Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

seismic assessment of roman concrete groin vaults through UAV, NDT and 3D analyses

In Roman Baths, the Romans employed barrel and groin vaults of great dimensions, with maximum span more than 20 m; simple tools of structural analysis of ancient wide span vaulted halls are still lacking, due to geometrical and material complexity. In this paper, we study the collapse behavior, under horizontal static action, of a corner cross vault of the Baths of Diocletian in Rome (Hall I). Two methods of analysis are here used: non-linear incremental finite element and limit analysis. In both cases, 3D models have been developed by means of UAV inspection, NDT measures, and AVT monitoring. The construction of the overall 3D geometry has been here afforded with a specific pre-processing approach. Midas commercial software has been employed for FEM analysis, assuming a constitutive law specifically developed for Roman concrete. In limit analysis, masonry is discretized as a system of interacting rigid bodies in no-tension and frictional contact. The computational code consists in a linear approach, which makes use of a series of optimization packages via lower and upper bound techniques. Finally, a strategy based on FEM analysis including discontinuities was implemented, and the results were compared with the two previous approaches

Comparison of different finite element model updates based on experimental onsite testing: the case study of San Giovanni in Macerata

Understanding the behavior of historic structures that have undergone structural changes, restorations, and damage over time is still a significant challenge for structural engineers, particularly in those countries subject to high seismic risk, such as Italy. The study of built heritage for its prevention and conservation is an active research topic, due to the numerous uncertainties present in historic structures. Finite element modelling has become the most common and accessible method to study the behavior of complex masonry structures, however, the gap between numerical and experimental analysis may lead to erroneous results. Model updating techniques can reduce the discrepancy between the behavior of the numerical models and the testing results. The goal of this work is to illustrate a methodology to integrate the information derived from local, global, and geotechnical investigations into the finite element model of the masonry historical church of San Giovanni in Macerata, considering the Douglas-Reid model updating method. The PRiSMa laboratory of Roma Tre University carried out local investigations such as sonic tomography, video endoscopy and double flat jack tests, along with five ambient vibration tests that were processed through the operational modal analysis to extrapolate the dynamic properties of the building (modal frequency, modal shape vector and modal damping). The combined use of global, local and geotechnical information implemented in the methodology effectively reduced the uncertainties of the model and led the refinement and validation of the most relevant structural parameters

Setup Optimization of Experimental Measures on a Historical Building: The Octagonal Hall of the Diocletian’s Bath

The growing use of highly specialized tools has led to a better knowledge of the mechanical properties of the structures, reducing the destructive tests. The paper is aimed to identify an investigation method capable of directing staff in the planning of non-destructive test. The experimental campaigns must be planned in order to optimize the number and the type of tests to limit invasiveness and impact. The proposed method has been organized in a logical scheme that permits, in five steps, to predict with a good approximation the critical sections for an optimal setup of testing instruments. This method has been applied to the Octagonal Hall in Diocletian’s Bath, to establish a better location for the dynamic endoscopy and tomographic tests. A geometrical model was built using the plans, elevations, sections provided by the National Roman Museum and the point cloud made through a drone. With HBIM (Heritage Building Information Modeling) it was possible to synthesize the information obtained from the geometric and material survey and then to convey it to a finite element model built on Midas Fea NX. Then, structural analyses, both linear and nonlinear, have been carried out for the optimal test setup

Integrated Modeling of Minerva Medica to Identify the Dynamic Effects of Rail-Traffic Vibrations

A comprehensive study was carried out to integrate information from different sources and evaluate the effects of induced vibrations on a temple. Historical analysis was fundamental to interpreting the evolution of the construction and defining the HBIM. Experimental data were implemented in the FEM of the site, including the temple, its foundations, and the soil stratifications. Sensitivity analysis was carried out to identify the most influential parameters, which were calibrated to reduce error with the experimental frequencies. The FEM was further optimized with the Douglas–Reid method, considering, simultaneously, modal frequencies and deformations. Two different nonlinear dynamic analyses were performed; one analysis studied the effect on the temple of the dynamically moving load of the tram, and the other analysis studied the response of the temple to three-dimensional accelerations applied at the base. The drawbacks of each simulation were identified by comparing the numerical and experimental results

Onsite Testing for Nonlinear Analysis of an Earthquake Damaged Historical Church in Italy

Analysis and diagnosis of historical masonry buildings are frequently affected by uncertainties due to unexpected behaviors caused by cumulative damage, material decay or transformations. This research work follows a methodology in the structural analysis of the historical masonry church of San Filippo Neri in Macerata, severely damaged after the Central Italy Earthquake occurred in October 2016. The PRiSMa laboratory (Proof testing and Research in Structures and Materials) of Roma Tre University carried out an extensive onsite testing campaign, including NDT tests as sonic tomography and endoscopy, and minor destructive technique as double flat jack test, together with dynamic monitoring under ambient vibrations, to investigate the state of conservation of the building. The onsite testing results were then implemented in an accurate finite element model, which was tuned up by means of global dynamic response provided by OMA (operational modal analysis) and updated, after the sensitivity analysis, through the Douglas-Reid method. Finally, nonlinear static and dynamic analyses were performed to investigate the state of damage of the church and reduce its uncertainties. This methodology will support the design of strengthening measures to achieve a higher level of safety concerning both needs of protection and conservation, thereby avoiding ineffectual or amiss interventions

Onsite Testing for Nonlinear Analysis of an Earthquake Damaged Historical Church in Italy

Analysis and diagnosis of historical masonry buildings are frequently affected by uncertainties due to unexpected behaviors caused by cumulative damage, material decay or transformations. This research work follows a methodology in the structural analysis of the historical masonry church of San Filippo Neri in Macerata, severely damaged after the Central Italy Earthquake occurred in October 2016. The PRiSMa laboratory (Proof testing and Research in Structures and Materials) of Roma Tre University carried out an extensive onsite testing campaign, including NDT tests as sonic tomography and endoscopy, and minor destructive technique as double flat jack test, together with dynamic monitoring under ambient vibrations, to investigate the state of conservation of the building. The onsite testing results were then implemented in an accurate finite element model, which was tuned up by means of global dynamic response provided by OMA (operational modal analysis) and updated, after the sensitivity analysis, through the Douglas-Reid method. Finally, nonlinear static and dynamic analyses were performed to investigate the state of damage of the church and reduce its uncertainties. This methodology will support the design of strengthening measures to achieve a higher level of safety concerning both needs of protection and conservation, thereby avoiding ineffectual or amiss interventions