The University of Sydney

Ultra‐Hypofractionated Whole Breast Radiotherapy (U‐WBRT) has been proven to be a viable treatment option for breast cancer patients receiving radiation therapy, however, due to its novelty our understanding of its non‐clinical benefits is still evolving. With increasing U‐WBRT selection during COVID and in rural and regional settings such as the Western New South Wales Local Health District (WNSWLHD), it's important to quantify the savings when compared to other fractionation schedules (e.g. Conventional fractionation (C‐WBRT) involving 25 fractions and Moderate hypofractionation (M‐WBRT) with 15 fractions.) Using literature sourced from Medline, Embase, Pubmed and reports from relevant websites and organisations this narrative review investigates quantifiable methods of assessing non‐clinical benefits of U‐WBRT in rural settings according to the triple bottom line philosophy. This review was able to identify a standard set of quantifiable metrics that can compare the non‐clinical benefits of various fractionation schedules, with relevance to a rural setting. These include: fractionation trends, financial subsidy, average linear accelerator (Linac) minutes, hospital visits, travel time and distance, Linac energy consumption, travel and Linac carbon emissions. By identifying these metrics, non‐clinical benefits between the fractionation schedules can easily be quantified and compared.

The fourth most common cancer worldwide is prostate cancer (PCa), which is also a common cancer in men. Its still a serious health problem, even though the treatment is improving. The androgen receptor (AR), a nuclear receptor for steroid hormones, is a transcription factor that is ligand dependent. Small-molecule drugs targeting AR have been shown to contribute to the treatment of PCa. These drugs inhibit the growth of PCa cells by blocking or regulating the AR signaling pathway and inhibiting the binding of androgens (such as testosterone or dihydrotestosterone) to receptors. In this paper, the principle of AR signaling pathway in PCa and mature drugs, including abiraterone and bicalutamide, was discussed. The clinical application, efficacy, and limitation of castration-resistant prostate cancer (CRPC) were also analyzed. Through the in-depth discussion of PCa treatment of small and medium-molecule drugs and its underlying principles, this paper provides a theoretical basis for more accurate and effective treatment programs in the future.

Time-out is an empirically supported component of parenting interventions for child conduct problems; however, it is receiving increasing criticism among parents and some practitioners. This study aimed to investigate practitioners’ use and acceptability of time-out for child conduct problems; examine whether perceived effectiveness and knowledge of evidence-based parameters of time-out implementation influence use and acceptability of time-out; and explore practitioners’ perceptions about alternatives to time-out. One hundred and ten Australian and New Zealand practitioners who have worked with children and families completed an online survey investigating their use and acceptability of time-out for children with conduct problems. Results showed that 55.5% of the sample have used timeout, with 38.0% considered current TO users. Acceptability of the strategy varied, with some practitioners critical of time-out. Increased knowledge of evidence-based parameters of time-out implementation was associated with increased frequency of time-out use and acceptability, while perceived effectiveness was associated with increased acceptability only. Practitioners perceived a number of other parenting strategies as effective alternatives to time-out. These findings have important implications for improving practitioners’ implementation of time-out with parents of children with conduct problems.

Nematode worms are one of the most abundant metazoan groups, occupying diverse ecological niches. Accurate recognition or identification of nematodes is of great importance for pest control, soil ecology, biogeography, habitat conservation, and climate change. Computer vision has witnessed a few successes in species recognition of nematodes; however, it is still in great demand. In this paper, we identify two main bottlenecks: (1) the lack of a publicly available microscopic-imaging dataset for diverse species of nematodes (especially the species only found in a natural environment) which requires considerable human resources in fieldwork and experts in taxonomy, and (2) the lack of a standard benchmark of state-of-the-art deep learning techniques on this dataset which demands the discipline background in computer science. With these in mind, we propose a large-scale microscopic image dataset consisting of 9215 images and 40 species (4 laboratories cultured and 36 naturally isolated species), which, to our knowledge, is the first time in the community. We further set up a species recognition benchmark by employing state-of-the-art deep learning networks on this dataset. We discuss the experimental results, compare the recognition accuracy of different networks, and show the challenges of our dataset. We will make our dataset publicly available.

According to the scale of the power capacity and the size of the service provided, microgrids can generally be categorized into different types, e.g., solar homes, campus and institutional microgrids, remote area microgrids, community microgrids, commercial and industrial microgrids, and military base microgrids.

Dr Marcelle Townsend-Cross’ work is driven by her commitment to social justice for Indigenous people, which drives her Indigenous Studies teaching research. This chapter sends a clear message to universities that providing creative and innovative options for Indigenous scholars can result in retaining talent, underlining the value of supporting Indigenous ECRs as they develop their new professional identities. Dr Townsend-Cross also highlights the importance of finding like-minded collaborators who can help to navigate the institutional and research practices that are not always known to Indigenous ECRs. Collaborators and mentors can help to demystify processes such as journal publishing and can lead to further invitations, bolstering opportunity and reputation. Dr Townsend-Cross reminds us of the critical role of journal reviewers and editors in supporting the development of beginning scholars.

In electrocatalytic carbon dioxide reduction (CO2RR), indium (In)‐based catalysts with low toxicity and environmental benefits are renowned for their specific high selectivity for formic acid and intrinsic inertia for the competing hydrogen evolution reaction. However, recent studies have reported various products over In‐based catalysts showing comparable or even higher selectivity for carbon monoxide (CO) than for formic acid (HCOOH), puzzling the reaction pathway for CO2 reduction. This article presents a comprehensive review of recent studies on electrocatalytic CO2RR over In‐based catalysts highlighting the formation pathway of specific products. First, the mechanism of electrocatalytic CO2RR with the multiple reaction pathways is concluded considering the relationship between reaction intermediates and selectivity. Furthermore, the regulation strategies for multiple product formation are summarized, including crystalline phase engineering, alloying, nanostructuring, and structural modulation of In single atom, where the effect of key intermediates (*COOH, *OOCH, and *OCHO) on product generation is systematically discussed to achieve high selectivity. Finally, the intrinsic regulation mechanisms of these strategies are analyzed and the challenges and opportunities for the development of next‐generation In‐based catalysts are proposed.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported. SEQUOIA (ClinicalTrials.gov identifier: NCT03336333 ) is a phase III, randomized, open-label trial that compared the oral Bruton tyrosine kinase inhibitor zanubrutinib to bendamustine plus rituximab (BR) in treatment-naïve patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). The initial prespecified analysis (median follow-up, 26.2 months) and subsequent analysis (43.7 months) found superior progression-free survival (PFS; the primary end point) in patients who received zanubrutinib compared with BR. At a median follow-up of 61.2 months, median PFS was not reached in zanubrutinib-treated patients; median PFS was 44.1 months in BR-treated patients (hazard ratio [HR], 0.29; one-sided P = .0001). Prolonged PFS was seen with zanubrutinib versus BR in patients with mutated immunoglobulin heavy-chain variable region (IGHV) genes (HR, 0.40; one-sided P = .0003) and unmutated IGHV genes (HR, 0.21 [95% CI, 0.14 to 0.33]; one-sided P < .0001). Median overall survival (OS) was not reached in either treatment arm; estimated 60-month OS rates were 85.8% and 85.0% in zanubrutinib- and BR-treated patients, respectively. No new safety signals were detected. Adverse events were as expected with zanubrutinib; rate of atrial fibrillation was 7.1%. At a median follow-up of 61.2 months, the results supported the initial SEQUOIA findings and suggested that zanubrutinib was a favorable treatment option for untreated patients with CLL/SLL.

Objective Evaluate the cost‐effectiveness of the Virtual Rural Generalist Service (VRGS) model of care. Design A cost–consequence analysis of the VRGS model of care compared with usual care (treatment by local or locum [non‐VRGS] doctors) from the perspective of the health care funder in 2022 prices. Setting Twenty‐nine rural and remote hospitals in the Western NSW Local Health District where the VRGS has been in operation (VRGS sites). Patients Patients of any age who presented to an emergency department (ED) or were admitted to hospital at VRGS sites over the pre‐VRGS period (1 February 2019 to 31 January 2020) or the post‐VRGS period (1 July 2021 to 30 June 2022). Intervention The VRGS model of care, which provides 24‐hour 7‐days‐a‐week rural generalist doctors, both virtually and in person, to small rural and remote hospitals, predominantly for lower acuity ED presentations, daily ward rounds for inpatients admitted by a VRGS medical officer, and ad hoc inpatient medical reviews when local doctors need support or are unavailable. Main outcomes measures Incremental cost per incremental quality‐of‐care outcome, maintenance of health service activity levels, workforce sustainability (measured by changes in locum shifts), and service acceptability (as determined by thematic analysis of interviews). Results The cost per standard unit of health care (national weighted activity unit) was lower for the VRGS ($1047) than for usual care ($1753). VRGS doctors dealt with ED presentations of similar complexity to non‐VRGS doctors, and admissions of significantly lower (40%) complexity. Health service activity remained stable from the pre‐VRGS period to the post‐VRGS period, only declining by 4% in the post‐VRGS period, which was during the coronavirus disease 2019 pandemic. Locum shifts decreased from 1456 days in the pre‐VRGS period to 609 days in the post‐VRGS period, improving the sustainability of the workforce. Local doctors and managers found the VRGS to be acceptable, but thought it could be enhanced with additional investment in nursing and technical staff. Conclusions Our economic evaluation of the VRGS showed that it provided lower cost care and equivalent quality‐of‐care outcomes when compared with usual care for ED presentations of the same complexity, and supported local clinical staff to maintain activity levels despite a pandemic. With additional investment in data capture and in nursing and technical staff to support the service, the VRGS has promise as a flexible service that can help sustain access to quality medical care in rural and remote communities.

Objectives To understand patients’ and carers’ experiences of virtual medical care delivered into rural and remote hospitals. Study design Qualitative study using semi‐structured interviews. Setting, participants Interviews were conducted between 7 June 2022 and 21 February 2023. Participants were people who had received a virtual medical service from the Virtual Rural Generalist Service (VRGS), and their carers, in rural and remote hospitals within the Western NSW Local Health District. Main outcome measures Acceptability of, access to, quality of and appropriateness of care provided by the VRGS. Results We interviewed 43 patients and carers about their experiences of VRGS services received in an emergency department or inpatient setting. About half of our participants thought that virtual medical care (supported by in‐person nursing staff) was highly acceptable and equivalent to in‐person care. For the remaining participants, virtual care was seen as being an acceptable alternative if in‐person care was not available. Patients reported that the model met their immediate needs, even if the virtual delivery mode was not their preference. VRGS doctors were generally seen as skilled and personable, and acceptability of virtual care increased with more experience of it. A key perceived benefit of virtual care was increased access to medical care without the need to travel long distances. Hospital‐based virtual care was not considered less appropriate for older adults or children. Conclusions Virtual care in a rural hospital setting, such as that delivered by the VRGS, is broadly acceptable to patients and carers. While most would prefer to have a doctor physically present, patients and carers are accepting of the need for virtual care to supplement in‐person care in rural and remote areas. Patients and carers who experience hospital‐based virtual care perceive that it can provide good quality medical care and meet many of their needs.

Objectives To explore the experiences of clinicians delivering, facilitating, and potentially affected by a hybrid virtual medical model servicing rural and remote hospitals in western New South Wales. Design, setting, participants Qualitative study using semi‐structured focus groups and individual interviews, conducted between 7 April 2022 and 16 March 2023, with rural generalist doctors delivering the Virtual Rural Generalist Service (VRGS) within the Western NSW Local Health District, local site staff, and local general practitioner visiting medical officers (GP VMOs). Main outcome measures Key themes in clinician experience of the model and recommendations for improved experience, based on qualitative content analysis. Results We interviewed 12 VRGS doctors, 25 site nursing staff and nine GP VMOs. Clinicians were overwhelmingly positive about the VRGS, seeing it as providing good quality care and being an innovative and translatable solution to rural workforce challenges. In‐person site visits by VRGS doctors were highly valued, especially by local site staff, for team building, skill building and increasing VRGS doctors’ understanding of the local context. The VRGS model relies on nursing availability and skill, and creates additional workload for nurses. Nurses in isolated sites valued the clinical support provided by the VRGS. Overall, most GP VMOs valued the fatigue relief offered by the VRGS; however, some viewed the VRGS as diminishing local doctors’ autonomy and the viability of their positions. Conclusions The hybrid VRGS model is widely accepted by clinicians as providing good quality care for patients and high job satisfaction for providers. The service supports the local health workforce and makes rural medical positions more attractive and sustainable. The in‐person shift requirement is central to the model's effectiveness and acceptability. Further investment is needed to train and resource local nurses who play an integral role in providing virtual medical care.

Objective To evaluate the quantity and quality of medical care provided by the Western NSW Local Health District Virtual Rural Generalist Service (VRGS). Design Retrospective cohort study; analysis of emergency department and administrative hospital data. Setting Twenty‐nine rural or remote hospitals in the Western NSW Local Health District at which the VRGS was providing medical care in the emergency department (ED) and/or inpatient setting. The VRGS was providing predominantly virtual medical support when local doctors needed relief or were unavailable, typically for lower acuity ED presentations and scheduled inpatient ward rounds. Patients All patients who presented or were admitted to a Western NSW Local Health District hospital serviced by the VRGS between 1 July 2021 and 30 June 2022. Main outcome measures Treatment completions, transfers, ED departure within 4 hours, length of stay, and hospital mortality. Results During 2021–22, 34% of ED presentations (13 660/39 701) and 40% of admissions (2531/6328) involved VRGS care. For ED presentations, after adjusting for socio‐demographic and clinical factors, patients attended by VRGS doctors had higher odds of not waiting (adjusted odds ratio [aOR], 3.69; 95% CI, 2.79–4.89), lower odds of transfer to another hospital (aOR, 0.66; 95% CI, 0.60–0.72) and slightly lower odds of ED departure within 4 hours (aOR, 0.92; 95% CI, 0.86–0.98) when compared with patients not attended by VRGS doctors (ie, those provided usual care). For admissions, after adjusting for socio‐demographic and clinical factors, inpatients attended exclusively by VRGS doctors had higher odds of discharging at their own risk (3.33; 95% CI, 1.98–5.61) and lower odds of being a long stay outlier (aOR, 0.51; 95% CI, 0.35–0.74) when compared with inpatients not attended by VRGS doctors. The odds of inpatient mortality were equivalent when comparing VRGS and non‐VRGS care (aOR, 0.78; 95% CI, 0.48–1.28) and when comparing combined (VRGS and non‐VRGS) and non‐VRGS care (aOR 1.21; 95% CI, 0.91–1.61). Conclusions In the current environment of rural medical workforce shortages, the VRGS achieved similar outcomes on routinely collected measures of quality of care. It is demonstrably an option for complementing and enhancing the delivery of medical care in rural and remote communities with limited or no local medical services.

Objective To describe the barriers to and facilitators of implementing and delivering virtual hospital (VH) services, and evidence and practice gaps where further research and policy changes are needed to drive continuous improvement. Study design Qualitative descriptive study. Setting, participants Online semi‐structured interviews and a focus group were conducted between July 2022 and April 2023 with doctors, nurses and leadership staff involved in VH services at three sites in New South Wales, Australia. Main outcome measures Barriers to and facilitators of implementing and delivering VH services in sites with differing operating structures and levels of maturity, and evidence and practice gaps relating to VH services. Results A total of 22 individuals took part in the study. Barriers, facilitators, and evidence and practice gaps emerged within five major themes: scope and structure of VH services; development and implementation of VH models of care; delivery of VH models of care; evaluation of VHs and VH models of care; and sustainment and scalability of VH services. Facilitators of VH success included hybrid approaches to care, partnerships with external services, and skills of the VH workforce. Barriers and gaps in evidence and practice included technical challenges, the need to define the role of VH services, the need to evaluate the tangible impact of VH care models and technologies, and the need to develop funding models that support VH care delivery. Participants also highlighted the perceived impacts and benefits of VH services on the workforce (within and beyond the VH setting), consumers, and the health care system. Conclusions Our findings can help inform the development of new VH services and the improvement of existing VH services. As VH services become more mainstream, gaps in evidence and practice must be addressed by future research and policy changes to maximise the benefits.

Objectives To identify research and development priorities for virtual care following the coronavirus disease 2019 pandemic from the perspective of key stakeholders (patients, clinicians, informaticians and academics). Design Qualitative study using a modified nominal group technique. Setting Online semi‐structured interviews and workshops held in November 2022 and February 2023. Participants Health workers involved in delivering virtual care in two metropolitan local health districts and one specialty statewide network, and people who had received care from these sites, were recruited using passive snowball sampling. Research and academic staff from a tertiary institution were also invited to participate. Main outcome measures Priorities to support a translational research agenda for virtual care. Results Twenty‐five individuals participated including 18 innovation deliverers, two innovation recipients and five implementation facilitators. Stakeholders identified several key priorities for developing virtual care models and for sustaining and scaling virtual care services. These included demonstrating the economic and societal value of virtual care, developing a common framework to support evaluation and comparison of virtual care services, ensuring virtual care services integrate acute and primary care, and defining which models of care are most appropriate for virtual care delivery. Conclusion As the health system recalibrates with the return of in‐person care, there is a growing need to demonstrate the value of virtual care models to patients, the health system, and society at large. Demonstrating this value while also demonstrating improvements to health outcomes will future‐proof virtual care, enabling it to be used to address broader challenges of health care delivery. In addition, sustaining virtual care will depend on robust operational structures and workforce training and education. As services evolve, research and development priorities must be revisited to ensure that translational research aligns with stakeholder interests.

Purpose Dietary macronutrients significantly impact cardiometabolic health, yet research often focuses on individual macronutrient relationships. This study aimed to explore the associations between dietary macronutrient composition and cardiometabolic health. Methods This study included 33,681 US adults (49.7 ± 18.3 years; 52.5% female) from the National Health and Nutrition Examination Survey during 1999–2014. Dietary data was derived from 1 to 2 separate 24-hour recalls and cardiometabolic health included lipid profile, glycemic control, blood pressure, and adiposity collected in a mobile examination center. Associations between dietary macronutrient composition and cardiometabolic health were examined using generalized additive models adjusted for age, socio-demographics, lifestyle, and diet quality. Results In females, triglycerides (P < 0.01) and HDL cholesterol (P < 0.01) were the least optimal in diets containing lower fat (10%) and higher carbohydrate (75%). In males, HDL cholesterol was positively associated with fat (P < 0.01) and no association with triglycerides was detected. Total-C associations were male specific (P = 0.01) and highest in diets composed of 25% protein, 30% carbohydrate, and 45% fat. In both sexes, systolic blood pressure (P ≤ 0.02) was highest in diets containing lower fat (10%) coupled with moderate protein (25%). Diastolic blood pressure associations were female specific (P < 0.01) with higher values in those consuming the upper range of fat (55%). There were no associations of macronutrient composition with glycemic control or adiposity. Conclusion This study revealed sex-specific relationships between macronutrient composition and cardiometabolic health. Future research is needed to explore these relationships across age groups.