Institutionalising wastewater surveillance systems to minimise the impact of COVID-19: cases of Indonesia, Japan and Viet Nam.

This mini review describes the current status and challenges regarding institutionalisation of wastewater surveillance systems against COVID-19. Monitoring SARS-CoV-2 in wastewater has been proposed to be a potential tool to understand the actual prevalence of COVID-19 in the community, and it could be an effective approach to monitor the trend during the COVID-19 pandemic. However, challenges to institutionalise wastewater surveillance systems are still abundant and unfolding at a rapid rate given that the international understanding regarding the scientific knowledge and socio-political impacts of COVID-19 are in the developing stages. To better understand the existing challenges and bottlenecks, a comparative study between Japan, Viet Nam, and Indonesia was carried out in the present study. Through gaining a better understanding of common issues as well as issues specific to each country, we hope to contribute to building a robust multistakeholder system to monitor SARS-CoV-2 in wastewater as an effective disease surveillance system for COVID-19.

Temporal variations in genotype distribution of human sapoviruses and Aichi virus 1 in wastewater in Southern Arizona, United States.

AIMS: To investigate the molecular epidemiology, especially temporal variations in genotype distribution, of sapoviruses and Aichi virus 1 (AiV-1) in Arizona, United States, by examining wastewater. METHODS AND RESULTS: A total of 26 wastewater samples (13 influent and 13 effluent) were collected monthly from a wastewater treatment plant and viral strains were identified through nested reverse transcription-PCR followed by cloning and sequencing analysis. Identified sapovirus strains were classified into seven genotypes belonging to three genogroups (GI, GII, and GV): GI.1, GI.2, GI.3, GII.1, GII.2, GII.8 and GV.1, with a clear temporal shift. The majority of AiV-1 strains identified from the wastewater samples were classified into genotype B, and genotype A strains were identified in only two samples. CONCLUSIONS: We identified a number of sapovirus and AiV-1 strains belonging to multiple genotypes in wastewater samples collected over a 13-month period. Our results suggested a temporal shift in prevalent genotypes in the community. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study elucidating the genotype distribution of human sapoviruses and AiV-1 in wastewater in the United States. Wastewater surveillance is especially useful for understanding molecular epidemiology of viruses that are less commonly tested in clinical diagnosis, including sapoviruses and AiV-1.

Selection of cellular genetic markers for the detection of infectious poliovirus.

AIMS: Cellular responses of an established cell line from human intestinal epithelial cells (INT-407 cells) against poliovirus (PV) infections were investigated in order to find cellular genetic markers for infectious PV detection. METHODS AND RESULTS: Gene expression profile of INT-407 cells was analysed by DNA microarray technique when cells were infected with poliovirus 1 (PV1) (sabin) at multiplicity of infection of 10-3 and incubated for 12 h. Poliovirus infection significantly altered the gene expressions of two ion channels, KCNJ4 and SCN7A. The expression profile of KCNJ4 gene was further investigated by real-time RT-qPCR, and it was found that KCNJ4 gene was significantly regulated at 24 h postinfection of PV1. CONCLUSIONS: KCNJ4 gene, coding a potassium channel protein, is proposed as a cellular genetic marker for infectious PV detection. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study to show the availability of cellular responses to detect infectious PV. The selection of cellular genetic markers for infectious viruses using DNA microarray and RT-qPCR can be applicable for the other enteric viruses.

Using Pseudomonas aeruginosa PAO1 to evaluate hydrogen peroxide as a biofouling control agent in membrane treatment systems.

Hydrogen peroxide (H2 O2 ) is widely used in water treatment for biofouling control and, in conjunction with catalysts, as a powerful oxidant for contaminant destruction. H2 O2 could potentially serve as an antifouling agent in reverse osmosis systems in lieu of chlorine-based disinfectants. The dependence of the biocidal efficiency of H2 O2 on cell density, temperature and H2 O2 concentration by determining the growth, attachment and viability of the model bacterium Pseudomonas aeruginosa PAO1 was studied. For controlling growth of planktonic PAO1 cells, the minimally required H2 O2 concentration depends on the cell density and temperature. The effect of H2 O2 to remove the existing biofilm was found to be effective in the presence of a high concentration bicarbonate (8·4 g l-1 ), which forms peroxymonocarbonate, a strong oxidant and disinfectant. Treatment with H2 O2 -bicarbonate reduced the density of live PAO1 cells, removed extracellular polymeric substances and lowered the average biofilm thickness while maintaining the integrity of the membrane, suggesting that this type of treatment may be a suitable 'in-place-cleaning' procedure for biofouled membranes. SIGNIFICANCE AND IMPACT OF THE STUDY: H2 O2 is evaluated as a potential replacement for chlorine to control biofouling in membrane-based water treatment systems. The biocidal efficacy of H2 O2 was evaluated as a function of H2 O2 concentration, cell density and temperature using the model organism Pseudomonas aeruginosa PAO1. Results demonstrated that at low temperatures and low cell densities, bacterial growth and membrane biofouling can be prevented by low H2 O2 concentrations, and existing biofilms could be removed by H2 O2 -bicarbonate mixtures. Findings suggested that H2 O2 could be used as a low cost agent for prevention and controlling biofouling in reverse osmosis applications.

Impact of disinfectant wipes on the risk of Campylobacter jejuni infection during raw chicken preparation in domestic kitchens.

AIMS: In the present study, we conducted a quantitative microbial risk assessment forecasting the exposure to Campylobacter jejuni contaminated surfaces during preparation of chicken fillets and how using a disinfectant-wipe intervention to clean a contaminated work area decreases the risk of infection following the preparation of raw chicken fillet in a domestic kitchen. METHODS AND RESULTS: Using a Monte Carlo simulation of the risk of transferring Camp. jejuni strain A3249, from various surfaces to hands and subsequently transferring it to the mouth was forecasted. The use of a disinfectant-wipe intervention to disinfect contaminated surface area was also assessed. Several assumptions were used as input parameters in the classical Beta-Poisson model to determine the risk of infection. The disinfectant-wipe intervention reduced the risk of Camp. jejuni infection by 2-3 orders on all fomites. CONCLUSIONS: The use of disinfectant wipes after the preparation of raw chicken meat reduces the risk of Camp. jejuni infections. SIGNIFICANCE AND IMPACT OF THE STUDY: This risk assessment shows that the use of disinfectant wipes to decontaminate surface areas after chicken preparation reduces the annual risk of Camp. jejuni infections up to 99·2%, reducing the risk from 2 : 10 to 2 : 1000.

Antitumor effects of baculovirus-infected dendritic cells against human pancreatic carcinoma.

Recently, we showed that baculovirus (BV)-infected dendritic cells (DCs) (BV-DCs) induced antitumor immunity against established tumors in mice. These antitumor effects were CD8(+) T-cell and natural killer (NK) cell dependent but CD4(+) T-cell independent. In the current study, we examined the antitumor effect of BV-DCs on human pancreatic cancer cells (AsPC-1). After treatment with BV-infected bone marrow-derived dendritic cells (BMDCs), human pancreatic tumors caused by AsPC-1 cells in a nude mouse model were significantly reduced in size, and the survival of the mice was improved compared with that of non-immature BMDC (iDC)- and BV-DC-immunized mice. We also found that wild-type BV could activate human DCs (HDCs) and that NK cells were activated by BV-infected HDCs (BHDCs). Our findings show that BV-DCs can induce antitumor immunity, which paves the way for the use of this technique as an effective tool for DC immunotherapy against malignancies.

Antiviral efficacy and mechanisms of action of oregano essential oil and its primary component carvacrol against murine norovirus.

AIMS: To investigate the antiviral efficacy of oregano oil and its primary active component, carvacrol, against the nonenveloped murine norovirus (MNV), a human norovirus surrogate. METHODS AND RESULTS: Along with an observed loss in cell culture infectivity, the antiviral mechanisms of action were determined in side-by-side experiments including a cell-binding assay, an RNase I protection assay and transmission electron microscopy (TEM). Both antimicrobials produced statistically significant reductions (P ≤ 0·05) in virus infectivity within 15 min of exposure (c. 1·0-log10). Despite this, the MNV infectivity remained stable with increasing time exposure to oregano oil (1·07-log10 after 24 h), while carvacrol was far more effective, producing up to 3·87-log10 reductions within 1 h. Based on the RNase I protection assay, both antimicrobials appeared to act directly upon the virus capsid and subsequently the RNA. Under TEM, the capsids enlarged from ≤35 nm in diameter to up to 75 nm following treatment with oregano oil and up to 800 nm with carvacrol; with greater expansion, capsid disintegration could be observed. Virus adsorption to host cells did not appear to be affected by either antimicrobial. CONCLUSIONS: Our results demonstrate that carvacrol is effective in inactivating MNV within 1 h of exposure by acting directly on the viral capsid and subsequently the RNA. SIGNIFICANCE AND IMPACT OF THE STUDY: This study provides novel findings on the antiviral properties of oregano oil and carvacrol against MNV and demonstrates the potential of carvacrol as a natural food and surface (fomite) sanitizer to control human norovirus.

Occurrence and reduction of human viruses, F-specific RNA coliphage genogroups and microbial indicators at a full-scale wastewater treatment plant in Japan.

AIMS: To evaluate and compare the reductions of human viruses and F-specific coliphages in a full-scale wastewater treatment plant based on the quantitative PCR (qPCR) and plate count assays. METHODS AND RESULTS: A total of 24 water samples were collected from four locations at the plant, and the relative abundance of human viruses and F-RNA phage genogroups were determined by qPCR. Of the 10 types of viruses tested, enteric adenoviruses were the most prevalent in both influent and effluent wastewater samples. Of the different treatment steps, the activated sludge process was most effective in reducing the microbial loads. Viruses and F-RNA phages showed variable reduction; among them, GI and GIII F-RNA phages showed the lowest and the highest reduction, respectively. CONCLUSIONS: Ten types of viruses were present in wastewater that is discharged into public water bodies after treatment. The variability in reduction for the different virus types demonstrates that selection of adequate viral indicators is important for evaluating the efficacy of wastewater treatment and ensuring the water safety. SIGNIFICANCE AND IMPACT OF THE STUDY: Our comprehensive analyses of the occurrence and reduction of viruses and indicators can contribute to the future establishment of appropriate viral indicators to evaluate the efficacy of wastewater treatment.

Molecular detection and genotyping of human noroviruses in influent and effluent water at a wastewater treatment plant in Japan.

AIMS: To investigate the prevalence, seasonality and genotype distribution of human noroviruses (NoVs) in wastewater in Japan. METHODS AND RESULTS: Influent and effluent water samples were collected monthly for a year from a wastewater treatment plant and examined for the presence of genogroups I and II (GI and GII) NoVs. Using real-time reverse transcription (RT)-PCR assays, 12 (100%) influent and six (50%) effluent samples were positive for both GI and GII NoV genomes, with a higher prevalence in winter. A total of 152 different NoV strains, comprising 84 GI and 68 GII strains, were identified using seminested RT-PCR assays followed by cloning and sequence analysis. These strains were classified into nine GI genotypes (GI/1, 2, 4, 5, 8, 9, 11, 12 and 14) and 13 GII genotypes (GII/1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15 and 16), showing considerable genetic diversity. CONCLUSIONS: Based on the partial capsid gene sequences, we identified a great number of NoV strains belonging to many genotypes, demonstrating that genetically diverse NoV strains are co-circulating in aquatic environments and human populations. SIGNIFICANCE AND IMPACT OF THE STUDY: Our results clearly demonstrate the seasonal trend and genetic diversity of NoVs in wastewater.

Genogroup distribution of F-specific coliphages in wastewater and river water in the Kofu basin in Japan.

AIMS: To determine the genogroup distribution of F-specific coliphages in aquatic environments using the plaque isolation procedure combined with genogroup-specific real-time PCR. METHODS AND RESULTS: Thirty water samples were collected from a wastewater treatment plant and a river in the Kofu basin in Japan on fine weather days. F-specific coliphages were detected in all tested samples, 187 (82%) of 227 phage plaques isolated were classified into one of the 4 F-specific RNA (F-RNA) coliphage genogroups and 24 (11%) plaques were F-specific DNA coliphages. Human genogroups II and III F-RNA coliphages were more abundant in raw sewage than animal genogroups I and IV, excluding one sample that was suspected to be heavily contaminated with sporadic heavy animal faeces. The secondary-treated sewage samples were highly contaminated with genogroup I F-RNA coliphages, probably because of different behaviours among the coliphage genogroups during wastewater treatment. The river water samples were expected to be mainly contaminated with human faeces, independent of rainfall effects. CONCLUSIONS: A wide range of F-specific coliphage genogroups were successfully identified in wastewater and river water samples. SIGNIFICANCE AND IMPACT OF THE STUDY: Our results clearly show the usefulness of the genogroup-specific real-time PCR for determining the genogroups of F-specific coliphages present in aquatic environments.

Dose-response time modelling for highly pathogenic avian influenza A (H5N1) virus infection.

AIMS: To develop time-dependent dose-response models for highly pathogenic avian influenza A (HPAI) of the H5N1 subtype virus. METHODS AND RESULTS: A total of four candidate time-dependent dose-response models were fitted to four survival data sets for animals (mice or ferrets) exposed to graded doses of HPAI H5N1 virus using the maximum-likelihood estimation. A beta-Poisson dose-response model with the N(50) parameter modified by an exponential-inverse-power time dependency or an exponential dose-response model with the k parameter modified by an exponential-inverse time dependency provided a statistically adequate fit to the observed survival data. CONCLUSIONS: We have successfully developed the time-dependent dose-response models to describe the mortality of animals exposed to an HPAI H5N1 virus. The developed model describes the mortality over time and represents observed experimental responses accurately. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study describing time-dependent dose-response models for HPAI H5N1 virus. The developed models will be a useful tool for estimating the mortality of HPAI H5N1 virus, which may depend on time postexposure, for the preparation of a future influenza pandemic caused by this lethal virus.

Genetic diversity of genogroup IV noroviruses in wastewater in Japan.

AIMS: To investigate the prevalence, seasonality and genetic diversity of genogroup IV noroviruses (GIV NoVs) in wastewater in Japan. METHODS AND RESULTS: Untreated and treated wastewater samples were collected monthly for a year from a wastewater treatment plant in Japan. The concentrated wastewater samples were examined for the presence of GIV NoV genomes with seminested RT-PCR assay targeting partial capsid gene. Among 12 untreated and 12 treated wastewater samples tested, GIV NoV genomes were detected in three (25%) untreated and two (17%) treated wastewater samples with a high positive ratio in winter season. Genetic analysis revealed that the GIV NoVs in the wastewater samples were genetically diverse and were classified into three different genetic clusters. CONCLUSIONS: Frequent detection of GIV NoVs in winter season, which is a common epidemic period of human NoVs in Japan, indicates that GIV NoVs exhibit temporal trends similar to GI and GII NoVs. Based on the partial capsid gene sequences, we identified several unique GIV NoV strains belonging to the novel genetic cluster, demonstrating that GIV NoVs are more genetically diverse than previously appreciated. SIGNIFICANCE AND IMPACT OF THE STUDY: Our findings provide novel evidence of considerable genetic diversity among the GIV NoV strains.

Development of a real-time RT-PCR assay combined with ethidium monoazide treatment for RNA viruses and its application to detect viral RNA after heat exposure.

A method was developed for discriminating damaged viruses or naked viral RNA from intact viruses by ethidium monoazide (EMA) treatment before RT-PCR. The applied EMA treatment consisted of three steps: (1) EMA dose, (2) exposure to light, and (3) additional purification by spin-column gel filtration. Approximately 4-log reduction in viral RNA concentration was observed by adding a dose of 10 µg/mL-EMA with 300 s of light irradiation. Although residual EMA can be an inhibitor of RT-PCR, its effect was reduced by spin-column gel filtration or a QIAamp® Viral RNA Mini Kit. EMA-RT-PCR was applied to the thermally treated PV1. Results of EMA-RT-PCR were similar to the plaque assay when PV1 was thermally inactivated. Although this is a preliminary study investigating applicability of the EMA-RT-PCR method for RNA viruses, the results suggest that the method is potentially applicable for the selective detection of epidemiologically important enteric viruses in water such as enteroviruses and noroviruses.

Rotational analysis for the Doppler-free photoelectron spectrum of water using the spectator model.

A photoelectron spectrum of H(2)O has been recorded at a resolution of 2 meV under Doppler-free conditions. Complex rotational structures appear in the individual vibrational states of the electronic X̃(+ 2)B(1) and Ã(+ 2)A(2) states in H(2)O(+). The rotational structures are analyzed and well reproduced using a spectator orbital model developed for rotationally resolved photoelectron spectroscopy.

Chlorine inactivation of human norovirus, murine norovirus and poliovirus in drinking water.

AIMS: To evaluate the reduction of human norovirus (HuNoV) by chlorine disinfection under typical drinking water treatment conditions. METHODS AND RESULTS: HuNoV, murine norovirus (MNV) and poliovirus type 1 (PV1) were inoculated into treated water before chlorination, collected from a drinking water treatment plant, and bench-scale free chlorine disinfection experiments were performed for two initial free chlorine concentrations, 0.1 and 0.5 mg l(-1). Inactivation of MNV reached more than 4 log(10) after 120 and 0.5 min contact time to chlorine at the initial free chlorine concentrations of 0.1 and 0.5 mg l(-1), respectively. CONCLUSIONS: MNV was inactivated faster than PV1, and there was no significant difference in the viral RNA reduction rate between HuNoV and MNV. The results suggest that appropriate water treatment process with chlorination can manage the risk of HuNoV infection via drinking water supply systems. SIGNIFICANCE AND IMPACT OF THE STUDY: The data obtained in this study would be useful for assessing or managing the risk of HuNoV infections from drinking water exposure.

Superiority of radioisotope over blue dye for sentinel lymph node detection in breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is commonly performed using radioisotopes and/or blue dye. However, it is still undefined which reagent is more suitable for identifying sentinel lymph nodes (SLN). PATIENTS AND METHODS: A consecutive series of 640 breast cancer patients who had undergone SLNB at the Keio University Hospital from 2001 to 2006 was analyzed. The SLN was identified by a combination of technetium-99m tin colloid and isosulfan blue dye. The correlation between clinicopathological factors and the distribution of radioisotopes and blue dye was analyzed. The single metastatic lymph node revealed by axillary lymph node dissection (ALND) is the 'true SLN', and the distribution of radioisotopes and blue dye to the 'true SLN' was also analyzed. RESULTS: Blue-dye- and radioisotope-positive SLN were identified in 79.6 and 94.7% of the patients, respectively. Taken together, SLN were identified in 625 patients (97.7%) by radioisotope and/or blue dye. No significant correlation was observed between clinicopathological features and the distribution of the reagents. ALND found 73 patients with single lymph node metastasis, and 73 'true SLN' were identified by blue dye in 65.7% (48/73), and by radioisotope in 95.9% (70/73) of the cases. CONCLUSION: These data suggest that radioisotopes are superior to blue dye in detecting SLN in breast cancer.

Acute Deterioration of Kidney Function after Total Hip Arthroplasty.

INTRODUCTION: Post-operative acute kidney injury is a serious complication and identifying modifiable factors could assist in peri-operative management. This study aimed to identify the pre-operative and intra-operative factors associated with the incidence of post-operative acute kidney injury and acute deterioration of kidney function after total hip arthroplasty.Materials and methods: This single-center, retrospective, observational study included 203 patients who underwent unilateral primary total hip arthroplasty. Acute kidney injury was determined using biochemical markers according to the risk, injury, failure, loss of kidney function, and end-stage kidney disease (RIFLE) criteria. Acute deterioration of kidney function was defined as the reduction of estimated glomerular filtration rate by ≥10ml/min/1.73m2. RESULTS: Prior to total hip arthroplasty, 20% of all patients met the chronic renal dysfunction criterion of glomerular filtration rates <60ml/min/1.73m2 (glomerular filtration rate categories G3a-G5). Incidence rates of acute kidney injury and acute deterioration of kidney function after total hip arthroplasty were 0.49% and 6.9%, respectively. Multivariate regression analysis showed that diabetes mellitus and use of nonsteroidal anti-inflammatory drugs before total hip arthroplasty were significant risk factors for acute deterioration of kidney function. Advanced age, preoperative renal dysfunction, antihypertensive, diuretics, or statin use, operation time, total blood loss, type of anesthetic, and body mass index were not significant risk factors. CONCLUSION: Diabetes mellitus and use of nonsteroidal anti-inflammatory drugs were controllable risks, and multidisciplinary approaches are a reasonable means of minimising peri-operative acute kidney injury or acute deterioration of kidney function.

Usefulness of Contrast-Enhanced 3D-FLAIR MR Imaging for Differentiating Rathke Cleft Cyst from Cystic Craniopharyngioma.

BACKGROUND AND PURPOSE: Because it can be difficult to discriminate between a Rathke cleft cyst and cystic craniopharyngioma by conventional MR imaging alone, we investigated whether contrast-enhanced 3D T2-FLAIR MR imaging at 3T helps to distinguish a Rathke cleft cyst from a cystic craniopharyngioma. MATERIALS AND METHODS: We evaluated pre- and postcontrast T1-weighted and 3D T2-FLAIR images of 17 patients with pathologically confirmed Rathke cleft cyst (n = 10) or cystic craniopharyngioma (n = 7). All underwent 3T MR imaging studies before surgery. Two neuroradiologists independently recorded the enhancement grade of the lesion wall as grade 2 (most of the wall enhanced), grade 1 (some of the wall enhanced), and grade 0 (none of the wall enhanced). One neuroradiologist performed a blinded reading study of conventional MR images with/without 3D T2-FLAIR images. Interobserver agreement was determined by calculating the κ coefficient. Statistical analyses, including receiver operating characteristic curve analysis were performed. RESULTS: Interobserver agreement for postcontrast T1WI and 3D T2-FLAIR images was excellent (κ = 0.824 and κ = 0.867, respectively). Although the difference in the mean enhancement grade of Rathke cleft cysts and cystic craniopharyngiomas was not significant on postcontrast T1WIs, it was significant on postcontrast 3D T2-FLAIR images (P = .0011). The area under the receiver operating characteristic curve of the conventional MR alone and conventional MR with 3D T2-FLAIR readings was 0.879 and 1.0, respectively, though there was no significant difference in the area under the curve between the 2 readings. CONCLUSIONS: Contrast-enhanced 3D T2-FLAIR imaging at 3T helps to distinguish a Rathke cleft cyst from cystic craniopharyngioma.

Detection of genogroup IV norovirus in wastewater and river water in Japan.

AIMS: To test wastewater and river water in Japan for genogroup IV norovirus (GIV NoV). METHODS AND RESULTS: Influent and effluent samples from a wastewater treatment plant and the Tamagawa River water samples were collected monthly for a year. The water samples were concentrated by the adsorption-elution method, using an HA electronegative filter with acid rinse procedure, followed by quantitative detection of GIV NoV using TaqMan-based real-time RT-PCR. Both wastewater and river water samples showed a high positive ratio of GIV NoV during winter and spring. The highest concentration in wastewater and river water was 6.9 x 10(4) and 1.5 x 10(4) copies l(-1), respectively. CONCLUSIONS: Presence of GIV NoV in the environments demonstrates that not only GI and GII NoVs but also GIV strains are circulating and that routine monitoring of GIV NoV in water environments is recommended to understand its epidemics, environmental distribution and potential health risks. SIGNIFICANCE AND IMPACT OF THE STUDY: This is the first study providing quantitative data on the occurrence of GIV NoV in environmental water over a 1-year period.

Correlation of motility and neuronal integrity with a focus on the grade of intestinal allograft rejection.

Intestinal graft motility after small bowel transplantation (SBT) is poorly characterized. The aim of this study was to compare motor patterns with myenteric neuronal cell population as a parameter of graft viability at various degrees of acute cellular rejection (ACR). Three grades of ACR were achieved in orthotopic allografts. Syngeneic transplants and allografts with immunosuppression served as controls. Motor activities were recorded using strain gauge force transducers and analyzed visually. Quantifications of myenteric neurons in whole mounts of intestinal grafts were used to evaluate neuronal population. A typical migrating motor complex (MMC) was found in syngeneic and allogenic transplants with immunosuppression. A high prevalence of discrete clustered contractions (DCC) and nonpropagating contractions (NPC) without MMC was seen in moderately and severely rejected allografts. Neuronal cell loss in the allografts, which could be one of the causes of motor dysfunction, was noted in moderate rejection (19.3%) and progressed until severe rejection (60.1%). Monitoring motility patterns in SBT could be an effective tool for assessing intestinal rejection. Allograft dysmotility, such as absence of MMC and high prevalence of DCC or NPC, could be useful markers of progression of acute rejection and help guide treatment decisions.