Signaling crosstalk between tumor endothelial cells and immune cells in the microenvironment of solid tumors.

Tumor-associated endothelial cells (TECs) are crucial mediators of immune surveillance and immune escape in the tumor microenvironment (TME). TECs driven by angiogenic growth factors form an abnormal vasculature which deploys molecular machinery to selectively promote the function and recruitment of immunosuppressive cells while simultaneously blocking the entry and function of anti-tumor immune cells. TECs also utilize a similar set of signaling regulators to promote the metastasis of tumor cells. Meanwhile, the tumor-infiltrating immune cells further induce the TEC anergy by secreting pro-angiogenic factors and prevents further immune cell penetration into the TME. Understanding the complex interactions between TECs and immune cells will be needed to successfully treat cancer patients with combined therapy to achieve vasculature normalization while augmenting antitumor immunity. In this review, we will discuss what is known about the signaling crosstalk between TECs and tumor-infiltrating immune cells to reveal insights and strategies for therapeutic targeting.

The distribution of strongylid egg and lungworm (Dictyocaulus eckerti) larval counts in adult female farmed red deer (Cervus elaphus), and the implications for parasite control.

Whilst healthy adult farmed red deer show little clinical indication of parasite infection, they may still be maintaining infection levels on the farm through low-level shedding of nematode eggs and lungworm larvae. This work was undertaken to establish the long-term distribution of parasite counts, to determine whether the higher counts seen in previous trials are repeatable across the same animals. All adult female red deer on a New Zealand North Island property were faecal sampled (n = 209), weighed, and body condition scored (BCS) on five sampling occasions from March - August 2021. Faecal samples were processed by modified Baermanns to recover, identify, and enumerate lungworm 1st stage larvae (FLC), and nematode faecal egg counts (FEC) were determined by mini-FLOTAC. Between animal variation for FEC was significant (p < 0.001); whilst many counts were low to zero, a few individuals were consistently shedding higher egg counts. Younger animals tended to have higher egg counts (p = 0.003), but there was no association between FEC and BCS (p = 0.22), and FEC and liveweight (p = 0.58). Modelling of the data indicated that 50% of the egg output resulted from 21% of the animals. Additionally, there was no significant association between the higher egg counts and the gastrointestinal nematode classification; 'long tails' (likely Oesophagostomum sp.) p = 0.76, and the Ostertagiinae complex p = 0.75. Lungworm counts tended to be very low (0 - 26 lpg); consistent with previous trials and literature in farmed adult deer. However, between animal differences were statistically significant (p < 0.001) indicating some animals were passing more larvae than others, and poorer conditioned animals (BCS 2.5) were significantly associated with higher larval count (p = 0.03). There was no relationship between larval count and age (p = 0.62) and larval count and liveweight (p = 0.22). Modelling indicates that 50% of pasture larval contamination was contributed by 15% of the animals. There was no correlation between nematode egg count and lungworm larvae count (p = 0.22). Adult deer may play an important role as a source of infection for young deer, therefore, an improved understanding of the distribution of infection is needed to improve parasite control.

Development of the scrupulosity inventory: A factor analysis and construct validity study.

BACKGROUND AND OBJECTIVES: Scrupulosity, despite its considerable prevalence and morbidity, remains under-investigated. The present study develops and examines the psychometric properties of a comprehensive assessment tool, the Scrupulosity Inventory (SI). METHODS: The SI, along with other measures of obsessive-compulsive disorder (OCD) and perfectionism, were administered to a sample (N = 150) of college undergraduates similar in size to other scale development studies of related measures. We conducted exploratory and confirmatory factor analyses of the SI, examined its convergent and divergent validity, and assessed its ability to predict categorical diagnoses of scrupulosity using a receiver operator characteristic analysis. RESULTS: We found a well-fitting confirmatory bifactor model (RMSEA = 0.049) with a strong general Scrupulosity factor ( [Formula: see text] ) and specific factors for Personal Violations ( [Formula: see text] ), Ritualized Behavior ( [Formula: see text] ), Interference with Life ( [Formula: see text] ), and Problem Pervasiveness ( [Formula: see text] ). As predicted, we also found the strongest convergence (r = 0.63) between the SI and the Penn Inventory of Scrupulosity (PIOS), intermediate convergence (r = 0.54) between the SI and Perfectionism Inventory (PI), and weaker convergence (r = 0.47) between the SI and YBOCS. Finally, we found that a categorical diagnosis of scrupulosity was highly predicted by the SI (AUC = 0.84), less well-predicted by the PIOS (AUC = 0.75) and less well predicted by the YBOCS (AUC = 0.69). LIMITATIONS: This study was conducted among a sample of undergraduates at a religiously affiliated university. CONCLUSIONS: These results suggest utility in using the SI to measure the severity of scrupulosity symptoms and that scrupulosity and OCD may present significantly different clinical features.

Simultaneous resistance to multiple anthelmintic classes in nematode parasites of cattle in New Zealand.

Resistance to the benzimidazole and macrocyclic lactone anthelmintics is widespread in Cooperia spp. on cattle farms in New Zealand. Since this was first documented in 2006 little has changed in cattle farming systems except for the widespread use of levamisole to control Cooperia spp. in young cattle (i.e., parasite control has maintained an almost total reliance on use of anthelmintics). Here we report the emergence of simultaneous resistance to the benzimidazole, macrocyclic lactone and levamisole anthelmintics in Cooperia spp. and in Ostertagia spp. Anthelmintic efficacy against nematode parasites of cattle was investigated on four commercial farms following reports of poor animal growth rates and welfare, and positive faecal egg counts, despite routine treatment with combination anthelmintics, which included levamisole. Faecal egg count reduction tests involved 15 animals per treatment group, individual egg counts (paired samples) conducted pre- and post-treatment, with eggs counted to ≤ 15 eggs per g faeces and larval cultures for morphological identification. Actives tested varied between farms but always included levamisole alone and several combination products containing levamisole. Of the 20 tests conducted (i.e., 5 products on each of 4 farms) only 3 exceeded 90% efficacy against Cooperia spp. even though 8 of the products tested were combinations containing levamisole and at least one other broad-spectrum anthelmintic. Levamisole used alone achieved efficacies between 44% and 71% against Cooperia spp. across the four trials. The only product to exceed 95% efficacy against Cooperia spp. was a combination of monepantel + abamectin which was 100% effective against all parasites. Resistance to oxfendazole in Ostertagia spp. was indicated on 3 farms, while on one farm efficacy of all the tested products was ≤75% against this parasite. All the farms involved in this study were farming intensive cattle operations with an almost total reliance on anthelmintics to control parasitism. The results clearly demonstrate the emergence of simultaneous resistance to oxfendazole, levamisole and the macrocyclic lactone anthelmintics. Despite years of advice and recommendations to change farming practices away from intensive monocultures, many farmers have continued with the practice, and some are now faced with the very real possibility of being unable to control cattle parasites on their farms.

Therapeutic targeting of tumor spheroids in a 3D microphysiological renal cell carcinoma-on-a-chip system.

Metastatic renal cell carcinoma (RCC) remains an incurable disease for most patients highlighting an urgent need for new treatments. However, the preclinical investigation of new therapies is limited by traditional two-dimensional (2D) cultures which do not recapitulate the properties of tumor cells within a collagen extracellular matrix (ECM), while human tumor xenografts are time-consuming, expensive and lack adaptive immune cells. We report a rapid and economical human microphysiological system ("RCC-on-a-chip") to investigate therapies targeting RCC spheroids in a 3D collagen ECM. We first demonstrate that culture of RCC cell lines A498 and RCC4 in a 3D collagen ECM more faithfully reproduces the gene expression program of primary RCC tumors compared to 2D culture. We next used bortezomib as a cytotoxin to develop automated quantification of dose-dependent tumor spheroid killing. We observed that viable RCC spheroids exhibited collective migration within the ECM and demonstrated that our 3D system can be used to identify compounds that inhibit spheroid collective migration without inducing cell death. Finally, we demonstrate the RCC-on-a-chip as a platform to model the trafficking of tumor-reactive T cells into the ECM and observed antigen-specific A498 spheroid killing by engineered human CD8+ T cells expressing an ROR1-specific chimeric antigen receptor. In summary, the phenotypic differences between the 3D versus 2D environments, rapid imaging-based readout, and the ability to carefully study the impact of individual variables with quantitative rigor will encourage adoption of the RCC-on-a-chip system for testing a wide range of emerging therapies for RCC.

Single cell atlas of kidney cancer endothelial cells reveals distinct expression profiles and phenotypes.

Background: Tumor endothelial cells (TECs) represent the primary interface between the tumor microenvironment and circulating immune cells, however their phenotypes are incompletely understood in highly vascularized clear cell renal cell carcinoma (ccRCC). Methods: We purified tumor and matched normal endothelial cells (NECs) from ccRCC specimens and performed single-cell RNA-sequencing to create a reference-quality atlas available as a searchable web resource for gene expression patterns. We established paired primary TECs and NECs cultures for ex vivo functional testing. Results: TECs from multiple donors shared a common phenotype with increased expression of pathways related to extracellular matrix regulation, cell-cell communication, and insulin-like growth factor signaling that was conserved in comparison to hepatocellular carcinoma associated TECs, suggesting convergent TEC phenotypes between unrelated tumors. Cultured TECs stably maintained a core program of differentially regulated genes, were inherently resistant to apoptosis after vascular endothelial growth factor removal and displayed increased adhesiveness to subsets of immune cells including regulatory T-cells. Conclusions: Our studies delineate unique functional and phenotypic properties of TECs, which may provide insights into their interactions with available and emerging therapies. Functional phenotypes of cultured TECs suggest potential mechanisms of resistance to both antiangiogenic and immune-based therapies.

Tumor stromal topography promotes chemoresistance in migrating breast cancer cell clusters.

Multicellular clustering provides cancer cells with survival advantages and facilitates metastasis. At the tumor migration front, cancer cell clusters are surrounded by an aligned stromal topography. It remains unknown whether aligned stromal topography regulates the resistance of migrating cancer cell clusters to therapeutics. Using a hybrid nanopatterned model to characterize breast cancer cell clusters at the migration front with aligned stromal topography, we demonstrate that topography-induced migrating cancer cell clusters exhibit upregulated cytochrome P450 family 1 (CYP1) drug metabolism and downregulated glycolysis gene signatures, which correlates with unfavorable prognosis. Screening on approved oncology drugs shows that cancer cell clusters on aligned stromal topography are more resistant to diverse chemotherapeutics. Full-dose drug testings further indicate that topography induces drug resistance of hormone receptor-positive breast cancer cell clusters to doxorubicin and tamoxifen and triple-negative breast cancer cell clusters to doxorubicin by activating the aryl hydrocarbon receptor (AhR)/CYP1 pathways. Inhibiting the AhR/CYP1 pathway restores reactive oxygen species-mediated drug sensitivity to migrating cancer cell clusters, suggesting a plausible therapeutic direction for preventing metastatic recurrence.

Integrated TCR repertoire analysis and single-cell transcriptomic profiling of tumor-infiltrating T cells in renal cell carcinoma identifies shared and tumor-restricted expanded clones with unique phenotypes.

Objective responses of metastatic renal cell carcinoma (RCC) associated with systemic immunotherapies suggest the potential for T-cell-mediated tumor clearance. Recent analyses associate clonally expanded T cells present in the tumor at diagnosis with responses to immune checkpoint inhibitors (ICIs). To identify and further characterize tumor-associated, clonally expanded T cells, we characterized the density, spatial distribution, T-cell receptor (TCR) repertoire, and transcriptome of tumor-infiltrating T cells from 14 renal tumors at the time of resection and compared them with T cells in peripheral blood and normal adjacent kidney. Multiplex immunohistochemistry revealed that T-cell density was higher in clear cell RCC (ccRCC) than in other renal tumor histologies with spatially nonuniform T-cell hotspots and exclusion zones. TCR repertoire analysis also revealed increased clonal expansion in ccRCC tumors compared with non-clear cell histologies or normal tissues. Expanded T-cell clones were most frequently CD8+ with some detectable in peripheral blood or normal kidney and others found exclusively within the tumor. Divergent expression profiles for chemokine receptors and ligands and the Ki67 proliferation marker distinguished tumor-restricted T-cell clones from those also present in blood suggesting a distinct phenotype for subsets of clonally expanded T cells that also differed for upregulated markers of T-cell activation and exhaustion. Thus, our single-cell level stratification of clonally expanded tumor infiltrating T-cell subpopulations provides a framework for further analysis. Future studies will address the spatial orientation of these clonal subsets within tumors and their association with treatment outcomes for ICIs or other therapeutic modalities.

Ophthalmic sequelae and psychosocial impact in pediatric ebola survivors.

Background: Ebola virus disease (EVD) outbreaks in West Africa (2013-2016) and the Democratic Republic of Congo (2018-2020) have resulted in thousands of EVD survivors who remain at-risk for survivor sequelae. While EVD survivorship has been broadly reported in adult populations, pediatric EVD survivors are under-represented. In this cross-sectional study, we investigated the prevalence of eye disease, health-related quality-of-life, vision-related quality-of-life, and the burden of mental illness among pediatric EVD survivors in Sierra Leone. Methods: Twenty-three pediatric EVD survivors and 58 EVD close contacts were enrolled. Participants underwent a comprehensive ophthalmic examination and completed the following surveys: Pediatric Quality of Life Inventory Version 4.0, Effect of Youngsters Eyesight on Quality-of-Life, and the Revised Child Anxiety and Depression Scale. Findings: A higher prevalence of uveitis was observed in EVD survivor eyes (10·8%) cohort compared to close contacts eyes (1·7%, p=0·03). Overall, 47·8% of EVD survivor eyes and 31·9% of close contact eyes presented with an eye disease at the time of our study (p=0·25). Individuals diagnosed with an ocular complication had poorer vision-related quality-of-life (p=0·02). Interpretation: Both health related quality-of-life and vision-related quality-of-life were poor among EVD survivors and close contacts. The high prevalence of eye disease associated with reduced vision health, suggests that cross-disciplinary approaches are needed to address the unmet needs of EVD survivors. Funding: National Institutes of Health R01 EY029594, K23 EY030158; National Eye Institute; Research to Prevent Blindness (Emory Eye Center); Marcus Foundation Combating Childhood Illness; Emory Global Health Institute; Stanley M. Truhlsen Family Foundation.

A model for the development of the free-living stages of Ostertagia leptospicularis, used in conjunction with on-farm egg count data, to estimate sources of pasture contamination on New Zealand red deer (Cervus elaphus) farms.

Farmed red deer face challenges from nematode parasites, primarily the pulmonary species Dictyocaulus eckerti and the complex of Ostertagiinae nematodes in the abomasum. Previous investigations on New Zealand deer farms identified limited seasonality in faecal egg and larval output in all stock classes, however, this does not indicate the key times of year those eggs develop into infective-stage larvae, and subsequently contribute to infection risk. A simple temperature-driven model was developed for the free-living stages of a representative deer-specific Ostertagiinae species; Ostertagia leptospicularis. The model was then validated using development data generated from seasonal plot trials. Using faecal egg counts and animal numbers from the previous monitoring study, and local weather data from each of the sampling farms, the relative contribution of each stock class to infective third-stage larvae population on pasture was estimated for each month of the year (2018-2019). The mixed-age adult females were the primary source of infective larvae on most of the sampled farms, principally due to their numerical dominance (i.e., venison breeding farms). The frequent anthelmintic use in the youngest stock class (< 12 months old) on some farms limited their output of eggs and hence their contribution to pasture infestation with infective larvae. However, the trends of larval development on pasture differed between the farms (due to local climate), and between the sampling years (2018-2019). Therefore, calendar-based application of anthelmintics to older stock is not recommended, as contribution to pasture contamination is multifactorial. The study provides a better understanding of deer parasite epidemiology on which to base improved management practices.

Acoustic vector sensor analysis of the Monterey Bay region soundscape and the impact of COVID-19.

From February 2019 through January 2021, data were collected by an acoustic vector sensor moored on the seafloor at a depth of approximately 900 m just outside of Monterey Bay, California, near a major shipping lane off the California coast. Analysis of the vector sensor data has shown the ability to accurately determine bearings to merchant vessels at ranges up to 60 km. This paper examines the features of the low-frequency soundscape using spectral probability densities and evaluates directional features through vector intensity processing as well as coherent linear and adaptive processing of the vector sensor channels. Merchant vessel acoustic data were analyzed using the 1/3 octave band centered at 63 Hz. Over the period analyzed, a reduction in merchant vessel noise was observed between February and June 2020 relative to the same period in 2019, consistent with a reduction in vessel traffic due to the worldwide response to COVID-19. The directional features of the data evaluated through adaptive processing methods also suggest this reduction can be most clearly distinguished towards the south, where the shipping lane is limited to transiting vessels, rather to the north-northwest, where merchant vessels tend to congregate on approach into the San Francisco Bay area.

Further structural characterization of ovine forestomach matrix and multi-layered extracellular matrix composites for soft tissue repair.

Decellularized extracellular matrix (dECM)-based biomaterials are of great clinical utility in soft tissue repair applications due to their regenerative properties. Multi-layered dECM devices have been developed for clinical indications where additional thickness and biomechanical performance are required. However, traditional approaches to the fabrication of multi-layered dECM devices introduce additional laminating materials or chemical modifications of the dECM that may impair the biological functionality of the material. Using an established dECM biomaterial, ovine forestomach matrix, a novel method for the fabrication of multi-layered dECM constructs has been developed, where layers are bonded via a physical interlocking process without the need for additional bonding materials or detrimental chemical modification of the dECM. The versatility of the interlocking process has been demonstrated by incorporating a layer of hyaluronic acid to create a composite material with additional biological functionality. Interlocked composite devices including hyaluronic acid showed improved in vitro bioactivity and moisture retention properties.

Toward best practice in cancer mutation detection with whole-genome and whole-exome sequencing.

Clinical applications of precision oncology require accurate tests that can distinguish true cancer-specific mutations from errors introduced at each step of next-generation sequencing (NGS). To date, no bulk sequencing study has addressed the effects of cross-site reproducibility, nor the biological, technical and computational factors that influence variant identification. Here we report a systematic interrogation of somatic mutations in paired tumor-normal cell lines to identify factors affecting detection reproducibility and accuracy at six different centers. Using whole-genome sequencing (WGS) and whole-exome sequencing (WES), we evaluated the reproducibility of different sample types with varying input amount and tumor purity, and multiple library construction protocols, followed by processing with nine bioinformatics pipelines. We found that read coverage and callers affected both WGS and WES reproducibility, but WES performance was influenced by insert fragment size, genomic copy content and the global imbalance score (GIV; G > T/C > A). Finally, taking into account library preparation protocol, tumor content, read coverage and bioinformatics processes concomitantly, we recommend actionable practices to improve the reproducibility and accuracy of NGS experiments for cancer mutation detection.

Route of administration affects the efficacy of moxidectin against Ostertagiinae nematodes in farmed red deer (Cervus elaphus).

The influence of route of administration on the pharmacokinetics and efficacy of macrocyclic lactone anthelmintics has been a subject of interest due to its potential to influence the development of anthelmintic resistance. For most parasite species studied so far, oral administration results in the highest concentrations of drug in the parasites and the highest efficacy against resistant genotypes. However, a recent study in cattle measured the highest levels of ivermectin in the abomasal Ostertagia ostertagi following subcutaneous injection, but it was not possible to correlate these elevated levels with efficacy. Therefore, the current study was initiated to determine whether injectable delivery might be optimal for attaining high efficacy against this important group of parasites. Three on-farm trials were conducted to measure the efficacy of moxidectin administered by the oral, injectable, and pour-on routes against Ostertagiinae parasites in farmed red deer. Groups of rising 1-year old stags (red or red-wapiti crossbreds) in the 84-104 kg weight range were randomised on liveweight into treatment groups of 6 (1 farm) or 8 (2 farms). Animals were treated to individual liveweight with moxidectin oral (0.2 mg/kg), injectable (0.2 mg/kg), pour-on (0.5 mg/kg) or remained untreated. Twelve days later all animals were euthanised and abomasa recovered for worm count. Adult worms were counted in a 2% aliquot of abomasal washings, and adult and fourth stage larvae in a 10 % aliquot following mucosal incubation in physiological saline. In addition, blood was collected from the same 5 animals in each of the treatment groups on days 0, 1, 2, 3, 5, 7 and 12 after treatment and moxidectin levels in plasma were determined using a mass spectrometer. The number of Ostertagiinae surviving treatment was significantly different for each of the treatment groups with injectable administration being most effective, oral administration being the next most effective and pour-on administration the least effective. This applied to both adult worms and fourth stage larvae. A similar pattern was seen in the levels of moxidectin in plasma with both the peak value and area under the concentration curve being highest following injectable administration and lowest following pour-on treatment. Although undertaken in a different host species, the results support the proposition that injectable administration of macrocyclic lactone anthelmintics is likely to be optimal for efficacy against Ostertagiinae parasites and potentially useful in slowing the emergence of resistance in these parasites.

Current and Future Projections of Amyotrophic Lateral Sclerosis in the United States Using Administrative Claims Data.

BACKGROUND: Various methodologies have been reported to assess the real-world epidemiology of amyotrophic lateral sclerosis (ALS) in the United States. The aim of this study was to estimate the prevalence, incidence, and geographical distribution of ALS using administrative claims data and to model future trends in ALS epidemiology. METHODS: We performed a retrospective analysis of deidentified administrative claims data for >100 million patients, using 2 separate databases (IBM MarketScan Research Databases and Symphony Health Integrated DataVerse [IDV]), to identify patients with ALS. We evaluated disease prevalence, annual incidence, age- and population-controlled geographical distribution, and expected future trends. RESULTS: From 2013 to 2017, we identified 7,316 and 35,208 ALS patients from the MarketScan databases and IDV, respectively. Average annual incidence estimates were 1.48 and 1.37 per 100,000 and point prevalence estimates were 6.85 and 5.16 per 100,000 and in the United States for the MarketScan databases and IDV, respectively. Predictive modeling estimates are reported out to the year 2060 and demonstrate an increasing trend in both incident and prevalent cases. CONCLUSIONS: This study provides incidence and prevalence estimates as well as geographical distribution for what the authors believe to be the largest ALS population studied to date. By using 2 separate administrative claims data sets, confidence in our estimates is increased. Future projections based on either database demonstrate an increase in ALS cases, which has also been seen in other large-scale ALS studies. These results can be used to help improve the allocation of healthcare resources in the future.

Current status of antigen-specific T-cell immunotherapy for advanced renal-cell carcinoma.

In renal-cell carcinoma (RCC), tumor-reactive T-cell responses can occur spontaneously or in response to systemic immunotherapy with cytokines and immune checkpoint inhibitors. Cancer vaccines and engineered T-cell therapies are designed to selectively augment tumor antigen-specific CD8+ T-cell responses with the goal to elicit tumor regression and avoid toxicities associated with nonspecific immunotherapies. In this review, we provide an overview of the central role of T-cell immunity in the treatment of advanced RCC. Clinical outcomes for antigen-targeted vaccines or other T-cell-engaging therapies for RCC are summarized and evaluated, and emerging new strategies to enhance the effectiveness of antigen-specific therapy for RCC are discussed.

Chromosome 8 gain is associated with high-grade transformation in MPNST.

One of the most common malignancies affecting adults with Neurofibromatosis type 1 (NF1) is the malignant peripheral nerve sheath tumor (MPNST), an aggressive and often fatal sarcoma that commonly arises from benign plexiform neurofibromas. Despite advances in our understanding of MPNST pathobiology, there are few effective therapeutic options, and no investigational agents have proven successful in clinical trials. To further understand the genomic heterogeneity of MPNST, and to generate a preclinical platform that encompasses this heterogeneity, we developed a collection of NF1-MPNST patient-derived xenografts (PDX). These PDX were compared with the primary tumors from which they were derived using copy number analysis, whole exome sequencing, and RNA sequencing. We identified chromosome 8 gain as a recurrent genomic event in MPNST and validated its occurrence by FISH in the PDX and parental tumors, in a validation cohort, and by single-cell sequencing in the PDX. Finally, we show that chromosome 8 gain is associated with inferior overall survival in soft-tissue sarcomas. These data suggest that chromosome 8 gain is a critical event in MPNST pathogenesis and may account for the aggressive nature and poor outcomes in this sarcoma subtype.

The need for improved discharge criteria for hospitalised patients with COVID-19-implications for patients in long-term care facilities.

In the COVID-19 pandemic, patients who are older and residents of long-term care facilities (LTCF) are at greatest risk of worse clinical outcomes. We reviewed discharge criteria for hospitalised COVID-19 patients from 10 countries with the highest incidence of COVID-19 cases as of 26 July 2020. Five countries (Brazil, Mexico, Peru, Chile and Iran) had no discharge criteria; the remaining five (USA, India, Russia, South Africa and the UK) had discharge guidelines with large inter-country variability. India and Russia recommend discharge for a clinically recovered patient with two negative reverse transcription polymerase chain reaction (RT-PCR) tests 24 h apart; the USA offers either a symptom based strategy-clinical recovery and 10 days after symptom onset, or the same test-based strategy. The UK suggests that patients can be discharged when patients have clinically recovered; South Africa recommends discharge 14 days after symptom onset if clinically stable. We recommend a unified, simpler discharge criteria, based on current studies which suggest that most SARS-CoV-2 loses its infectivity by 10 days post-symptom onset. In asymptomatic cases, this can be taken as 10 days after the first positive PCR result. Additional days of isolation beyond this should be left to the discretion of individual clinician. This represents a practical compromise between unnecessarily prolonged admissions and returning highly infectious patients back to their care facilities, and is of particular importance in older patients discharged to LTCFs, residents of which may be at greatest risk of transmission and worse clinical outcomes.