In Sool Yoo

Magnetic resonance imaging as a diagnostic adjunct to Wernicke encephalopathy in the ED.

This report describes usefulness of magnetic resonance imaging (MRI) for the evaluation of the patient suspected of Wernicke encephalopathy (WE). Magnetic resonance imaging shows characteristic findings of symmetric hyperintense lesions predominantly located in the bilateral medial thalami, the periaqueductal regions, and the mamillary bodies. The diagnosis of Wernicke encephalopathy has been based generally on history and clinical symptoms. We now believe that MRI could be used as a diagnostic adjunct in the patient suspected of WE.

A comparison of the area of chest compression by the superimposed-thumb and the alongside-thumb techniques for infant cardiopulmonary resuscitation

OBJECTIVES We investigated whether the superimposed-thumb technique could reduce the chest compression area in infant cardiopulmonary resuscitation (CPR). METHODS Charts and multidirectional computed tomography images of infants presented to four hospitals from January 2007 to September 2010 were reviewed retrospectively. We measured at the point of maximal anterior-posterior heart diameter the width of the sternum meter (S(ap)), vertical heart length from S(ap), length and width of the superimposed-thumb technique and length and width of the alongside-thumb technique. We studied the structures located underneath thumbs superimposed and thumbs alongside at S(ap) and S(nipple) (the sternum of the inter-nipple line). RESULTS In the 84 infants enrolled, the width of the sternum at S(ap), and the vertical heart length from S(ap) were 0.85 ± 0.31 and 1.71 ± 0.47 cm, respectively. The length and width of the superimposed-thumb technique were 1.65 ± 0.13 and 2.73 ± 0.22 cm, respectively. The length and width of the alongside-thumb technique were 3.00 ± 0.48 and 3.77 ± 0.24 cm, respectively. The liver was situated underneath thumbs superimposed at S(ap) in 59.5% infants. The livers and lungs of 73.8% and 64.3% infants, respectively, were underneath thumbs alongside at S(nipple). CONCLUSION In this study, we confirmed that the superimposed-thumb technique may reduce chest compression area in infant CPR. The lungs or livers were located more often underneath thumbs alongside at S(nipple) than underneath thumbs superimposed at S(ap). However, further studies are needed to validate the efficiency and safety of this technique.

Diffusion-weighted MRI of intracerebral hemorrhage clinically undifferentiated from ischemic stroke

This report describes diffusion-weighted MRI findings of some intracerebral hemorrhages clinically undifferentiated from ischemic stroke. We treated patients with characteristic features of intracerebral hemorrhages that could distinguish themselves from ischemic lesion on diffusion-weighted imaging. Therefore, we think diffusion-weighted imaging could be an emergency screening tool for ischemic stroke as an alternative to computed tomography, and the EP should be familiar with the diffusion-weighted imaging findings of intracerebral hemorrhage as well as cerebral infarction.

THU0548 Interleukin-7 Accelerates Osteoclast Formation from Monocytes in Synovial Fluid from Patients from Rheumatoid Arthritis

Background Interleukin-7 (IL-7), a member of the common gamma-chain cytokine family, plays a crucial role in T cell development, which induces T cell survival, proliferation, differentiation in mature naive and memory T cells. IL-7 is expressed by stromal cells, epithelial cells, and fibroblasts. IL-7 is highly expressed in synovial tissue (ST) of patients with rheumatoid arthritis (RA) and its expression level correlates with the disease activity. Although IL-7Rα is mainly expressed in T cells, IL-7 receptor α (IL-7Rα) is able to be expressed in CD19-positive B cells and monocytes of synovial fluid mononuclear cells (SFMC) in RA patients. IL-7 promotes the secretion of osteoclastogenic factors, such as M-CSF and RANKL, in T cells, and eventually induces osteoclastogenesis. In contrast, It has been shown that IL-7α-deficient mice promote osteoclastogenesis and IL-7 treatment inhibits the osteoclastogenesis in vitro. Thus, the role of IL-7 involved in osteoclastogenesis is still unclear. Objectives In order to resolve this discrepancy, we investigated the effect of IL-7 on the differentiation of monocytes into osteoclasts. Methods First, we examined the expression level of IL-7Rα in several subsets from PBMC and SFMC of RA patients as well as healthy subjects. Second, we determined the direct role of IL-7 in osteoclast differentiation of monocytes expressing IL-7Rα in vitro. Results As results, we found that IL-7Rα was highly expressed in monocytes from RA SFMC compared to health PBMC, and its expression was confined to specific monocyte-subsets, intermediate monocyte (CD14+CD16+) and inflammatory monocyte (CD14-CD16++). Furthermore, IL-7 induced osteoclastogenesis from RA monocytes in the presence or absence of M-CSF and RANKL, and also promoted the osteoclastogenesis in earlier than done by M-CSF and RANKL. Conclusions These finding suggest that IL-7 may directly affect monocyte differentiation in osteoclast cells in inflammatory condition, such as synovial fluid of RA, and blocking IL-7 or IL-7Rα as therapy may give a new pathway to treatment of bone erosion in patient with RA. Disclosure of Interest : None declared DOI 10.1136/annrheumdis-2014-eular.1500

Novel body positioning maximizes femoral venous size in adults: An ultrasonographic evaluation

Introduction: Increased femoral vein size may lead to a higher first pass success rate during central venous cannulation. The aim of this study was to evaluate the effects of body position on femoral vein anatomy for cannulation. Methods: This prospective study examined the femoral vein of healthy volunteers by ultrasound scanner. The changes in cross-sectional area and diameter of the femoral vein were evaluated. Right-sided measurements were taken at four different leg positions: neutral, frog leg, back-up, and back-up/frog leg position. Results: A total of 50 subjects were enrolled in the study. The mean femoral vein cross-sectional area were 0.57 ± 0.29 cm2, 0.90 ± 0.26 cm2, 1.05 ± 0.33 cm2, and 1.47 ± 0.34 cm2, and the mean femoral vein diameter were 0.75 ± 0.20 cm, 1.05 ± 0.28 cm, 1.25 ± 0.21 cm, and 1.46 ± 0.25 cm in order of neutral, back-up, frog leg, and back-up/frog leg position (p < 0.001). Conclusion: Performing the right femoral vein catheterization in back-up and frog leg position is associated with a greater cross-sectional area of the femoral vein.

Is it possible to reduce intra-hospital transport time for computed tomography evaluation in critically ill cases using the Easy Tube Arrange Device?

Objective Patients are often transported within the hospital, especially in cases of critical illness for which computed tomography (CT) is performed. Since increased transport time increases the risks of complications, reducing transport time is important for patient safety. This study aimed to evaluate the ability of our newly invented device, the Easy Tube Arrange Device (ETAD), to reduce transport time for CT evaluation in cases of critical illness. Methods This prospective randomized control study included 60 volunteers. Each participant arranged five or six intravenous fluid lines, monitoring lines (noninvasive blood pressure, electrocardiography, central venous pressure, arterial catheter), and therapeutic equipment (O2 supply device, Foley catheter) on a Resusci Anne mannequin. We measured transport time for the CT evaluation by using conventional and ETAD method. Results The median transport time for CT evaluation was 488.50 seconds (95% confidence interval [CI], 462.75 to 514.75) and, 503.50 seconds (95% CI, 489.50 to 526.75) with 5 and 6 fluid lines using the conventional method and 364.50 seconds (95% CI, 335.00 to 388.75), and 363.50 seconds (95% CI, 331.75 to 377.75) with ETAD (all P<0.001). The time differences were 131.50 (95% CI, 89.25 to 174.50) and 148.00 (95% CI, 116.00 to 177.75) (all P<0.001). Conclusion The transport time for CT evaluation was reduced using the ETAD, which would be expected to reduce the complications that may occur during transport in cases of critical illness.

THU0093 Nadph oxidases associated production of reactive oxygen species in rheumatoid arthritis

Background Reactive oxygen species (ROS) is produced during metabolism of Oxygen. ROS is important in cell signalling and homeostasis. Production of ROS can be elevated in stressful condition. Oxidative stress has been known to be related with the disease like infection and malignancy. NADPH oxidases (Nox) are membrane proteins which produce ROS. Objectives In this study we aimed to investigate the role of Nox in rheumatoid arthritis (RA) associated with production of ROS. Methods Nox and Granulocyte macrophage colony-stimulating factor (GMCSF) messenger ribonucleic acid (mRNA) were analysed in fibroblast like synoviocyte (FLS) of patients with RA and osteoarthritis (OA) by reverse transcription polymerase chain reaction. Amount of ROS which is produced in FLS of patients with RA and OA is determined using the cell permeant fluoroprobe 5-(and-6)-chloromethyl-2’,7’-dichlorodihydrofluorescein diacetate acetyl ester (CM-H2DCFDA) by flowcytometry. Same experiments were performed after treatment with cytokine, interleukin (IL)−17 and tumour necrosis factor-α (TNF-α). Results Among Nox subunits (Nox1, Nox2, Nox4, Nox5, DUOX1, DUOX2, NOXA1, NOXO1), NOXA1 and NOXO1 mRNA were expressed higher in RA FLS than in OA FLS. After treatment with IL-17 and TNF-α for 24 hours GMCSF, Nox1 and NOXO1 mRNA in RA FLS were elevated. Amount of ROS production was also elevated after treatment with IL-17 and TNF-α. When RA FLS were treated with bromopyruvic acid (BrPa), glucolysis inhibitor by inhibition of hexokinase II, GMCSF mRNA and ROS were decreased and Nox1 and Nox4 mRNA showed no diffrence. Conclusions Several factors may be involved between ROS and Nox in RA FLS. Both ROS and Nox were elevated in inflammatory condition in RA FLS. From this result we expect that Nox-targeted therapy may be effective for treatment with RA. References [1] Drummond GR, Selemidis S, Griendling KK, Sobey CG. Combating oxidative stress in vascular disease: NADPH oxidases as therapeutic targets. Nat Rev Drug Discov2011;10:453–71. [2] Neumann E, Lefèvre S, Zimmermann B, Gay S, Müller-Ladner U. Rheumatoid arthritis progression mediated by activated synovial fibroblasts. Trends Mol Med2010;16:458–68. [3] Rodiño-Janeiro BK, Paradela-Dobarro B, Castiñeiras-Landeira MI, Raposeiras-Roubín S, González-Juanatey JR, Alvarez E. Current status of NADPH oxidase research in cardiovascular pharmacology. Vasc Health Risk Manag2013;9:401–28. [4] Xiao C, Li J, Dong X, He X, Niu X, Liu C, Zhong G, Bauer R, Yang D, Lu A. Anti-oxidativeand TNF-α suppressive activities of puerarin derivative (4AC) in RAW264.7 cells and collagen-induced arthritic rats. Eur J Pharmacol2011;666:242–50. [5] Yun JM, Chien A, Jialal I, Devaraj S. Resveratrol up-regulates SIRT1 and inhibits cellular oxidative stress in the diabetic milieu: mechanistic insights. J Nutr Biochem2012;23:699–705. Disclosure of Interest None declared

What are the key elements in suture education? Comparison of cosmetic appearances after facial lacerations repaired by junior residents and experts

Purpose: The technical factors which improve cosmetic outcomes and which need to be emphasized in education of junior residents have yet to be described. We compared cases in which suturing was performed by either junior emergency medicine residents or experts, in order to determine the focus of future education and training. Methods: Wound registry data was reviewed and retrospectively analyzed from September 2015 to February 2016. Only patients who visited the emergency room with facial lacerations were enrolled, and their wound registry data sheets were reviewed. Practitioners were divided into junior resident and expert groups. We assessed the progress using the Stony Brook Scar Evaluation Scale (SBSES) 5–10 days following suturing. Results: Sixty‐six patients were enrolled; 43 (65.2%) were men. The median (interquartile range) cosmetic scores (SBSES scale) for suturing performed by junior residents or experts were 3 (2–4) and 5 (4–5), respectively (p = 0.001). The percentage of maximum scores for each SBSES category was significantly lower in the junior resident group than in the expert group for width (68% vs. 86%), hatch marks (68% vs. 93%), and overall appearance (41% vs. 80%) (all p < 0.001). Conclusions: There were significant differences in scar widths and hatch marks, which were attributable to the skill level of the practitioner who performed the suturing of facial lacerations. Junior residents should be educated about maintenance of proper tension, atraumatic technique, and performing appropriate trimming or debridement.

AB0113 The Serum and Synovial Fluid Levels of Cold-Inducible Rna-Binding Protein (Cirp) in Patients with Rheumatoid Arthritis

Background The cold-inducible RNA-binding protein (CIRP) is 18 kDa protein of the glycine-rich RNA binding protein (GRP) family, and these proteins function as RNA chaperones to facilitate translation. Extracellular CIRP is a recently identified endogenous proinflammatory mediator and damage-associated molecular pattern molecules (DAMP) that triggers inflammatory responses in sepsis and inflammatory bowel disease. Objectives This study was planned to investigate the relationship between CIRP and rheumatoid arthritis. Methods Peripheral blood and synovial fluid were collected from 15 patients with rheumatoid arthritis (RA) and 16 patients with osteoarthritis (OA). The concentration of CIRP was measured by sandwich Enzyme-Linked Immunosorbent Assay (ELISA). Results The concentration of serum CIRP was significantly elevated in RA patients group (RA patients=26.39±10.48 pg/ml, OA patients=17.14±7.24 pg/ml, p=0.009). Furthermore, the RA patients group showed significantly higher CIRP concentration than the OA patients group in synovial fluid (153.56±108.93 pg/ml vs. 23.63±16.18 pg/ml, p<0.001) (Fig.1). The mean concentration of synovial fluid CIRP was significantly higher than that of serum in RA patients group (Serum concentration=26.39±10.48 pg/ml, Synovial fluid=153.56±108.93 pg/ml, p<0.001). Also, we found the tendency that the CIRP concentration of synovial fluid was significantly higher than that of serum in same patient (P=0.025) (Fig.2). DAS28-ESR and DAS28-CRP were positively correlated with synovial fluid concentration of CIRP (DAS28-ESR: r=0.582, p=0.023, DAS28-CRP: r=0.541, p=0.037, by correlation analysis). Conclusions The serum and synovial concentration of CIRP in RA patients was increased compared to OA patients. Also synovial concentration of CIRP in RA patients correlated well with the disease activity, i.e. the DAS28-ESR/CRP. Based on these results, the CIRP mediates the inflammation and is potential marker for synovial inflammation. References Qiang X, Yang WL, Wu R, Zhou M, Jacob A, Dong W, Kuncewitch M, Ji Y, Yang H, Wang H, Fujita J, Nicastro J, Coppa GF, Tracey KJ, Wang P (2013) Cold-inducible RNA-binding protein (CIRP) triggers inflammatory responses in hemorrhagic shock and sepsis. Nat Med 19:1489–95. Nishiyama H, Higashitsuji H, Yokoi H, Itoh K, Danno S, Matsuda T, Fujita J (1997) Cloning and characterization of human CIRP (cold-inducible RNA-binding protein) cDNA and chromosomal assignment of the gene. Gene 204:115–20. Nishiyama H, Danno S, Kaneko Y, Itoh K, Yokoi H, Fukumoto M, Okuno H, Millán JL, Matsuda T, Yoshida O, Fujita J (1998) Decreased expression of cold-inducible RNA-binding protein (CIRP) in male germ cells at elevated temperature. Am. J. Pathol 152:289–96. Nishiyama H, Xue JH, Sato T, Fukuyama H, Mizuno N, Houtani T, Sugimoto T, Fujita J (1998) Diurnal change of the cold-inducible RNA-binding protein (Cirp) expression in mouse brain. Biochem. Biophys. Res. Commun 245:534–8. Disclosure of Interest None declared

SAT0190 Histological Study on The Expression of Transcriptional Intermediary Factor 1 (TIF 1) in The Patients with Inflammatory Myopathies

Background Myositis-specific antibodies in patients with inflammatory myopathies are known to be associated with various clinical manifestations, classifications and diagnosis. Among them, recently found anti-transcriptional intermediary factor 1 (TIF1) α, β, or γ antibodies, has been reported to be associated with dermatomyositis (DM) accompanied by cancer. Objectives Although previous studies have evaluated the association of the antibodies in serum and clinical subtypes, the information about the target antigen is insufficient. The purpose of this study was to confirm the overexpression of TIF1s in the muscle and skin tissues of patients with inflammatory myopathies. Methods From February 2004 to November 2014, skin and muscle biopsies were performed on 45 patients diagnosed with dermatomyositis and polymyositis. We stained skin and muscle tissue by immunohistochemistry using anti-TIF1α, β, or γ and compared with the results of healthy control. We analyzed the association between the clinical manifestations and protein expression in each tissue. Results When compared with the control group, any antigens showed no significant overexpression in the muscle. However, TIF1α showed higher positive rate in the skin of DM (12/15 [80%]) than in the skin of healthy control (0/7 [0%]) (p=0.001). TIF1γ expression was higher in the muscle of patients with DM while there was no expression in the muscle of healthy controls (DM, 8/19 [80%] vs. healthy control 0/7 [0%], p=0.039). In the tissues of inflammatory myopathies, TIF1α and TIF1γ demonstrated higher positive rates in the skin than in the muscle (TIF1α, muscle, 4/35 [11%] vs. skin, 12/15 [80%], p<0.001; TIF1γ, muscle, 10/35 [29%] vs. skin, 13/15 [87%], p<0.001). When analyzing DM patients only, the result was similar (TIF1α, muscle, 1/19 [5%] vs. skin, 12/15 [80%], p<0.001; TIF1γ, muscle, 8/19 [42%] vs. skin, 13/15 [87%], p=0.013). TIF1β showed strong positivity in all tissues of myositis or healthy control. Analyzing the association with TIF1s expression and cancer, there was no significant difference in the positive rate of TIF1α or γ in the muscle or skin between the myositis patient with or without cancer. Conclusions TIF1α was expressed more in the skin of DM patients than that in that of control group and TIF1γ in the muscle of DM patients than in that of control. The expression of TIF1α in the skin and TIF1γ in the muscle of cancer associated DM was not higher than those of DM without cancer. Thus the expression levels of TIF1α in the skin and TIF1γ in the muscle may be associated with myositis rather than with cancer. References Hoshino K, et al. Anti-MDA5 and anti-TIF1-gamma antibodies have clinical significance for patients with dermatomyositis. Rheumatology (Oxford) 2010;49(9):1726–1733. Fiorentino D. Casciola-Rosen L, Autoantibodies to transcription intermediary factor 1 in dermatomyositis shed insight into the cancer-myositis connection. Arthritis Rheum 2012;64(2):346–349. Disclosure of Interest None declared