Rural versus metropolitan ST elevation infarction (STEMI) patients experience delays to care [1]. Existing NSW protocols only divert patients within 90 minutes to percutaneous coronary intervention (PCI) sites. In 2019, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) extended this range by implementing a fully centralised management system (CMS), with immediate hot transfer, for all STEMI patients to a PCI centre, covering a vast area of 250,000 km2.

Rural, versus metropolitan, Australians have higher cardiovascular mortality, driven by risk profile differences and reduced timely access to care for ST elevation myocardial infarction (STEMI) [1,2]. In 2019, a centralised management system (CMS), with routine, immediate hot transfer of STEMI patients to a PCI centre, was implemented in Western NSW Local Health District (WNSWLHD).

Access to timely care for ST elevation myocardial infarction (STEMI) is poorer in rural versus metropolitan NSW [1,2]. To mitigate this disadvantage, Western NSW Local Health District (WNSWLHD) and NSW Ambulance (NSWA) established a centralised management system (CMS) for routine "hot" transfer of all STEMI patients to a percutaneous coronary intervention (PCI) centre in Orange (OHS) in 2019.

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed "risk-based approach" [1], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care.

Regional Australians have a higher rate of cardiovascular disease and excess mortality for AMI. This has been driven by diminished timely access to cardiac catheterisation. Orange Health Service (OHS) has developed cardiac catheter services in Western NSW LHD, an area of 276,000 km2. Starting as a diagnostic lab in 2005, the service has developed to an FFR/IVUS capable lab providing 24/7 PCI, supporting a centralised smartphone linked acute ECG reading Cardiology service and prehospital lysis for remote STEMI patients. The development of the service, percentage of patients managed in area and improvements in 30 day AMI mortality are described. Database interrogation was conducted within the OHS cardiac catheter unit database and within NSW Bureau of Health Information (BHI) 30 day AMI mortality reports. Total number of cardiac catheterisation rose (835 in 2007 to 1727 in 2019), PCI from 172 in 2007 to 576 in 2019. PCI for STEMI rose from 29 in 2009 to 208 in 2019 and by 2019 89.4% of all ACS were fully managed within the LHD. NSW BHI data showed a drop in 30 day AMI mortality from 7% in 2009- 12 to 4.8% in 2015-18 which was below the NSW average of 5.9%, with OHS being the 7th busiest catheter lab in NSW for AMI with a risk stratified mortality ratio(RSMR) of 0.91 indicated below expected deathrate for casemix. A rural cardiac catheter service providing a centralised STEMI service and 24/7 rescue PCI in a large geographical area, supported by IT and centralised transport systems, can reduce 30 day AMI mortality in a high risk population. Methodologies are applicable to other rural settings.

The Radium Delayed Coincidence Counter (RaDeCC) is one of the most extensively used equipment for measuring Ra-223 and Ra-224 activities in water and sediment samples. Samples are placed in a closed He-circulation system that carries the Rn produced by the decay of Ra to a scintillation cell. Each alpha decay recorded in the cell is routed to an electronic delayed coincidence system which enables the discrimination of Ra-223 and Ra-224. In this study, the measurement and quantification methods using the RaDeCC system are assessed through analyses of registered data in different RaDeCC systems worldwide and a set of simulations. Results of this work indicate that the equations used to correct for Ra-223 and Ra-224 cross-talk interferences are only valid for a given range of activities and ratios between isotopes. Above certain limits that are specified in this study, these corrections may significantly overestimate the quantification of Ra-223 and Ra-224 activities (up to similar to 40% and 30%, respectively), as well as the quantification of their parents Ac-227 and Th-228. High activities of Ra-226 may also produce an overestimation of Ra-224 activities due to the buildup of Rn-222, especially when long measurements with low activities of Ra-224 are performed. An improved method to quantify Ra-226 activities from the buildup of Rn-222 with the RaDeCC system is also developed in this study. Wethus provide a new set of guidelines for the appropriate quantification of Ra-223, Ra-224, Ac-227, Th-228, and Ra-226 with the RaDeCC system. Plain Language Summary In the last decades, there has been a growing interest in using radioactive isotopes to evaluate environmental processes. Their concentrations in environmental settings can reveal information about provenance, path, time, and duration. In this scenario, the research in the techniques to measure isotopes from samples has played a key role. In 1996, the launching of the Radium Delayed Coincidence Counter (RaDeCC) facilitated the fast and precise measurement of Ra isotopes, which provide information on land-ocean interaction processes (e.g., groundwater discharge to the sea and coastal residence times). Nowadays, this detector has become a fundamental tool for oceanographers, geochemist, and hydrologist among other scientific communities. Nevertheless, when the RaDeCC system was released, its quantification limits were not provided, and the recommendations on its use were mostly qualitative. More than 20 years later, we address these questions in a study that contains a comprehensive analysis of the RaDeCC counting mechanism and the determination of the limits of quantification. This study should serve as guidance for the measurement and quantification of Radium isotopes for the scientific community using the RaDeCC system.

Patients from rural areas carry a high burden of cardiovascular (CV) risk factors [1Kotwal S, Ranasinghe I, Brieger D, Clayton P, Cass A, Gallagher M. Long-term outcomes of patients with Acute Myocardial Infarction presenting to regional and remote hospitals. Heart Lung Circ. 2016 Feb;25(2):124-131.Google Scholar, 2AIHW Heart Stroke and vascular diseases July 2018.Google Scholar, 3Bureau of Health InformationMortality following hospitalisation for seven clinical conditions, July 2015–June 2018. BHI, Sydney (NSW)2019Google Scholar]. Rural STEMI patients presenting to non PCI-capable sites have a 21% higher mortality at 18 months [[4]Breiger DB, Chew DP, Redfern J, Ellis C et al MJA Nov 2015 Survival after an acute coronary syndrome:18 month outcomes from the Australian and New Zealand SNAPSHOT ACS Study.Google Scholar]. Orange Health Service (OHS) has provided a centralised cardiology service and rescue PCI to WNSWLHD, spanning an area roughly 250,000km2, since 2015. A retrospective, analysis was conducted of rates of PCI for ACS within WNSWLHD throughout 2015-19. LHD performance in BHI 30 day AMI mortality reports were examined. Cardiac catheterisation increased (1367 in 2015 to 1727 in 2019). Percentage of locally managed ACS cases rose from 84.1% (n=614) in 2015 to 89.4% (n=981) in 2019. STEMIs rose from 163 in 205 to 208 in 2019, with a larger percentage admitted directly to the PCI centre. (65% 2015-18; 45% 2012-15; 26% 2009-12). The BHI 2015-18 report showed OHS managed 1298 AMIs, the 7th highest lab volume in NSW. Mortality remained below state average (OHS 4.8%; NSW wide 5.9%). The risk-standardised mortality ratio (RSMR) of 0.84 (<1.0) indicated lower than expected mortality for casemix. This compares to 894 AMIs 2012-2015 (mortality 4.7% (RSMR 0.84)) and 470 AMIs 2009-2012 (7% mortality (RSMR 0.95)). The 24/7 ECG reading and rescue-PCI service, has led to increased volume and complexity of cardiac catheterisation for AMI at OHS with an increasing percentage of patients managed within WNSWLHD. This has been achieved safely, with decreasing BHI 30 day mortality corrected for casemix, driven by centralisation of STEMI management.

Background: Limited data exist examining TCM in rural populations. Objective: To examine the current features of TCM in a single, rural, tertiary referral centre. Methods: Retrospective database analysis of all patients undergoing angiography with TCM in 2018 at Orange Health Service, NSW. Results: 35 patients with TCM were identified, from 1580 diagnostic procedures. Incidence was 13/100,000 population/year. Mean age = 71 (±11). N = 32 (91%) were female. Physiological stressors were present in n = 16 (46%), emotional triggers in n = 12 (34%), of which major grievance (family death/illness) occurred in n = 7 (58%). Males (n = 3) had exclusively physiological stressors. Chest pain was present in n = 24 (69%). Mean initial Ejection Fraction was 39% (n = 26). N = 30 (86%) patients had an Inter-TAK score of >40, with those ≤40 (n = 5) all diagnostic of TCM by imaging. “Classical” apical TCM accounted for n = 26 (76%) with midventricular (n = 4, 12%), focal (n = 3, 9%) and basal (n = 1, 3%) variants. Eight (23%) patients had a prior cancer diagnosis, with 1 patient having prior chemotherapy. N = 16 (46%) patients had prior neurological or psychiatric diagnoses. N = 11 (31%) patients experienced significant complications, including systemic embolism (n = 5) and acute pulmonary oedema (n = 4). N = 28 (80%) patients had an admission <10 days. In all cases of >10 day admission (n = 7), this was secondary to the initial physiological stressor. 33/35 patients (94%) returned to premorbid function. Conclusions: TCM in this rural population is common, and associated with significant acute morbidity but high recovery rates, comparable to previous reports. Recently suggested associations with prior cancer - though not chemotherapy - appear reflected in this population.

Unmet medical needs are not infrequent in oncology, and these needs are usually of higher magnitude in rare cancers. The field of neuroendocrine neoplasms (NENs) has evolved rapidly during the last decade, and, currently, a new WHO classification is being implemented and several treatment options are available in the metastatic setting after the results of prospective phase III clinical trials. However, several questions are still unanswered, and decisions in our daily clinical practice should be made with limited evidence. In the 2016 meeting of the advisory board of the European Neuroendocrine Tumor Society (ENETS), the main unmet medical needs in the metastatic NENs setting were deeply discussed, and several proposals to try to solve them are presented in this article, including biomarkers, imaging, and therapy.

Background: In phase IIIb PROMID, oct l-a (30mg intramuscular/monthly) significantly extended time to tumor progression (HR = 0.34; 95% CI: 0.20, 0.59; p = 0.000072) compared with PBO in treatment-naïve pts with well-differentiated mmNETs. We report post-hoc analyses for HRQoL. Methods: HRQoL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30), a 30-item self-report questionnaire with 5 functional, 1 global, and 9 symptom scales. Assessments were completed at baseline and every 12 wks until tumor progression. Time to definitive deterioration (TDD) was analyzed with the Kaplan-Meier method (using ≥10 points minimal important difference, range 0-100); distributions were compared using a stratified log-rank test adjusting for tumor functionality. Linear mixed models were fit to assess change from baseline in QLQ-C30 scores by treatment arm over time. Results: Of 85 pts enrolled between 2001 and 2008, 82 (96%) completed the QLQ-C30 at baseline (oct l-a: 40, PBO: 42). There were few events of definitive deterioration for most scales. Median TDD was not reached in 11/15 scales for oct l-a and 5/15 scales for PBO. Significantly longer TDD was reported for oct l-a vs. PBO for fatigue (median 6.8 months vs 18.5; p = 0.0006), pain (not reached (NR) vs 18.2; p = 0.0435), and insomnia (NR vs 16.4; p = 0.0046). Change from baseline to wk 24 fatigue scores were stable for oct l-a (least squares [LS] mean 0.78 (95% CI -6.3: 7.8) but worsened for PBO (LS mean 9.1; 95% CI 1.9: 16.4); with mean difference -8.4 (95% CI -18.5: 1.8). For diarrhea there were improvements for oct l-a (LS mean -8.0; 95% CI -19.6: 3.5) and worsening for PBO (LS mean 11.2; 95% CI -0.7: 23.1); with mean difference -19.3 (95% CI: -36.1; -2.5). Conclusions: These post-hoc analyses showed significantly longer TDD for oct l-a vs. PBO in pts with mmNET for symptoms relevant in NET: fatigue, pain, and insomnia; alongside improved tumor control. Change from baseline showed that HRQoL was maintained in oct l-a pts whereas significant deterioration for some symptoms was observed in PBO pts, further supporting HRQoL benefits of oct l-a treatment. Clinical trial identification: SMS995ADE05 / NCT00171873. Legal entity responsible for the study: Novartis Pharmaceuticals Incorporated. Funding: Novartis Pharmaceutical Corporation. Disclosure: A. Rinke: Advisory boards: Novartis, Ipsen. M.P. Neary: Employee: Novartis Pharmaceuticals Corporation. J. Eriksson, M. Hunger: Employee: ICON plc. T. Doan, D. Karli: Employee: Novartis Ireland Ltd. All other authors have declared no conflicts of interest.

Within emergency department (ED) sepsis patients, delayed deterioration resulting in shock is associated with increased risk of death. Heparin-binding protein (HBP), a neutrophil-released serum biomarker, has been shown to be elevated in patients developing delayed shock. The objective of this study was to assess the performance of HBP to predict delayed shock among sepsis sub-populations.

The built environment of health care systems plays a crucial role in factors such as patient safety, staff satisfaction, patient experience, and optimal health. As hospital centers are being renovated or expanded over the past decade or so, the clinical built environment of many of them have not been redesigned to align with today’s evolving clinical roles. Just as medicine has increasingly moved toward “evidence-based medicine,” where clinical choices are informed by research, healthcare design is increasingly guided by rigorous research linking the physical environment of hospitals to patients and staff outcomes and is moving toward “evidence-based design”. The goal of human simulations in the context of architectural builds is to present the workflow (both normal and emergent) in the design of the complex cooperative work environment. The results obtained can be used to change the design process by improving the built environment to support end users to provide optimal health, exceptional experience, and organizational vitality. These proceedings describe the process and provide an example of the evaluation of a future single patient neonatal intensive care unit room.

P001 - Sepsis impairs the capillary response within hypoxic capillaries and decreases erythrocyte oxygen-dependent ATP efflux

Background: Orange is a regional base hospital servicing a rural population of 270,775 people across 250,000km2. It offers 24/7 rescue PCI to support pre-hospital and in-hospital thrombolysis across the LHD. Additionally, PPCI is offered for patients presenting directly or by ambulance diversion to Orange within business hours and for lytic ineligible patients presenting anytime within the LHD. Methods: A retrospective audit of patients who underwent PPCI and rescue PCI at Orange Hospital from 1/1/15-31/12/15 was performed. Patients were identified using audits and medical records. Results: PPCI was performed for 22 patients: 17 presented in-hours and 5 presented out-of-hours but had a contraindication to lysis. The median door-to-balloon (DTB) time was 52min (see table). DTB times were shorter for patients who had their diagnostic ECG performed by paramedics using the LIFENET system compared to by ED (median DTB time 35min versus 74min). Rescue PCI was required in 32 of the 104 patients who were thrombolysed in 2015 (31%). The majority (68%) of rescue PCI cases were performed outside business hours (0800-1700 weekdays). Mean transport time to Orange hospital was 75+/-48min and mean transport distance was 131km. Median DTB time was 70min (see table).Tabled 1DTB time0-30min30-60min60-90min>90minPPCI (%)11442817Rescue PCI (%)19192537 Open table in a new tab Conclusion: Orange Hospital has demonstrated the feasibility of a 24/7 primary and rescue PCI service operating within a rural setting. Better systems of transport and ambulance diversion to the PPCI centre will expand the benefits of this service.

Background: Rural STEMI patients have lower rates of reperfusion and higher mortality compared to their metropolitan counterparts, in part due to the large distances and resource limitations of rural NSW. We aimed to review the contribution of patient delays in accessing timely reperfusion. Methods: A retrospective audit of STEMI patients within Western NSW LHD in 2015 was undertaken. Comparisons were made with NSW ambulance data on metropolitan STEMI patients from a single month in 2012. Results: 150 patients were diagnosed with STEMI in 2015. Of these, 49% called an ambulance and 51% presented directly to ED. For patients calling an ambulance, the median symptom-onset-to-call time was 34 min, compared to 66 min for metropolitan patients. Symptom onset to first clinical contact (FCC) was significantly longer for rural patients presenting direct to ED (median 110min) compared to those presenting via ambulance (median 72min)(p=0.037). Mean FCC time to lysis for rural ambulance was 44+/-26 min versus 60+/-33 min for ED (p=0.02). FCC was outside the thrombolysis window (12hrs) in 9% of rural patients, compared to 4% in metro patients.Tabled 1Table: Symptom onset to FCC according to mode of presentation and locationSymptom onset to FCC0-30min30-60min60-90min>90minMetro Ambulance(%)25161346Rural Ambulance(%)31171735Rural ED(%)2113956 Open table in a new tab Conclusion: The majority of rural STEMI patients do not call an ambulance, delaying care and preventing access to pre-hospital thrombolysis. Strategies to reduce these delays are vital to address disparities in clinical outcomes for rural patients.