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This technical note aims to verify the hippocampus and adjacent organs at risk (OARs) sparing ability of an improved beam arrangement, namely hybrid split-arc partial-field volumetric modulated arc therapy (VMAT) (Hsapf-VMAT) during whole brain radiation therapy (WBRT).Computed tomography simulation images of 22 patients with brain metastases were retrieved in this retrospective planning study. The hippocampus was manually delineated according to the criterion of RTOG 0933. Plans delivering 30 Gy in 10 fractions were generated for each patient using split-arc partial-field VMAT (sapf-VMAT) and Hsapf-VMAT. The sapf-VMAT plans consisted of 4 arc fields of 179.9° each with reduced field size. The Hsapf-VMAT consisted of 4 arc fields similar to sapf-VMAT in addition to 2 lateral opposing static fields. Statistical comparisons between treatment plans of both techniques were performed using the paired t-test at 5% level significance.The results demonstrated that Hsapf-VMAT can achieve superior dose sparing in hippocampus which is comparable to sapf-VMAT (p0.05). In both eyes, Hsapf-VMAT had significantly lower DThe present study adopts a hybrid technique, namely Hsapf-VMAT, for hippocampal sparing WBRT. Hsapf-VMAT can achieve promising dose reduction to the hippocampus, both eyes and lenses. Therefore, Hsapf-VMAT can be considered an improved version of sapf-VMAT.

Intrapleural misplacement of epidural catheter is a rare complication of thoracic epidural placement, which can be difficult to detect in intubated patients with unreliable pain reports and hemodynamic response to the test dose. We describe a case of intrapleural misplacement of thoracic epidural in a 50-year-old man status-post bilateral lung transplant and highlight the use of radiographic techniques to identify the misplacement.

In recent years, deep cement mixing (DCM) method, a non-dredged ground improvement technique, has been adopted in several local large-scale reclamation works. It is also a robust ground improvement solution and can expedite land formation. Currently, design and construction methods adopted in Hong Kong are mostly referred to the practice or guidelines developed in other countries. With more local experience gained and in view of the potential application in possible coming mega development projects which involve reclamation and ground treatment works, it is considered worthwhile and timely to conduct more detailed studies to understand the engineering properties of the materials improved by this technique and to harness the design and construction practice, with a view to enhancing the cost effectiveness of DCM works. This paper briefly introduces some on-going research related to DCM method covering several design and construction aspects including engineering properties, ground investigation and laboratory testing using laboratory mixed and field mixed cores. The objectives, potential application and preliminary results of the studies are presented and discussed in the paper.

Introduction:Nasopharyngeal carcinoma (NPC) is a prevalent disease in Southern China. Radiation therapy remains the primary treatment modality for NPC due to its high radiation sensitivity. Conventional volumetric-modulated arc therapy (VMAT) can achieve excellent target volume coverage and superior conformal dose distributions while sparing organs at risk (OARs). However, VMAT may also produce substantial volume of low-dose region in the surrounding normal tissue. Our oncology centre has incorporated the concept of anterior cervical field with VMAT in clinical practice of NPC treatment planning. The purpose of this treatment-comparison case study is to demonstrate the lower neck OARs sparing ability of hybrid volumetric-modulated arc therapy (hybrid-VMAT) over conventional VMAT for NPC.Methods:Four patients diagnosed with NPC of different clinical lymph node staging (N staging) were enrolled for this treatment-comparison case study. Planning target volumes and OARs were delineated with reference to Radiation Therapy Oncology Group (RTOG) 0225/0615. Additional OARs from lower neck region, including thyroid, trachea, cervical spine and pharyngeal constrictor muscles (PCMs), were also delineated. Two treatment techniques, hybrid-VMAT and VMAT, were created for each patient’s dataset.Results and findings:Both treatment techniques produced adequate target coverage and reduced radiation dose to the OARs as suggested in RTOG 0225/0615. Hybrid-VMAT plans achieved superior dose reduction in larynx, oesophagus, middle PCM, inferior PCM, cervical spine and trachea comparing with VMAT plans. Hence, the clinical usability and functional outcome of hybrid-VMAT should be further investigated for NPC radiation therapy.

SUMMARY Behavior arises from concerted activity throughout the brain. Consequently, a major focus of modern neuroscience is defining the physiology and behavioral roles of projection neurons linking different brain areas. Single-cell RNA sequencing has facilitated these efforts by revealing molecular determinants of cellular physiology and markers that enable genetically targeted perturbations such as optogenetics, but existing methods for sequencing defined projection populations are low throughput, painstaking, and costly. We developed a straightforward, multiplexed approach, virally encoded connectivity transgenic overlay RNA sequencing (VECTORseq). VECTORseq repurposes commercial retrogradely infecting viruses typically used to express functional transgenes (e.g., recombinases and fluorescent proteins) by treating viral transgene mRNA as barcodes within single-cell datasets. VECTORseq is compatible with different viral families, resolves multiple populations with different projection targets in one sequencing run, and identifies cortical and subcortical excitatory and inhibitory projection populations. Our study provides a roadmap for high-throughput identification of neuronal subtypes based on connectivity., Graphical abstract, In brief Neurons with different axonal projection targets and distinct molecular and functional properties are intermingled throughout the brain. Cheung et al. establish a high-throughput method, VECTORseq, to transcriptionally define projection neurons. The method reimagines transgenes expressed by widely used retrogradely infecting viruses as multiplexed RNA barcodes that are detected in single-cell sequencing.

Antibiotics are frequently prescribed inappropriately for acute respiratory infections in the outpatient setting. We report the implementation of a multifaceted outpatient antimicrobial stewardship initiative resulting in a 12.3% absolute reduction of antibiotic prescribing for acute bronchitis in primary care clinics receiving active interventions.

Background Due to the role expansion of radiotherapists in dosimetric aspect, radiotherapists have taken up organs at risk (OARs) contouring work in many clinical settings. However, training of newly qualified radiotherapists in OARs contouring can be time consuming, it may also cause extra burden to experienced radiotherapists. As web-based open-source radiotherapy delineation software (WORDS) has become more readily available, it has provided a free and interactive alternative to conventional one-to-one coaching approach during OARs contouring training. The present study aims to evaluate the effectiveness of WORDS in training OARs contouring skills of newly qualified radiotherapists, compared to those trained by conventional one-to-one coaching approach. Methods Nine newly qualified radiotherapists (licensed in 2017 – 2018) were enrolled to the conventional one-to-one coaching group (control group), while 11 newly qualified radiotherapists (licensed in 2019 – 2021) were assigned to WORDS training group (measured group). Ten OARs were selected to be contoured in this 3-phases quantitative study. Participants were required to undergo phase 1 OARs contouring in the beginning of the training session. Afterwards, conventional one-to-one training or WORDS training session was provided to participants according to their assigned group. Then the participants did phase 2 and 3 OARs contouring which were separated 1 week apart. Phase 1 – 3 OARs contouring aimed to demonstrate participants’ pre-training OARs contouring ability, post-training OARs contouring ability and knowledge retention after one-week interval respectively using either training approach. To prevent bias, the computed tomography dataset for OARs contouring in each phase were different. Variations in the contouring scores for the selected OARs were evaluated between 3 phases using Kruskal-Wallis tests with Dunn tests for pairwise comparisons. Variations in the contouring scores between control and measured group in phase 1 – 3 contouring were analyzed using Wilcoxon signed-rank test. A p-value Results In both control group and measured group, significant improvement (p < 0.05) in phase 2 and 3 contouring scores have been observed comparing to phase 1 contouring scores. In comparison of contouring scores between control group and measured group, no significant differences (p > 0.05) were observed in all OARs between both groups. Conclusions The results in this study have demonstrated that the outcome of OARs contouring training using WORDS is comparable to the conventional training approach. In addition, WORDS can offer flexibility to newly qualified radiotherapists to practice OARs contouring at will, as well as reduce staff training burden of experienced radiotherapists.

Background: The CDC recommends that consultant pharmacists support antimicrobial stewardship programs (ASPs) in long-term care facilities (LTCFs). We studied CDC-recommended ASP core elements implementation and antibiotic use in LTCFs before and after training consultant pharmacists. Methods: Between August 2017 and October 2017, consultant pharmacists from a regional long-term care pharmacy attended 5 didactic sessions preparing them to assist LTCFs in implementation of CDC-recommended ASP core elements. Training also included creating a process for evaluating appropriateness of all systemic antibiotics and providing prescriber feedback during their monthly mandatory drug-regimen reviews. Once monthly “meet-the-expert” sessions were held with consultant pharmacists throughout the project (November 2017 to December 2018). LTCF enrollment began in November 2017 and >90% of facilities joined by January 2018. After enrollment, consultant pharmacists initiated ASP interventions including antibiotic reviews and feedback using standard templates. They also held regular meetings with infection preventionists to discuss Core Elements implementation and provided various ASP resources to LTCFs (eg, antibiotic policy template, guidance documents and standard assessment and communication tools). Data collection included ASP Core Elements, antibiotic starts, days of therapy (DOT), and resident days (RD). The McNemar test, the Wilcoxon signed-rank test, generalized estimating equation model, and the classic repeated measures approach were used to compare the presence of all 7 core elements and antibiotic use during the baseline (2017) and intervention (2018) year.Results: In total, 9 trained consultant pharmacists assisted 32 LTCFs with ASP implementation. When evaluating 27 LTCFs that provided complete data, a significant increase in presence of all 7 Core Elements after the intervention was noted compared to baseline (67% vs 0; median Core Elements, 7 vs 2; range, 6–7 vs 1–6; P < .001). Median monthly antibiotic starts per 1,000 RD and DOT per 1,000 RD decreased in 2018 compared to 2017: 8.93 versus 9.91 (P < .01) and 106.47 versus 141.59 (P < .001), respectively. However, variations in antibiotic use were detected among facilities (Table 1). When comparing trends, antibiotic starts and DOT were already trending downward during 2017 (Fig. 1A and 1B). On average, antibiotic starts decreased by 0.27 per 1,000 RD (P < .001) and DOT by 1.92 per 1,000 RD (P < .001) each month during 2017. Although antibiotic starts remained mostly stable in 2018, DOT continued to decline further (average monthly decline, 2.60 per 1,000 RD; P < .001). When analyzing aggregated mean, antibiotic use across all sites per month by year, DOT were consistently lower throughout 2018 and antibiotic starts were lower for the first 9 months (Fig. 1C and 1D). Conclusions: Consultant pharmacists can play an important role in strengthening ASPs and in decreasing antibiotic use in LTCFs. Educational programs should be developed nationally to train long-term care consultant pharmacists in ASP implementation.Funding: Merck & Co., Inc, provided funding for this study.Disclosures: Muhammad Salman Ashraf and Scott Bergman report receipt of a research grant from Merck.

Objectives: To conduct a prospective pilot trial to test the clinical efficacy and accuracy of a newly developed Bluetooth-enabled retainer, which was synchronized with an iOS mobile application, cloud database and provider webpage. Setting and Sample Population: Five orthodontic residents in a university setting. Material and Methods: At the delivery of the retainers (T0), each participant was given an Bluetooth-enabled retainer, logbook and iPod Touch installed with the mobile application. Participants were instructed to wear the retainer for 12 hours per day and record in the logbook each time the retainer was inserted or removed and trained to synchronize the device daily to the mobile application. After the 5-day study period (T1), statistical analysis was performed comparing the device-reported data to the logbook data using two calculation methods. Results: From T0 – T1, the participants wore their retainers for a median of 11.55 hours per day and the median difference between the self-reported (logbook) data and the device data was 35 minutes or 5.1% over the 5-day study period. Using an adjusted method to calculate the device-reported wear time, the median error was 13 minutes or 1.9%. Conclusion: Subjects were able to successfully wear the retainer and upload the data to the mobile application and cloud database. Patient compliance and technical issues could be monitored daily via the provider webpage, and early intervention was possible with reminder messaging. The Bluetooth-enabled retainer showed a clinically acceptable level of accuracy and usability that validates it for future clinical testing.

Hong Kong is situated at the south-eastern tip of China. It has a sub-tropical climate, with a rainy season from April to October each year. Rainfall intensities can be high, with 50 mm to 100 mm per hour and 250 mm to 350 mm in 24 hours being not uncommon. Because of its mountainous terrain, Hong Kong is susceptible to landsliding during the periods of heavy rainfall. As part of the Slope Safety System, the Geotechnical Engineering Office (GEO) of the Hong Kong Special Administrative Region Government has been operating a territory-wide Landslip Warning System for over 40 years. The primary objective of the Landslip Warning is to forewarn the public of possible landslide risk during periods of heavy rainfall. This paper summarises the major components of the current GEO Landslip Warning System as a landslide risk management tool. Hong Kong has an extensive network of automatic raingauges and comprehensive records of landslides. With this, rainfall-landslide correlation models have been established and updated regularly through statistical means to facilitate the prediction of the severity of landslide based on real-time rainfall recorded in the raingauge network and the rainfall forecast by the Hong Kong Observatory (HKO). The System has been continuously enhanced and upgraded along with the development of novel technology and analytical techniques. Currently, Internet of Things (IoT) technology are used in the automatic raingauge network jointly operated by the GEO and the HKO to ensure reliable data transmission. The collected rainfall data are stored and processed using cloud computing service that predicts the severity of landslide at every five-minute intervals. The prediction allows the GEO and the HKO to determine the necessity of issuing a Landslip Warning. Apart from technology, the effectiveness of the Landslip Warning also depends on the actions taken by the public when it is in force. The GEO has ongoing public education campaigns to raise the public awareness and preparedness to reduce vulnerability to landslide hazards. In recent years, occurrence of severe landslides and casualties in landslide have been significantly reduced, which is attributed largely to the successful implementation of the Slope Safety System and partly to the absence of extreme rainfall events. As a result, there is a genuine concern that the public is becoming complacent to the potential landslide hazards. The GEO has enhanced the efforts in maintaining public participation in combating landslide hazards and improved the public perception of the landslide risk of a rainstorm by using a quantitative Landslide Potential Index. Besides providing public warning, the GEO also endeavours to enhance the emergency response to landslide incidents through innovative solutions. Selected debris barriers are installed with IoT sensors for providing immediate alert of the occurrence of sizable landslides and quadrupled robots are being studied and tested for inspecting landslide sites. It is anticipated that innovation and technology have great potential in improving the GEO’s capability in emergency management, in particular in the case of extreme rainfall events that are expected be more frequent and intense in future.

This is a submission by the Australasian Legal Information Institute to the Australian Government's Digital Technology Taskforce on the proposed Australian Data Strategy. The submission is framed around seven questions asked in the Discussion Paper on the Strategy. The submission concentrates on the role of legal information in the Australian Data Strategy, with additional comments on issues which we think are of particular importance, such as data privacy. In answer to Question 4.'What are the top three outcomes from the Australian Data Strategy you would like to see by 2025?' we identify: (i) Undo data monopolies – There are three main impediments to the full realisation of a free access legal data commons in Australia, concerning court decisions, legislation and standards. (ii) Reform data privacy – Australia’s Privacy Act should be reformed to meet the highest international standard, currently that of the EU’s GDPR. (iii) Legislate for ethical AI - Australian AI innovations will pose considerable risks to Australian citizens, and may also find that they are internationally non-competitive as the international environment moves toward regulation. The Discussion Paper often refers to public trust, but we argue that the question is not one of public ‘trust’, but rather whether our public institutions and their systems for handing data are ‘trustworthy’. Examples concerning personal data disasters in Australia are given. AustLII welcomes proposals of substance coming from a more developed Strategy, and will aim to interact with what should be a significant national initiative.

The New South Wales Law Reform Commission (NSWLRC) in relation to the Consultation Paper (CP22) in its ‘Open Justice Review’. This paper is a submission to that review on issues relating to how free online access to court and tribunal decisions has become an important part of 'open justice' in countries like Australia. The submission argues that a high value should be placed on facilitating (or not impeding) free access to timely, high quality, full reports of court decisions, and a recognition that publication of such decisions raises different issues than those presented by publications of news media. It argues that all statutory prohibitions on publication should contain a general exception allowing publication of decisions by a publisher with the consent of, or at the request of, the court, to that publisher. A general exception to such prohibitions is desirable. Further, courts making discretionary non-disclosure or suppression orders should be required to consider whether there should be an exception allowing the information to be published on legal websites publishing the full text of decisions in legal databases. These submissions are relevant to free access publishers of case law in other countries, particularly those with a similar approach to 'open justice' as is found in Australia.

Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.

Background: Placenta praevia (PP) is a rare obstetric condition associated with significant maternal and perinatal morbidity. Traditionally, the degree of PP has been classified into minor and major; however, there are very few robust studies that compare the maternal outcomes of these types of PP. Aims: To identify any significant differences in obstetric outcomes between major and minor PP, including antepartum, intraoperative and postpartum complications. Materials and Methods: A retrospective cohort study was conducted at the Royal Brisbane & Women’s Hospital between 2009 and 2018; all women were diagnosed with PP. Results: Of the total of 368 women recruited, over half of the participants were diagnosed with major PP (57%), while the remaining had minor PP. Women with major PP, compared to women with minor PP, had an increased risk of antepartum haemorrhage (odds ratio (OR) 2.77, P < 0.001), delivery at an earlier gestational age (36.1 vs 37.4 weeks), general anaesthesia (OR 3.25, P < 0.001), greater proportion of emergency lower segment (51% vs 40%) and classical caesarean (7.7% vs 3.8%), increased number of uterotonics (incidence rate ratio (IRR) 1.17, P < 0.031), greater blood loss (IRR 1.32, P < 0.001) and higher frequency of blood transfusion (IRR 2.00, P < 0.027), and longer postpartum hospital stay (IRR 1.26, P < 0.001). Hysterectomy was performed for three women with major PP, compared to one with minor PP. Conclusions: The degree of PP significantly impacts obstetric outcomes, with major PP associated with worse maternal morbidity antenatally, intraoperatively and postpartum. Therefore, to optimise patient care, this study emphasises the importance of identifying and distinguishing between different types of PP.