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Context Thyroid hormone (TH) is crucial for the adaptation to cold. Objective To evaluate the effect of hyperthyroidism on resting energy expenditure (REE), cold-induced thermogenesis (CIT) and changes in body composition and weight. Methods This was a prospective cohort study at the endocrine outpatient clinic of a tertiary referral center. Eighteen patients with overt hyperthyroidism were included. We measured REE during hyperthyroidism, after restoring euthyroid TH levels and after 3 months of normal thyroid function. In 14 of the 18 patients, energy expenditure (EE) was measured before and after a mild cold exposure of 2 hours and CIT was the difference between EEcold and EEwarm. Skin temperatures at 8 positions were recorded during the study visits. Body composition was assessed by dual X-ray absorption. Results Free thyroxine (fT4) and free triiodothyronine (fT3) decreased significantly over time (fT4, P = .0003; fT3, P = .0001). REE corrected for lean body mass (LBM) decreased from 42 ± 6.7 kcal/24 hour/kg LBM in the hyperthyroid to 33 ± 4.4 kcal/24 hour/kg LBM (–21%, P Conclusion CIT is not increased in patients with overt hyperthyroidism.

Recent clinical trials have moved iodine-131 (I-131) metaiodobenzylguanidine (MIBG) therapy into frontline management of high-risk neuroblastoma. With this expansion, it is reasonable to anticipate the need for intensive care level resuscitations. Radiation exposure remains the greatest risk to health care professionals managing these patients. We combined shock simulation scenario data with actual radiation dosimetry data to create a care model allowing for aggressive, prolonged in situ resuscitation of a critically ill pediatric patient after I-131 MIBG administration. This model will maintain a critical care provider's radiation level below 10% of the annual occupational dose limit (5 mSv, 500 mrem) per patient managed.

Background Hand hygiene (HH) is the single most important practice in the prevention of healthcare-associated infections (HAIs). However, HH is commonly suboptimal, with compliance often only 30–60%. In 2010, the Joint Commission Center for Transforming Healthcare launched the Targeted Solutions Tool (TST) for Hand Hygiene to aid institutions to increase HH compliance. After successfully deploying the TST at our medical center in 2015, we noted a remarkable improvement in overall HH. Unfortunately, improvements in HH across services were not uniform. Some services, like the environmental services (EVS), remained set in their old ways and continued to perform suboptimal HH. Methods We continued to engage staff using the TST model and just-in-time coaching (JITC) to encourage best HH practices. In addition, we often met with small groups for HH huddles, and reinforced the importance of EVS staff and their HH in helping to protect themselves and our patients, and reduce HAIs. Increasing EVS leadership commitment was key to further engage EVS staff and encourage better HH amongst EVS staff. Review of HH metrics was hard wired into the daily functions of the EVS department. Results Figure 1 shows EVS HH compliance from January 2014 through October 2017. This highlights the substantial progressive, albeit slow, improvement in EVS HH practices from a baseline of 40% to 60% to 80% over the course of nearly 4 years. Conclusion EVS HH rates remained suboptimal for prolonged periods. Initially the lack of leadership commitment and high staff turnover made training and engagement difficult. Continued interventions and use of just-in-time coaching proved to be effective to help improve compliance and better understand barriers to best practices. Connecting with EVS staff in small group huddles and the engagement of EVS leadership was key to success. Disclosures J. P. Parada, Merck: Speaker’s Bureau, Speaker honorarium.

BACKGROUND: Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision. Video-based online teaching is an increasingly utilized educational tool in higher and clinical education. YouTube is a popular video-sharing Web site that can be accessed as a teaching source. OBJECTIVE: The objective of this study was to assess the educational value of YouTube videos on knee arthrocentesis posted by health professionals and institutions during the period from 2008 to 2012. METHODS: The YouTube video database was systematically searched using 5 search terms related to knee arthrocentesis. Two independent clinical reviewers assessed videos for procedural technique and educational value using a 5-point global score, ranging from 1 = poor quality to 5 = excellent educational quality. As validated international guidelines are lacking, we used the guidelines of the Swiss Society of Rheumatology as criterion standard for the procedure. RESULTS: Of more than thousand findings, 13 videos met the inclusion criteria. Of those, 2 contained additional animated video material: one was purely animated, and one was a check list. The average length was 3.31 +/- 2.28 minutes. The most popular video had 1388 hits per month. Our mean global score for educational value was 3.1 +/- 1.0. Eight videos (62 %) were considered useful for teaching purposes. Use of a "no-touch" procedure, meaning that once disinfected the skin remains untouched before needle penetration, was present in all videos. Six videos (46%) demonstrated full sterile conditions. There was no clear preference of a medial (n = 8) versus lateral (n = 5) approach. CONCLUSIONS: A discreet number of YouTube videos on knee arthrocentesis appeared to be suitable for application in a Web-based format for medical students, fellows, and residents. The low-average mean global score for over educational value suggests an improvement of future video-based instructional materials on YouTube would be necessary before regular use for teaching could be recommended.

This paper deals with history, difference of loading in shaft and gear dendendum and flank, load time histories and distributions, transformation of load to stress as well as with examples and cases of damage or loss regarding the particularities of structural fatigue of toothed gears.

Background Knee arthrocentesis is a commonly performed diagnostic and therapeutic procedure in rheumatology and orthopedic surgery. Classic teaching of arthrocentesis skills relies on hands-on practice under supervision. Video-based online teaching is an increasingly utilized educational tool in higher and clinical education. YouTube is a popular video-sharing Web site that can be accessed as a teaching source. Objectives The objective of this study was to assess the educational value of YouTube videos on knee arthrocentesis posted by health professionals and institutions during the period from 2008 to 2012. Methods The YouTube video database was systematically searched using 5 search terms related to knee arthrocentesis. Two independent clinical reviewers assessed videos for procedural technique and educational value using a 5-point global score, ranging from 1 = poor quality to 5 = excellent educational quality. As validated international guidelines are lacking, we used the guidelines of the Swiss Society of Rheumatology as criterion standard for the procedure. Results Of more than thousand findings, 13 videos met the inclusion criteria. Of those, 2 contained additional animated video material: one was purely animated, and one was a check list. The average length was 3.31±2.28 minutes. The most popular video had 1388 hits per month. Our mean global score for educational value was 3.1±1.0. Eight videos (62%) were considered useful for teaching purposes. Use of a “no-touch” procedure, meaning that once disinfected the skin remains untouched before needle penetration, was present in all videos. Six videos (46%) demonstrated full sterile conditions. There was no clear preference of a medial (n=8) versus lateral (n=5) approach. Conclusions A discreet number of YouTube videos on knee arthrocentesis appeared to be suitable for application in a Web-based format for medical students, fellows, and residents. The low-average mean global score for overall educational value suggests an improvement of future video-based instructional materials on YouTube would be necessary before regular use for teaching could be recommended. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1786

Background Recent investigations have provided substantial evidence that distinct molecular and morphological changes in subchondral bone tissue, most notably sclerosis, play an active and important role in the pathogenesis of OA. The cellular and molecular regulation of this pathological process remains poorly understood. Objectives We investigated whether osteoimmunology, the reciprocal signaling between cells from the immune and bone system, is involved in OA subchondral bone sclerosis. Methods Tibial plateaus and informed consent were obtained from patients undergoing total knee arthroplasty due to end-stage OA. Subchondral bone mineralization distribution was analyzed using computed tomography osteoabsoptiometry (CT-OAM) and standardized cryosections of low (non-sclerotic) and high (sclerotic) bone mineralization were prepared ( n =18 each). Cartilage degeneration was graded in Safranin- O -stained sections using the Mankin scoring system. The presence of T-lymphocytes, B-cells and macrophages was assessed using immunohistochemical staining of their respective surface markers CD3, CD20 and CD68. Osteoclast activity was visualized by staining of the enzyme marker tartrate-resistant acid phosphatase (TRAP). Cellular characterization of ex vivo subchondral bone outgrowth cultures was performed using alkaline phosphatase (ALP), TRAP staining. Correlation between histological parameters was assessed using Spearman´s rank correlation. Statistical differences were calculated using Wilcoxon signed rank test or paired t -test, where appropriate. Results CT-OAM revealed a heterogeneous distribution of subchondral bone mineralization in OA tibial plateaus, displaying focal areas of sclerosis that overlapped macroscopically with areas of cartilage damage. These data were confirmed at the histological level by a strong correlation between Mankin score and grade of sclerosis ( r =0.7, p + , but not CD3 + , lymphocytes and CD68 + mononuclear (macrophage) and multinucleated (osteoclast) cells were present in subchondral marrow spaces. Notably, the number of CD20 + lymphocytes and CD68 + cells was significantly ( p p + cells in sclerotic bone. Finally, the number of CD68 + cells was strongly correlated ( p r =0.7), grade of sclerosis ( r =0.8), CD20 + lymphocytes ( r =0.8), and TRAP-positive cells ( r =0.9). Outgrowth cultures of subchondral bone showed cells of different morphologies including fibroblast-shaped osteoblasts and macrophage-like cells. Expression of ALP was detected in the prior, while TRAP expression was evident in the latter. Corresponding with histological analyses, the number of TRAP + cells was increased in ex vivo outgrowth cultures of sclerotic compared to non-sclerotic subchondral bone. Conclusions Together, our data suggest that osteoimmunological mechanisms, specifically the interaction of CD68 + macrophages with bone-resident cells, play a - previously unknown - role in regulating subchondral bone sclerosis in progressive OA. Targeting osteoimmunology might hold potential as a disease-modifying treatment for OA. Disclosure of Interest None Declared

It is generally felt that long term addicts die before they reach old age, while survivors have generally given up the use of drugs. Evidence suggests that this is not the case. Examination of the life styles of elderly street addicts and methadone treatment patients reveals a change in pattern of drug use motivated primarily by economic factors. The older addict tends to maintain low profile and avoids harassment, arrest and public attention. The number of older persons in methadone treatment is increasing rapidly. New approaches in treatment and public policy are needed to deal with these problems. Additionally a considerable number of elderly persons misuse other drugs particularly barbiturates, alcohol and other depressants. These are usually obtained from legal sources.

I come to Brookhaven for the second time in my life. The first time was twenty-two years ago when, as a budget analyst, I came to look at a machine that I did not understand at all. It was called the Alternating Gradient Synchrotron, the Brookhaven AGS, a 30 billion electron volt proton accelerator which was being designed and built by a man named Lee Hayworth, if I remember correctly, who was the Director of the Laboratory and the godfather of that proton accelerator, and who later became the Director of the National Science Foundation. At that time I was a budget examiner for an organization called the Bureau of the Budget in the Federal Government of the United States. I was assigned to the Atomic Energy Program to review whether or not we should make, what we considered at that time, massive investments in basic research tools in the physical sciences.

Extensive development of encapsulated transformers for electrical distribution service has been going on since the late 1950's. During this period oil-filled pad-mounted and vault-type transformers have made rapid inroads toward replacing the older more conventional pole or overhead types. However, solid insulation or cast-type transformers are still not broadly marketed or have received customers' acceptance on the American electrical utilities scene. There is good reason for this. Many problems have been encountered, some of which progressive technology has solved and some of which even today offer a challenge to and tax the imagination and the economic resources of the industry.

• Sequential ablative hormonal manipulations have produced tumor regressions in metastatic male breast carcinoma. Information with regard to the use of additive hormonal therapy after orchiectomy is limited. Regression of a pulmonary metastasis during treatment with megestrol acetate occurred in a man who had metastatic steroid receptor-positive breast carcinoma that had progressed after orchiectomy. (Arch Intern Med1981;141:809-810)