PLS-based soft-sensor to predict ammonium concentration evolution in hollow fibre membrane contactors for nitrogen recovery

[EN] Hollow fibre membrane contactors (HFMC) have emerged as a promising technology for nitrogen-recovery that can be implemented in wastewater treatment plants (WWTPs) to promote circular economy. In this process, a hydrophobic membrane allows the transference of free-ammonia across the hollow fibres. During its operation, the ammonium concentration decreases, and real-time measurements would be of great value for process monitoring, optimization and control. Ammonium probes exist, but they are expensive and present noticeably maintenance costs. In this work, results from eight N-recovery experiments performed at different pH values using real supernatant of a full-scale anaerobic digester were analysed in terms of the time-evolution profiles of pH and total ammonium nitrogen (TAN). The pH revealed to carry relevant information related to the TAN concentration, as it decreased in the feed solution due to free ammonia stripping. The pH is an inexpensive-to measure process variable that can be routinely acquired in any WWTP. Therefore, a data-driven soft-sensor has been developed. It uses the pH, its derivative, and the pH increments after each reagent dosing as input signals, to estimate the TAN concentration via PLS. An extended PLS-model incorporating interaction terms, quadratic and cubic forms of the three input variables improved the TAN concentration estimation. The developed soft-sensor was able to accurately reproduce the evolution of TAN concentration (in the range 0-1000 mgNH(4)(+)-N/L with R-2 > 0.97 and RMSE < 40 mg/L) during the HFMC process operation, thus making it possible to monitor the process as well as enabling future development of different control and optimization strategies.This research was financially supported by the Spanish Ministry of Economy and Competitiveness (MINECO projects CTM2014-54980-C2-1/2-R and CTM2017-86751-C2-1/2-R) with the European Regional Development Fund (ERDF) as well as the Universitat Polite`cnica de Vale`ncia via a pre-doctoral FPI fellowship to Guillermo Noriega.Aguado García, D.; Noriega-Hevia, G.; Ferrer, J.; Seco, A.; Serralta Sevilla, J. (2022). PLS-based soft-sensor to predict ammonium concentration evolution in hollow fibre membrane contactors for nitrogen recovery. Journal of Water Process Engineering. 47:1-7. https://doi.org/10.1016/j.jwpe.2022.102735174

Plant-wide modelling in wastewater treatment: showcasing experiences using the Biological Nutrient Removal Model

[EN] Plant-wide modelling can be considered an appropriate approach to represent the current complexity in water resource recovery facilities, reproducing all known phenomena in the different process units. Nonetheless, novel processes and new treatment schemes are still being developed and need to be fully incorporated in these models. This work presents a short chronological overview of some of the most relevant plant-wide models for wastewater treatment, as well as the authors' experience in plant-wide modelling using the general model BNRM (Biological Nutrient Removal Model), illustrating the key role of general models (also known as supermodels) in the field of wastewater treatment, both for engineering and research.Seco, A.; Ruano, MV.; Ruiz-Martínez, A.; Robles Martínez, Á.; Barat, R.; Serralta Sevilla, J.; Ferrer, J. (2020). Plant-wide modelling in wastewater treatment: showcasing experiences using the Biological Nutrient Removal Model. Water Science & Technology. 81(8):1700-1714. https://doi.org/10.2166/wst.2020.056S17001714818Barat, R., Montoya, T., Seco, A., & Ferrer, J. (2011). Modelling biological and chemically induced precipitation of calcium phosphate in enhanced biological phosphorus removal systems. Water Research, 45(12), 3744-3752. doi:10.1016/j.watres.2011.04.028Barat, R., Serralta, J., Ruano, M. V., Jiménez, E., Ribes, J., Seco, A., & Ferrer, J. (2013). Biological Nutrient Removal Model No. 2 (BNRM2): a general model for wastewater treatment plants. Water Science and Technology, 67(7), 1481-1489. doi:10.2166/wst.2013.004Batstone, D. J., Hülsen, T., Mehta, C. M., & Keller, J. (2015). Platforms for energy and nutrient recovery from domestic wastewater: A review. Chemosphere, 140, 2-11. doi:10.1016/j.chemosphere.2014.10.021Borrás F. L. 2008 Técnicas microbiológicas aplicadas a la identificación y cuantificación de organismos presentes en sistemas EBPR (Microbiological Techniques Applied to Identification and Quantification of Organisms Present in EBPR Systems). PhD Thesis, Universitat Politècnica de València, Valencia, Spain.Claros, J., Jiménez, E., Aguado, D., Ferrer, J., Seco, A., & Serralta, J. (2013). Effect of pH and HNO2 concentration on the activity of ammonia-oxidizing bacteria in a partial nitritation reactor. Water Science and Technology, 67(11), 2587-2594. doi:10.2166/wst.2013.132Copp, J. B., Jeppsson, U., & Rosen, C. (2003). TOWARDS AN ASM1 – ADM1 STATE VARIABLE INTERFACE FOR PLANT-WIDE WASTEWATER TREATMENT MODELING. Proceedings of the Water Environment Federation, 2003(7), 498-510. doi:10.2175/193864703784641207Dorofeev, A. G., Nikolaev, Y. A., Kozlov, M. N., Kevbrina, M. V., Agarev, A. M., Kallistova, A. Y., & Pimenov, N. V. (2017). Modeling of anammox process with the biowin software suite. Applied Biochemistry and Microbiology, 53(1), 78-84. doi:10.1134/s0003683817010100Drewnowski, J., Zaborowska, E., & Hernandez De Vega, C. (2018). Computer Simulation in Predicting Biochemical Processes and Energy Balance at WWTPs. E3S Web of Conferences, 30, 03007. doi:10.1051/e3sconf/20183003007Durán F. 2013 Modelación matemática del tratamiento anaerobio de aguas residuales urbanas incluyendo las bacterias sulfatorreductoras. Aplicación a un biorreactor anaerobio de membranas (Mathematical Model of Urban Wastewater Anaerobic Treatment Including Sulphate Reducing Bacteria. Application to an Anaerobic Membrane Bioreactor). PhD Thesis, Universitat Politècnica de València, Valencia, Spain.Ekama, G. A. (2009). Using bioprocess stoichiometry to build a plant-wide mass balance based steady-state WWTP model. Water Research, 43(8), 2101-2120. doi:10.1016/j.watres.2009.01.036EPA 2006 User's manual version 4.03 2006. Available from: https://www.epa.gov/ceam/minteqa2-equilibrium-speciation-model (accessed July 2019).Fernández-Arévalo, T., Lizarralde, I., Fdz-Polanco, F., Pérez-Elvira, S. I., Garrido, J. M., Puig, S., … Ayesa, E. (2017). Quantitative assessment of energy and resource recovery in wastewater treatment plants based on plant-wide simulations. Water Research, 118, 272-288. doi:10.1016/j.watres.2017.04.001Ferrer, J., Seco, A., Serralta, J., Ribes, J., Manga, J., Asensi, E., … Llavador, F. (2008). DESASS: A software tool for designing, simulating and optimising WWTPs. Environmental Modelling & Software, 23(1), 19-26. doi:10.1016/j.envsoft.2007.04.005Ferrer J., Seco A., Ruano M. V., Ribes J., Serralta J., Gómez T., Robles A. 2011 LoDif BioControl® Control Software, Intellectual Property. Main Institution: Universitat de València; Universitat Politècnica de València.Flores-Alsina, X., Corominas, L., Snip, L., & Vanrolleghem, P. A. (2011). Including greenhouse gas emissions during benchmarking of wastewater treatment plant control strategies. Water Research, 45(16), 4700-4710. doi:10.1016/j.watres.2011.04.040Flores-Alsina, X., Arnell, M., Amerlinck, Y., Corominas, L., Gernaey, K. V., Guo, L., … Jeppsson, U. (2014). Balancing effluent quality, economic cost and greenhouse gas emissions during the evaluation of (plant-wide) control/operational strategies in WWTPs. Science of The Total Environment, 466-467, 616-624. doi:10.1016/j.scitotenv.2013.07.046Flores-Alsina, X., Kazadi Mbamba, C., Solon, K., Vrecko, D., Tait, S., Batstone, D. J., … Gernaey, K. V. (2015). A plant-wide aqueous phase chemistry module describing pH variations and ion speciation/pairing in wastewater treatment process models. Water Research, 85, 255-265. doi:10.1016/j.watres.2015.07.014Ge, Z. (2017). Review on data-driven modeling and monitoring for plant-wide industrial processes. Chemometrics and Intelligent Laboratory Systems, 171, 16-25. doi:10.1016/j.chemolab.2017.09.021Grau, P., de Gracia, M., Vanrolleghem, P. A., & Ayesa, E. (2007). A new plant-wide modelling methodology for WWTPs. Water Research, 41(19), 4357-4372. doi:10.1016/j.watres.2007.06.019Grau, P., Copp, J., Vanrolleghem, P. A., Takács, I., & Ayesa, E. (2009). A comparative analysis of different approaches for integrated WWTP modelling. Water Science and Technology, 59(1), 141-147. doi:10.2166/wst.2009.589Henze M., Gujer W., Mino T., van Loosdrecht M. C. M. 2000 Activated Sludge Models ASM1, ASM2, ASM2d and ASM3. IWA Scientific and Technical Report No.9. IWA Publishing, London, UK.Jeppsson, U., & Pons, M.-N. (2004). The COST benchmark simulation model—current state and future perspective. Control Engineering Practice, 12(3), 299-304. doi:10.1016/j.conengprac.2003.07.001Jeppsson, U., Rosen, C., Alex, J., Copp, J., Gernaey, K. V., Pons, M.-N., & Vanrolleghem, P. A. (2006). Towards a benchmark simulation model for plant-wide control strategy performance evaluation of WWTPs. Water Science and Technology, 53(1), 287-295. doi:10.2166/wst.2006.031Ji, X., Liu, Y., Zhang, J., Huang, D., Zhou, P., & Zheng, Z. (2018). Development of model simulation based on BioWin and dynamic analyses on advanced nitrate nitrogen removal in deep bed denitrification filter. Bioprocess and Biosystems Engineering, 42(2), 199-212. doi:10.1007/s00449-018-2025-xJiménez, E., Giménez, J. B., Ruano, M. V., Ferrer, J., & Serralta, J. (2011). Effect of pH and nitrite concentration on nitrite oxidation rate. Bioresource Technology, 102(19), 8741-8747. doi:10.1016/j.biortech.2011.07.092Jiménez, E., Giménez, J. B., Seco, A., Ferrer, J., & Serralta, J. (2012). Effect of pH, substrate and free nitrous acid concentrations on ammonium oxidation rate. Bioresource Technology, 124, 478-484. doi:10.1016/j.biortech.2012.07.079Kazadi Mbamba, C., Flores-Alsina, X., John Batstone, D., & Tait, S. (2016). Validation of a plant-wide phosphorus modelling approach with minerals precipitation in a full-scale WWTP. Water Research, 100, 169-183. doi:10.1016/j.watres.2016.05.003Kazadi Mbamba, C., Lindblom, E., Flores-Alsina, X., Tait, S., Anderson, S., Saagi, R., … Jeppsson, U. (2019). Plant-wide model-based analysis of iron dosage strategies for chemical phosphorus removal in wastewater treatment systems. Water Research, 155, 12-25. doi:10.1016/j.watres.2019.01.048Liu, Y., Peng, L., Ngo, H. H., Guo, W., Wang, D., Pan, Y., … Ni, B.-J. (2016). Evaluation of Nitrous Oxide Emission from Sulfide- and Sulfur-Based Autotrophic Denitrification Processes. Environmental Science & Technology, 50(17), 9407-9415. doi:10.1021/acs.est.6b02202Lizarralde, I., Fernández-Arévalo, T., Brouckaert, C., Vanrolleghem, P., Ikumi, D. S., Ekama, G. A., … Grau, P. (2015). A new general methodology for incorporating physico-chemical transformations into multi-phase wastewater treatment process models. Water Research, 74, 239-256. doi:10.1016/j.watres.2015.01.031Lizarralde, I., Fernández-Arévalo, T., Manas, A., Ayesa, E., & Grau, P. (2019). Model-based opti mization of phosphorus management strategies in Sur WWTP, Madrid. Water Research, 153, 39-52. doi:10.1016/j.watres.2018.12.056Maere, T., Verrecht, B., Moerenhout, S., Judd, S., & Nopens, I. (2011). BSM-MBR: A benchmark simulation model to compare control and operational strategies for membrane bioreactors. Water Research, 45(6), 2181-2190. doi:10.1016/j.watres.2011.01.006Mannina, G., Ekama, G., Caniani, D., Cosenza, A., Esposito, G., Gori, R., … Olsson, G. (2016). Greenhouse gases from wastewater treatment — A review of modelling tools. Science of The Total Environment, 551-552, 254-270. doi:10.1016/j.scitotenv.2016.01.163Martí, N., Barat, R., Seco, A., Pastor, L., & Bouzas, A. (2017). Sludge management modeling to enhance P-recovery as struvite in wastewater treatment plants. Journal of Environmental Management, 196, 340-346. doi:10.1016/j.jenvman.2016.12.074Moretti, P., Choubert, J.-M., Canler, J.-P., Buffière, P., Pétrimaux, O., & Lessard, P. (2017). Dynamic modeling of nitrogen removal for a three-stage integrated fixed-film activated sludge process treating municipal wastewater. Bioprocess and Biosystems Engineering, 41(2), 237-247. doi:10.1007/s00449-017-1862-3Nagy, J., Kaljunen, J., & Toth, A. J. (2019). Nitrogen recovery from wastewater and human urine with hydrophobic gas separation membrane: experiments and modelling. Chemical Papers, 73(8), 1903-1915. doi:10.1007/s11696-019-00740-xNewhart, K. B., Holloway, R. W., Hering, A. S., & Cath, T. Y. (2019). Data-driven performance analyses of wastewater treatment plants: A review. Water Research, 157, 498-513. doi:10.1016/j.watres.2019.03.030Nopens, I., Batstone, D. J., Copp, J. B., Jeppsson, U., Volcke, E., Alex, J., & Vanrolleghem, P. A. (2009). An ASM/ADM model interface for dynamic plant-wide simulation. Water Research, 43(7), 1913-1923. doi:10.1016/j.watres.2009.01.012Nopens, I., Benedetti, L., Jeppsson, U., Pons, M.-N., Alex, J., Copp, J. B., … Vanrolleghem, P. A. (2010). Benchmark Simulation Model No 2: finalisation of plant layout and default control strategy. Water Science and Technology, 62(9), 1967-1974. doi:10.2166/wst.2010.044Ontiveros, G. A., & Campanella, E. A. (2013). Environmental performance of biological nutrient removal processes from a life cycle perspective. Bioresource Technology, 150, 506-512. doi:10.1016/j.biortech.2013.08.059Penya-Roja, J. M., Seco, A., Ferrer, J., & Serralta, J. (2002). Calibration and Validation of Activated Sludge Model No.2d for Spanish Municipal Wastewater. Environmental Technology, 23(8), 849-862. doi:10.1080/09593332308618360Pretel, R., Robles, A., Ruano, M. V., Seco, A., & Ferrer, J. (2016). A plant-wide energy model for wastewater treatment plants: application to anaerobic membrane bioreactor technology. Environmental Technology, 37(18), 2298-2315. doi:10.1080/09593330.2016.1148903Pretel, R., Robles, A., Ruano, M. V., Seco, A., & Ferrer, J. (2016). Economic and environmental sustainability of submerged anaerobic MBR-based (AnMBR-based) technology as compared to aerobic-based technologies for moderate-/high-loaded urban wastewater treatment. Journal of Environmental Management, 166, 45-54. doi:10.1016/j.jenvman.2015.10.004Rehman, U., Audenaert, W., Amerlinck, Y., Maere, T., Arnaldos, M., & Nopens, I. (2017). How well-mixed is well mixed? Hydrodynamic-biokinetic model integration in an aerated tank of a full-scale water resource recovery facility. Water Science and Technology, 76(8), 1950-1965. doi:10.2166/wst.2017.330Rieger L., Gillot S., Langergraber G., Ohtsuki T., Shaw A., Takacs I., Winkler S. 2012 Guidelines for Using Activated Sludge Models Scientific and Technical report No. 21. EWA Task Group on Good Modelling Practice. IWA Publishing Volume 11.Robles, A., Ruano, M. V., Ribes, J., Seco, A., & Ferrer, J. (2014). Model-based automatic tuning of a filtration control system for submerged anaerobic membrane bioreactors (AnMBR). Journal of Membrane Science, 465, 14-26. doi:10.1016/j.memsci.2014.04.012Robles, A., Capson-Tojo, G., Ruano, M. V., Seco, A., & Ferrer, J. (2018). Real-time optimization of the key filtration parameters in an AnMBR: Urban wastewater mono-digestion vs. co-digestion with domestic food waste. Waste Management, 80, 299-309. doi:10.1016/j.wasman.2018.09.031Ruano, M. V., Serralta, J., Ribes, J., Garcia-Usach, F., Bouzas, A., Barat, R., … Ferrer, J. (2012). Application of the general model ‘Biological Nutrient Removal Model No. 1’ to upgrade two full-scale WWTPs. Environmental Technology, 33(9), 1005-1012. doi:10.1080/09593330.2011.604877Seco, A., Ribes, J., Serralta, J., & Ferrer, J. (2004). Biological nutrient removal model No.1 (BNRM1). Water Science and Technology, 50(6), 69-70. doi:10.2166/wst.2004.0361Serralta, J., Ferrer, J., Borrás, L., & Seco, A. (2004). An extension of ASM2d including pH calculation. Water Research, 38(19), 4029-4038. doi:10.1016/j.watres.2004.07.009Shoener, B. D., Schramm, S. M., Béline, F., Bernard, O., Martínez, C., Plósz, B. G., … Guest, J. S. (2019). Microalgae and cyanobacteria modeling in water resource recovery facilities: A critical review. Water Research X, 2, 100024. doi:10.1016/j.wroa.2018.100024Solon, K., Flores-Alsina, X., Kazadi Mbamba, C., Ikumi, D., Volcke, E. I. P., Vaneeckhaute, C., … Jeppsson, U. (2017). 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Real-time control strategy for nitrogen removal via nitrite in a SHARON reactor using pH and ORP sensors

This paper presents a real-time control strategy for nitrogen removal via nitrite in a continuous flow SHARON reactor using on-line available and industrially feasible sensors (pH and ORP). The developed control strategy optimizes the length of aerobic and anoxic phases as well as the external carbon source addition. This strategy, implemented in a laboratory-scale SHARON reactor fed with synthetic wastewater and real dewatering sludge supernatant, was able to cope with step variations in influent flow rate and ammonium concentration. The main advantages of this control strategy over the traditional operation mode with fixed carbon source dosification and fixed length cycle operation were: better effluent quality (ammonia concentration decreased from 12 to 2 mg NH4–N L−1 and nitrogen removal efficiency raised from 95% to 98%) as result of the shorter cycle length: 2.9 h versus 4.0 h, and savings in external carbon addition: 1332 mg COD d−1 versus 2100 mg COD d−1.Financial support from MCYT (project CTM2005-06919-C03/TECN), Generalitat Valenciana (ACOMP06/144), and Universidad Politecnica de Valencia (UPV-FPI grant 2008-11 and PAID-06-06) are gratefully acknowledged.Claros Bedoya, JA.; Serralta Sevilla, J.; Seco Torrecillas, A.; Ferrer, J.; Aguado García, D. (2012). Real-time control strategy for nitrogen removal via nitrite in a SHARON reactor using pH and ORP sensors. Process Biochemistry. 47:1510-1515. https://doi.org/10.1016/j.procbio.2012.05.020S151015154

Behavior of mixed Chlorophyceae cultures under prolonged dark exposure. Respiration rate modeling

[EN] The behavior of three different microalgal cultures, when exposed for a long period (>48 h) to dark conditions, was studied with a methodology based on respirometry. The cultures were transferred to darkness and the oxygen evolution in the reactors was monitored after successive air injections. Several sequential oxygen uptake rates were thus calculated and a respiration constant, assuming a first order decay of a fraction of the biomass, was obtained by calibration. Initial specific oxygen uptake rates were in the range of 0.9 5.1 mg O2 g TSS&#8722;1 h&#8722;1 and dark respiration constants in the range of 0.005 0.018 h&#8722;1.This research work has been supported by the Spanish Ministry of Economy and Competitiveness (MINECO, CTM2011-28595-C02- 01/02) jointly with the European Regional Development Fund (ERDF) which are gratefully acknowledged. This research was also supported by the Spanish Ministry of Science and Innovation via a pre doctoral FPU fellowship to the first author (AP2009-4903). The authors would also like to thank the water management entities of the Generalitat Valenciana (EPSAR).Ruiz Martínez, A.; Serralta Sevilla, J.; Seco Torrecillas, A.; Ferrer, J. (2016). Behavior of mixed Chlorophyceae cultures under prolonged dark exposure. Respiration rate modeling. Ecological Engineering. 91:265-269. https://doi.org/10.1016/j.ecoleng.2016.02.025S2652699

Potential use of the organic fraction of municipal solid waste in anaerobic co-digestion with wastewater in submerged anaerobic membrane technology

Food waste was characterized for its potential use as substrate for anaerobic co-digestion in a submerged anaerobic membrane bioreactor pilot plant that treats urban wastewater (WW). 90% of the particles had sizes under 0.5 mm after grinding the food waste in a commercial food waste disposer. COD, nitrogen and phosphorus concentrations were 100, 2 and 20 times higher in food waste than their average concentrations in WW, but the relative flow contribution of both streams made COD the only pollutant that increased significantly when both substrates were mixed. As sulphate concentration in food waste was in the same range as WW, co-digestion of both substrates would increase the COD/SO4-S ratio and favour methanogenic activity in anaerobic treatments. The average methane potential of the food waste was 421 +/- 15 mL CH4 g(-1) VS, achieving 73% anaerobic biodegradability. The anaerobic co-digestion of food waste with WW is expected to increase methane production 2.9-fold. The settleable solids tests and the particle size distribution analyses confirmed that both treatment lines of a conventional WWTP (water and sludge lines) would be clearly impacted,by the incorporation of food waste into its influent. Anaerobic processes are therefore preferred over their aerobic counterparts due to their ability to valorise the high COD content to produce biogas (a renewable energy) instead of increasing the energetic costs associated with the aeration process for aerobic COD oxidation. (C) 2016 Elsevier Ltd. All rights reserved.This research work was possible thanks to financial support from the Generalitat Valenciana (project PROMETEO/2012/029) which is gratefully acknowledged.Moñino Amorós, P.; Jiménez Douglas, E.; Barat Baviera, R.; Aguado García, D.; Seco Torrecillas, A.; Ferrer, J. (2016). Potential use of the organic fraction of municipal solid waste in anaerobic co-digestion with wastewater in submerged anaerobic membrane technology. Waste Management. 56:158-165. https://doi.org/10.1016/j.wasman.2016.07.021S1581655

Acute cholecystitis – early laparoskopic surgery versus antibiotic therapy and delayed elective cholecystectomy: ACDC-study

<p>Abstract</p> <p>Background</p> <p>Acute cholecystitis occurs frequently in the elderly and in patients with gall stones. Most cases of severe or recurrent cholecystitis eventually require surgery, usually laparoscopic cholecystectomy in the Western World. It is unclear whether an initial, conservative approach with antibiotic and symptomatic therapy followed by delayed elective surgery would result in better morbidity and outcome than immediate surgery. At present, treatment is generally determined by whether the patient first sees a surgeon or a gastroenterologist. We wish to investigate whether both approaches are equivalent. The primary endpoint is the morbidity until day 75 after inclusion into the study.</p> <p>Design</p> <p>A multicenter, prospective, randomized non-blinded study to compare treatment outcome, complications and 75-day morbidity in patients with acute cholecystitis randomized to laparoscopic cholecystectomy within 24 hours of symptom onset or antibiotic treatment with moxifloxacin and subsequent elective cholecystectomy. For consistency in both arms moxifloxacin, a fluorquinolone with broad spectrum of activity and high bile concentration is used as antibiotic. Duration: October 2006 – November 2008</p> <p>Organisation/Responsibility</p> <p>The trial was planned and is being conducted and analysed by the Departments of Gastroenterology and General Surgery at the University Hospital of Heidelberg according to the ethical, regulatory and scientific principles governing clinical research as set out in the Declaration of Helsinki (1989) and the Good Clinical Practice guideline (GCP).</p> <p>Trial Registration</p> <p>ClinicalTrials.gov NCT00447304</p

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes

Objective To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). Methods and results Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm+ wet, 1929 (17.1%) cold+ wet, 675 (6.0%) warm+ dry, and 99 (0.9%) cold+ dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm+ wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm+ dry, the adjusted hazard ratios were significantly increased for cold+ wet (1.660; 95% confidence interval 1.400-1.968) and cold+ dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. Conclusions Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic