Regarded as a superior urban stormwater management solution, rain gardens can effectively store rainfall runoff and purify water quality. However, the efficiency of traditional rain gardens (TRG) in regulating runoff and removing nitrogen and phosphorus varies under different hydrological conditions. In this study, the TRG was retrofitted to construct a two-stage tandem rain garden (TTRG). Based on the experimental monitoring of rain gardens under natural rainfall from 2011 to 2013, results indicated a significantly higher runoff reduction capacity for the TTRG compared to the traditional garden (p < 0.05), with average runoff and peak flow reduction rates increasing by 42.8% and 36.2%, respectively. Rainfall characteristics significantly impacted the runoff reduction of the TRG (p < 0.05), but not the TTRG (p > 0.05), demonstrating the enhanced control and stability of the TTRG in managing rainfall runoff. The concentration removal efficiency of nitrate nitrogen (NO3--N) was significantly improved (p < 0.05), whereas the total phosphorus (TP), ammonium nitrogen (NH3-N) and total nitrogen (TN) were not significantly changed (p > 0.05). The first-order kinetic model was used to fit the removal effect of different pollutants before and after retrofitting the rain garden, and the removal of NO3--N by the TTRG was better than that of the TRG. The TTRG showed significantly higher load removal efficiencies for TP, NO3--N, and NH3-N compared to TRG (p < 0.05), with average load removal rates increasing by 49.92%, 75.02%, and 14.81%, respectively. The TTRG can regulate urban rainfall runoff more efficiently and stably. By changing the water flow path in the rain garden, the TTRG has a better runoff reduction ability and pollutant purification effect.

BACKGROUND: Concomitant gallbladder and common bile duct (CBD) stones, known as cholecystocholedocholithiasis, are clinically prevalent. There is currently no consensus on sequential versus simultaneous management approaches, and, if simultaneous, which approach to adopt. This meta-analysis evaluates the safety and efficacy of one-stage laparoscopic cholecystectomy (LC) with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) versus two-stage ERCP followed by LC for treating concomitant gallbladder and CBD stones.
METHODS: A comprehensive literature search was conducted in five databases, PubMed, Embase, Web of Science, VIP, and Wanfang, for all randomized controlled trials (RCTs), cohort and retrospective studies published up to February 2024. Data extraction was performed independently by two reviewers. The primary outcomes were CBD stone clearance rate and postoperative complications morbidity. Secondary outcomes included conversion to other procedures and length of hospital stay. Statistical analyses were performed using R (v.4.3.2) with weighted mean differences and odds ratios (ORs) calculated for continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs).
RESULTS: A total of 17 studies involving 2120 patients have been included, with 898 patients receiving single-stage and 1222 patients undergoing two-stage treatment. Of these studies, 9 were RCTs and 8 were retrospective cohort study. The one-stage group demonstrated superior outcomes in terms of CBD stone clearance (OR = 2.07, p = 0.0004), overall morbidity (OR = 0.35, p < 0.0001), post-operative pancreatitis (OR = 0.49, p = 0.006), conversion to other procedures (OR = 0.38, p = 0.0006), and length of hospital stay (MD = - 2.6456, 95% CI - 3.5776; - 1.7136, p < 0.0001). No significant differences were observed in post-operative cholangitis (OR = 0.44, p = 0.12), post-operative bleeding (OR = 0.76, p = 0.47), or bile leakage (OR = 1.28, p = 0.54).
CONCLUSIONS: For patients with concomitant gallbladder and CBD stones, the one-stage approach combining ERCP and LC appears safer and more effective, with advantages including higher stone clearance rates, reduced postoperative complications (particularly pancreatitis), shorter hospital stays, fewer residual stones, and decreased need for additional procedures. However, additional high-quality clinical trials are needed to establish the optimal treatment approach for various patient scenarios.

UNASSIGNED: Lung cancer is a malignant tumor, for which pulmonary nodules are considered to be significant indicators. Early recognition and timely treatment of pulmonary nodules can contribute to improving the survival rate of patients with cancer. Positron emission tomography-computed tomography (PET/CT) is a noninvasive, fusion imaging technique that can obtain both functional and structural information of lung regions. However, studies of pulmonary nodules based on computer-aided diagnosis have primarily focused on the nodule level due to a reliance on the annotation of nodules, which is superficial and unable to contribute to the actual clinical diagnosis. The aim of this study was thus to develop a fully automated classification framework for a more comprehensive assessment of pulmonary nodules in PET/CT imaging data.
UNASSIGNED: We developed a two-stage multimodal learning framework for the diagnosis of pulmonary nodules in PET/CT imaging. In this framework, Stage I focuses on pulmonary parenchyma segmentation using a pretrained U-Net and PET/CT registration. Stage II aims to extract, integrate, and recognize image-level and feature-level features by employing the three-dimensional (3D) Inception-residual net (ResNet) convolutional block attention module architecture and a dense-voting fusion mechanism.
UNASSIGNED: In the experiments, the proposed model\'s performance was comprehensively validated using a set of real clinical data, achieving mean scores of 89.98%, 89.21%, 84.75%, 93.38%, 86.83%, and 0.9227 for accuracy, precision, recall, specificity, F1 score, and area under curve values, respectively.
UNASSIGNED: This paper presents a two-stage multimodal learning approach for the automatic diagnosis of pulmonary nodules. The findings reveal that the main reason for limiting model performance is the nonsolitary property of nodules in pulmonary nodule diagnosis, providing direction for future research.

Sacrococcygeal chordoma is a malignant, slow-growing, and locally aggressive bone tumor. A wide surgical margin is recommended to prevent local recurrence and metastasis. This disease tends to cause massive defects when rectal resection and sacrectomy are required. Therefore, soft tissue reconstruction is required and a pedicled vertical rectus abdominis muscle flap (VRAM) is a viable option. Important anatomical landmarks, advantages and limitations are discussed and the procedure is described step by step. This case report presents a two-stage operation with an anterior rectal resection and VRAM flap harvest followed by a complementary posterior approach with sacrectomy and soft tissue reconstruction: approach and results. The wound completely healed in six weeks. Three years after surgery, no local recurrence or distal metastasis was detected. This two-stage strategy presents a viable and safe option for large sacrococcygeal chordomas.

BACKGROUND: Chronic osteomyelitis is a debilitating bone infection, characterized by a persistent infection over months to years, poses diagnostic and therapeutic challenges due to its insidious nature and potential for severe bone and soft tissue destruction. This systematic review and meta-analysis aims to review the literature on the treatment of chronic osteomyelitis in long bones and assess cure rates in single versus two-stage surgery.
METHODS: Following the PRISMA guidelines and registered with PROSPERO (ID: CRD42021231237), this review included studies that reported on the management of chronic osteomyelitis in long bones using either a planned one-stage or two-stage surgical approach in adult patients. Databases searched included Medline, Embase, Web of Science, CINAHL, HMIC, and AMED, using keywords related to osteomyelitis, long bones, and surgical management. Eligibility criteria focused on adults with chronic osteomyelitis in long bones, with outcomes reported after a minimum follow-up of 12 months. The meta-analysis utilized the random-effects model to pool cure rates.
RESULTS: The analysis included 42 studies with a total of 1605 patients. The overall pooled cure rate was 91% (CI 95%) with no significant difference observed between single-stage and two-stage surgeries (X2 = 0.76, P > 0.05). Complications were reported in 26.6% of cases in single-stage procedures and 27.6% in two-stage procedures, with prolonged wound drainage noted as a common issue. Dead space management techniques varied across studies, with antibiotic-loaded calcium sulphate beads used in 30.4% of cases.
CONCLUSIONS: This meta-analysis reveals no significant difference in cure rates between single and two-stage surgical treatments for chronic osteomyelitis in long bones, supporting the efficacy of both approaches. The current treatment strategy should include a combination of debridement, dead space management using local and systematic antibiotics and soft tissue reconstruction if necessary.

Increased consumer awareness for healthier and more sustainable products has driven the search for naturally sourced compounds as substitutes for chemically synthesized counterparts. Research on pigments of natural origin, such as carotenoids, particularly lutein, has been increasing for over three decades. Lutein is recognized for its antioxidant and photoprotective activity. Its ability to cross the blood-brain barrier allows it to act at the eye and brain level and has been linked to benefits for vision, cognitive function and other conditions. While marigold flower is positioned as the only crop from which lutein is extracted from and commercialized, microalgae are proposed as an alternative with several advantages over this terrestrial crop. The main barrier to scaling up lutein production from microalgae to the commercial level is the low productivity compared to the high costs. This review explores strategies to enhance lutein production in microalgae by emphasizing the overall productivity over lutein content alone. Evaluation of how culture parameters, such as light quality, nitrogen sufficiency, temperature and even stress factors, affect lutein content and biomass development in batch phototrophic cultures was performed. Overall, the total lutein production remains low under this metabolic regime due to the low biomass productivity of photosynthetic batch cultures. For this reason, we describe findings on microalgal cultures grown under different metabolic regimes and culture protocols (fed-batch, pulse-feed, semi-batch, semi-continuous, continuous). After a careful literature examination, two-step heterotrophic or mixotrophic cultivation strategies are suggested to surpass the lutein productivity achieved in single-step photosynthetic cultures. Furthermore, this review highlights the urgent need to develop technical feasibility studies at a pilot scale for these cultivation strategies, which will strengthen the necessary techno-economic analyses to drive their commercial production.

Total joint arthroplasty is the recommended treatment for patients with end-stage osteoarthritis, as it reduces disability and pain and restores joint function. However, prosthetic joint infection is a serious complication of this procedure, with the two-stage exchange being the most common treatment method. While there is consensus on diagnosing prosthetic joint infection, there is a lack of agreement on the parameters that can guide the surgeon in performing definitive reimplantation in a two-stage procedure. One approach that has been suggested to improve the accuracy of microbiologic investigations before definitive reimplantation is to observe a holiday period from antibiotic therapy to improve the accuracy of cultures from periprosthetic tissues, but these cultures report some degree of aspecificity. Therefore, several pieces of evidence highlight that performing reimplantation using continuous antibiotic therapy should be considered a safe and effective approach, leading to higher cure rates and a shorter period of disability. Dosage of C-reactive protein (CRP), erythrocyte sedimentation rate (ERS) and D-dimer are helpful in diagnosing prosthetic joint infection, but only D-dimer has shown sufficient accuracy in predicting the risk of infection recurrence after a two-stage procedure. Synovial fluid analysis before reimplantation has been shown to be the most accurate in predicting recurrence, and new cutoff values for leukocyte count and neutrophil percentage have shown a useful predictive rule to identify patients at risk of unfavourable outcome. A new scoring system based on a numerical score calculated from the beta coefficient derived through multivariate analysis of D-dimer levels, synovial fluid leukocytes and relative neutrophils percentage has demonstrated high accuracy when it comes to guiding the second step of two-stage procedure. In conclusion, reimplantation may be a suitable option for patients who are on continuous therapy without local symptoms, and with CRP and ERS within the normal range, with low synovial fluid leukocytes (< 952/mL) and a low relative neutrophil percentage (< 52%) and D-dimer below 1100 µg/mL. A numerical score derived from analysing these three parameters can serve as a valuable tool in determining the feasibility of reimplantation in these patients.

Periprosthetic joint infections (PJIs) are a prominent subject of discussion in orthopedics and are frequently debated at conferences and congresses. In the context of PJIs affecting the knee, the decision between following a one-stage or two-stage treatment approach has historically been a pivotal consideration. The first option is limited by indications and potentially devastating complications in case of failure, whereas the second is widely accepted as the gold standard. Initially, the spacer was conceived solely to restore and maintain knee space after removal of the implant. An articulating spacer was introduced to mitigate patient limitations and improve knee function and quality of life. Two main types of articulating spacers are utilized in knee PJI treatment: the mold spacer and the metal-on-poly spacer. This text outlines a technique for metal-on-poly spacer implants. Based on our experience and the existing literature, this approach facilitates early full weight bearing and faster recovery of the knee\'s range of motion, ultimately improving the quality of life after surgery, thus allowing the spacer retention for an extended period, as suggested by the 1.5-stage revision.

OBJECTIVE: Septic arthritis (SA) is a rare but significant clinical challenge in orthopedics that can impact patients\' quality of life. This study aims to examine the clinical outcomes of patients undergoing two-stage total joint replacement (TJR) in hip and knee SA and analyze potential predictors of treatment failure.
METHODS: A retrospective analysis was conducted using data from a prospectively collected institutional arthroplasty registry from January 1st, 2012, to January 1st, 2019. Patients with hip or knee SA who underwent a two-stage TJR and had at least two years of follow-up were included. Demographic characteristics, surgical variables, and outcomes were collected and analyzed from clinical and surgical data. Statistical analysis was performed using IBM SPSS Statistics, with statistical significance at p < 0.05.
RESULTS: One hundred and fourteen patients (61 with hip SA, 53 with knee SA) were included in the study. The mean follow-up was 72.8 months. Postoperatively, both clinical and functional outcomes significantly improved, as indicated by the Hip Society Score (HHS) and Knee Society Score (KSS). The overall success rate of the two-stage protocol was 89.5%. Complications that did not require revision occurred in 21% of cases. The most identified pathogen was methicillin-sensitive Staphylococcus aureus (MSSA). Difficult-to-treat (DTT) infections and post-traumatic etiology were identified as predictors of treatment failure in patients undergoing two-stage TJR for hip and knee SA.
CONCLUSIONS: Two-stage TJR in hip and knee SA demonstrated favorable clinical outcomes at mid-term follow-up. The procedure significantly improved functional scores and achieved a high success rate, while DTT infections and post-traumatic etiology were associated with a higher risk of treatment failure.

BACKGROUND: Despite 2-stage revision being a common treatment for elbow prosthetic joint infection (PJI), failure rates are high. The purpose of this study was to report on a single institution\'s experience with 2-stage revisions for elbow PJI and determine risk factors for failed eradication of infection. The secondary purpose was to determine risk factors for needing allograft bone at the second stage of revision in the setting of compromised bone stock.
METHODS: We retrospectively analyzed all 2-stage revision total elbow arthroplasties (TEAs) performed for infection at a single institution between 2006 and 2020. Data collected included demographics and treatment course prior to, during, and after 2-stage revision. Radiographs obtained after explantation and operative reports were reviewed to evaluate for partial component retention and incomplete cement removal. The primary outcome was failed eradication of infection, defined as the need for repeat surgery to treat infection after the second-stage revision. The secondary outcome was the use of allograft for compromised bone stock during the second-stage revision. Risk factors for both outcomes were determined.
RESULTS: Nineteen patients were included. Seven patients (37%) had either the humeral or ulnar component retained during the first stage, and 10 (53%) had incomplete removal of cement in either the humerus or ulna. Nine patients (47%) had allograft strut used during reimplantation and reconstruction. Nine patients (47%) failed to eradicate the infection after 2-stage revision. Demographic data were similar between the repeat-infection and nonrepeat-infection groups. Six patients (60%) with retained cement failed compared with 3 patients (33%) with full cement removal (P = .370). Two patients (29%) with a retained component failed compared to 7 patients (58%) with full component removal (P = .350). Allograft was used less frequently when a well-fixed component or cement was retained, with no patients with a retained component needing allograft compared to 9 with complete component removal (P = .003). Three patients (30%) with retained cement needed allograft, compared with 6 patients (67%) who had complete cement removal (P = .179).
CONCLUSIONS: Nearly half of the patients failed to eradicate infection after 2-stage revision. The data did not demonstrate a clear association between retained cement or implants and risk of recurrent infection. Allograft was used less frequently when a component and cement were retained, possibly serving as a proxy for decreased bone loss during the first stage of revision. Therefore, the unclear benefit of removing well-fixed components and cement need to be carefully considered as it likely leads to compromised bone stock that complicates the second stage of revision.