Targeted amplicon sequencing of wastewater samples for detecting SARS-CoV-2 variants with high sensitivity and resolution.

Wastewater-based epidemiology (WBE) is a promising approach for monitoring the spread of SARS-CoV-2 within communities. Although qPCR-based WBE is powerful in that it allows quick and highly sensitive detection of this virus, it can provide limited information about which variants are responsible for the overall increase or decrease of this virus in sewage, and this hinders accurate risk assessments. To resolve this problem, we developed a next generation sequencing (NGS)-based method to determine the identity and composition of individual SARS-CoV-2 variants in wastewater samples. Combination and optimization of targeted amplicon-sequencing and nested PCR allowed detection of each variant with sensitivity comparable to that of qPCR. In addition, by targeting the receptor binding domain (RBD) of the S protein, which has mutations informative for variant classification, we could discriminate most variants of concern (VOC) and even sublineages of Omicron (BA.1, BA.2, BA.4/5, BA.2.75, BQ.1.1 and XBB.1). Focusing on a limited domain has a benefit of decreasing the sequencing reads. We applied this method to wastewater samples collected from a wastewater treatment plant in Kyoto city throughout 13 months (from January 2021 to February 2022) and successfully identified lineages of wild-type, alpha, delta, omicron BA.1 and BA.2 as well as their compositions in the samples. The transition of these variants was in good agreement with the epidemic situation reported in Kyoto city during that period based on clinical testing. These data indicate that our NGS-based method is useful for detecting and tracking emerging variants of SARS-CoV-2 in sewage samples. Coupled with the advantages of WBE, this method has the potential to serve as an efficient and low cost means for the community risk assessment of SARS-CoV-2 infection.

Anterior knee pain post-multiple surgeries for tibia fracture effectively managed with infrapatellar fat pad injection: a case report.

BACKGROUND: The anterior knee compartment is filled by the infrapatellar fat pad (IFP) and has been emphasized as a source of anterior knee pain (AKP). CASE PRESENTATION: A 51-year-old woman sustained a right tibial plateau and open diaphyseal fracture 2 years earlier. She remained with chronic AKP after undergoing bone fixations. Increased anterior portion of the IFP brightness and decreased adipose tissue gliding with flexion and extension compared to the unaffected side was shown on ultrasonography. An injection of 0.2% lidocaine between the patellar tendon and IFP, and into the IFP under ultrasound guidance, immediately relieved the pain. The pain kept recurring although injections were effective for a while; thus, surgery was scheduled. Scar tissue on the IFP surface was endoscopically excised and her pain dramatically reduced. CONCLUSION: This is the first report in which the detection of increased brightness on ultrasound of IFP and the injections into the IFP triggered an additional surgical intervention. Ultrasound evaluation and injection may be beneficial in pain clinic patients presenting with AKP and may provide an opportunity for diagnosis.

Update on the SedLine® algorithm for calculating the Patient State Index of older individuals during general anesthesia: a randomized controlled trial.

BACKGROUND: The SedLine® sensor processes (Masimo Corporation; Irvine, CA, USA) raw electroencephalogram (EEG) signals and displays the depth of sedation as a Patient State Index (PSi). Reliance on standard processed EEG data and failure to recognize age-related effects can lead to an erroneous interpretation that low-amplitude EEG findings in an older patient signify an insufficient depth of anesthesia presented as abnormally high PSi values (AHPSi). We hypothesized that the incidence of AHPSi would decrease with the use of the recently-updated version of the SedLine® sensor, in which the Bispectral Index (BIS) values were used to titrate anesthesia. METHODS: Thirty-three patients undergoing sevoflurane-remifentanil anesthesia were randomized into two groups. SedLine® sensors designed based on an old (v.1203) or updated (v.2000) algorithms were used. The BIS (v.4.1) and absolute index of total EEG power (TP) were simultaneously recorded. The attending anesthesiologists titrated the anesthetics, and BIS was maintained at 40-60. The incidence of AHPSi (PSi>50 with BIS 40-60) was calculated during the first 30 min after the start of surgery. RESULTS: Compared to the old algorithm group, the incidence of AHPSi was significantly lower in the updated algorithm group (26.7% vs. 4.2%, P<0.001). Lower TP values and the use of the old algorithm have significant effect on increased PSi values (P<0.001). CONCLUSIONS: The incidence of AHPSi decreased with the use of the updated version of the SedLine® algorithm.

Transient maintenance of tracheal patency upon the insertion of a flexible bronchoscope in a patient with an anterior mediastinal mass: a case report.

BACKGROUND: Patients with an anterior mediastinal mass are at risk of perioperative respiratory collapse. CASE PRESENTATION: A 74-year-old woman with a large anterior mediastinal mass that led to partial tracheal collapse (shortest diameter, 1.3 mm) was scheduled for tracheobronchial balloon dilation and stent placement under general anesthesia. Although veno-venous extracorporeal membrane oxygenation (V-V ECMO) had been established, maximum flow was limited to 1.6 L/min, and general anesthesia induction was followed by hypoxia probably due to inadequate ventilation. A flexible bronchoscope was inserted through the tracheal lumen that was being compressed by the anterior mass; this not only increased tracheal patency but also enabled positive pressure ventilation and resulted in recovery from hypoxia. Scheduled procedures were successfully performed without complications. CONCLUSION: We describe a case wherein tracheal patency was transiently maintained by inserting a flexible bronchoscope in a patient with an anterior mediastinal mass.

Latent environment allocation of microbial community data.

As data for microbial community structures found in various environments has increased, studies have examined the relationship between environmental labels given to retrieved microbial samples and their community structures. However, because environments continuously change over time and space, mixed states of some environments and its effects on community formation should be considered, instead of evaluating effects of discrete environmental categories. Here we applied a hierarchical Bayesian model to paired datasets containing more than 30,000 samples of microbial community structures and sample description documents. From the training results, we extracted latent environmental topics that associate co-occurring microbes with co-occurring word sets among samples. Topics are the core elements of environmental mixtures and the visualization of topic-based samples clarifies the connections of various environments. Based on the model training results, we developed a web application, LEA (Latent Environment Allocation), which provides the way to evaluate typicality and heterogeneity of microbial communities in newly obtained samples without confining environmental categories to be compared. Because topics link words and microbes, LEA also enables to search samples semantically related to the query out of 30,000 microbiome samples.

Effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) measurement.

To retrospectively investigate the effects of indigo carmine intravenous injection on oxygen reserve index (ORi™) in 20 patients who underwent elective gynecologic surgery under general anesthesia. The study subjects were patients who underwent elective gynecologic surgery under general anesthesia between April 2016 and January 2017, and were administered a 5-ml intravenous injection of 0.4% indigo carmine for clinical purposes during surgery with ORi monitoring. Changes in ORi within 20 min after indigo carmine injection were observed. A relevant decrease in ORi was defined as ≥ 10% reduction in ORi from pre-injection level. ORi rapidly decreased after indigo carmine intravenous injection in all patients. In 10 of 19 patients, ORi decreased to 0 after indigo carmine injection. The median lowest value of ORi was 0 (range 0-0.16) and the median time to reach the lowest value of ORi was 2 min (range 1-4 min) after injection. ORi values returned to pre-injection levels within 20 min in 13 of 19 patients, and the median time to return to pre-injection levels was 10 min (range 6-16 min) after injection. During ORi monitoring it is necessary to consider the rapid reduction in ORi after intravenous injection of indigo carmine.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement with using the Revision L sensor.

The effects of intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated with the Revision L sensor. The subjects were 18 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was injected intravenously, and changes in SpHb concentrations between before and after the injection were evaluated. The mean age was 52.4 ± 12.8 years. Before injection, the median SpHb level was 10.1 (range, 6.8-13.4) g/dL. The results demonstrated no change in SpHb concentration between before and after indigo carmine injection as detected by the Revision L sensor. SpHb measurements as determined with the Revision L sensor were not affected, even after the intravenous injection of indigo carmine.

Analysis of the sexual development-promoting region of Schizophyllum commune TRP1 gene.

This study aims to elucidate the mechanism of sexual development of basidiomycetous mushrooms from mating to fruit body formation. Sequencing analysis showed the TRP1 gene of basidiomycete Schizophyllum commune encoded an enzyme with three catalytic regions of GAT (glutamine amidotransferase), IGPS (indole-3-glycerol phosphate synthase), and PRAI (5-phosphoribosyl anthranilate isomerase); among these three regions, the trp1 mutant (Trp(-)) had a missense mutation (L→F) of a 338th amino acid residue of the TRP1 protein within the IGPS region. To investigate the function of IGPS region related to sexual development, dikaryons with high, usual, and no expression of the IGPS region of TRP1 gene were made. The dikaryotic mycelia with high expression of the IGPS formed mature fruit bodies earlier than those with usual and no expression of the IGPS. These results showed that the IGPS region in TRP1 gene promoted sexual development of S. commune.

Coronary artery bypass grafting in a patient with hemophilia B: continuous recombinant factor IX infusion as per the Japanese guidelines for replacement therapy.

We herein report our experience of successfully managing the hemostatic system by controlling serum factor IX levels throughout the perioperative period in a patient with hemophilia B. Coronary artery bypass grafting with cardiopulmonary bypass was planned for a 52-year-old man with moderate severity of hemophilia B. During surgery, recombinant factor IX (rFIX; BeneFIX(®) Pfizer Japan inc., Tokyo, Japan) was administered by bolus infusion followed by continuous infusion as per the guidelines of the Japanese Society on Thrombosis and Hemostasis. The operative course was uneventful without any considerable bleeding or complications.

Effects of indigo carmine intravenous injection on noninvasive and continuous total hemoglobin measurement.

The effects of an intravenous injection of indigo carmine on noninvasive and continuous total hemoglobin (SpHb) measurement were retrospectively evaluated. The subjects were 21 patients who underwent elective gynecologic surgery under general anesthesia. During surgery, 5 mL of 0.4 % indigo carmine was intravenously injected, and subsequent changes in SpHb concentrations were evaluated. The results demonstrate that the pre-injection SpHb level was 10 g/dL, and the minimum post-injection SpHb level was 8.3 g/dL. The amount of decrease was 1.8 g/dL. The time to reach the minimum value was 4 min, and the time to return to the pre-injection value was 15 min. The decrease in SpHb was greater in the group with a perfusion index (PI) < 1.4 than in the group with a PI > 1.4. The assessment of SpHb after an intravenous injection of indigo carmine necessitates caution.

Life-threatening urethral hemorrhage after placement of a Foley catheter in a patient with uroseptic disseminated intravascular coagulation due to chronic urinary retention induced by untreated benign prostatic hyperplasia.

Case: A 77-year-old man with severe septic disseminated intravascular coagulation following urinary infection was transported to our hospital. He had developed urinary retention induced by untreated prostatic hyperplasia. Immediate drainage with a Foley catheter was successfully carried out, but the hematuria progressed to life-threatening hemorrhage. Outcome: Complete hemostasis was impossible by surgical treatment because the tissue around the prostatic urethra was very fragile and hemorrhagic. Organized treatments (continuous hemodiafiltration combined with polymyxin-B immobilized fiber column hemoperfusion and systemic treatment with antibiotics and coagulation factors) were commenced soon after the operation. The patient eventually recovered from the septic disseminated intravascular coagulation. Conclusion: This case report illustrates the risk of placement of Foley catheters in patients with severe septic disseminated intravascular coagulation.

[Effects of Anesthetics on Perioperative Short-term Outcomes in Patients Undergoing Thoracic Surgery with One-lung Ventilation].

BACKGROUND: The present study was designed to evaluate the postoperative values such as body temperature (BT), white blood cells (WBC), P/F ratio and C-reactive protein (CRP) associated with propofol or sevoflurane in patients undergoing thoracic surgery with one-lung ventilation. METHODS: We retrospectively reviewed outcomes of patients undergoing video-associated thoracic surgery of the esophagus (VATS-E) with propofol (group P, n = 71) or sevoflurane (group S, n = 34). Data were taken at 1 POD and 2 POD in ICU. In addition, data of WBC and CRP were taken just before the operation and on 5 POD. Statistical analyses used t-value and two-way ANOVA with statistic significance as P < 0.05. RESULTS: There was no significant difference between the two groups and we could not find the correlation between anesthetics and each factor. CONCLUSIONS: Propofol and sevoflurane had similar effect on BT, WBC, P/F ratio and CRP in patients undergoing thoracic surgery with one-lung ventilation.

Two cases of bilateral lung transplantation combined with intracardiac repair and pulmonary artery replacement: perioperative managements based on the left ventricular function.

We report on two patients who underwent bilateral lung transplantation (BLTx) combined with cardiac surgery. Patient 1 was a female whose pulmonary hypertension resulted from a congenital atrial septal defect (ASD) and idiopathic pulmonary arterial hypertension. She had a very small left ventricle (LV). We initiated venoarterial extracorporeal membrane oxygenation (ECMO) before induction of general anesthesia. She underwent ASD patch closure, pulmonary artery replacement, and BLTx under cardiopulmonary bypass (CPB). At the weaning from CPB, primary graft dysfunction and pulmonary edema induced by LV diastolic dysfunction was apparent. We gradually decreased the ECMO support and eventually weaned off the ECMO on the 4th postoperative day (POD) and the ventilator on the 29th POD. Patient 2 was a male with Eisenmenger syndrome, which resulted from ASD and ventricular septal defect (VSD). He had a normal LV. General anesthesia was induced smoothly without ECMO. He underwent ASD and VSD patch closure, pulmonary artery replacement, and BLTx under CPB. Weaning from CPB proceeded smoothly. These patients needed different management because of their different LV function. Especially, perioperative management of the BLTx patient with LV diastolic dysfunction was difficult. Assessment of perioperative cardiac function is very important in BLTx combined with cardiac surgery.

Dislocated dental bridge covering the larynx: usefulness of tracheal tube guides under video-assisted laryngoscopy for induction of general anesthesia, thus avoiding tracheostomy.

BACKGROUND: To describe a case with dislodgement of dental bridge with clasps covering the vocal cords, in a patient who was successfully intubated using tube exchanger under video-assisted laryngoscopy. STUDY DESIGN, METHODS: Clinical case record with a video clip. SETTING: University hospital. CASE PRESENTATION: A 83-year-old woman presented with dislodgement of her dental bridge whilst eating. Laryngoscopy revealed a foreign body almost entirely covering the vocal cords, with the clasps of the dislodged partial denture piercing the pharyngeal wall. Before induction of general anesthesia, a tracheal tube introducer combined with video-assisted laryngoscopy was introduced into the trachea in the awake condition, followed by successful endotracheal intubation. Thereafter, the dislodged denture was extracted via the oral cavity. CONCLUSIONS: Tracheal tube introducers combined with video-assisted laryngoscopy appear to be useful for airway management, decreasing the number of avoidable tracheostomies performed.

[Anesthetic management of six patients with surgically repaired tetralogy of Fallot undergoing the second intra-cardiac surgery].

In Japan, more than 9,000 patients with congenital heart disease reach adulthood every year with improved medical treatment, and perioperative encounter with patients requiring the second intra-cardiac operation in adulthood is more often. Tetralogy of Fallot (TOF) is the most common form of cyanotic congenital heart disease, and long-term prognosis is good. Therefore, we have more chances to care the postoperarive adult patients with TOF. This is a retrospective study in 6 patients with TOF who underwent the second intra-cardiac operation in adulthood from 2008 to 2012. Among the six patients, six had pulmonary valve replacement; four had tricuspid valve replacements or valvuloplastys; four had ventricular septal defect closures; two had right ventricular outflow tract obstruction releases; one had aortic valve replacement; and three had cryoablations. Right ventricular end-diastolic volume was 194.1 +/- 83.5 ml x m(-2) (mean +/- SD), and right ventricular ejection fraction was 38.2 +/- 4.8%. The factors which influence the anesthetic management were as follows: right cardiac failure by abnormality of the pulmonary valve; residual disease and deuteropathy of two or more combination; the risks associated with the second open chest surgery such as long operative time and severe bleeding. Perioperative management of an adult with congenital heart disease requires full understanding of its pathophysiology such as congenital heart disease, adult-specific complications, and the second open chest surgery.

Annual FEV1 changes and numbers of circulating endothelial microparticles in patients with COPD: a prospective study.

OBJECTIVE: Growing evidence suggests that endothelial injury is involved in the pathophysiology of chronic obstructive pulmonary disease (COPD). Circulating endothelial microparticles (EMPs) increase in patients with COPD because of the presence of endothelial injury. We examined the relationship between EMP number and changes in forced expiratory volume in 1 s (FEV1) in patients with COPD. DESIGN: Prospective study. SETTING: One hospital in Japan. PARTICIPANTS: A total 48 outpatients with stable COPD coming to the hospital from September 2010 to September 2011. PRIMARY AND SECONDARY OUTCOMES MEASURED: Blood samples were collected and vascular endothelial (VE)-cadherin EMPs (CD144+ EMPs), E-selectin EMPs (CD62E+ EMPs) and platelet endothelial cell adhesion molecule EMPs (CD31+/CD41- EMPs) were measured using fluorescence-activated cell sorting. Annual FEV1 changes were evaluated using FEV1 data acquired a year before and a year after sample collection. RESULTS: The number of E-selectin and VE-cadherin EMPs showed significant negative correlations with annual FEV1 changes (rs=-0.65, p<0.001, rs=-0.43, p=0.003, respectively). Leucocyte counts tended to be correlated with annual FEV1 changes, but this correlation was not significant (rs=-0.28, p=0.057). There were significant differences in annual FEV1 changes between with and without history of frequent exacerbation (p=0.006), and among Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages (p=0.009). Multiple linear regression analysis revealed E-selectin EMP to be the only significant parameter associated with annual FEV1 changes, independent of VE-cadherin EMP, GOLD stages, leucocyte counts, and history of frequent exacerbation. Receiver operating characteristic curves showed the optimum E-selectin EMP cut-off level for prediction of rapid FEV1 decline (>66 mL/year) to be 153.0/µL (areas under curve 0.78 (95% CI 0.60 to 0.89); sensitivity, 67%; specificity, 81%). CONCLUSIONS: The high E-selectin EMP levels in stable patients with COPD are predictive of rapid FEV1 decline. TRIAL REGISTRATION NUMBER: UMIN000005168.

Lower incidence of emergence agitation in children after propofol anesthesia compared with sevoflurane: a meta-analysis of randomized controlled trials.

BACKGROUND: Emergence agitation (EA) from general anesthesia has been reported as an adverse effect of sevoflurane in children. We describe a meta-analysis of randomized controlled trials that compared the incidence of EA between children who underwent sevoflurane anesthesia and those who underwent propofol anesthesia. METHODS: A literature search was conducted to identify clinical trials that met our inclusion criteria. Prospective randomized trials comparing sevoflurane and propofol anesthesia in children less than 15 years of age were included in the meta-analysis. Data from each trial were combined using the random effects model to calculate pooled odds ratios (ORs) and their corresponding 95 % confidence intervals (CIs). The heterogeneity of data was assessed by Cochran's Q and I (2) tests. Sensitivity analysis was conducted for study quality, patient age, and type of surgical procedure. RESULTS: The meta-analysis included 14 studies, in which 560 patients received sevoflurane and 548 received propofol. The pooled OR for EA was 0.25 with a 95 % CI of 0.16-0.39 (P = 0.000), which indicates that propofol anesthesia resulted in a lower incidence of EA. The heterogeneity of data was not statistically supported (P = 0.191). All sensitivity analyses strengthened the evidence for the lower incidence of EA with propofol. CONCLUSIONS: Our meta-analysis demonstrated that EA in children is less likely to occur after propofol anesthesia compared with sevoflurane anesthesia.

Glucocorticoid mediates the transcription of OAT-PG, a kidney-specific prostaglandin transporter.

OAT-PG is a kidney-specific prostaglandin transporter and exclusively expressed at the basolateral membrane of proximal tubules in rodent kidneys. We previously reported that OAT-PG was dominantly expressed in the male kidney similar to the other SLC22 family proteins as organic anion transporter (OAT) 1 and OAT3. Recently, Wegner et al. revealed that a transcription factor, B-cell CLL/lymphoma 6 (BCL6), is associated with the male-dominant expressions of OAT1 and OAT3 in the rat kidney. Here, we performed the luciferase assay to investigate whether OAT-PG is also transcriptionally regulated by BCL6. However, the promoter activity of OAT-PG was not directly affected by BCL6 overexpression nor the testosterone treatment, suggesting that different regulatory mechanisms underlie the male-dominant transcriptional regulation of OAT-PG compared to those of OAT1 and OAT3. We newly found that adrenalectomy (Adx) of male rat caused a significant reduction of OAT-PG expression without any significant changes in the OAT1 and OAT3 expressions, and it was recovered by the dexamethasone administration. Furthermore, the renocortical PGE2 concentration was markedly increased in Adx male rat, concomitant with the downregulation of OAT-PG, and it was reduced to the basal level by dexamethasone treatment. In the luciferase assay, dexamethasone stimulated OAT-PG promoter activity but not OAT1. The luciferase activity responsiveness to dexamethasone was significantly reduced by the deletion of glucocorticoid response elements in the OAT-PG promoter region. These results suggest that glucocorticoid plays an important role in the regulation of the renocortical PGE2 concentration by the transcriptional regulation of OAT-PG in the rat kidney.