested and four patients were positive, three of them were mildly symptomatic and all of them were positive for IgG. Conclusion A positive RT-PCR in a recovering patient may represent reinfection. While we did not have the resources to prove reinfection by genetic sequencing of the infective viruses, we believe presence of mild symptoms in the three patients who tested positive over 100 days after becoming asymptomatic, can be diagnosed as reinfection. The IgG may have abated the symptoms of the reinfection, without providing complete protection.

Since the start of the SARS-CoV-2 pandemic, it has been difficult to differentiate between SARS-CoV-2 re-infection and prolonged RNA shedding. In this report, we identified patients with positive rtPCR results for SARS-CoV-2 ≥70 days apart. Clinical and laboratory data were collected and criteria were applied to discern whether the presentation was consistent with SARS-CoV-2 re-infection or prolonged viral RNA shedding. Eleven individuals met the initial testing criteria, of which, seven met at least one criteria for re-infection and four were consistent with prolonged RNA shedding. These data demonstrate the need for criteria to differentiate SARS-CoV-2 re-infection from prolonged RNA shedding.