Assessment of Post-Earthquake Damage: St. Salvatore Church in Acquapagana, Central Italy

This article proposes a multidisciplinary approach for the assessment of seismic damage from the perspective of conservation and prevention. A comparison of the state of damage has been carried out in a case study, St. Salvatore church in Acquapagana (MC), as an example of church, which underwent two important seismic events in the Central Italy area, the 1997 and the 2016 earthquakes. The comparison of the state of damage passes through the following stages: (a) the territorial seismic overview; (b) the historical description and material analysis; (c) the identification of macro-elements with activated damage mechanisms; (d) the comparison between the two seismic events both from a territorial-and building-scale perspective. This work puts together the archived and the on-site survey data with those elaborated starting from seismogenic information, available from the National Seismological Institute, and it provides a strategy also for other similar conditions. This work is to be considered a contribution to a wider study that could be carried out in the areas hit by the 2016 earthquake. It could also represent a way to collect documentation in the post-earthquake phase, improving the effectiveness of procedures currently applied to the first level of damage assessment

Diagnostic performance of Wells score combined with point-of-care lung and venous ultrasound in suspected pulmonary embolism

Objective: Lung and venous ultrasound are bedside diagnostic tools increasingly used in the early diagnostic approach of suspected pulmonary embolism (PE). However, the possibility of improving the conventional prediction rule for PE by integrating ultrasound has never been investigated. Methods: We performed lung and venous ultrasound in consecutive patients suspected of PE in four emergency departments. Conventional Wells score (Ws) was adjudicated by the attending physician, and ultrasound was performed by one of 20 investigators. Signs of deep venous thrombosis (DVT) at venous ultrasound and signs of pulmonary infarcts or alternative diagnoses at lung ultrasound were considered to recalculate two items of the Ws: signs and symptoms of DVT and alternative diagnosis less likely than PE. The diagnostic performances of the ultrasound-enhanced Ws (USWs) and Ws were then compared after confirmation of the final diagnosis. Results: A total of 446 patients were studied. PE was confirmed in 125 patients (28%). USWs performed significantly better than Ws, with a sensitivity of 69.6% versus 57.6% and a specificity of 88.2% versus 68.2%. In combination with D-dimer, USWs showed an optimal failure rate (0.8%) and a significantly superior efficiency than Ws (32.3% vs. 27.2%). A strategy based on lung and venous ultrasound combined with D-dimer would allow to avoid CT pulmonary angiography in 50.5% of patients with suspected PE, compared to 27.2% when the rule without ultrasound is applied. Conclusions: A pretest risk stratification enhanced by ultrasound of lung and venous performs better than Ws in the early diagnostic process of PE

Potentially harmful effects of inspiratory synchronization during pressure preset ventilation

Purpose: Pressure preset ventilation (PPV) modes with set inspiratory time can be classified according to their ability to synchronize pressure delivery with patient's inspiratory efforts (i-synchronization). Non-i-synchronized (like airway pressure release ventilation, APRV), partially i-synchronized (like biphasic airway pressure), and fully i-synchronized modes (like assist-pressure control) can be distinguished. Under identical ventilatory settings across PPV modes, the degree of i-synchronization may affect tidal volume (V T), transpulmonary pressure (P TP), and their variability. We performed bench and clinical studies. Methods: In the bench study, all the PPV modes of five ventilators were tested with an active lung simulator. Spontaneous efforts of −10cmH2O at rates of 20 and 30breaths/min were simulated. Ventilator settings were high pressure 30cmH2O, positive end-expiratory pressure (PEEP) 15cmH2O, frequency 15breaths/min, and inspiratory to expiratory ratios (I:E) 1:3 and 3:1. In the clinical studies, data from eight intubated patients suffering from acute respiratory distress syndrome (ARDS) and ventilated with APRV were compared to the bench tests. In four additional ARDS patients, each of the PPV modes was compared. Results: As the degree of i-synchronization among the different PPV modes increased, mean V T and P TP swings markedly increased while breathing variability decreased. This was consistent with clinical comparison in four ARDS patients. Observational results in eight ARDS patients show low V T and a high variability with APRV. Conclusion: Despite identical ventilator settings, the different PPV modes lead to substantial differences in V T, P TP, and breathing variability in the presence spontaneous efforts. Clinicians should be aware of the possible harmful effects of i-synchronization especially when high V T is undesirabl

POST-EARTHQUAKE DAMAGED CHURCHES: A TEMPORARY VALORISATION

Earthquakes periodically strike the Italian territory, which is scattered with churches. In the last decades, the L’Aquila 2009, the Emilia-Lombardy 2012, and the Central Italy 2016 earthquakes have confirmed the high seismic vulnerability of churches, due to intrinsic structural characteristics. Churches remain “crystallized” in a damage state at the specific moment the earthquake strikes them. This status could represent an opportunity for a temporary valorisation in the time lapse between the realization of provisional safety interventions and the moment when organization procedures are set, and funds are available for final retrofitting and restoration works. This article aims at proposing a possible temporary valorisation of damaged churches. Such an approach, including participative actions, is proposed as a driver for: increasing the sense of identity in a community, with churches as part of its cultural heritage asset, and encouraging a sustainable renewal of normal life in such territories

Seismic vulnerability of churches. First results of the study on three façade typologies

The series of seismic events which have struck the Italian territory have allowed the damage observation for different typologies of unreinforced masonry buildings. In particular, churches are constantly studied because of their high vulnerability observed in seismic prone areas. The façade is one of the most vulnerable structural units, called macro-elements. Up to date, three kinematic mechanisms (overturning of the façade, gable mechanism and in-plane mechanism) have been identified for damage and vulnerability assessment procedures. In this context, this work focuses on the analysis of three façade typologies diffused on the Italian territory. The aim is to evaluate the seismic response of three façade typologies, different for geometry and construction technique, in order to provide a contribution on their seismic vulnerability assessment. The study was performed through non-linear dynamic analyses, recurring to a model constituted of rigid elements connected by springs (RBSM: Rigid Body Spring Model). The RBS-model simulates the out-of-plane behavior and it considers the orthotropic nature of the masonry, assigning phenomenological elastic-plastic laws to the springs

Hic et nunc: churches and the 2016 earthquake in central italy; from the emergency to the potentiality for a temporary re-use. CHURCHES AND THE

Seismic events that hit our National territory with a relatively high frequency pose a threat to our Cultural Heritage, which is largely composed of churches. The earthquakes that have recently occurred in Central Italy –with its strongest strikes on August 24, October 26 and 30, 2016, and January 18, 2017– have left many damaged churches. These were "crystallized" at the instant when the earthquakes struck them. Until now, only provisional interventions for safety have been carried out, waiting for better conditions in the future, when organization procedures and financial supports can bring these heritage assets back to life. These churches are currently deprived of their essence, having lost, beyond their specific function, both their role of works of art and containers of works of art. In this specific period of transition, the community cannot benefit from these goods. Actually, even when their functional activities have been temporarily relocated to tents or emergency structures, it is impossible to enjoy the artistic and cultural values when access is restricted. Therefore, this period of interruption is determined by economic, administrative and logistic reasons. In recent times, "bottom-up" initiatives have been adopted to take care of several neglected heritage assets. Through participatory actions, these have sought to go beyond the normal valorization and restoration processes. The economic crisis and the ever-decreasing resources for interventions on Cultural Heritage, have surely influenced these activities, giving way to projects of temporary re-use. In this moment of post-earthquake emergency, where the normality is disrupted, the need of "reinventing” and “rethinking” may become a promoter of changes. To this regard, the work proposed here will present examples taken from other comparable situations. In this perspective, the post-earthquake emergency could become a potentiality for living Art and Architecture in this specific span of time in an unusual way. Situations like these can make a community feel and share unique emotions and, in many ways, they could help in the process of safeguard, conservation and valorization. Indeed, some forms of partial and controlled access could be possible thanks to provisional emergency interventions, allowing the appreciation of decorative or constructive elements that under normal conditions cannot be perceived from that perspective and with such attention. This makes the considered building a sort of temporary museum of itself. Moreover, impacting events like these enable us to experience an unrepeatable moment in the life of a heritage asset, that will, in the future, become part of its history, but that will certainly not be lived again. Hic et Nunc, as part of the title of this article, intends to emphasize precisely this aspect

Chiese nel terremoto del centro Italia: confronti e osservazioni

Nel patrimonio edilizio italiano le chiese manifestano un’alta vulnerabilità sismica legata alle loro caratteristiche costruttive, quali ampi spazi liberi, pareti di grandi dimensioni, grandi aperture e torri snelle; allo stesso tempo esse sono elementi preminenti di tale patrimonio per la loro importanza artistica, storica e sociale, oltreché religiosa, e per la loro numerosità sul territorio. Molte chiese hanno subito notevoli danni e in qualche caso situazioni di collasso esteso nei terremoti che si sono susseguiti in Italia negli ultimi decenni. Per la protezione di questo patrimonio lo studio dei danni subiti e dei criteri di riduzione della loro vulnerabilità ha concentrato notevole attenzione. Questo lavoro si basa su una serie di sopralluoghi ad edifici di culto danneggiati nel recente sisma del Centro Italia, 2016-17. I sopralluoghi sono stati condotti nella regione Marche in periodi diversi; alcuni si sono svolti agli inizi di ottobre 2016, prima degli eventi particolarmente intensi di fine mese che hanno presentato epicentri particolarmente prossimi alle zone già visitate. Una successiva visita nella stessa zona a primavera 2017 ha permesso di esaminare nuovi casi, ma anche osservare o conoscere la risposta di chiese già esaminate per le quali divenivano possibili considerazioni sull’evoluzione del danno. Questo aspetto è di particolare interesse, soprattutto considerando che alcuni di questi edifici erano stati oggetto di interventi di riparazione e miglioramento dopo il terremoto di Umbria-Marche del 1997 e che erano quindi possibili alcune osservazioni e comparazioni preliminari. L’analisi di queste situazioni richiederà ulteriori approfondimenti, tuttavia le osservazioni sul campo hanno permesso di fare alcune prime considerazioni anche relative agli interventi. Gli eventi successivi al primo sopralluogo hanno prodotto danni sulle strutture già indebolite sviluppando ulteriormente gli stessi meccanismi di danno già iniziati, in qualche caso con collassi locali. Alcuni interventi semplici e di limitato impatto si sono mostrati efficaci a evitare o limitare note tipologie di danno, che in alcuni casi si è sviluppato in altre posizioni presumibilmente elevando la soglia d’innesco

Are benzodiazepines and opioids really safe in patients with severe COPD?

Breathlessness is a key symptom in chronic obstructive pulmonary disease (COPD) with prognostic implications on health status and survival. Since most conditions underlying chronic refractory breathlessness in COPD are not modifiable, the use of opioids and benzodiazepines has been proposed to relieve it. However, respiratory depression is a known adverse event of these drugs, and concerns have been raised on their use in patients with chronic respiratory failure. Despite safety-related concerns, benzodiazepines are frequently prescribed for a variety of reasons, including treatment of insomnia, depression and anxiety, as well as to relieve refractory dyspnea in patients with COPD. The key role of opioids in the end-of-life and in the management of dyspnea that is unresponsive to best-possible disease management is recognized. Moreover, the use of low dose opioids to treat dyspnea, discomfort or refusal for patient undergoing non-invasive ventilation is still debated. In the current review, we aim at discussing and analyzing recently published findings on the use of benzodiazepines and opioids in patients with COPD and at reviewing the literature on this topic. Recent observations favor the use of lower doses of opioids (≤30 mg oral morphine equivalents/day) for reduction of symptoms in those patients with severe COPD receiving long-term oxygen therapy. Low dose opioids are not associated with an increased risk of hospital admission or death in cohorts of COPD patients on long term oxygen therapy. On the contrary, benzodiazepines and opioids at higher doses might increase mortality