Core outcome set for pulmonary rehabilitation of patients with COPD: results of a modified Delphi survey.

INTRODUCTION: There is high heterogeneity of outcomes and measures reported in pulmonary rehabilitation (PR) trials of people with chronic obstructive pulmonary disease (COPD). This hinders study comparability and benchmarking of PR. We have developed a core outcome set (COS) to overcome these challenges. METHODS: This study was informed by a systematic review and two qualitative studies and had patient involvement since its inception. A two-round Delphi survey was available in seven languages. Outcomes (n=63) scored 7-9 (crucial) by ≥70% of the participants and 1-3 (not that important) by ≤15% of participants from both groups in the Likert scale were automatically included in the COS, while outcomes that were considered crucial by only one of the groups were further discussed by the authors in a meeting. RESULTS: A total of 299 people (n=229 healthcare professionals/researchers/policy-makers; n=70 people with COPD and informal caregivers) participated in the survey (83% retention), which covered 29 countries/five continents. After the second round, six outcomes were included and three were added in the meeting. The final COS contains dyspnoea, fatigue, functional exercise capacity, health-related quality of life, health behaviours/lifestyle, knowledge about the disease, lower limb muscle function, personal goals and problematic activities of daily living. CONCLUSION: A COS for PR of people with COPD is now available and can be used by different stakeholders to improve consistency and comparability of studies, benchmark PR and improve the quality of care provided. Future research should establish the core measures and investigate the uptake of this COS.

Mobilizing Patient and Public Involvement in the Development of Real-World Digital Technology Solutions: Tutorial.

Although the value of patient and public involvement and engagement (PPIE) activities in the development of new interventions and tools is well known, little guidance exists on how to perform these activities in a meaningful way. This is particularly true within large research consortia that target multiple objectives, include multiple patient groups, and work across many countries. Without clear guidance, there is a risk that PPIE may not capture patient opinions and needs correctly, thereby reducing the usefulness and effectiveness of new tools. Mobilise-D is an example of a large research consortium that aims to develop new digital outcome measures for real-world walking in 4 patient cohorts. Mobility is an important indicator of physical health. As such, there is potential clinical value in being able to accurately measure a person's mobility in their daily life environment to help researchers and clinicians better track changes and patterns in a person's daily life and activities. To achieve this, there is a need to create new ways of measuring walking. Recent advancements in digital technology help researchers meet this need. However, before any new measure can be used, researchers, health care professionals, and regulators need to know that the digital method is accurate and both accepted by and produces meaningful outcomes for patients and clinicians. Therefore, this paper outlines how PPIE structures were developed in the Mobilise-D consortium, providing details about the steps taken to implement PPIE, the experiences PPIE contributors had within this process, the lessons learned from the experiences, and recommendations for others who may want to do similar work in the future. The work outlined in this paper provided the Mobilise-D consortium with a foundation from which future PPIE tasks can be created and managed with clearly defined collaboration between researchers and patient representatives across Europe. This paper provides guidance on the work required to set up PPIE structures within a large consortium to promote and support the creation of meaningful and efficient PPIE related to the development of digital mobility outcomes.

ERS statement: a core outcome set for clinical trials evaluating the management of COPD exacerbations.

Clinical trials evaluating the management of acute exacerbations of COPD assess heterogeneous outcomes, often omitting those that are clinically relevant or more important to patients. We have developed a core outcome set, a consensus-based minimum set of important outcomes that we recommend are evaluated in all future clinical trials on exacerbations management, to improve their quality and comparability. COPD exacerbations outcomes were identified through methodological systematic reviews and qualitative interviews with 86 patients from 11 countries globally. The most critical outcomes were prioritised for inclusion in the core outcome set through a two-round Delphi survey completed by 1063 participants (256 patients, 488 health professionals and 319 clinical academics) from 88 countries in five continents. Two global, multi-stakeholder, virtual consensus meetings were conducted to 1) finalise the core outcome set and 2) prioritise a single measurement instrument to be used for evaluating each of the prioritised outcomes. Consensus was informed by rigorous methodological systematic reviews. The views of patients with COPD were accounted for at all stages of the project. Survival, treatment success, breathlessness, quality of life, activities of daily living, the need for a higher level of care, arterial blood gases, disease progression, future exacerbations and hospital admissions, treatment safety and adherence were all included in the core outcome set. Focused methodological research was recommended to further validate and optimise some of the selected measurement instruments. The panel did not consider the prioritised set of outcomes and associated measurement instruments to be burdensome for patients and health professionals to use.

Insights into solar photo-Fenton reaction parameters in the oxidation of a sanitary landfill leachate at lab-scale.

This work evaluates the effect of the main photo-Fenton (PF) reaction variables on the treatment of a sanitary landfill leachate collected at the outlet of a leachate treatment plant, which includes aerated lagooning followed by aerated activated sludge and a final coagulation-flocculation step. The PF experiments were performed in a lab-scale compound parabolic collector (CPC) photoreactor using artificial solar radiation. The photocatalytic reaction rate was determined while varying the total dissolved iron concentration (20-100 mg Fe(2+)/L), solution pH (2.0-3.6), operating temperature (10-50 °C), type of acid used for acidification (H2SO4, HCl and H2SO4 + HCl) and UV irradiance (22-68 W/m(2)). This work also tries to elucidate the role of ferric hydroxides, ferric sulphate and ferric chloride species, by taking advantage of ferric speciation diagrams, in the efficiency of the PF reaction when applied to leachate oxidation. The molar fraction of the most photoactive ferric species, FeOH(2+), was linearly correlated with the PF pseudo-first order kinetic constants obtained at different solution pH and temperature values. Ferric ion speciation diagrams also showed that the presence of high amounts of chloride ions negatively affected the PF reaction, due to the decrease of ferric ions solubility and scavenging of hydroxyl radicals for chlorine radical formation. The increment of the PF reaction rates with temperature was mainly associated with the increase of the molar fraction of FeOH(2+). The optimal parameters for the photo-Fenton reaction were: pH = 2.8 (acidification agent: H2SO4); T = 30 °C; [Fe(2+)] = 60 mg/L and UV irradiance = 44 WUV/m(2), achieving 72% mineralization after 25 kJUV/L of accumulated UV energy and 149 mM of H2O2 consumed.

Tracking pollutants in a municipal sewage network impairing the operation of a wastewater treatment plant.

This work provides a screening of organic contaminants and characterization of the dissolved organic matter in the sewer network until the municipal wastewater treatment plant (WWTP), identifying the network areas with a higher degree of contamination and their impact on the WWTP performance, particularly in the activated sludge reactor. Three monitoring campaigns were carried out at six selected locations of the sewage system (PVZ-1, PVZ-2, PS-F, PS-VC, CP-VC, and PS-T), influent (WWTPINF) and effluent (WWTPEFF) of the WWTP. Advanced analytical techniques were employed, namely excitation/emission matrix fluorescence-parallel factor analysis (EEM-PARAFAC), size exclusion chromatography with organic carbon detector (SEC-OCD), and liquid chromatography with high-resolution-mass spectrometric detection (LC-HRMS). EEM-PARAFAC showed higher fluorescence intensity for the protein-like component (C2), particularly at CP-VC (near seafood industries) associated with the presence of surfactants (~50 mg/L). SEC-OCD highlighted the WWTP efficiency in removing low molecular weight acids and neutrals. LC-HRMS tentatively identified 108 compounds of emerging concern (CEC) and similar detection patterns were obtained for all wastewater samples, except for PVZ-2 (lower detection), many of which occurred in the effluent. Eight CECs included on relevant Watch-Lists were detected in all WWTPEFF samples. Furthermore, 111 surfactants were detected, the classes more frequently found being alcohol ethoxylates (AEOs), nonylphenol polyethoxylates (NPEOs) and linear alkylbenzene sulphonates (LAS). The continuous presence of LAS and NPEOs allied to surfactants concentrations in the WWTPINF of 15-20 mg/L, with CP-VC location (linked with food industries) as an important contributor, explain the morphological changes in the activated sludge and high LAS content in the dewatered sludge, which may have impacted WWTP performance.

Discussing treatment burden.

Healthcare professionals should help patients to reach informed decisions about treatments in order to maximise benefits while minimising treatment burden https://bit.ly/2XRtRPK.

Women with COPD.

Health inequalities regarding gender are extremely prevalent, and specifically in conditions such as COPD. No woman should ever be dismissed in regard to their health and underlying medical history. https://bit.ly/2X7Klmd.

Core outcome set for the management of acute exacerbations of chronic obstructive pulmonary disease: the COS-AECOPD ERS Task Force study protocol.

Randomised controlled trials (RCTs) on the management of COPD exacerbations evaluate heterogeneous outcomes, often omitting those that are clinically important and patient relevant. This limits their usability and comparability. A core outcome set (COS) is a consensus-based minimum set of clinically important outcomes that should be evaluated in all RCTs in specific areas of health care. We present the study protocol of the COS-AECOPD ERS Task Force, aiming to develop a COS for COPD exacerbation management, that could remedy these limitations. For the development of this COS we follow standard methodology recommended by the COMET initiative. A comprehensive list of outcomes is assembled through a methodological systematic review of the outcomes reported in relevant RCTs. Qualitative research with patients with COPD will also be conducted, aiming to identify additional outcomes that may be important to patients, but are not currently addressed in clinical research studies. Prioritisation of the core outcomes will be facilitated through an extensive, multi-stakeholder Delphi survey with a global reach. Selection will be finalised in an international, multi-stakeholder meeting. For every core outcome, we will recommend a specific measurement instrument and standardised time points for evaluation. Selection of instruments will be based on evidence-informed consensus. Our work will improve the quality, usability and comparability of future RCTs on the management of COPD exacerbations and, ultimately, the care of patients with COPD. Multi-stakeholder engagement and societal support by the European Respiratory Society will raise awareness and promote implementation of the COS.

Why is medical oxygen a challenge for people travelling by air?

There are currently 3.5 million people in Europe who require medical oxygen, and as life expectancies increase, this figure is likely to grow. At the same time, air travel is becoming more accessible to a wider range of people, as costs of flights fall, and airlines and airports make improvements to the accessibility of their services. People who need medical oxygen to fly experience a wide range of difficulties when planning to travel by plane, and sometimes during or after the flight. A European Commission Regulation (EC No 1107/2006) sets the standard for airlines when it comes to making air travel accessible, but healthcare professionals and oxygen providers can both help patients to navigate the various requirements for using medical oxygen when travelling. In this review, we discuss the journey of the patient planning to travel by air, from initial consultation and fit-to-fly test, through to planning their air travel and oxygen supply, travelling, and arriving at their destination. We also highlight some common problems at each stage and suggest points for healthcare professionals to discuss with patients. KEY POINTS: Patients who require medical oxygen for air travel should begin planning their trip as far in advance as possible.It is very advantageous for healthcare professionals to be able to advise patients on travelling with oxygen and what they need to do.Requirements and policies can vary greatly between airlines, causing problems for patients who are trying to book their flights.Patients or their carers need to be confident operating their oxygen equipment, as the stress of travel and lack of medical assistance on an airplane can put them at risk.Careful arrangements need to be made by the patient to make sure that they have the correct oxygen therapy at their destination, and can access support if they need it. EDUCATIONAL AIMS: To understand the process and potential challenges for a patient who requires oxygen to travel by plane.To be confident in discussing air travel with patients who are affected by lung disease.

ERS Presidential Summit 2018: multimorbidities and the ageing population.

As the average age of the population increases, so will the prevalence of chronic respiratory diseases and associated multimorbidity. This will result in a more complex clinical environment. Part of the solution will be to allow patients to be co-creators in the design of their care. It will also require clinicians to shift in their current approaches to care, step out of the disease- or pathology-oriented approach and embrace new ideas. In an effort to prepare the respiratory community for the challenge, we reflect on concepts to empower patients via multidisciplinary systems, new technologies and transition from end-of-life care to advanced care planning.

What do patients know? Education from the European Lung Foundation perspective.

The European Lung Foundation (ELF) is an organisation whose mission is to bring together the public and patients with respiratory professionals to improve lung health. A core part of all its activities focus on education: the education of patients on their condition, including how to prevent, treat and manage it; the education of healthcare professionals on how to improve work with patients and awareness about the issues that are important to patients; and education of the public and policy makers of the importance of lung health at a European level. ELF was founded and works in a unique partnership with the European Respiratory Society (ERS). This article has been written by the recent past Chairs and the new Chairs of three ELF committees (Council (D. Smyth and I. Saraiva), Professional Advisory Committee (K. Lisspers and G. Hardavella) and Patient Advisory Committee (J. Fuertes and K. Hill)) in order to reflect on ELF's journey in this regard over recent years. In particular, it seems a good moment to assess the success and impact of the first patient Chair of ELF, Dan Smyth, and reflect on what this has meant for ELF's educational activities, and what the future now looks like. EDUCATIONAL AIMS: To understand the importance of educated patients (patients that are knowledgeable on their condition and how healthcare processes work).To understand the importance of guiding patients to quality reliable sources of information and education.To establish ways to ensure that healthcare professionals are prepared to work with educated patients.To outline the initiatives that ELF has driven forward in the field of education.To see the value in patients advocating at the European level for raising standards of education for patients and physicians.

An innovative multistage treatment system for sanitary landfill leachate depuration: Studies at pilot-scale.

In this work, an innovative methodology for the treatment of landfill leachates, after aerobic lagooning, is proposed and adjusted at pilot-scale. This methodology involves an aerobic activated sludge biological pre-oxidation (ASBO), a coagulation/sedimentation step (240mgFe3+/L, at pH4.2) and a photo-oxidation through a photo-Fenton (PF) reaction (60mg Fe2+, at pH2.8) combining solar and artificial light. The ASBO process applied to a leachate after aerobic lagooning, with high organic and nitrogen content (1.1-1.5gC/L; 0.8-3.0gN/L) and low biodegradability (BOD5/COD =0.07-0.13), is capable to oxidise 62-99% of the ammonium nitrogen, consuming only the affluent alkalinity (70-100%). The coagulation/sedimentation stage led to the humic acids precipitation, promoting a marked change in leachate colour, from dark-brown to yellowish-brown (related to fulvic acids), accompanied by a reduction of 60%, 58% and 88% on DOC, COD and TSS, respectively. The PF system promoted the degradation of the recalcitrant organic molecules into more easily biodegradable ones. According to Zahn-Wellens biodegradability test, a leachate with 419mg DOC/L after coagulation, would have to be photo-oxidized until DOC <256mg/L, consuming 117mM of H2O2 and 10.4kJ/L of accumulated UV energy, to achieve an effluent that can be biologically treated in compliance with the COD discharge limit (150mg O2/L) into water bodies. The biological process downstream from the photocatalytic system would promote a mineralization >60%. The PF step cost to treat 100m3/day of leachate was 6.41€/m3, combining 1339m2 of CPCs with 31 lamps.

Incorporation of electrochemical advanced oxidation processes in a multistage treatment system for sanitary landfill leachate.

The current study has proved the technical feasibility of including electrochemical advanced oxidation processes (EAOPs) in a multistage strategy for the remediation of a sanitary landfill leachate that embraced: (i) first biological treatment to remove the biodegradable organic fraction, oxidize ammonium and reduce alkalinity, (ii) coagulation of the bio-treated leachate to precipitate humic acids and particles, followed by separation of the clarified effluent, and (iii) oxidation of the resulting effluent by an EAOP to degrade the recalcitrant organic matter and increase its biodegradability so that a second biological process for removal of biodegradable organics and nitrogen content could be applied. The influence of current density on an UVA photoelectro-Fenton (PEF) process was firstly assessed. The oxidation ability of various EAOPs such as electro-Fenton (EF) with two distinct initial total dissolved iron concentrations ([TDI]0), PEF and solar PEF (SPEF) was further evaluated and these processes were compared with their analogous chemical ones. A detailed assessment of the two first treatment stages was made and the biodegradability enhancement during the SPEF process was determined by a Zahn-Wellens test to define the ideal organics oxidation state to stop the EAOP and apply the second biological treatment. The best current density was 200 mA cm(-2) for a PEF process using a BDD anode, [TDI]0 of 60 mg L(-1), pH 2.8 and 20 °C. The relative oxidation ability of EAOPs increased in the order EF with 12 mg [TDI]0 L(-1) < EF with 60 mg [TDI]0 L(-1) < PEF with 60 mg [TDI]0 L(-1) ≤ SPEF with 60 mg [TDI]0 L(-1), using the abovementioned conditions. While EF process was much superior to the Fenton one, the superiority of PEF over photo-Fenton was less evident and SPEF attained similar degradation to solar photo-Fenton. To provide a final dissolved organic carbon (DOC) of 163 mg L(-1) to fulfill the discharge limits into the environment after a second biological process, 6.2 kJ L(-1) UV energy and 36 kWh m(-3) electrical energy were consumed using SPEF with a BDD anode at 200 mA cm(-2), 60 mg [TDI]0 L(-1), pH 2.8 and 20 °C.

Biodegradability enhancement of a leachate after biological lagooning using a solar driven photo-Fenton reaction, and further combination with an activated sludge biological process, at pre-industrial scale.

This work proposes an integrated leachate treatment strategy, combining a solar photo-Fenton reaction, to enhance the biodegradability of the leachate from an aerated lagoon, with an activated sludge process, under aerobic and anoxic conditions, to achieve COD target values and nitrogen content according to the legislation. The efficiency and performance of the photo-Fenton reaction, concerning a sludge removal step after acidification, defining the optimum phototreatment time to reach a biodegradable wastewater that can be further oxidized in a biological reactor and, activation sludge biological process, defining the nitrification and denitrification reaction rates, alkalinity balance and methanol dose necessary as external carbon source, was evaluated in the integrated system at a scale close to industrial. The pre-industrial plant presents a photocatalytic system with 39.52 m(2) of compound parabolic collectors (CPCs) and 2 m(3) recirculation tank and, an activated sludge biological reactor with 3 m(3) capacity. Leachate biodegradability enhancement by means of a solar driven photo-Fenton process was evaluated using direct biodegradability tests, as Zahn-Wellens method, and indirect measure according to average oxidation state (AOS), low molecular carboxylic acids content (fast biodegradable character) and humic substances (recalcitrant character) concentration. Due to high variability of leachate composition, UV absorbance on-line measurement was established as a useful parameter for photo-Fenton reaction control.

Multistage treatment system for raw leachate from sanitary landfill combining biological nitrification-denitrification/solar photo-Fenton/biological processes, at a scale close to industrial--biodegradability enhancement and evolution profile of trace pollutants.

A multistage treatment system, at a scale close to the industrial, was designed for the treatment of a mature raw landfill leachate, including: a) an activated sludge biological oxidation (ASBO), under aerobic and anoxic conditions; b) a solar photo-Fenton process, enhancing the bio-treated leachate biodegradability, with and without sludge removal after acidification; and c) a final polishing step, with further ASBO. The raw leachate was characterized by a high concentration of humic substances (HS) (1211 mg CHS/L), representing 39% of the dissolved organic carbon (DOC) content, and a high nitrogen content, mainly in the form of ammonium nitrogen (>3.8 g NH4(+)-N/L). In the first biological oxidation step, a 95% removal of total nitrogen and a 39% mineralization in terms of DOC were achieved, remaining only the recalcitrant fraction, mainly attributed to HS (57% of DOC). Under aerobic conditions, the highest nitrification rate obtained was 8.2 mg NH4(+)-N/h/g of volatile suspended solids (VSS), and under anoxic conditions, the maximum denitrification rate obtained was 5.8 mg (NO2(-)-N + NO3(-)-N)/h/g VSS, with a C/N consumption ratio of 2.4 mg CH3OH/mg (NO2(-)-N + NO3(-)-N). The precipitation of humic acids (37% of HS) after acidification of the bio-treated leachate corresponds to a 96% DOC abatement. The amount of UV energy and H2O2 consumption during the photo-Fenton reaction was 30% higher in the experiment without sludge removal and, consequently, the reaction velocity was 30% lower. The phototreatment process led to the depletion of HS >80%, of low-molecular-weight carboxylate anions >70% and other organic micropollutants, thus resulting in a total biodegradability increase of >70%. The second biological oxidation allowed to obtain a final treated leachate in compliance with legal discharge limits regarding water bodies (with the exception of sulfate ions), considering the experiment without sludge. Finally, the high efficiency of the overall treatment process was further reinforced by the total removal percentages attained for the identified organic trace contaminants (>90%).

Treatment of a sanitary landfill leachate using combined solar photo-Fenton and biological immobilized biomass reactor at a pilot scale.

A solar photo-Fenton process combined with a biological nitrification and denitrification system is proposed for the decontamination of a landfill leachate in a pilot plant using photocatalytic (4.16 m(2) of Compound Parabolic Collectors - CPCs) and biological systems (immobilized biomass reactor). The optimum iron concentration for the photo-Fenton reaction of the leachate is 60 mg Fe(2+) L(-1). The organic carbon degradation follows a first-order reaction kinetics (k = 0.020 L kJ(UV)(-1), r(0) = 12.5 mg kJ(UV)(-1)) with a H(2)O(2) consumption rate of 3.0 mmol H(2)O(2) kJ(UV)(-1). Complete removal of ammonium, nitrates and nitrites of the photo-pre-treated leachate was achieved by biological denitrification and nitrification, after previous neutralization/sedimentation of iron sludge (40 mL of iron sludge per liter of photo-treated leachate after 3 h of sedimentation). The optimum C/N ratio obtained for the denitrification reaction was 2.8 mg CH(3)OH per mg N-NO(3)(-), consuming 7.9 g/8.2 mL of commercial methanol per liter of leachate. The maximum nitrification rate obtained was 68 mg N-NH(4)(+) per day, consuming 33 mmol (1.3 g) of NaOH per liter during nitrification and 27.5 mmol of H(2)SO(4) per liter during denitrification. The optimal phototreatment energy estimated to reach a biodegradable effluent, considering Zahn-Wellens, respirometry and biological oxidation tests, at pilot plant scale, is 29.2 kJ(UV) L(-1) (3.3 h of photo-Fenton at a constant solar UV power of 30 W m(-2)), consuming 90 mM of H(2)O(2) when used in excess, which means almost 57% mineralization of the leachate, 57% reduction of polyphenols concentration and 86% reduction of aromatic content.