Patient effort at a glance

A: Patient with little effort. Top: Volume Controlled Ventilation: airway pressure in cmH2O in yellow, constant flow in L/min in pink. Middle: Pressure controlled ventilation: airway pressure in cmH2O in yellow, decelerating flow in L/min in pink. Bottom: Esophageal pressure in cmH2O. B: Patient with high effort. Top: Volume Controlled Ventilation: airway pressure with convex negative deflection during trigger and first half of inspiration (blue arrow). Middle: Pressure controlled ventilation: airway pressure with negative deflection during the trigger (yellow arrow) and slight convex deflection (green arrow), concave deflection in the flow (orange arrow). Bottom: Convex deflection in esophageal pressure (grey arrow).

VERBALIZATION OF THE CONCEPT “WAY” IN V.O. PELEVIN`S NOVEL “YELLOW ARROW”

Statement of the problem. The conceptual world picture of an author of a text is a key element to his/her understanding and correct interpretation. It helps to make conclusions about the author’s individual understanding of the world. The concept “way” is one of the basic concepts both in the Russian language and in the individual author’s pictures of the world, and is put on a par with such universal concepts as life, death, God, etc. The purpose of the article is to study the semantic content of the concept “way” in V.O. Pelevin’s novel “Yellow Arrow” and the ways of its lexical representation, identifying the features of the individual author’s picture of the world. Methodology (materials and methods). Research material consists of contexts verbalizing the concept “way”, extracted by continuous sampling from the text of the story “Yellow Arrow” by V.O. Pelevin. Basic analysis methods include descriptive and conceptual analysis, contextual and component analysis of lexical units, semantic analysis of dictionary definitions. Research results. In the aspect of verbal contextual representations, the concept “way” denotes a direction, a vector of development of human life in the novel: the common human route moves to the “destroyed bridge”. This idea is embodied in the lexemes of the near periphery (passengers, arrow) and the far periphery (knocking of wheels, low-style proper nouns). Not everyone can find an individual path, but the main character was able to “get off the train”.

Modifying Highway Capacity Manual Methodology for Inclusion of Flashing-Yellow-Arrow Delay and Suppression

Dallas phasing is an effective strategy for increasing the efficiency of protected-permissive left turns (PPLTs) at signalized intersections, without creating left-turn traps. The flashing yellow arrow (FYA) is the most widely used PPLT signal indication when Dallas phasing is utilized. The Highway Capacity Manual (HCM) signalized intersection methodology currently contains guidance on how to handle PPLTs with Dallas phasing. At intersections with the FYA indication, some agencies have been using a feature known as FYA delay, which delays the FYA indication, usually by 1 to 4 s. More recently, some agencies have also began using another feature, which suppresses the FYA when a conflicting pedestrian phase is active. The HCM does not contain guidance on how to handle FYA delay or suppression. This research proposed modifications to the HCM signalized intersection methodology to address these two FYA strategies. A sensitivity analysis was conducted to check the reasonableness of the proposed modifications. The sensitivity analysis showed that the proposed modifications are reasonable and produced the expected results.

THU0601 REFRACTORY ACUTE CORONARY SYNDROME AND CARDIOGENIC SHOCK AS ATYPICAL ONSET OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background:Eosinophilic Granulomatosis with Polyangiitis (EGPA) is an ANCA-associated vasculitis, characterized by eosinophilic infiltration in tissues, intravascular and extravascular granuloma formation. It is a rare disease, affecting between 0 and 4 per million population per year. The cardiac involvement occurs in 15-60% of EGPA patients (generally ANCA-negative); it is often insidious, underestimated and it has a poor prognosis. The disease usually shows a prodromal phase characterized by asthma and allergic manifestations.Objectives:We report the case of a young patient with acute coronary syndrome (ACS) complicated by cardiogenic shock as the first manifestation of EGPA.Methods:A 36 year old Indian male patient, with a previous history of asthma, rhinitis, Raynaud syndrome and allergy to ketoprofen, presented to the emergency department with a complaint of chest pain and dyspnea. Cardiac troponin was elevated and he was admitted to intensive care unit with a diagnosis of ACS. The patient conditions rapidly deteriorated due to acute cardiogenic shock and an urgent coronary angiogram was performed. An occlusion of the left main coronary artery was treated with angioplasty and two drug-eluting stents. Echocardiography showed severe left ventricular dysfunction requiring inotropic and intra-aortic balloon pump support. A mild dermatitis after salicylic acid administration resolved with intravenous hydrocortisone 1 g. The thrombophilia screening was negative, as well as cardiovascular risk factors. Over the next days, the clinical conditions rapidly improved with recovery of normal ventricular function on discharge. However, two weeks later he was readmitted with recurrent mandibular and chest pain. Troponin levels were elevated and fluctuated, suggesting recurrent ischemic events. Repeated ECG during angina crisis showed ischemic alterations in different coronary territories. The coronary angiogram detected coronary vasospasm of the circumflex artery, reversible after nitroglycerin (Figure 1). Nitroglycerin and calcium channel blockers were initiated, but did not resolve the vasospastic angina crisis, occurring daily. Laboratory tests revealed eosinophilia (4390 cells/mcl), increased C reactive protein (9.4 mg/l) and positive antinuclear antibodies (1:320). The other serological and immunological tests were negative, including MPO-ANCA and PR3-ANCA. An abdomen and chest CT scan was negative.Figure 1.Coronary angiogram showing coronary vasospasm in the left circumflex artery (panel A, yellow arrow), reversible after nytroglicerin infusion (panel B, yellow arrow)Results:The eosinophilia and the history of asthma rose the suspect of EGPA vasculitis. The patient was treated with intravenous methylprednisolone 250 mg once daily for 3 days, followed by oral prednisone 1 mg/kg/day, with rapid and complete resolution of the recurrent angina episodes. Intravenous cyclophosphamide 10 mg/kg was administered every 2 weeks for 2 times, then 12 mg/kg every 4 weeks. Oral corticosteroid was tapered, with the persistence of a complete remission of the symptoms, after 2 months of immunosuppressive therapy.Conclusion:Coronary involvement in EGPA can mimic atherosclerotic artery disease and can be life threatening, if not promptly recognized. An accurate medical history and complete serological and immunological tests are crucial to detect an atypical onset of EGPA, prompting early immunosuppressive therapy which is pivotal for the patient survival.References:[1]MR Hazebroek et al. Prevalence and Prognostic Relevance of Cardiac Involvement in ANCA-associated Vasculitis: Eosinophilic Granulomatosis With Polyangiitis and Granulomatosis With Polyangiitis. Int J Cardiol 2015, 199: 170-9.Disclosure of Interests:None declaredDOI: 10.1136/annrheumdis-2020-eular.6482

1114 NSTEMI originated from an insulin injection needle

A fifty-eight-old previously healthy woman presented to the emergency department with chest pain radiating to the retrosternal area on her way to work. Initial ECG showed no ST-T segment change, but the troponin level was elevated. Urgent coronary angiography demonstrated normal coronary arteries. Ergonovine provocation was also undergone, and no coronary spasm was provoked. During angiography, a fine mobile artifact near the distal portion of left anterior descending artery was observed (Figure A and B, yellow arrow). Her chest wall was fully clear without recent injury. She didn"t receive any acupuncture treatment or is not an intravenous drug user. She is a factory worker making insulin injection needle. Echocardiography showed a hyperechogenic sharp foreign body penetrating interventricular septum with color jet (Figure C and D, yellow arrow). No pericardial effusion was observed. She underwent surgery to remove the foreign object. A fresh fine needle approximately 23 mm-long was entirely removed without extensive dissection under fluoroscopic guidance (Figure E and F). Her symptom was fully resolved after removing the needle and she discharged without further event. Abstract 1114 Figure.