Phosphorus recovery via the formation of hydroxyapatite crystals at various nitrogen loading rate in an anammox-based UAFB

A strategy that integrates the anammox and hydroxyapatite crystallization in an up-flow anaerobic fixed-bed reactor (UAFB) was investigated to simultaneously remove nitrogen and recover phosphorus. During the 430 days of operation, 73.1 ± 6.6% of influent phosphorus was removed with an efficient nitrogen removal efficiency of 87.8 ± 1.7%. After long-term operation, numerous acicular and micron-sized crystals were observed on the matured biofilm, of which the phosphorus content was around 10.21% (wt%) and hydroxyapatite was the main form of crystals through SEM-EDS, FT-IR and XRD analysis. The variation of substrates along the axial length of UAFB showed that phosphate removal was positively correlated with anammox and pH. Moreover, three anammox bacteria including Candidatus Brocadia (19.73%), Candidatus Jettenia (0.49%) and Candidatus Kuenenia (0.85%) were detected at the bottom of UAFB, while Candidatus Jettenia (4.67%) was dominant at the top. Hence, the anammox-based biofilm system could be alternative for the recovery of phosphorus from nutrient-rich wastewater.

[Efficacy observation of the caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy]

Objective: To investigate the safety and feasibility of caudal-medial approach combined with "page-turning" middle lymphadenectomy in the laparoscopic right hemicolectomy. Methods: A descriptive cohort study was conducted. Clinical data of 35 patients who underwent laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy at Department of Gastrointestinal Surgery, Guangdong Hospital of Chinese Medicine from April 2018 to May 2020 were retrospectively analyzed. All operations were performed consecutively by the same surgeon. The caudal-medial approach was used to dissect the right Toldt's fascia and the anterior pancreaticoduodenal space in a caudal-to-cranial and medial-to-lateral manner guided by the duodenum. The "page-turning" middle lymphadenectomy was used to dissect the mesocolon along the superior mesenteric vein with ileocolic vein, Henle's trunk and pancreas exposed preferentially. Results: All the 35 patients completed the operation successfully, and there was no damage and bleeding of superior mesenteric vessels and their branches. The operative time was (186.9±46.2) minutes, and the blood loss was 50 (10-200) ml. The first time to flatus was (2.1±0.6) days, and the time to fluid intake was (2.5±0.8) days. The postoperative hospital stay was 6 (3-18) d. The overall morbidity of postoperative complication was 8.6% (3/35), including grade II in 1 cases (2.8%) and grade IIIa in 2 case (5.7%) according to the Clavien-Dindo grading standard. The total number of lymph node dissected was 30.2±5.6, and the positive lymph node was 0 (0-7). Tumor staging revealed 5 cases of stage I, 18 cases of stage II, 11 cases of stage III, and 1 case of stage IVA. In this study, the median follow-up time was 15 (4-29) months. One patient died due to cerebrovascular accident 12 months after surgery, and no tumor recurrence or metastasis was observed in all other patients. Conclusions: Laparoscopic radical right hemicolectomy using caudal-medial approach combined with "page-turning" middle lymphadenectomy is safe and feasible. The anterior pancreaticoduodenal space is preferentially mobilized, which reduces the difficulty of central vascular dissection.

The influence of a stepwise pH increase on volatile fatty acids production and phosphorus release during Al-waste activated sludge fermentation

In this study, the performance of volatile fatty acids (VFAs) production and phosphorus (P) release during Al-waste activated sludge (Al-WAS) anaerobic fermentation with stepwise pH increases from 8 to 11 was investigated via a long-term acclimation strategy. As results, VFAs concentration increased with increasing pH and the maximum yield of VFAs was 358.03 mg-COD/g VS at pH 11, which was much higher than at pH 8. P was also released during the process, and the P concentration increased gradually from 26 mg/L at pH 8 to 186 mg/L at pH 11, accounting for 35.8% of the total P in the Al-WAS. The P distribution results demonstrated the dissolution of non-apatite inorganic phosphorus (NAIP) and organic P in the sludge contributed to release P into the liquid at pH 8, 9, and 10, while inorganic P release originated from the dissolution of NAIP at pH 11.

Defining heart disease risk for death in COVID-19 infection

BACKGROUND

Cardiovascular disease (CVD) was in common in coronavirus disease 2019 (COVID-19) patients and associated with unfavorable outcomes. We aimed to compare the clinical observations and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients with or without CVD.

METHODS

Patients with laboratory-confirmed SARS-CoV-2 infection were clinically evaluated at Wuhan Seventh People's Hospital, Wuhan, China, from 23 January to 14 March 2020. Demographic data, laboratory findings, comorbidities, treatments and outcomes were collected and analyzed in COVID-19 patients with and without CVD.

RESULTS

Among 596 patients with COVID-19, 215 (36.1%) of them with CVD. Compared with patients without CVD, these patients were significantly older (66 vs. 52 years) and had higher proportion of men (52.5% vs. 43.8%). Complications in the course of disease were more common in patients with CVD, included acute respiratory distress syndrome (22.8% vs. 8.1%), malignant arrhythmias (3.7% vs. 1.0%) including ventricular tachycardia/ventricular fibrillation, acute coagulopathy(7.9% vs. 1.8%) and acute kidney injury (11.6% vs. 3.4%). The rate of glucocorticoid therapy (36.7% vs. 25.5%), Vitamin C (23.3% vs. 11.8%), mechanical ventilation (21.9% vs. 7.6%), intensive care unit admission (12.6% vs. 3.7%) and mortality (16.7% vs. 4.7%) were higher in patients with CVD (both P < 0.05). The multivariable Cox regression models showed that older age (≥65 years old) (HR 3.165, 95% CI 1.722-5.817) and patients with CVD (HR 2.166, 95% CI 1.189-3.948) were independent risk factors for death.

CONCLUSIONS

CVD are independent risk factors for COVID-19 patients. COVID-19 patients with CVD were more severe and had higher mortality rate, early intervention and vigilance should be taken.

[Detection of right-to-left shunt with transthoracic contrast echocardiography in patients with pulmonary hypertension]

Objective: To explore the value of right heart contrast echocardiography in etiological diagnosis and severity assessment of pulmonary hypertension (PH). Methods: A retrospective analysis was conducted on 74 patients who underwent transthoracic contrast echocardiography in China-Japan Friendship Hospital from May 2015 to July 2018, all of whom were diagnosed as PH by right heart catheterization. Patients were divided into three groups according to contrast echocardiography: the intra-cardiac shunt group (<4 cardiac cycles with microbubbles in the left heart); Intrapulmonary shunt group (>4 cardiac cycles with microbubbles in the left heart); non-shunt group. The etiology, partial arterial oxygen pressure (PO(2)), N-terminal pro-brain natriuretic peptide (NT-proBNP), mean pulmonary artery pressure (mPAP), right atrial pressure (RAP), pulmonary vascular resistance (PVR) and cardiac output (CO) were analyzed. Central nervous system complications were also compared among the three groups. Results: Among the 74 patients, right-to-left shunt was found in 28 cases (37.8%) by contrast echocardiography, including 11 cases (14.9%) of intra-cardiac shunt and 17 cases (23.0%) of intrapulmonary shunt. In the 11 cases of intra-cardiac shunt, 7 were diagnosed with congenital heart disease and 4 were patent foramen. Two with hereditary hemorrhagic telangiectasia (HHT) and 1 with pulmonary arteriovenous malformation (PAVM) were included in the 16 cases of intrapulmonary shunt. There was no statistical difference in PO(2), mPAP, PVR, NT-proBNP, RAP, CO and functional class among the three groups (all P>0.05). A total of 5 cases (6.8%) were found with nervous system comorbidities, 4 cases (5.4%) with cerebral infarction and 1 cases epilepsy, and 2 cases of cerebral infarction were diagnosed as paradoxical embolism. Nervous system complications were more common in patients with intra-cardiac shunt than in other groups. Conclusion: While right-to-left shunt detected by contrast echocardiography has no relationship with disease severity, it has complementary value in the etiological diagnosis of PH, and intra-cardiac shunt may increase the risk of nervous system complications.

[Risk factors and clinical features of hospital-associated venous thromboembolism]

Objective: To investigate the clinical features and risk factors of hospital-associated venous thromboembolism (VTE). Methods: The study enrolled acute VTE patients admitted into China-Japan Friendship Hospital from January 1, 2017 to December 31, 2017. The hospital-associated VTE (HA-VTE) group and the community-associated VTE (CA-VTE) group were classified according to whether the VTE occurred during hospitalization or within a 90-day period of admission to hospital (including inpatient with at least two days of hospital stay or a surgical procedure under general or regional anaesthesia). Differences in clinical features, risk factors, and mortality rate were compared between the two groups. Results: A total of 437 patients with acute VTE were analyzed in the study. Among them, 266 patients were HA-VTE, 171 patients were CA-VTE. Patients in the CA-VTE group were more likely to have varicose veins, sedentary, long-distance travel, and patients in the HA-VTE group were more complicated with recent surgery (<1 month), bed rest, active malignant tumor, acute infections, acute cerebral infarction, fracture, central venous catheter (P<0.05). The CA-VTE group had more clinical symptoms such as lower extremity pain, dyspnea, chest pain and chest tightness (P<0.05). HA-VTE patients had less clinical symptoms but were more severe than the CA-VTE patients, with more sudden deaths (0 vs 3.4%, P=0.035). Among HA-VTE patients, 92.8% experienced VTE during hospitalization or within 1 month of the preceding hospital encounter, with a 13-day median time to VTE. The all-cause mortality rate was higher for HA-VTE group than CA-VTE group (8.3% vs 1.2%, P<0.001), and the in-hospital VTE was more common compared to VTE diagnosed post-discharge (12.2% vs 3.4%, P<0.001). Conclusions: More than half events of VTE are related to recent hospitalizations. HA-VTE has different risk factors from CA-VTE, combined with fewer clinical symptoms but higher all-cause mortality rate. More attention about VTE should be paid to hospitalized patients to reduce the incidence of HA-VTE events.

Formation and characteristics of filamentous granular sludge

Aerobic granular sludge process as a promising biotechnology has been one of the research hotspots in the area of wastewater treatment during the last two decades. In our study, after around 60 days' operation, filamentous granular sludge (FGS) was formed under low aeration (SAV = 0.085 cm/s) and multi-feeding conditions. The characteristics of FGS and the performance of the FGS system for organic matter and nutrients removal were investigated. The results showed that chemical oxygen demand (COD) and total organic carbon (TOC) removal efficiencies were relatively stable, while COD removal efficiency increased from 82% to 94% in the presence of sulfamethoxazole (SMZ) at low concentration (1 mg/L). At the same time, the TP removal efficiency could be improved and maintained at around 75%, while TN removal efficiency was flocculated at around 50%. The analysis of microbial diversity showed that Thiothrix and Trichococcus as typical filamentous species were detected and dominant in the FGS system. The abundance of Thiothrix increased from 15% to 34%, while Trichococcus decreased from 23% to 3% in the presence of SMZ.

Enhancement of syntrophic acetate oxidation pathway via single walled carbon nanotubes addition under high acetate concentration and thermophilic condition

The effect of single walled carbon nanotubes (SWCNT) on methane production under high acetate concentration and thermophilic condition was evaluated. An isotope labeling experiment verified that >85% of methane was generated from syntrophic acetate oxidation (SAO) at 50, 100 and 150 mM acetate and almost 100% at 200 mM. SWCNT addition had little effect on the methanogenesis pathway, whereas it accelerated methane production via decreasing lag phase times and increasing maximum methane production rates. Electrochemical impedance spectroscopy (EIS) results revealed the electrical resistivity of sludge in groups of SWCNT was distinctly smaller than CK groups, indicating higher sludge conductivity was achieved. Further, the results of communities described that Coprothermobacter and Thermacetogenium played the most important role in SAO under all conditions. Meanwhile, the enriched Thermacetogenium and direct interspecies electron transfer (DIET) pathway in SAO consortia contributed to the acceleration of methane production via SWCNT addition.

Combined heterotrophic and autotrophic system for advanced denitrification of municipal secondary effluent in full-scale plant and bacterial community analysis

Total nitrogen (TN) removal is the major technical challenge for wastewater treatment plants to meet the more stringent discharge standard. In this study, lab- (0.05 m³/d), pilot- (1000 m³/d) and full-scale (10,000 m³/d) combined heterotrophic and autotrophic denitrification reactors (HARs) were designed and operated to treat municipal secondary effluent. During the 110-day stable operation, the effluent TN was reduced below 2.5 mg/L without secondary pollution causing by the excessive addition of organics, close to Class IV of Environmental Quality Standards for Surface Water. The bacterial richness and diversity increased with the expansion of reactor scale. Denitrifying bacteria (DB) dominated in all reactors, however, Thiomonas (12.42%), Methylotenera (6.35%), Thiobacillus (20.62%), Methyloverstatilis (5.44%) and Thauera (8.21%) were the main genera in lab-, pilot- and full-scale reactors respectively. The denitrification efficiency temporarily deteriorated at the later stage, and redundancy analysis (RDA) indicated the obviously increased sulfate reducing bacteria (SRB) and sulfide were main contributors. Sludge supplement rapidly recovered the reactors performance in five days. This study suggests that HARs could be a promising technique for advanced denitrification of the municipal secondary effluent.

[Efficacy and safety of Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension]

Objective: To study the efficacy and safety of Balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Methods: Patients who were diagnosed CTEPH in China-Japan Friendship Hospital from Feb 2018 to Sep 2019 were evaluated. The ineligibility for pulmonary endarterectomy (PEA) and the indication for BPA were decided on the basis of a consensus among the multidisciplinary team for all CTEPH patients. 6-min walk distance (6MWD), the plasma level of N-terminal pro-brain natriuretic peptide (NT-proBNP), mixed venous oxygen saturation, mean pulmonary artery pressure (mPAP), cardiac index (CI) and pulmonary vascular resistance (PVR) were collected and analyzed before the first and the last BPA session. Results: A total of 67 BPA sessions were performed for 302 subsegmental pulmonary arteries in 25 inoperable CTEPH patients. 10 males (40.0%) and 15 females (60.0%), with the age of (57.8±7.1) years old. The median interval between CTEPH diagnosis and first BPA was 20.0 (9.0, 48.5) months. 18 patients were received more than 2 BPA sessions, the median follow-up time was 5.0 (3.5, 8.3) months. 6MWD, CI and the mixed venous oxygen saturation were significant improved after BPA [(425±74) vs (345±109) m, (1.99±0.45) vs (1.62±0.35) L·min(-1)·m(-2), (68.1%±6.5%) vs (61.2%±6.3%)](all P<0.05). The plasma level of NT-proBNP, mPAP and PVR were significantly decreased after BPA [259 (93, 739) vs 806 (148, 2 159) ng/L, (40.6±8.3) vs (47.3±10.7) mmHg (1 mmHg=0.133 kPa), (11.9±4.9) vs (17.2±6.5) WU (1 WU=80 dyn·s·cm(-5))](all P<0.05). Hemoptysis occurred in 5 sessions (7.5%) and reperfusion pulmonary edema (RPE) occurred in 2 sessions (1.5%), 1 patient needed non-invasive mechanical ventilation because of RPE, 1 patient died from right heart failure caused by hemoptysis during perioperative period. Conclusions: BPA can significantly improve the exercise tolerance and hemodynamic parameters for inoperable CTEPH patients, the risks of BPA are acceptable. BPA is an effective and relatively safe treatment for inoperable CTEPH patients.

Enhanced biodegradation of pyridine using sequencing batch biofilm reactor under intermittent micro-aerobic condition

A sequencing batch biofilm reactor under intermittent micro-aerobic or anaerobic conditions was investigated to remove pyridine at various concentrations from synthetic wastewater. The results showed that over 98% of pyridine (influent concentration ≤200 mg L^-1) was degraded under intermittent micro-aerobic condition, while about 21% of pyridine was removed under anaerobic condition. Additionally, at least 60% of nitrogen located in the pyridine ring was transformed to ammonium. At the same time, the sulphate reduction was obviously inhibited under intermittent micro-aerobic conditions. The microscopic observation showed that abundant microorganisms were attached on the surface or inside of porous biocarriers under intermittent micro-aerobic conditions after a short-term period of operation. High-throughput sequencing analysis demonstrated that Azotobacter, Rhodobacteraceae and Tolumonas were the dominant species in the intermittent micro-aerobic system. The kinetic study at steady period showed that pyridine degradation was fitted well with the pseudo-first-order model (R² > 0.96). The two possible intermediate products were identified and the possible biodegradation pathway of pyridine was proposed under micro-aerobic condition.

[Clinical characteristics of patients with chronic thromboembolic pulmonary hypertension]

Objective: To investigate the clinical characteristics of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods: CTEPH cases consecutively admitted into China-Japan Friendship Hospital from September 2015 to June 2019 were enrolled with prospective data collection. The medical histories, clinical characteristics, laboratory tests, imaging manifestation and hemodynamic parameters were analyzed. Patients were divided into high pulmonary vascular resistance (PVR) group and low PVR group according to the PVR level>1 000 dyn·s·cm(-5) or not, and clinical characteristics were compared between these two groups. Results: In the 148 cases of CTEPH, right heart catheterization was performed in 103 cases with mPAP (45.1±11.0) mmHg and PVR of (992±430) dyn·s·cm(-5). At diagnosis, 88 (59.5%) cases were in WHO functional class Ⅲ and 27 (18.2%) in class Ⅳ. Most common presenting symptoms were dyspnea (147, 99.3%), chest tightness (68, 45.9%), hemoptysis (42, 28.3%), syncope (30, 20.3%), and most common signs were P2 accentuation (95, 64.9%), edema (65, 43.9%), cyanosis (47, 31.8%), systolic murmur (44, 29.7%) and jugular vein distention (35, 23.6%). In 103 cases with right heart catheterization, 52 were in the low PVR group and 51 in high PVR group. Compared to the low PVR group, high PVR group patients had higher WHO functional class and more jugular vein distention (both P<0.05). In all the 148 cases, previous venous thromboembolism (VTE) was confirmed in 105 (70.9%) patients, with a higher prevalence of previous VTE in low PVR group than that in high PVR group (P<0.001). 30 (20.3%) patients had varicose veins of the lower extremities, and 21 (14.2%) had other thrombophilic disorders including antiphospholipid syndrome, protein C and S deficiency and antithrombin Ⅲ deficiency. Conclusions: Dyspnea, P2 accentuation and edema are the most common clinical presentation of CTEPH. Previous history of VTE is common in CTEPH patients with thrombophilia in some cases.

Enhanced removal of nitrate and refractory organic pollutants from bio-treated coking wastewater using corncobs as carbon sources and biofilm carriers

The quality of the bio-treated coking wastewater (BTCW) is difficult to meet increasingly stringent coking wastewater discharge standards and future wastewater recycling needs. In this study, the pre-treatment process of BTCW was installed including the two up-flow fixed-bed bioreactors (UFBRs) which were separately filled with alkali-pretreated or no alkali-pretreated corncobs used as solid carbon sources as well as biofilm carriers. Results showed that this pre-treatment process could significantly improve the biodegradability of BTCW and increase the C/N ratio. Thus, over 90% of residual nitrate in BTCW were removed stably. Furthermore, GC-MS analysis confirmed that the typical refractory organic matters decreased significantly after UFBRs pre-treatment. High-throughput sequencing analysis using 16S rRNA demonstrated that dominant denitrifiers, fermentative bacteria and refractory-organic-pollutants-degrading bacteria co-existed inside the UFBRs system. Compared with no alkali-pretreated corncobs, alkali-pretreated corncobs provided more porous structure and much stable release of carbon to guarantee the growth and the quantity of the functional bacteria such as denitrifiers. This study indicated that the UFBRs filled with alkali-pretreated corncobs could be utilized as an effective alternative for the enhanced treatment of the BTCW.

[Brain protection strategy and effectivity in pulmonary thromboendarterectomy]

Objective: To summarize the experience and effectivity of brain protection in 25 patients who suffered from chronic thromboembolic pulmonary hypertension (CTEPH) and received pulmonary thromboendarterectomy (PTE) under deep hypothermic circulatory arrest. Methods: Retrospective analysis of 25 PTE surgeries in our center from December 2016 to August 2018. All cases were completed underdeep hypothermic circulatory arrest. Standard brain protections were strictly executed, including: balanced and controlled extracorporeal circulation cooling, cerebral oxygen saturation (rSO(2)) monitoring, strictly control of circulatory arrest time, and etc. The neurological adverse events during the perioperative period were recorded and statistically analyzed, and the intelligence level and cognitive function of the patients were evaluated by MMSE scale and MoCA scale before surgery and discharge. Results: All the 25 patients successfully completed the surgery, and 1 patient (4%) died of postoperative infection. The mean pulmonary arterial pressure decreased from (52.9±16.7) mmHg before surgery to (23.6±8.1) mmHg immediately after surgery (t=10.01, P<0.01), and(20.7±7.9) mmHg at 3 months follow-up (t=10.73, P<0.01). Pulmonary vascular resistance decreased from 975.4 (788.6-1 292.8) dyn·s·cm(-5) to 376.1 (283.6-565.5) dyn·s·cm(-5) (Z=5.34, P<0.01). Neurological complications occurred in 3 patients during the perioperative period, including 2 patients with hypoxic encephalopathy, and 1 patient with cerebral hemorrhage. All 3 patients fully recovered before discharge. Univariate analysis showed that the duration of rSO(2)<40% and the maximum decrease rate of rSO(2) from baseline were significantly correlated with postoperative neurological damage. Multivariate analysis showed only time of rSO(2)<40% was significantly correlated with postoperative neurological damage. There was no significant difference in MMSE and MoCA score before and after surgery (P>0.05). Conclusions: Adequate brain protection measures are essential to reduce the neurological complications of PTE surgery. Real-time intraoperative monitoring of rSO(2) and strict control of circulatory arrest time can further reduce the occurrence of neurological damage.

Extracorporeal shock wave lithotripsy versus ureteroscopy for management of pediatric nephrolithiasis in upper urinary tract stones: multi-institutional outcomes of efficacy and morbidity

INTRODUCTION

As the incidence of pediatric nephrolithiasis rises, understanding the efficacy and morbidity of surgical treatment options is critical. Currently, there are limited comparative data assessing shock wave lithotripsy (SWL) and ureteroscopy (URS) outcomes in children.

OBJECTIVE

The objective of this study was to compare stone clearance, 30-day emergency department visits, and the number of general anesthetics required per stone treatment for both modalities.

STUDY DESIGN

A multi-institutional retrospective review of children presenting for either URS or SWL between 2000 and 2017 was performed. Stone clearance, need for retreatment, the number of anesthetics, as well as the number and reason for emergency room visit were captured and compared between groups. Multivariate statistical analysis accounting for age, stone location, stone diameter, pre-intervention stent, and provider volume was performed for adjusted analysis.

RESULTS

A total of 84 SWL and 175 URS procedures were included. Complete stone clearance and rates of residual stone fragments <4 mm after final procedure for SWL were 77.0% and 90.8% and for URS were 78.5% and 91.7%, respectively. Retreatment rates for both procedures were not significantly different (17.9% SWL vs. 18.9% URS, P = 0.85). Children who underwent SWL had lower rates of emergency room visits for infections (0% vs. 5.1%, P = 0.03) and flank pain (3.6% vs. 10.9%, P = 0.05) and required fewer general anesthetics per treatment (1.2 vs. 2.0, P < 0.01) than those who underwent URS (Figure).

DISCUSSION

Stone clearance after both the initial and final treatments and need for repeat interventions were similar between surgical modalities. However, SWL carries less morbidity than URS. Specifically, patients who underwent SWL experienced lower rates of ED visits for urinary tract infection and for flank pain, parallel to conclusions in current comparative literature. In addition, SWL requires less general anesthetics (2.0 vs. 1.2), secondary to lower rates of ureteral stent placement and removal. Data on the potential risk of general anesthetics to neurodevelopment support thoughtful utilization of these medications. Limitations of this study include its retrospective nature and the prolonged 20-year time period over which data were collected.

CONCLUSIONS

When adjusting for confounders, SWL and URS achieve similar stone clearance. In the setting of equivalent efficacy, considerations regarding necessity of repeat interventions, morbidity of anesthesia, and complications should be integrated into clinical practice.