Fahmy's four quadrant sutures: a new technique for control of blood loss during cesarean delivery for placenta previa

Background: The objective of this study is to assess the efficacy and safety of Fahmy's four quadrant suture technique (FFQS) in controlling blood loss during cesarean delivery for placenta previa (PP).Methods: The study was carried out in a tertiary University Hospital between January 2017 to December 2017 involved 12 women with heavy bleeding occurred after removal of the placenta from the lower section during cesarean delivery for PP. The FFQS technique consisted of two sutures to ligate the uterine branches on both sides and two sutures on the anterior and posterior wall of the lower uterine segment. Details regarding the management and maternal outcomes were recorded.Results: The mean age of the study participants was 29.58±5.29 years and the mean parity was 2.25±1.14. The mean gestational age at termination of pregnancy was 36.91±1.38 weeks.  The mean duration of the whole surgery was 78.75±43.28 minutes, while the mean duration of FFQS technique was only 10±2.09 minutes. The technique was exclusively effective in 8 out of 12 cases (66.67%) while 2 cases needed bilateral internal iliac artery ligation and 2 cases needed hysterectomy. The mean amount of blood loss in all cases was 2433.33±833.76 ml. the mean amount of transfused packed RBCs was 3.92±1.68 units and fresh frozen plasma (FFP) was 3.42±1.44 units. All cases had uneventful postoperative course and no mortality cases in present series.Conclusions: The new technique; FFQS represents a rapid, effective, and inexpensive opportunity for women with bleeding from the lower segment of uterus due to PP. This simple procedure should be attempted before other complex measures to achieve good hemostasis

TRA-954: SOLUTION MODEL FOR URBAN TRAFFIC CONGESTION: EGYPTIAN CASE STUDY

Traffic congestion is a major problem in many cities around the world resulting in massive delays, increased fuel wastage, environmental impact and other negative consequences affecting the daily life of each individual. From a transportation engineering point of view, making the correct decision to eliminate such congestion problems can be very difficult for decision-makers who carry the burden of analyzing large quantities of data which could be vague and conflicting in nature. Therefore, an effective and consistent system is required to simplify the decision-making process of the traffic congestion control. Traffic simulation could be that tool. The seriousness of traffic congestion in Egypt is the main motive for the study presented herein. The study aims at developing a model that sets guidelines on how to approach an urban congested traffic area, be able to tackle the problem and choose the effective engineering solution in terms of either geometry and/or structure. Sectors of El Nasr Road, Cairo with a total length of 2.4 km is chosen as a typical example of an urban area with traffic congestion hotspots. It serves as an excellent location to implement the traffic solution model on. The model is developed and implemented as follows: collection of traffic data, diagnosis of the congestion problems in terms of social, commercial, cultural, and behavioral aspects. The analysis of the data finger points out the flag areas by conducting total and peak traffic volume counts, simulation of the existing traffic conditions to get the delayed travel times of vehicles in that area. The analysis of the output would finally help decide whether such problem would be solved by geometric adjustments of the surface or the problem requires a multi-layered intersection

MAT-725: SELF LEVELING MORTAR: WHY AND HOW?

Concrete floors can develop faults over time which can cause damage thus hindering smooth transportation, industrial aspects and some residential drawbacks. In addition, flaws and cracks are known to progress into more serious damage with time and use. Self leveling mortar has been used on a relatively limited scale worldwide to allow for more even, higher performance and easy-to-apply flooring. However, there has been little information available with respect to their use and best practices. The primary focus of this work is to prepare mortar that possesses self-levelling flow characteristics. Hence, several mixtures have been designed using various constituents with moderate 28-day strength of 35 MPa. Chemical and mineral admixtures have been incorporated together with limestone to enhance the flow and cohesiveness as well as improve performance. The results reveal that self-levelling mortar can be successfully produced with comparable properties to ready-to-use market product. These mixtures were evaluated to have both performance and economic merits

MAT-724: LOW ENERGY CONCRETE

The escalating demand on energy consumption as well as the scarcity of non renewable energy resources represents a major concern worldwide. Hence, efforts are being exerted to resort to lower energy alternatives in almost all aspects of life. Portland cement concrete has been known as an energy intensive material that emits large amount of CO2 during its various stages of manufacturing. While concrete has been classified over the decades based on its performance, it has seldom been assessed and evaluated based on its embodied energy. This work aims at evaluating concrete mixtures based on energy and CO2 emission together with strength and durability characteristics. Alternative mixtures were targeted for both normal as well as moderate strength concrete as ones potentially having less energy and less CO2. The results were used to establish a simplified user-friendly model for this process. Results reveal that concrete that is somewhat environmental-friendly can be prepared while fulfilling performance criteria and at a relatively less cost

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Development of Interaction Diagram for Eccentrically Loaded RC Sandwich Walls with Different Design Parameters

Sandwich sections have a very complex nature due to variability of behavior of different materials within the section. Cracking, crushing and yielding capacity of constituent materials enforces high complexity of the section. Furthermore, slippage between the different layers adds to the section complex behavior. Conventional methods implemented in current industrial guidelines do not account for the above complexities. Thus, a throughout study is needed to understand the true behavior of the sandwich panels thus, increase the ability to use them effectively and efficiently. The purpose of this paper is to conduct numerical investigation using ANSYS software for the structural behavior of sandwich wall section under eccentric loading. Sandwich walls studied herein are composed of two RC faces, a foam core and linking shear connectors. Faces are modeled using solid elements and reinforcement together with connectors are modeled using link elements. The analysis conducted herein is nonlinear static analysis incorporating material nonlinearity, crashing and crushing of concrete and yielding of steel. The model is validated by comparing it to test results in literature. After validation, the model is used to establish extensive parametric analysis to investigate the effect of three key parameters on the axial force bending moment interaction diagram of the walls. These parameters are the concrete compressive strength, face thickness and number of shear connectors. Furthermore, the results of the parametric study are used to predict a coefficient that links the interaction diagram of a solid wall to that of a sandwich wall. The equation is predicted using the parametric study data and regression analysis. The predicted ? was used to construct the interaction diagram of the investigated wall and the results were compared with ANSYS results and showed good agreement

A method for performance-based seismic design of reinforced concrete frame buildings

© 2019 The authors. A method for preliminary design of reinforced-concrete frames to satisfy predefined performance objectives is developed. It is directly based on performance targets and therefore fits in the context of emerging next-generation performance-based engineering. The key objective of the proposed method is achieving designs that are more reliable in meeting the targeted performance so that subsequent performance assessment iterations are minimized, while at the same time maintaining traditional design formats. The procedure is an adaptation of the force-based design where a force-reduction factor is still used; however, its value is calculated based on displacement parameters that are estimated at the initial design stage. Extensive parametric studies encompassing the inelastic response of regular moment-resisting frames to several ground motion records are performed, employing hundreds of nonlinear time-history analyses where the seismic records are scaled to different intensities to drive the structures to different levels of inelastic excursion. By conducting statistical analysis of the created response databank, a mathematical expression that relates the maximum displacement to some geometrical factors as well as a performance and damage metrics can be developed, while being independent of the frame section dimensions, such that it can be used at the initial stage of design. Using this estimate of maximum displacement, designers can calculate approximate values of force-reduction factors that are well correlated to performance, and then design can proceed in the conventional way