Shoalhaven District Memorial Hospital

Absorbed dose determination for therapeutic kilovoltage (kV) x rays is performed following international recommendations to ensure consistency in practice and equivalence in dose delivery for patients worldwide. These recommendations include limits on the variation of ionization chamber calibration coefficients with beam quality. To date, data on energy-dependence have only been published for a limited set of ionization chambers and kV beams, and there are limited guidelines regarding which models of cylindrical ionization chambers are suitable for kV reference dosimetry. To provide cylindrical ionization chamber energy-dependence data with enough beam qualities and chambers to assist medical physicists to assess the compliance of chamber models with protocol recommendations regarding chamber characteristics. Air kerma calibration coefficients for 150 cylindrical ionization chamber calibrations performed between 2017 and 2024 in 59 medium-energy x-ray beam qualities at the Australian Primary Standards Laboratory were analyzed. Chamber response was scrutinized and assessed for compliance with international recommendations on absorbed dose determination for kilovoltage x-ray beams. All chambers showed some degree of energy dependence, with none of the chamber models investigated fully satisfying international recommendations. Chamber response is dominated by filtration (half-value layer), with a weaker dependence on generating potential (kVp); differences of up to ±4.3% were observed for a 100 kVp beam spanning 1.30-6.61mm Al HVL. Distinct differences in response were observed between chamber models, providing rationale for use or exclusion in kV absorbed dose determination. Energy dependence was observed to vary between chambers of the same model type, indicating that calibration coefficients cannot be interchanged between individual chambers of the same model. Cylindrical ionization chambers frequently used for reference dosimetry of kV x-ray beams exhibit different energy dependence based on model type. Some models frequently employed and recommended for use in absorbed dose determination do not satisfy international protocol recommendations regarding energy dependence. International recommendations and protocols for absorbed dose determination for kilovoltage x-rays based solely on kVp should be reviewed and further developed to explicitly account for the effect of filtration (HVL) on chamber response. The results of this work support the adoption or refinement of the recommended chamber types within reference dosimetry protocols.

Energy and protein provision for critically ill patients who receive oral nutrition often falls below recommended targets. We compared characteristics and nutrition processes during hospital stay (within and post-intensive care unit [ICU] stay) of those who received oral nutrition as the sole nutrition source to those who first commenced enteral (EN) or parenteral nutrition (PN) within an Australian or New Zealand (ANZ) ICU. Multicentre, observational study of routine nutrition care in 44 hospitals across ANZ, including adult patients within ICU admitted for at least 48 h. Those receiving oral nutrition as the sole source of nutrition (with or without oral nutrition supplements) were included in the 'oral nutrition' group and those who first received EN and/or PN in the ICU as the 'EN/PN group'. The primary outcome was median daily energy delivery in ICU. Data are presented as number (%) or median [interquartile range]. Of the 409 patients enroled, median [IQR] age was 64 [51-74] years and 257 patients (62%) were male. APACHE II score, use of invasive ventilation and hospital length of stay (LOS) were all lower in those receiving oral nutrition (n = 200) compared to those receiving EN/PN (n = 209). In ICU, 63 (31.5%) and 169 (81%) (p < 0.001), patients who were receiving oral nutrition and in the EN/PN group received a nutrition assessment, respectively. Oral nutrition supplements were provided for 40 (20%) patients in the oral nutrition group and 31 of 94 (33%) of those receiving oral nutrition in the EN/PN group (p = 0.019). Energy and protein intake in ICU for the oral nutrition group was 716 [597-1069] kcal/day and 37 [19-46] g/day versus 1158 [664-1583] kcal/day and 57 [31-77] g/day for those receiving EN/PN (p = 0.020 energy, p = 0.016 protein). Quantification of oral nutrition was attempted in 78/294 (27%) patients in ICU and completed on 27/78 (36%) occasions. On the ward, attempts were made for 120/273 (44%) patients, with 60/120 (50%) complete. Patients who received oral nutrition as the sole nutrition source in ICU had lower illness severity, rates of nutrition assessment and provision of oral supplements compared to those who first received EN/PN. Quantification of oral nutrition was often incomplete for all patients in ICU and on the ward.

Low mucinous neoplasm of the appendix (LAMN) and appendiceal diverticulum are both uncommon pathologies that may pose a diagnostic challenge. Both may present as either appendicitis or asymptomatically and have a risk of perforation. LAMN, carries the additional risk of pseudomyxoma pertitonei and metastasis. Ensuring correct histopathology is crucial, as computed tomography (CT) abdomen/pelvis may only demonstrate a mildly dilated appendix, delaying diagnostic laparoscopy and appendicectomy. Here, we describe the case report of a 56-year-old woman who presented with chronic intermittent right iliac fossa pain initially determined to be chronic appendicitis. Following laparoscopic appendicectomy, histopathology demonstrated LAMN, however, on further re- assessment of histopathology, as well as the completion of a normal pan-CT and colonoscopy, a final diagnosis of ruptured appendiceal diverticulum was made. Our case demonstrates the utility of a multi-disciplinary approach in evaluating patients with possible appendiceal LAMN or appendiceal diverticulum.

3535 Background: Pan added to combination chemotherapy is a preferred first-line therapy for unresectable RAS and BRAF wild type mCRC. Elderly patients may not be suitable for such combination regimens, where FU plus bevacizumab (bev) is used. We therefore investigated two lower intensity pan-containing first-line regimens in an elderly population. Methods: We conducted a prospective, non-comparative, randomized phase 2 study of pan alone (arm A) or pan plus FU (arm B). The study recruited previously untreated patients with unresectable mCRC who were aged 70 years or older; with RAS and BRAF wild type mCRC, and ECOG performance 0-2. Patients were randomized (1:1) to pan 6mg/kg 2 weekly or pan plus FU 400 mg/m2 bolus; leucovorin 200mg/m2; FU 2400mg/m2 46-hour infusion 2 weekly. Treatment was continued until progression. The primary study endpoint was 6-month progression-free survival (PFS). Secondary endpoints were: overall survival (OS), response rate (RR), feasibility of a composite geriatric assessment (EORTC QLQ-C30, symptoms, Mini-Mental State Examination, timed 20-metre walk, Charlson Co-morbidity Index, weight loss/arm circumference), toxicity and overall treatment utility (OTU)- a composite measure of treatment benefit based on radiological response, clinician-assessed clinical progress, toxicity and patient-reported treatment impact and worth. The planned sample size was 40 patients per arm, based on an expected PFS of 73% at 6 months. Results: 36 of the planned 80 patients (arm A n=19, arm B n=17) were randomized between June 2018 and June 2021. Recruitment was hampered by a high rate of RAS and BRAF mutations and COVID19. Median age was 79 and 80 years, left sided primary in 74% and 82% and ECOG 0/1 in 89% and 100% in arms A and B, respectively. Median follow up was 36 months. 6-month PFS was 63% (95% CI 38-80%) in arm A and 82% (95%CI 55%-94%) in arm B. Median OS was 21 months in arm A (95%CI 13-31) and 28 (95%CI 14-39) months in arm B. RR was 47% and 65% in arms A and B respectively. Baseline comprehensive geriatric assessments were fully completed in &gt;80% of patients. At week 16, OTU was categorized as good in 92% (arm A) and 90% (arm B) of patients . Rates of adverse events and serious adverse events were similar between the arms. Conclusions: 6-month PFS in both arms was consistent with the hypothesized rate of 73% achieved with FU/bev, whilst the rate was numerically higher for arm B. Baseline comprehensive geriatric assessments were feasible and OTU was high in both arms. Both treatment arms might be suitable first-line options in appropriately selected patients. Acknowledgements: Partial funding and panitumumab provided by AMGEN. MONARCC was partially funded and sponsored by AGITG; co-ordinated by NHMRC CTC, University of Sydney. Clinical trial information: ACTRN 12618000233224.

Breast cancer management is complex, requiring personalised care from multidisciplinary teams. Research shows that there is unwarranted clinical variation in mastectomy rates between rural and metropolitan patients; that is, variation in treatment which cannot be explained by disease progression or medical necessity. This study aims to determine the clinical and nonclinical factors contributing to any unwarranted variation in breast cancer management in rural patients and to evaluate how these factors and variations relate to patient outcomes. Comprehensive data from patients who had primary breast cancer surgery from 2010 to 2014 in either a rural or metropolitan location in a single local health district was analysed (n = 686). Records were subset into two rurality groupings based on the postcode in which the patient resided, and the Modified Monash Model (MMM), an Australian system for classifying rurality. Statistical analysis was used to compare rural and metropolitan cohorts on treatments, patient characteristics, timeliness, and outcomes (recurrence and survival). Rural patients had higher mastectomy rates than metropolitan patients (57% vs. 34%, p < 0.001), despite a lack of difference in clinical or demographic factors accounting for such variation. The length of time between treatment pathway stages was consistently longer amongst rural patients (p < 0.01). Rural women also had worse survival outcomes, especially amongst HER2-positive patients who had significantly lower survival (5-year 74% vs 82%; 10-year 49% vs 71%, p < 0.05) than metropolitan HER2-positive patients. This study reveals clinical disparities among rural breast cancer patients, that cannot be explained by demographic and clinical factors alone. Rural patients face lower rates of breast-conserving surgery and treatment delays, attributable to systemic barriers such as limited access to specialist care, high travel costs, and suboptimal care coordination. These findings have important implications for improving equity and collaboration in delivering person-centred breast cancer care.

Cushing syndrome resulting from adrenocortical carcinoma in pregnancy is exceedingly rare. There are no validated guidelines to establish a diagnosis or guide management in pregnancy. We provide a case of a 31-year-old woman presenting for management of diabetes in pregnancy who appeared cushingoid. She was subsequently diagnosed with ACTH-independent Cushing syndrome and experienced preterm labor at 33 weeks' gestation, delivering a healthy infant. Four weeks postpartum, the patient underwent a left adrenalectomy and was subsequently diagnosed with adrenocortical carcinoma.

The aim of this study was to characterise and compare the biopsychosocial characteristics of children admitted with failure to thrive (FTT), subdivided into those with underlying medical complexities (categorised as organic FTT - OFTT) and those with none (categorised as non-organic FTT - NOFTT), with a focus on the medical, nutritional, feeding skills and psychosocial domains. A retrospective review of medical records was conducted in children admitted with FTT from January 2010 to December 2020. Descriptive statistics were used for data analysis. A total of 353 children were included, with the mean age of presentation 0.82 ± 2.05 years (OFTT 1.16 ± 2.50 years, NOFTT 0.49 ± 1.41 years, P = 0.002). Approximately, half of the children were classified as having OFTT. These children had lower birth weights, were more likely to have a history of intrauterine growth restriction and had longer hospital stays. The NOFTT group had significantly more abnormal feeding strategies identified in their caregivers, whereas the OFTT group had more delayed feeding skills and oral aversion. There was no significant difference in psychosocial domains, with both groups having a comparably high risk of abuse and neglect. The classification of FTT as non-organic or organic based purely on psychosocial parameters did not reflect the complex nature of FTT within our local population. These groups had different medical variables, and caregiver feeding strategies. A multidisciplinary team approach is recommended for the assessment and intervention for children with FTT to address these domains and the complex interactions between them.

Abstract IntroductionUltrasound (USS) and magnetic resonance imaging (MRI) have been used as screening tools for rotator cuff tears with MRI reported as superior. When comparing USS and MRI for supraspinatus tears, less data is available.AimCompare the diagnostic sensitivity of USS and MRI in the pre‐operative diagnosis of partial thickness tears (PTT) and full thickness tears (FTT) of supraspinatus tendons compared to gold‐standard shoulder arthroscopy to assess if differences in detection rates exist.MethodRetrospective study of deidentified electronic medical records including post‐operative surgical notes and pre‐operative imaging USS and MRI results.ResultsN = 103 participants, male: female ratio of 63:40, mean age 64 years. FTT were diagnosed by arthroscopy in 63/103 (61.2%), PTT &lt;5 mm in 18/103 (17.5%), PTT &gt;5 mm in 22/103 (21.4%). USS and MRI sensitivity were both 95.2% for FTT. PTT &lt;5 mm sensitivity for USS and MRI were 83.3% and 77.7%, and PTT &gt;5 mm sensitivity were 73.3% and 86.4% respectively. Overall supraspinatus tears USS sensitivity was 88.4% and MRI 90.3%.DiscussionComparable sensitivity was demonstrated for FTT for USS and MRI. USS had better sensitivity than MRI for PTT &lt;5 mm, MRI performed better for PTT &gt;5 mm. Pre‐operative evaluation of suspected supraspinatus tears could include USS as a first line imaging modality, due to its low cost and easier availability.ConclusionUSS has high diagnostic accuracy for diagnosing supraspinatus FTT and PTT. MRI may be used where significant glenohumeral joint osteoarthritis needs to be assessed. Further studies with larger numbers are needed to verify these results.

The lack of dedicated theatre time for orthopaedic surgeries at a small rural hospital meant that operations were regularly performed after hours as well as on weekends. Retrospective observational audit. Data were collected for 317 patients admitted for trauma surgery between August 2019 and March 2020 at Shoalhaven District Memorial Hospital, which has an orthopaedic service and acts as a referral hospital for a 4561-km2 catchment on the South Coast of New South Wales. Decreased time to surgery, length of stay and proportion of after-hours operating. To quantify patient outcomes demonstrating effectiveness of the trauma list in theatre operations at the hospital, providing evidence for adequate provision of care at the rural location A reduction in out-of-hours operations results in a significant financial saving to the hospital, as well as increased safety to patients. Significantly more operations were performed before 16:00hours as well as on a weekday. Trauma list patients have a shorter length of stay (4.82 vs 7.8days). Patients prior to the trauma list waited on average 89hours for surgery, whereas patients on the trauma list waited only 43hours. A dedicated, twice-weekly orthopaedic trauma list is able to significantly reduce after hours and weekend surgeries. Patients placed on the trauma list had a significantly shorter length of stay and time to surgery. We therefore recommend the usage of dedicated trauma lists at small, regional sites not just to achieve cost savings but also to improve the patient journey and keep patients closer and returning to the home sooner.