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Gravitational waves from coalescing neutron stars encode information about nuclear matter at extreme densities, inaccessible by laboratory experiments. The late inspiral is influenced by the presence of tides, which depend on the neutron star equation of state. Neutron star mergers are expected to often produce rapidly rotating remnant neutron stars that emit gravitational waves. These will provide clues to the extremely hot post-merger environment. This signature of nuclear matter in gravitational waves contains most information in the 2–4 kHz frequency band, which is outside of the most sensitive band of current detectors. We present the design concept and science case for a Neutron Star Extreme Matter Observatory (NEMO): a gravitational-wave interferometer optimised to study nuclear physics with merging neutron stars. The concept uses high-circulating laser power, quantum squeezing, and a detector topology specifically designed to achieve the high-frequency sensitivity necessary to probe nuclear matter using gravitational waves. Above 1 kHz, the proposed strain sensitivity is comparable to full third-generation detectors at a fraction of the cost. Such sensitivity changes expected event rates for detection of post-merger remnants from approximately one per few decades with two A+ detectors to a few per year and potentially allow for the first gravitational-wave observations of supernovae, isolated neutron stars, and other exotica.
The concentration of radiocarbon (14C) differs between ocean and atmosphere. Radiocarbon determinations from samples which obtained their 14C in the marine environment therefore need a marine-specific calibration curve and cannot be calibrated directly against the atmospheric-based IntCal20 curve. This paper presents Marine20, an update to the internationally agreed marine radiocarbon age calibration curve that provides a non-polar global-average marine record of radiocarbon from 0–55 cal kBP and serves as a baseline for regional oceanic variation. Marine20 is intended for calibration of marine radiocarbon samples from non-polar regions; it is not suitable for calibration in polar regions where variability in sea ice extent, ocean upwelling and air-sea gas exchange may have caused larger changes to concentrations of marine radiocarbon. The Marine20 curve is based upon 500 simulations with an ocean/atmosphere/biosphere box-model of the global carbon cycle that has been forced by posterior realizations of our Northern Hemispheric atmospheric IntCal20 14C curve and reconstructed changes in CO2 obtained from ice core data. These forcings enable us to incorporate carbon cycle dynamics and temporal changes in the atmospheric 14C level. The box-model simulations of the global-average marine radiocarbon reservoir age are similar to those of a more complex three-dimensional ocean general circulation model. However, simplicity and speed of the box model allow us to use a Monte Carlo approach to rigorously propagate the uncertainty in both the historic concentration of atmospheric 14C and other key parameters of the carbon cycle through to our final Marine20 calibration curve. This robust propagation of uncertainty is fundamental to providing reliable precision for the radiocarbon age calibration of marine based samples. We make a first step towards deconvolving the contributions of different processes to the total uncertainty; discuss the main differences of Marine20 from the previous age calibration curve Marine13; and identify the limitations of our approach together with key areas for further work. The updated values for ΔR, the regional marine radiocarbon reservoir age corrections required to calibrate against Marine20, can be found at the data base http://calib.org/marine/.
Introduction: A critical component for successful implementation of any innovation is an organization's readiness for change. Competence by Design (CBD) is the Royal College's major change initiative to reform the training of medical specialists in Canada. The purpose of this study was to measure readiness to implement CBD among the 2019 launch disciplines. Methods: An online survey was distributed to program directors of the 2019 CBD launch disciplines one month prior to implementation. Questions were developed based on the R = MC2 framework for organizational readiness. They addressed program motivation to implement CBD, general capacity for change, and innovation-specific capacity. Questions related to motivation and general capacity were scored using a 5-point scale of agreement. Innovation-specific capacity was measured by asking participants whether they had completed 33 key pre-implementation tasks (yes/no) in preparation for CBD. Bivariate correlations were conducted to examine the relationship between motivation, general capacity and innovation specific capacity. Results: Survey response rate was 42% (n = 79). A positive correlation was found between all three domains of readiness (motivation and general capacity, r = 0.73, p < 0.01; motivation and innovation specific capacity, r = 0.52, p < 0.01; general capacity and innovation specific capacity, r = 0.47, p < 0.01). Most respondents agreed that successful launch of CBD was a priority (74%). Fewer felt that CBD was a move in the right direction (58%) and that implementation was a manageable change (53%). While most programs indicated that their leadership (94%) and faculty and residents (87%) were supportive of change, 42% did not have experience implementing large-scale innovation and 43% indicated concerns about adequate support staff. Programs had completed an average of 72% of pre-implementation tasks. No difference was found between disciplines (p = 0.11). Activities related to curriculum mapping, competence committees and programmatic assessment had been completed by >90% of programs, while <50% of programs had engaged off-service rotations. Conclusion: Measuring readiness for change aids in the identification of factors that promote or inhibit successful implementation. These results highlight several areas where programs struggle in preparation for CBD launch. Emergency medicine training programs can use this data to target additional implementation support and ongoing faculty development initiatives.
Ground-penetrating radar data acquired in the 2016/17 austral summer on Sørsdal Glacier, East Antarctica, provide evidence for meltwater lenses within porous surface ice that are conceptually similar to firn aquifers observed on the Greenland Ice Sheet and the Arctic and Alpine glaciers. These englacial water bodies are associated with a dry relict surface basin and consistent with perennial drainage into an interconnected englacial drainage system, which may explain a large englacial outburst flood observed in satellite imagery in the early 2016/17 melt season. Our observations indicate the rarely-documented presence of an englacial hydrological system in Antarctica, with implications for the storage and routing of surface meltwater. Future work should ascertain the spatial prevalence of such systems around the Antarctic coastline, and identify the degree of surface runoff redistribution and storage in the near surface, to quantify their impact on surface mass balance.
Drawing on a landscape analysis of existing data-sharing initiatives, in-depth interviews with expert stakeholders, and public deliberations with community advisory panels across the U.S., we describe features of the evolving medical information commons (MIC). We identify participant-centricity and trustworthiness as the most important features of an MIC and discuss the implications for those seeking to create a sustainable, useful, and widely available collection of linked resources for research and other purposes.
A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital.
This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments.
Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes.
The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.
Excitable temperament disrupts physiological events required for reproductive development in cattle, but no research has investigated the impacts of temperament on growth and puberty attainment in Bos indicus females. Hence, this experiment evaluated the effects of temperament on growth, plasma cortisol concentrations and puberty attainment in B. indicus heifers. A total of 170 Nelore heifers, weaned 4 months before the beginning of this experiment (days 0 to 91), were managed in two groups of 82 and 88 heifers each (mean ± SE; initial BW=238±2 kg, initial age=369±1 days across groups). Heifer temperament was evaluated via exit velocity on day 0. Individual exit score was calculated within each group by dividing exit velocity into quintiles and assigning heifers with a score from 1 to 5 (1=slowest; 5=fastest heifer). Heifers were classified according to exit score as adequate (ADQ, n=96; exit score⩽3) or excitable temperament (EXC, n=74; exit score>3). Heifer BW, body condition score (BCS) and blood samples were obtained on days 0, 31, 60 and 91. Heifer exit velocity and score were recorded again on days 31, 60 and 91. Ovarian transrectal ultrasonography was performed on days 0 and 10, 31 and 41, 60 and 70, 81 and 91 for puberty evaluation. Heifer was declared pubertal at the first 10-day interval in which a corpus luteum was detected. Exit velocity and exit score obtained on day 0 were correlated (r⩾0.64, P<0.01) with evaluations on days 31, 60 and 91. During the experiment, ADQ had greater (P<0.01) mean BCS and BW gain, and less (P<0.01) mean plasma cortisol concentration compared with EXC heifers. Temperament × time interactions were detected (P<0.01) for exit velocity and exit score, which were always greater (P<0.01) in EXC v. ADQ heifers. A temperament × time interaction was also detected (P=0.03) for puberty attainment, which was delayed in EXC v. ADQ heifers. At the end of the experiment, a greater (P<0.01) proportion of ADQ were pubertal compared with EXC heifers. In summary, B. indicus heifers classified as EXC had reduced growth, increased plasma cortisol concentrations and hindered puberty attainment compared to ADQ heifers. Moreover, exit velocity may serve as temperament selection criteria to optimize development of B. indicus replacement heifers.
Artificial rearing of young animals represents a challenge in modern ruminant production systems. This work aims to evaluate the short- and long-term effects of the type of rearing on the animal’s health, growth, feed utilization and carcass performance. A total of 24 pregnant ewes carrying triplets were used. Within each triplet set, lambs were randomly allocated to one experimental treatment: natural rearing on the ewe (NN); ewe colostrum for 24 h followed by artificial rearing with milk replacer (NA) and 50 g of colostrum alternative supplementation followed by artificial rearing (AA). Milk replacer, ryegrass hay and creep feed were offered ad libitum, and each experimental group was kept in independent pens until weaning at 45 days of age. After weaning all lambs were placed together on the same pasture for fattening for 4 months. Blood samples were taken at 24 h after birth, at weaning and at the end of the fattening period (23 weeks). Results showed that no failure in the passive immune transfer was detected across treatments. Although artificially reared lambs at weaning had lower plasma levels of β-hydroxy-butyrate (−62%), high-density lipoproteins (−13%) and amylase (−25%), and higher levels of low-density lipoproteins (+38%) and alkaline phosphatase (+30%), these differences disappeared during the fattening period. Only the greater levels of calcium and the lower levels of haemoglobin and white blood cells detected at weaning in artificially reared lambs (+7.2%, −2.8% and −17.8%) persisted by the end of the fattening period (+4.3%, −3.3% and −9.5%, respectively). Minor diarrheal events from weeks 2 to 5 were recorded with artificial rearing, leading to lower growth rates during the 1st month. However, these artificially reared lambs caught up towards the end of the milk feeding period and reached similar weaning weights to NN lambs. During the fattening period NN lambs had a greater growth rate (+16%) possibly as a result of their greater early rumen development, which allowed a higher feed digestibility during the fattening period in comparison to NA lambs (+5.9%). As a result, NN lambs had heavier final BWs (+7.0%), but tended to have lower dressing percentage (−5.7%) than artificially reared lambs, thus no differences were noted in either carcass weight or in carcass conformation across treatments. In conclusion, the use of a colostrum alternative and milk replacer facilitated the successful rearing of lambs, reaching similar productive parameters; however, special care must be taken to maximize the rumen development before weaning.
Antibodies at gastrointestinal mucosal membranes play a vital role in immunological protection against a range of pathogens, including helminths. Gastrointestinal health is central to efficient livestock production, and such infections cause significant losses. Fecal samples were taken from 114 cattle, across three beef farms, with matched blood samples taken from 22 of those animals. To achieve fecal antibody detection, a novel fecal supernatant was extracted. Fecal supernatant and serum samples were then analysed, using adapted enzyme-linked immunosorbent assay protocols, for levels of total immunoglobulin (Ig)A, IgG, IgM, and Teladorsagia circumcincta-specific IgA, IgG, IgM and IgE (in the absence of reagents for cattle-specific nematode species). Fecal nematode egg counts were conducted on all fecal samples. Assays performed successfully and showed that IgA was the predominant antibody in fecal samples, whereas IgG was predominant in serum. Total IgA in feces and serum correlated within individuals (0.581, P = 0.005), but other Ig types did not. Results support the hypothesis that the tested protocols are an effective method for the non-invasive assessment of cattle immunology. The method could be used as part of animal health assessments, although further work is required to interpret the relationship between results and levels of infection and immunity.
The discovery of the first electromagnetic counterpart to a gravitational wave signal has generated follow-up observations by over 50 facilities world-wide, ushering in the new era of multi-messenger astronomy. In this paper, we present follow-up observations of the gravitational wave event GW170817 and its electromagnetic counterpart SSS17a/DLT17ck (IAU label AT2017gfo) by 14 Australian telescopes and partner observatories as part of Australian-based and Australian-led research programs. We report early- to late-time multi-wavelength observations, including optical imaging and spectroscopy, mid-infrared imaging, radio imaging, and searches for fast radio bursts. Our optical spectra reveal that the transient source emission cooled from approximately 6 400 K to 2 100 K over a 7-d period and produced no significant optical emission lines. The spectral profiles, cooling rate, and photometric light curves are consistent with the expected outburst and subsequent processes of a binary neutron star merger. Star formation in the host galaxy probably ceased at least a Gyr ago, although there is evidence for a galaxy merger. Binary pulsars with short (100 Myr) decay times are therefore unlikely progenitors, but pulsars like PSR B1534+12 with its 2.7 Gyr coalescence time could produce such a merger. The displacement (~2.2 kpc) of the binary star system from the centre of the main galaxy is not unusual for stars in the host galaxy or stars originating in the merging galaxy, and therefore any constraints on the kick velocity imparted to the progenitor are poor.
In this paper, first results comparing modified Longin and ninhydrin collagen extraction methodologies are presented. The goal of this study is to investigate the bones of several species with different ages, preservation conditions, and collagen contents to determine the most suitable preparation method. Different types of samples are used such as VIRI samples, previously dated bones, and background samples. Each bone has undergone elemental analysis, infrared analysis, and 14C measurement. The results are presented and the advantages and disadvantages of each preparation method are discussed. In general, results obtained by the two methods are in accordance with the consensus value for 2σ uncertainty. For VIRI I and a mammoth bone, the ninhydrin preparation gives, respectively, 8450±70 BP and 14,870±60 BP whereas the modified Longin process gives 8365±45 BP and 14,750±100 BP in agreement with the expected values. From the experimental point of view, the modified Longin process is easier to implement than the ninhydrin protocol. From this approach, we can conclude that the modified Longin process could be preferred in most cases and particularly when the amount of bone is small and the sample is not too contaminated.
TAOS II is a next-generation occultation survey with the goal of measuring the size distribution of the small end of the Kuiper Belt (objects with diameters 0.5–30 km). Such objects have magnitudes r > 30, and are thus undetectable by direct imaging. The project will operate three telescopes at San Pedro Mártir Observatory in Baja California, México. Each telescope will be equipped with a custom-built camera comprised of a focal-plane array of CMOS imagers. The cameras will be capable of reading out image data from 10,000 stars at a cadence of 20 Hz. The telescopes will monitor the same set of stars simultaneously to search for coincident occultation detections, thus minimising the false-positive rate. This talk described the project, and reported on the progress of the development of the survey infrastructure.
We explore the properties of sound and human sound recognition as a means to enhance and accelerate visual-only data analysis methods. The aim of this work is to enable and improve the analysis of large data sets, data requiring rapid analysis, multi-dimensional data, and signal detection in data with low signal-to-noise ratio. We present a prototype tool, StarSound, to sonify data such as astronomical transient light curves, spectra, and power spectra. Stereophonic sound is used to ‘visualise’ and localise the data under examination, and 3-D sound is discussed in conjunction with virtual reality technology, as a means to enhance analysis efficiency and efficacy, including rapid data assessment and training machine learning software. In addition, we explore the use of higher-order harmonics as a means to examine simultaneously multi-dimensional data sets. Such an approach can allow the data to be interpreted in a holistic manner and facilitates the discovery of previously unseen connections and relationships. Furthermore, we exploit the capability of the human brain for selective or focused hearing that enables the identification of desired signals in noisy data, or amidst similar or more significant signals. Finally, we provide research examples that benefit directly from data sonification. The work presented here aims to help tackle the challenges of the upcoming era of Big Data and help optimise, speed up and expand aspects of data analysis requiring human interaction.
The Deeper Wider Faster programme (DWF) is a project that coordinates more than 30 multi-wavelength and multi-messenger facilities worldwide and in space, in order to detect and study fast transients (durations of milliseconds to hours). DWF has four main components: (1) simultaneous observations, where ∼10 major facilities, from radio to gamma-ray, are coordinated to perform short-cadence, deep, wide-field observations of the same field at the same time. Radio telescopes search for fast radio bursts, while optical imagers and high-energy instruments search for transient events whose time-scales are seconds to hours, (2) supercomputer data processing and candidate identification in real time (seconds to minutes), along with human inspection of candidates, also in real time (minutes), using sophisticated visualisation technology, (3) rapid-response (minutes) follow-up spectroscopy and imaging, and conventional ToO observations, and (4) long-term follow up by a global network of 1-m to 4-m telescopes. The principal goals of DWF are to discover and study counterparts to fast radio bursts and gravitational-wave events, as well as transients at all wavelengths that have durations of milliseconds to hours.
Terrestrial gastropods are problematical for radiocarbon (14C) measurement because they tend to incorporate carbon from ancient sources as a result of their dietary behavior. The 14C ecology of the pulmonate land snail, Helix melanostoma in Cyrenaica, northeastern Libya, was investigated as part of a wider study on the potential of using terrestrial mollusk shell for 14C dating of archaeological deposits. H. melanostoma was selected out of the species available in the region as it has the most predictable 14C ecology and also had a ubiquitous presence within the local archaeology. The ecological observations indicate that H. melanostoma has a very homogenous 14C ecology with consistent variations in F14C across sample sites controlled by availability of dietary vegetation. The majority of dated specimens from non-urbanized sample locations have only a small old-carbon effect, weighted mean of 476±48 14C yr, with between ~1% and 9% of dietary F14C from non-organic carbonate sources. Observed instabilities in the 14C ecology can all be attributed to the results of intense human activity not present before the Roman Period. Therefore, H. melanostoma and species with similar ecological behavior are suitable for 14C dating of archaeological and geological deposits with the use of a suitable offset.
Dementia is a neurodegenerative syndrome that interferes with multiple aspects of life, including cognition, daily functioning, and behavior. Despite the large heterogeneity in symptom development, these three domains are seldom studied simultaneously. This study investigates how trajectories of these domains are interrelated within individuals over time, and how they in turn are related to dementia severity and quality of life (QoL).
We used data from a longitudinal clinical cohort study, including 331 dementia patients. Cognitive status was measured using the Mini-Mental State Examination, daily functioning was measured with the disability assessment for dementia and neuropsychiatric symptoms (NPS) were scored using the neuropsychiatric inventory. We investigated the relationships in the time course of the various dementia domains using random effects multilevel models and parallel-process growth models.
Changes in cognition and daily functioning were highly correlated over time (r = 0.85, p < 0.01), as were changes in NPS and functioning (r = −0.60, p < 0.01), while changes in cognition and NPS were not (r = −0.20, p = 0.06). All three domains were strongly associated with dementia severity over time (p < 0.01). Decreased functioning and increased NPS were both associated with decreased QoL (β = 2.97, p < 0.01 and β = −2.41, p < 0.01, respectively), while cognition was not (β = 0.01, p = 0.93).
This study demonstrates the heterogeneity of dementia progression between individuals and between different dementia domains within individuals. To improve our understanding of dementia progression, future research should embrace a broader perspective encompassing multiple outcome measures along with the patient's profile, including neurological factors as well as physical, social, and psychiatric health.
Introduction: Youth injured by violence is a major public health concern in Canada. It is the fourth leading cause of death in youth and the foremost reason youth visit an emergency department (ED). In Winnipeg, 20% of youth who visit an ED with an injury due to violence will have an ED visit for a subsequent violent injury within one year. Youth injured by violence are in a reflective and receptive state of mind, rendering the ED setting appropriate for intervention. Methods: We completed a randomized control trial in November 2015 comparing wraparound care for youth age 14 - 24 who were injured by violence to standard ED care. Youth were excluded if their injury was due to child maltreatment, sexual assault or self-harm. An adapted pre-consent randomization methodology was used. The intervention was developed using a community based participatory research approach. Wraparound care was delivered by a support worker with lived experience with violence. Support workers were on call 24/7 in order to start the intervention in the ED and take advantage of the “teachable moment.” Care continued in the community for approximately one year. Results: A total of 133 youth were randomized (68 intervention, 65 control) in one year. There was no difference in age, gender, or severity of injury between the two groups. Patients randomized to the intervention spent a median of 30 minutes less in the ED than those receiving standard care (p=0.22). Youth are safely housed, have enrolled in education opportunities, and are engaged in addictions care. Results of a chart review examining repeat visits to the ED for violent injury, substance use and mental health will be completed in Spring 2016 and will be presented. Conclusion: There were no differences between standard care and intervention groups on baseline characteristics reflecting effective randomization. The introduction of an intervention at bedside in the ED did not have a negative impact on patient length of stay.
Introduction: Recently, intranasal (IN) fentanyl and inhaled nitrous oxide/oxygen (N2O) mixture have been increasingly used for procedural sedation and analgesia (PSA) alone or in combination. There is a lack of data on the efficacy of these combined agents. Methods: The objective was to evaluate the efficacy of IN fentanyl and N2O as PSA for the reduction of mildly-to-moderately displaced fractures and dislocations. We performed a prospective, observational cohort study between September 2014 and October 2015. Patients were recruited at CHU Sainte Justine (Montréal) and Royal Children Hospital (Melbourne, Australia). Patients aged 4 to 18 years were eligible if PSA consisted of IN fentanyl and N2O for the reduction of mildly-to-moderately displaced fractures or dislocations. Patients received at least IN fentanyl 1.5 mcg/kg (100 mcg max) and at least a 50/50% mixture of N2O with oxygen. Primary outcome was the efficacy of PSA measured by the patient assigned Facial Pain Scale-Revised (FPS-R). The Face, Legs, Activity, Cry, Consolability (FLACC) scale was also recorded. Depth of sedation was evaluated using University of Michigan Sedation Scale (UMSS). Adverse events were recorded following criteria of the Consensus Panel on Sedation Research of PERC/PECARN. Additional data concerning satisfaction or discomfort were evaluated via questionnaires, and follow-up telephone calls were made to elicit information on adverse events after discharge. Results: A total of 91 patients aged 9.7 ± 3.0 years were enrolled. There was no difference between the median FPS-R score during the procedure compared to before: Median 2 and 2 (median difference 0 [95% CI 0, 0]), respectively. The FLACC score was higher during the procedure than before: Median 4 and 0 (median difference 2 [95% CI 1, 3]). UMSS was 1 (95% CI 1, 2) during the procedure. 42 (46%) patients had adverse events, all mild: vertigo (20%), nausea (16%)]or vomiting (12%). A total of 85/88 (97%) parents and 82/85 (96%) ED physicians would want the same sedation in another procedure. Conclusion: PSA with IN fentanyl and N2O seems effective in our study, as evaluated by patient assigned FPS-R. Patients were minimally sedated. Adverse events were frequent but mild. Overall, parents and medical staff would want the same agents used in another procedure. Thus, PSA with IN fentanyl and N2O appears to be an attractive option for reduction of mildly displaced fractures or dislocations.
Introduction: Nova Scotia has a province wide reperfusion strategy for the treatment of patients presenting with acute ST-Elevation Myocardial Infarction (STEMI). Patients are referred for primary percutaneous coronary intervention (PPCI) if a first medical contact to device time can be achieved within 90 to 120 minutes; otherwise, fibrinolytic therapy is administered, as per guideline recommendations. Since 2011, Nova Scotian paramedics have been providing prehospital fibrinolysis (PHF) and prehospital catheterization (cath) lab activation for STEMI patients outside and within the PPCI catchment area, respectively. Patients who received fibrinolysis are transferred to a PCI facility if rescue PCI is required or if there are other indications for urgent intervention. This province wide approach is unique and the objective of this retrospective cohort study is to compare the impact of this approach on the primary outcome of 30-day mortality. Methods: For the study period, July 2011 to July 2013, STEMI patients who were diagnosed prehospital or in the ED who subsequently underwent reperfusion therapy were identified in the Emergency Health Services (EHS), Cardiovascular Information Systems (CVIS) and Cardiovascular Health Nova Scotia (CVHNS) databases. Baseline demographics and outcomes were then compared according to the treatment received: 1) PHF; 2) ED Fibrinolysis (EDF); 3) prehospital activated PPCI (EHS PPCI); and 4) ED activated PPCI (ED PPCI). Results: There were a total of 1107 STEMI patients identified during the study period, of whom 742 received lytic therapy (146 PHF; 596 EDF) and 332 underwent PPCI (202 EHS PPCI; 130 ED PPCI). Demographic variables were similar across the groups. The primary outcome of 30-day mortality was not significantly different across groups: 5 (3%) in PHF, 26 (4%) in EDF, 8 (4%) in EHS to PPCI and 2 (2%) in ED to PPCI. The number of rescue PCIs was 28 (19%) in PHF and 102 (17%) in EDF. Other outcomes (key timestamps) are pending. Conclusion: Our results show that the 30-day mortality was lowest for patients undergoing PPCI and slightly less for patients receiving pre-hospital fibrinolytic compared to those receiving ED fibrinolytic with no difference in the proportion requiring subsequent rescue PCI. The majority of patients in rural areas received EDF as opposed to PHF; pending results will show if this represents a delay in patient presentation after symptom onset.