Second-stage Treatment Research Articles

Second-stage treatment strategy for severely obese patient with primary aldosteronism—laparoscopic adrenalectomy after laparoscopic sleeve gastrectomy: a case report

Second-stage treatment strategy for severely obese patient with primary aldosteronism—laparoscopic adrenalectomy after laparoscopic sleeve gastrectomy: a case report

Efficacy of flexible ureterorenoscopy with holmium laser in the management of calyceal diverticular calculi

The purpose of this study was to evaluate the efficacy and safety of flexible ureteroscopy with holmium laser lithotripsy in the management of calyceal diverticular calculi. In this study, we retrospectively analyzed the clinical data of 27 patients with calyceal diverticular calculi admitted to the Department of Urology of the Zigong First People’s Hospital from May 2018 to May 2021. Intraoperatively, the diverticular neck was found in all 27 patients, but flexible ureterorenoscopy lithotripsy was not performed in 2 cases because of the slender diverticular neck, and the success rate of the operation was 92.6%. Of the 25 patients with successful lithotripsy, the mean operative time was 76.9 ± 35.5 (43–200) min. There were no serious intraoperative complications such as ureteral perforation, mucosal avulsion, or hemorrhage. Postoperative minor complications (Clavien classification I-II) occurred in 4 (16%) patients. The mean hospital stay was 4.4 ± 1.7 (3–12) days. The stone-free rate was 80% at the 1-month postoperative follow-up. After the second-stage treatment, the stone-free rate was 88%. In 22 cases with complete stone clearance, no stone recurrence was observed at 5.3 ± 2.6 (3–12) months follow-up. This retrospective study demonstrated that flexible ureterorenoscopy with holmium laser is a safe and effective choice for the treatment of calyceal diverticular calculi, because it utilizes the natural lumen of the human body and has the advantages of less trauma, fewer complications, and a higher stone-free rate.

Mini-PCNL with a vacuum-assisted access sheath for renal calculi with pyonephrosis in the second stage

Objective To compare the safety and efficacy of mini-PCNL with vacuum-assisted access sheath in the second-stage treatment of renal calculi with obstructive pyonephrosis. Material and methods A prospective, randomized clinical study was performed at our hospital from May 2020 to May 2022. Patients with pyogenic drainage fluid who needed percutaneous nephrolithotomy were randomized to the peel-away assisted mini-PCNL group (group A) and the vacuum-assisted mini-PCNL group (group B). Demographic information, clinical features, and perioperative period data were collected. Results Fifty mini-PCNLs using a single 16 F access sheath were performed in all patients of our study. All patients underwent second-stage surgical treatment. Demographic information and clinical features were not significantly different between groups A and B. But compared with group A, patients in group B had a short operative time (60.60 ± 7.68 min vs. 82.20 ± 14 min p = 0.018), a lower post-operative fever rate (8% vs. 32% p = 0.034), and a higher stone-free rate 2 d after the operation (88% vs. 64% p = 0.047). There was no significant difference between the two groups in blood transfusion, HB deficit, PCT after the operation, total hospitalization costs, stone-free rate 30 d after the operation, and length of stay or stay post-operative. And no serious complications after the operation occurred in either group. Conclusions Mini-PCNL with vacuum-assisted access sheath is a safe and efficient treatment for patients with calculi-related obstructive pyonephrosis in the second stage.

The Percutaneous Endoscopic Lumbar Debridement and Irrigation Drainage Technique for the First-Stage Treatment of Spontaneous Lumbar Spondylodiscitis: A Clinical Retrospective Study.

Background Minimally invasive or open surgery is contentious in the treatment of spondylodiscitis, therefore finding a balance between the two is urgently needed. In this study, we propose a new treatment paradigm for treating spontaneous lumbar spondylodiscitis by percutaneous endoscopic lumbar debridement and irrigation drainage (PELDID). Then, the Pola classification was used to guide subsequent treatment. Methods From November 2017 to April 2019, this study collected data on 16 patients with lumbar spondylodiscitis who were surgically treated utilizing this treatment paradigm in our department. Clinical effectiveness was determined using the visual analogue scale (VAS), the Oswestry Disability Index (ODI), the MOS 36-item short-form health survey (SF-36), and Kirkaldy-Willis criteria. Results All 16 patients completed the treatment using the above paradigm and were followed up for 28.13 ± 10.15 months. The preoperative Pola classification is as follows: 7 cases of type A, 3 cases of type B, and 6 cases of type C. After the first-stage surgery, the evaluation results of Pola classification were as follows: 8 cases of type A, 8 cases of type B, and 0 cases of type C. Four patients received second-stage surgery with internal fixation through the paravertebral multifidus space approach and intervertebral bone graft fusion through the transforaminal approach, and the reoperation rate was 25% (4/16 cases). The Visual analogue scale (VAS), Oswestry Disability Index (ODI), and SF-36 score all improved significantly from 2.43 ± 0.89 to 0.18 ± 0.40, from 77.31% ± 11.15%to 16.93% ± 5.45%, and from 18.34 ± 7.47 to 80.3 ± 15.36. The CRP and ESR decreased dramatically from 49.61 ± 48.84 to12.50 ± 12.18 and from 65.56 ± 26.89 to 29.68 ± 20.68. There were no recurrences of infection in our study. Conclusions The paradigm of the first-stage PELDID technique combined with the Pola classification system to guide the second-stage treatment for spontaneous spondylodiscitis is a novel and effective strategy for treating spontaneous spondylodiscitis.

Insight into understanding sequential two-stage pretreatment on modifying lignin physiochemical properties and improving holistic utilization of renewable lignocellulose biomass

The key to obtain the full benefits of renewable lignocellulosic biomass is to develop sustainable and economical fractionation technology of lignocellulosic components. Acidic pretreatment usually solubilizes the majority of hemicellulose, but also aggravates lignin repolymerization which would intensify lignin inhibition on cellulose hydrolysis. Thus, in this work, two approaches were utilized to modify the lignin physiochemical properties and synergistically improve holistic utilization of lignocellulose biomass. Firstly, the addition of 2-naphthol in dilute acid (DA) pretreatment largely suppressed lignin repolymerization and mitigated lignin inhibition, resulting in increased cellulose hydrolysis yield from 46.81% to 55.74%. Secondly, it was found that the phenolic groups of lignin played a pivotal role in determining the ease of cellulose hydrolysis, thus a second-stage treatment with acid-chlorite (CHL) or poly(ethylene glycol) diglycidyl ether (PEE) was introduced to selectively oxidize/block phenolic groups of lignin, which further improved cellulose hydrolysis to theoretically maximum yield. In addition to enhanced cellulose hydrolysis, the lignin residues recovered after PEE modification and enzymatic hydrolysis could be used as high-capacity adsorbents for lead ions removal from wastewater, while xylose was utilized for xylonic acid production. Results showed that the biorefinery process based on DA pretreatment and PEE post-treatment could enable a holistic utilization of renewable lignocellulosic biomass.

BestFIT Sequential Multiple Assignment Randomized Trial Results: A SMART Approach to Developing Individualized Weight Loss Treatment Sequences.

State-of-the-art behavioral weight loss treatment (SBT) can lead to clinically meaningful weight loss, but only 30-60% achieve this goal. Developing adaptive interventions that change based on individual progress could increase the number of people who benefit. Conduct a Sequential Multiple Assignment Randomized Trial (SMART) to determine the optimal time to identify SBT suboptimal responders and whether it is better to switch to portion-controlled meals (PCM) or acceptance-based treatment (ABT). The BestFIT trial enrolled 468 adults with obesity who started SBT and were randomized to treatment response assessment at Session 3 (Early TRA) or 7 (Late TRA). Suboptimal responders were re-randomized to PCM or ABT. Responders continued SBT. Primary outcomes were weight change at 6 and 18 months. PCM participants lost more weight at 6 months (-18.4 lbs, 95% CI -20.5, -16.2) than ABT participants (-15.7 lbs, 95% CI: -18.0, -13.4), but this difference was not statistically significant (-2.7 lbs, 95% CI: -5.8, 0.5, p = .09). PCM and ABT participant 18 month weight loss did not differ. Early and Late TRA participants had similar weight losses (p = .96), however, Early TRA PCM participants lost more weight than Late TRA PCM participants (p = .03). Results suggest adaptive intervention sequences that warrant further research (e.g., identify suboptimal responders at Session 3, use PCMs as second-stage treatment). Utilizing the SMART methodology to develop an adaptive weight loss intervention that would outperform gold standard SBT in a randomized controlled trial is an important next step, but may require additional optimization work. ClinicalTrials.gov identifier; NCT02368002.

Influence of multi-stage heat treatment on the microstructure and mechanical properties of TC21 titanium alloy

Duplex-structured TC21 alloy samples were first solution-treated at a higher temperature in the α + β region (940°C) with furnace cooling (FC), air cooling (AC), and water cooling (WC), followed by a second-stage solution treatment at a lower temperature in the α + β region (900°C), and then finally aged at 590°C. The effects of the morphology and quantity of α phases on the structure and properties of the TC21 alloy after the different heat treatments were analyzed. The in-situ tensile deformation process and crack propagation behavior were observed using scanning electron microscopy (SEM). The quantity of equiaxed α phases as well as the thickness of lamellar α phases reduced, the tensile strength increased firstly and then decreased, the elongation decreased with the increasing cooling rate after the first-stage solution treatment. The amount and size of lamellar α phases increased after the second-stage solution treatment because of sufficient diffusion of the alloying elements, thereby leading to increased tensile strength. The amount of dispersed α phases increased after the third-stage aging treatment owing to the increase in the nucleation rate, resulting in a noteworthy strengthening effect. After the third-stage aging treatment, the first-stage FC sample exhibited better mechanical properties because it contained more equiaxed α and βtrans phases than the first-stage AC and WC samples.

Komplike Akut Tip B Aortik Diseksiyonların Tedavisinde Donmuş Fil Hortumu Prosedürü

Introduction: This study aimed to define midterm clinical outcomes and morphological changes of acute complicated type B aortic dissections after the application of frozen elephant trunk technique. Patients and Methods: Data were collected from 143 patients treated with frozen elephant trunk procedure for complex thoracic aortic diseases between May 2012 and October 2018. Twenty-seven patients with acute complicated type B aortic dissection were included in the study. Results: The mean age of the study population was 56.9 ± 9.1 years, and 23 (85.2%)patients were male. Complete false lumen thrombosis in the descending aorta before the distal end of the stent graft was achieved in 88.9% of cases. There was no late mortality observed at a mean follow-up of 50.7 ± 22.5 months. Only one patient died due to multiple organ failure 62 days after the operation. Five patients underwent secondary distal aortic endovascular repair because of stent graft-induced new entry (n= 3) and second-stage treatment for post-dissection aneurysm (n= 2). Conclusion: Aortic arch involvement in acute complicated type B aortic dissections requires more extensive treatment, and frozen elephant trunk procedure serves as an alternative treatment modality.

A randomized controlled trial of a six-session cognitive behavioral treatment of emotional disorders in adolescents 14\u201317\u2009years old in child and adolescent mental health services (CAMHS)

BackgroundThis study aims to investigate effectiveness of a 6-week, transdiagnostic cognitive behavioral therapy (CBT) for anxiety and depression in adolescents, the Structured Material for Therapy (SMART), in naturalistic settings of child and adolescent mental health outpatient services (CAMHS).MethodsA randomized controlled trial with waiting list control (WLC) was performed at three community CAMHS in Norway. Referred adolescents (N = 163, age = 15.72, 90.3% girls) scoring 6 or more on the emotional disorders subscale of the Strengths and Difficulties Questionnaire (SDQ) were randomly assigned to SMART or to WLC.ResultsIn the treatment group (CBT), 32.9% improved in the main outcome measure (SDQ), compared to 11.6% in the WLC. Clinically significant and reliable change was experienced by 17.7% in the CBT condition, compared to 5.8% in the WLC. No patients deteriorated. Statistically significant treatment effects were achieved for internalization symptoms, anxiety symptoms and general functioning.ConclusionsThese promising findings indicate that SMART may be considered as a first step in a stepped care model for anxiety and/or depression treatment in CAMHS. The recovery rates imply that further investigations into the effectiveness of brief treatments should be made. Furthermore, there is a need for more comprehensive second-stage treatments for some of these patients.Trial registrationClinicalTrials.gov Identifier: NCT02150265. First registered May 292,014.

Minimally invasive management of acute ureteral obstruction and severe infection caused by upper urinary tract calculi.

PURPOSETo evaluate therapeutic efficacy of two minimally invasive surgical methods in managing acute ureteral obstruction and severe infection caused by upper urinary tract calculi (UUTC).PATIENTS AND METHODSData of 47 patients diagnosed with acute upper urinary tract obstruction and severe infection caused by ureteral calculus using X-ray CT between September 2014 and January 2019 were retrospectively analyzed. All patients were treated with immediate renal drainage and, after infection and ureteral obstruction were relieved, UUTC removal. Renal drainage was performed by ultrasound-guided percutaneous nephrostomy and retrograde ureteral catheterization was performed using cystoscopy. Kidney and ureteral stones were removed; renal function and the urinary tract were examined by X-ray during follow-up.RESULTSPercutaneous nephrostomy was performed in 29 patients in a critical condition including intolerance to surgery, high-grade hydronephrosis, or failure of retrograde ureteric stent placement. In other 18 patients diagnosed with small stones (≤10 mm) and low-grade hydronephrosis, indwelling double-J ureteral stents were temporally installed by a cystoscope. Acute infection and ureteral obstruction were relieved; white blood cell counts returned to normal values within 3 to 7 days after drainage in all patients. In the second-stage treatment, percutaneous nephrolithotomy (PCNL), ureteroscopic lithotripsy, extracorporeal shock wave lithotripsy and nephrectomy were performed in 24, 10, 8 and 5 patients, respectively. No patients developed severe complication after stone removal surgery. All patients were followed up for 3 months to 4.5 years. Renal function was significantly recovered; 17/29 (59%) patients with elevated serum creatinine returned to normal and serum creatinine in 12/29 (41%) patients improved significantly after drainage, with a pre-operation level of 285±169μM vs 203±91μM post-operation (P = 0.014). Five patients were lost during follow-up.CONCLUSIONThis study demonstrated an optimal approach for relieving upper urinary tract obstruction and acute infection in which percutaneous nephrostomy drainage is preferred for patients with severe pyonephrosis, large stones (>10 mm) with high-grade hydronephrosis, steinstrasse, or failure in retrograde ureteric stent placement, while retrograde ureteral catheterization using cystoscopy is suitable for patients diagnosed with small stones (≤10 mm) and low-grade hydronephrosis.

Fabricating mono-dispersed Fe3O4-SiO2 core-shell particles with help of triboelectrification

For years, it has been widely held that triboelectrification is not the sought-after technique to develop innovative materials with enhanced functionalities. In this study, we tried to break such a traditional concept and find its ever-expanding roles in material science. In our strategy, triboelectrification brought adequate charge to particles, so as to achieve their mono-dispersity in solutions. Following this strategy, the synthesis of mono-dispersed Fe3O4-SiO2 core-shell particles involved two-stage triboelectrification treatment. In the first-stage treatment, positive triboelectric charges on Fe3O4 cores ensured their uniform SiO2 coating and well-defined core-shell structure. In the second-stage treatment, positive triboelectric charges on Fe3O4-SiO2 core-shell particles guaranteed their mono-dispersity for further biological use. The Zeta potential of these triboelectrically-treated Fe3O4-SiO2 core-shell particles still maintained at ca. +55 mV after standing for two months, and their conglomeration was negligible owing to their limited increase in hydrodynamic size. Besides, their excellent linearity between relaxivities and iron concentration, and their virtually unchanged r2/r1 ratio within two months manifested that triboelectrification can be a promising technique in fabricating advanced materials.

Open descending aortic replacement after Thoraflex™ hybrid graft implantation.

The Thoraflex™ device is a composite 4-branched graft with a distal endovascular stent that allows either a one-stage treatment or an endovascular second-stage treatment of multisegment aortic pathologies. Reports on open second-stage treatment after the Thoraflex™ device implantation are sparse especially regarding the technical aspects. We described our surgical procedure of open second-stage descending thoracic aortic replacement after Thoraflex™ implantation with a special focus on the anastomosis technique to a stent graft. We found excellent haemostasis and a good postoperative outcome using our approach of the stent graft to graft anastomosis.

Repeating enlargement, recanalisations, and subarachnoid haemorrhages after middle cerebral artery aneurysm embolisation using pCONus stent and coils - a case report.

PurposeLarge and wide-necked bifurcation aneurysms remain technically challenging to treat by the endovascular approach. Several endovascular strategies have been established in recent years for treating wide-necked bifurcation aneurysms, such as balloon-assisted coiling, stent-assisted coiling, waffle cone technique (WCT), and intrasaccular flow disruptors.Case reportA 64-year-old woman was diagnosed with three intracranial aneurysms of the right and left middle cerebral artery and right internal carotid artery. She was qualified for endovascular treatment of the left middle cerebral artery (LMCA) aneurysm because it posed the greatest risk of rupture. Due to complicated morphology, a pCONus stent and coils were chosen for treatment. Three months later the right middle cerebral artery aneurysm was embolised and the woman was scheduled for second-stage treatment of the LMCA aneurysm. One week before the planned admission the woman was diagnosed with subarachnoid haemorrhage (SAH) in the region of the previously treated LMCA aneurysm, and the second-stage treatment was conducted with a good result. The woman was discharged in improved condition. Three months later the woman was once again admitted with SAH – an enlarged LMCA aneurysm was observed and immediate third-stage embolisation was performed, but due to complications of SAH the woman eventually died.ConclusionsOn the basis of the presented case we would like to emphasise the importance of sufficient initial coil packing and frequent control of neck region of the aneurysm for the long-term stability and safety after pCONus-assisted coiling of intracranial aneurysms.

Estimating survival distributions for time-varying SMART designs

Treatment of complex diseases such as cancer, HIV, leukemia and depression usually follows complex treatment sequences. In two-stage randomization designs, patients are randomized to first-stage treatments, and upon response, a second randomization to the second-stage treatments is done. The clinical goal in such trials is to achieve a response such as complete remission of leukemia, 50% shrinkage of solid tumor or increase in CD4 count in HIV patients. These responses are presumed to predict longer survival. The focus in two-stage randomization designs with survival endpoints is on estimating survival distributions and comparing different treatment policies. In this article, we propose a parametric approach for estimating survival distributions in time-varying SMART designs. To evaluate the performance of our approach, a simulation study is conducted. The results of the simulation study reveal that the new approach gives survival probabilities that are less biased and more precise than the nonparametric methods. The new method is applied to a data set from a leukemia clinical trial.

The sequential treatment of temporomandibular joint ankylosis with secondary deformities by distraction osteogenesis and arthroplasty or TMJ reconstruction

The purpose of this study was to evaluate the sequential treatment of patients with temporomandibular joint (TMJ) ankylosis and secondary deformities by distraction osteogenesis and subsequent arthroplasty or TMJ reconstruction. This study included 40 patients treated at a stomatological hospital in China; they ranged in age from 9 to 53years (mean age 24.5years). Ten of these patients were diagnosed with unilateral TMJ ankylosis and 30 with bilateral TMJ ankylosis. Twenty-seven patients also presented obstructive sleep apnoea–hypopnoea syndrome (OSAHS). All patients underwent distraction osteogenesis as the initial surgery, followed by arthroplasty or TMJ reconstruction. Some patients underwent orthognathic surgery to improve occlusion and face shape along with or after arthroplasty or TMJ reconstruction. The therapeutic effects were evaluated in terms of the improvements in maximum inter-incisal opening (MIO), appearance, and respiratory function. After the completion of treatment, all patients showed improvements in MIO and appearance, and the symptom of snoring disappeared. The airway space was significantly increased. Patient follow-up ranged from 6 to 85months (mean 28.3months), and four patients experienced relapse. This study suggests that treating TMJ ankylosis with secondary deformities by distraction osteogenesis as the initial surgery and arthroplasty or TMJ reconstruction as the second-stage treatment may achieve favourable outcomes, especially for patients with OSAHS; however, some patients may require orthognathic surgery.

Mandibular positioning techniques to improve sleep quality in patients with obstructive sleep apnea: current perspectives.

The purpose of this article is to review 1) mandibular advancement device (MAD) – indication, treatment success, and side effects; 2) maxillomandibular advancement (MMA) surgery of the jaws – indication, treatment success, and side effects; and 3) current perspectives. Both MAD and MMA are administered to increase the upper airway volume and reduce the collapsibility of the upper airway. MAD is noninvasive and is indicated as a first-stage treatment in adult patients with mild-to-moderate obstructive sleep apnea (OSA) and in patients with severe OSA unable to adhere to continuous positive airway pressure (CPAP). MAD remains inferior to CPAP in reducing the apnea–hypopnea index (AHI) with a treatment success ranging between 24% and 72%. However, patient compliance to MAD is greater, and with regard to subjective sleepiness and health outcomes, MAD and CPAP have been found to be similarly effective. Short-term side effects of MAD are minor and often transient. Long-term side effects primarily appear as changes in the dental occlusion related to decreases in overjet and overbite. MMA is efficacious but highly invasive and indicated as a second-stage treatment in patients with moderate-to-severe OSA, with prior failure to other treatment modalities or with craniofacial abnormalities. The surgical success and cure rates are found to be 86.0% and 43.2%, respectively. Side effects may appear as postsurgical complications such as temporary facial paresthesia and compromised facial esthetics. However, most patients report satisfaction with their postsurgical appearance. Both treatment modalities require experienced clinicians and multidisciplinary approaches in order to efficaciously treat OSA patients. Some researchers do propose possible predictors of treatment success, but clear patient selection criteria and clinical predictive values for treatment success are still needed in both treatment modalities.

A critical appraisal of randomized controlled trials on intravenous phenytoin in convulsive status epilepticus.

Since the 1970s, intravenous (IV) phenytoin (PHT) has traditionally been used as second-stage treatment for convulsive status epilepticus (SE) after failure of benzodiazepines. The aim of this review was to critically assess the evidence supporting the use of IV PHT as treatment of convulsive SE in patients of any age. In particular, we critically appraised the results of randomized controlled trials (RCTs) evaluating IV PHT as treatment of convulsive SE. A systematic search of the literature was carried out to identify RCTs evaluating IV PHT as treatment of convulsive SE in patients of any age. Eight RCTs (544 patients allocated to IV PHT) were included. The included studies differed in almost every single characteristic considered. Six RCTs (472 patients) used IV PHT without demonstrating refractoriness of SE to benzodiazepines. Only two RCTs (72 patients) used IV PHT as second-line treatment for benzodiazepine-resistant convulsive SE. Overall, most evidence from RCTs supports the use of IV PHT immediately after IV diazepam, even if seizures have not recurred. The recommendation derived from RCTs supporting the use of IV PHT as second-line treatment in benzodiazepine-resistant convulsive SE is weak. This is emblematic of the lack of robust evidence from large RCTs to inform clinical practice on how to treat SE after failure of first-line drugs. IV PHT given immediately after first-line benzodiazepines could prolong their short antiepileptic effect and prevent seizure recurrence.

A comparison of various lignin-extraction methods to enhance the accessibility and ease of enzymatic hydrolysis of the cellulosic component of steam-pretreated poplar

BackgroundCurrent single-stage delignification-pretreatment technologies to overcome lignocellulosic biomass recalcitrance are usually achieved at the expense of compromising the recovery of the polysaccharide components, particularly the hemicellulose fraction. One way to enhance overall sugar recovery is to tailor an efficient two-stage pretreatment that can pre-extract the more labile hemicellulose component before subjecting the cellulose-rich residual material to a second-stage delignification process. Previous work had shown that a mild steam pretreatment could recover >65% of the hemicellulose from poplar while limiting the acid-catalysed condensation of lignin. This potentially allowed for subsequent lignin extraction using various lignin solvents to produce a more accessible cellulosic substrate.ResultsA two-stage approach using steam and/or solvent pretreatment was assessed for its ability to separate hemicellulose and lignin from poplar wood chips while providing a cellulose-rich fraction that could be readily hydrolysed by cellulase enzymes. An initial steam-pretreatment stage was performed over a range of temperatures (160–200 °C) using an equivalent severity factor of 3.6. A higher steam temperature of 190 °C applied over a shorter residence time of 10 min effectively solubilized and recovered 75% of the hemicellulose while enhancing the ability of various solvents [deep eutectic solvent (DES), ethanol organosolv, soda/anthraquinone (soda/AQ) or a hydrotrope] to extract lignin in a second stage. When the second-stage treatments were compared, the mild DES treatment (lactic acid and betaine) at 130 °C, removed comparable amounts of lignin with higher selectivity than did the soda/AQ and organosolv pretreatments at 170 °C. However, the cellulose-rich substrates obtained after the second-stage organosolv and soda/AQ pretreatments showed the highest cellulose accessibility, as measured by the Simon’s staining technique. They were also the most susceptible to subsequent enzymatic hydrolysis.ConclusionsThe second-stage pretreatments varied in their ability to solubilize and extract the lignin component of steam-pretreated poplar while enhancing the enzymatic hydrolysis of the resulting cellulose-rich residual fractions. Although DES extraction was more selective in extracting lignin from the steam-pretreated substrates, the organosolv and soda/AQ post treatments disrupted the cellulose structure to a greater extent while enhancing the ease of enzymatic hydrolysis. Graphical abstractEffective hemicellulose removal via steam pretreatment followed by subsequent lignin extraction under acidic, alkaline or solvolytic conditions results in a highly accessible, more readily hydrolysed cellulose fraction.

Improving Polycyclic Aromatic Hydrocarbon Biodegradation in Contaminated Soil Through Low-Level Surfactant Addition After Conventional Bioremediation

Efficacy of bioremediation for soil contaminated with polycyclic aromatic hydrocarbons (PAHs) may be limited by the fractions of soil-bound PAHs that are less accessible to PAH-degrading microorganisms. In previous test-tube-scale work, submicellar doses of nonionic surfactants were screened for their ability to enhance the desorption and biodegradation of residual PAHs in soil after conventional bioremediation in a laboratory-scale, slurry-phase bioreactor. Polyoxyethylene sorbitol hexaoleate (POESH) was the optimum surfactant for enhancing PAH removal, especially the high-molecular weight PAHs. This work extends that concept by treating the effluent from the slurry-phase bioreactor in a second-stage batch reactor, to which POESH was added, for an additional 7 or 12 days. Surfactant amendment removed substantial amounts of the PAHs and oxy-PAHs remaining after conventional slurry-phase bioremediation, including more than 80% of residual 4-ring PAHs. Surfactant-amended treatment decreased soil cytotoxicity, but often increased the genotoxicity of the soil as measured using the DT-40 chicken lymphocyte DNA damage response assay. Potential ecotoxicity, measured using a seed germination assay, was reduced by bioreactor treatment and was reduced further after second-stage treatment with POESH. Of bacteria previously implicated as potential PAH degraders under POESH-amended conditions in a prior study, members of the Terrimonas genus were associated with differences in high-molecular weight PAH removal in the current study. Research using submicellar doses of surfactant as a second-stage treatment step is limited and these findings can inform the design of bioremediation systems at field sites treating soil contaminated with PAHs and other hydrophobic contaminants that have low bioaccessibility.

Percutaneous recanalization for combined-type Budd-Chiari syndrome: strategy and long-term outcome.

To investigate the feasibility, strategy, and long-term outcome of percutaneous recanalization for combined-type Budd-Chiari syndrome (BCS). From December 2007 to August 2014, consecutive symptomatic combined-type BCS patients were treated by percutaneous recanalization in our centers. Inferior vena cava (IVC) recanalization was the first-stage treatment for all patients. Recanalization of one hepatic vein (HV) was the second-stage treatment for the selected patients. If the patient had the compensatory and patent accessory HV (AHV), we observed this patient for 7 days after IVC recanalization. If the symptoms of portal hypertension improved, HV recanalization was not needed. Otherwise, HV recanalization was performed. If the patient had no patent AHV, HV recanalization was performed 3 days after IVC recanalization. Data on technical success, clinical success, and follow-up were analyzed, respectively. Sixty-two symptomatic combined-type BCS patients were enrolled. Technical success of percutaneous recanalization was achieved in 60 patients. Among them, 52 patients had the patent AHV and underwent single IVC recanalization, and 8 patients had no patent AHV and underwent combined IVC and HV recanalization. Clinical success was achieved in all of the 60 patients. Three patients died during the follow-up. The cumulative 1-, 2-, and 4-year survival rates were 98.3%, 96.5%, and 92.7%, respectively. Percutaneous recanalization is suitable for most combined-type BCS patients. Treatment strategy can be made according to the situation of AHV. If the patient has the patent AHV, single IVC recanalization is enough. Otherwise, combined IVC and HV recanalization should be performed.