Okay, I'm going to give you a little bit of history of my personal experience. Maybe it could be interesting to you. I know a lot of people come from different places. You come from maybe different hospitals. You maybe just start your career and you think you're coming here. You can learn everything. So when you go home, you have everything you can do. Then for the rest of your medical professional, medical physics professional, I'm going to give you some history. So that's what you can see. Okay, I'm just talking about head and neck because I'm only in charge of the neck. Head and M.D. Anderson, okay? So we first started our head and neck MRT on 1998, relatively late. A lot of people has been doing that already. We first started 1998, that's the number one cases. And we have to spend a lot of time, yesterday I mentioned, to convince our doctor, say, this is what we're going to treat. They scratch their head, say, no way, because it feels too small. And then later, we gradually, because they don't have confidence, we have to increase the, you know, treat the patient gradually. So from 1999 to 2000, that's the number 20 cases for two years. Almost one and a half years, see? But then, after they gain their experience, they have the confidence, we increase very fast. Year 2001, within one year, we reached 100. And then 2000, we get 1,000. See the difference? Maybe show the curve, maybe even easier. This is the curve. We started in 1998, and suddenly we increased. But at the beginning, very slow. I think in this population, you need to do also, when you go back, you need to start slowly. And once you get the confidence, then you increase the number. You don't want to make a mistake. At the beginning, if you make a mistake, you're corrected. So you can get more experience. When you feel comfortable, you increase the number. Okay, that's a take-home message. Okay, for all physicians, that's the same story. Okay, this gives you a different way to explain this. Okay, this is a different curve. This is a physician say, for all advanced oral friends cases, when we do like year 2000, 2001, most of them using conventional, meaning 3D conformal therapy, okay? But then after they have this, before that actually nothing, okay? Very small number. But then after they gain experience, by year 2006, 2007, most of them MRT. So they have to have this experience to build up before you do all the MRTs, okay? So that's my story. What I'm trying to say is, even for the physician, for the physicists, at this point, we don't have an idea of what the MRT is. And then at this point, I try to explain. You think the MRT is a good thing knowledge, but I can tell you after maybe five years, 10 years, people will laugh at us. Say, why are you doing this?  Just like we are laughing at the people using also voltage machine. Why are you still using water machine? We use the electron or the cobalt machine.  But when we first doing this, we're still trying to do it right, doing like a sophisticated way. So that we deliver the right dose. Even though we don't have a good detector, we don't have a good technology, but we need to use the most current technology and the knowledge to do what it is right. But you need to know the knowledge keep changing, keep adding up. See what I'm saying? Right now, okay, maybe use the next slide. This is another, keep the story, okay? So the number increase very fast, okay? Right now, just for the head and neck, every year, we're perpetrating 630 patient just for head and neck, okay? This is just the story. My personal story, okay? When I first practiced, we are using cerebellum. I was cutting the cerebellum. I was, physicists was cutting the cerebellum, okay? When we first practiced. We just serve them to, to get a treatment. And then very soon, we don't, at that time, we have a very big, big mode room. We make the mask, make the cerebellum, make everything very dirty. But after this MRI, all this disappeared. It's not saying when I first practice, I learned everything I know about how to cut the blocks and I stopped there. You know, I have to keep going, keep going. You see what I'm saying? Same thing for everybody. Even though we think the MRT is the best thing to do, by the time we use this MRT, we are crazy, okay? So, but this is the way it is. Things keep changing, okay? That's the rule. One thing's never changes, everything's going to change. Going to be changed, okay? Okay, so give you some software. Okay, that's the hardware things, okay? Using the, from the servant to the, to the VMAG. When I first tried to do that, computer training for the MRT, I was using normal cover three. That's what we use for our first cases. And then that time, we think that's the best in the world. We're using normal. But every time we set things up, everything's fine. We turn the keys and start optimization, take 14 minutes. So I go out to take a coffee break. When I come back, still running. When it's come out, it's not good. I have to change some parameters to rerun it, okay? And once I change and then turn it again, another 14 minutes disappeared. See what I'm saying? So that's the time. And then, but pretty soon, we change everything. We change it from version three to version, software version four, which we can do a lot more, a lot more things. We have to learn very quick. And by the time of December 2003, we decided to do another version. Every time you change a different version, you need to learn new things, okay? But when we wanted to upgrade to version three, we decided not to upgrade to version three. We decided to change it totally, different treatment plan system. We decided to change to pinnacle treatment plan system. At that time, when we do 3D treatment planning, we use a pinnacle. When we do MRT, we use normal. Then when we have like a half pin matching, so on the upper neck, we do MRT, no neck. We do superclap code. We send the two different plans to the treatment plan, to the treatment machine, so that we can deliver the treatment. When physician wants to see this composite dose, that's our physician always want to see. We cannot show them. That's why our physician at the beginning really reluctant to do MRT treatment. That's another reason, see what I'm saying? But instead of using normal, version five, we decided to use pinnacle. Why? Because at that time, before that version, version six come up, 40 minutes is the fast at that time. I said 40 minutes for the break, but at that time, the version five, pinnacle can do MRT treatment planning. But when you turn in the job, you say, oh, everything set up, parameter set up, objective function set up, you say, stop. It takes six, seven hours. So it's no way for us to use the pinnacle to do the MRT plan. We have to make sure everything is set up, and then you go home.  Hopefully after the sleep, you come back next day, you have a good plan. But when it's not happening, you lose one day, basically. So at that time, we cannot do the treatment plan using the pinnacle for MRT. But for the version six, then we do the test, they can do like in 40 minutes, and we were very happy. So we quickly change to pinnacle so that we can see composite plan, combo plan, or in eclipse, we call the sum plan. We can sum the plan. So since we changed to pinnacle, we have to relearn everything. We have to unlearn everything from the anomalous, because that's a totally different concept. Then we need to do this now. After we know all this difference, the take home messages, no matter how much you learn over here, I know for sure you learn a lot. But when you go back home, or you practice, you need to know, you need to keep learning, okay? Keep learning things. I'm going to talk today about why we needed to do a MRT QA, okay? Very easy. I think Dr. Pippen has discussed already, because we do have very complex dose distribution. And what the problem we have is this, we call the steep dose gradient because of this MLLC, they are moving, okay? And how precise they are moving to a certain location, you need to do these tests. So this is called the mechanic test. This is like a peak offense. This is not related to a specific patient. You have to have a rigorous QA system like we talk about for these all accessories, make sure they work as it is predicted, okay? So that you can have a good dosimetry with each patient. Well, I'm not talking about this now, but I'm going to talk about how you verify your plan, okay? So when we see the plan before the MRT, see that for the breast, you want to treat maybe 180 a day or 200 a day, maybe 200 a day or tangential or lateral, maybe give 100 a day. And you know roughly 120, 130 MU is probably good enough, okay? If a sicker patient maybe 140, 150. If a wedge maybe 200, you know roughly where the mountain units should be. So you know what I'm saying? You have some quick way to say or this is the way, this number is supposed to be correct or not too far away, at least within 10%. But when you see the MRT, the MU come out, it doesn't make sense at all. Certain field like 100, certain field maybe just like a 50. Another field suddenly 200. Your overall, your MU is about three or four times whatever you had before. And each field has so many variations that you don't really have a clue why we have these different numbers. You have to go back there, see each field, switch subfield, switch subsegments no way you can calculate that. No way you can do that. So it's not intuitive. So, and in order to calculate those for each individual patient, we have to call the modeling so that we can have this modeling to calculate the dose. And this modeling could be very, I think the last talk, talking about all this modeling could be very tricky. Sometimes you messed up. Like when we do the normal streaming plan system, no matter how good we are, we make all the measurements and the calculation and the measurement just doesn't match. Okay, no matter how you do it, the measurement and the calculation does not agree with each other. All we can do, we call this the farge factor. This is like artificial correction factor. Whatever the number we have, give like a ratio 1.05. Whatever we have, we need to give this number so that our measurement agree with our calculation, which is very dangerous. So I'm saying because this just for the orders or the standard plan or standard patient, this probably is a good number. But for each individual, some patient may be too small or too big. This farge factor may not be applied. That's why you have to do the test. But the point I'm trying to say is, sometimes this modeling could be very, very hard to do. Actually for each term machine, there's at least we call the tweaking parameters. You need to know where are they. So sometimes it's just like a leakage.  Then you have a different way to calculate those so your measurement and your calculation will agree. You need to know how to tweak. And then we now go to the VMA, that's even harder. Actually, at least at the beginning, our physician, we discussed with our physician, our physician does not want to use the sliding window. So from the beginning, we use a step and shoot because when it's moving, during the treatment, our physician just crazy. I say it's no way. When I train the patient, I don't know what we are treating because during the treatment, since moving, I don't want to see that. Okay, so we are never using sliding window for MRT until we have this VMA. That's why at the beginning when we do the VMA, it's very slow process also. But basically we have a big jump. We found step and shoot, we jumped to VMA. But we have to spend a lot of time to demonstrate how it works anyway. Okay, so we need to do this MRT QA. That's the reason, okay? We need to verify for each individual patient now, after you commissioned your treatment plan system, you calculate this plan for this particular patient, then you need to verify this particular calculation, this particular modeling, whether it is applied for this particular, because different patient may have a different complication. You know, if some patient is complicated, some patients may be easier. Some patients are sicker, some patients are thinner. So everyone's different. I think my throat is bad. But at this point, we have some material, I can only show the homogeneous phantom. At this point, ideally, you need to do this in homogeneity correction. But hopefully when you do the three-dimensional plan system, we have verified that at least those kernel or this convolution, whatever, or this like the way you correct this in homogeneity has been verified, okay? Now, basically what we're going to show you is how we can make sure our approved plan by physician is why we're going to deliver those to the patient, okay? We just can do quick, okay? At the beginning, at the beginning, we are using this, we call the traditional protocol. This has been used for a long time. This we call the arc phantom. This is arc phantom. This is originally made because, you know, our department used to use, we call the electron arc to treat chest wall. And this is arc phantom made to verify that the electron arc works. But when we started to do this MRT, we realized this is like a circle we treat in like nine angles. And we realized, oh, this is got phantom to verify our MRT plans. So we take this phantom. Basically, this is where you put on chamber here. This is like a holder. This can have a screw over here, can move this at a different depth, different location. So it can have a six or seven location to move up and down to check the different depth. When we do the arc check, this is what may be the isocenter to check the brainstorm, okay? Anyway, that's for the electron arc. And then you can move to the surface to check what's the surface does, okay? So we use this and the iron chamber to measure the absolute dose. So we have a waterproofed iron chamber. We try to see the dose difference for at least different location, okay? And then this is at the point dose in the homogeneous phantom in water. Yes, the point. The measure. The measure. There are four things. Uh-huh. Basically, we just made, yes. That kind of point for you. Okay, for this phantom, the purpose to check one point, dose difference at one point. If you are not sure, as I say, you can move up and down to check only several points. But usually you pick a point. This point is to measure, we call the dose saturation. Usually it's high dose region. So that you know your dose, total dose delivered at the least target is what you prescribed, physician prescribed. If you want to see this different location, then you need a solid water phantom to do film measurement, okay? To see the whole picture, okay? That's why we need, you need the two, for each patient, you need to do two measurement. One measurement, point measurement using iron chamber. Another measurement using film to check the dose distribution, okay? For each patient, which is time consuming, correct? Showing you, okay, this is the way, origin, this is like a prostate patient, correct? This is the plan, okay?  I was going to show you the arc not towards the end. I'm going to show how to commission this. This just give you the result, okay? Basically this is for a different point I'm showing you, different point. See this is different iron chamber locations. You scan, you specify in the, in your phantom, okay? So you can calculate any point you want to. Usually you don't want to put your iron chamber here. This is called the dose gradient. You don't put over here. You put the chamber, iron chamber measurement somewhere over there called the dose flat region, okay? You find this patient plan, put this plan to calculate dose on this phantom. This is called the hybrid plan, okay?  Then you put this phantom. You cannot put the patient on, okay? You put this phantom on the treatment machine and to do the measurement, okay? See it? You need to choose the right location, okay? For prostate, it is right in the middle. But for the head and neck, you have to move. Usually we have this happy matching. You have to move at least two centimeters away from the center. That's why that phantom is useful anyway. But then after making this measurement, you do phantom, field measurement. Okay, I think it's time to talk about. Okay, this is what we're going to do. I don't even have time. But the basic list is you need to do trans, dose transfer factor, meaning you need the commissioning system so that you know for this setup, actually we do 270 and 90 degree to make sure that the setup is precise and that you can average our list number. Then you measure, give different beans from individual angle and then you deliver the treatment to the phantom and then you give the measurement and to calculate the dose, okay? I have to bypass this. Basically you need to make sure what's the number, the ratings you have on this particular point on that date corresponding to what centigrade, okay? For the end chamber, we know it's really like insensitive to the any spectrum, insensitive to the some other factors. Basically it is a good chamber, it's that golden standard. Only thing we need to do is the temperature pressure. Instead of we do temperature pressure, we ask our physics assistant to do this setup check, 90 and 270 and then we just take this dose transfer factor and say they don't have to take temperature pressure. That's introduce another error. This is kind of a double check also for the setup. By the way, okay, for all amnesia, physics is not doing the MRT measurement, QA measurement. There's like a group called the physics assistant, they do this all measurement. Why? Because this has to be done after treatment finished. Usually that's a late evening, all the physicists are lazy and go home. They just come back next morning to verify everything's fine, okay? But point is you need to set up, you need to establish this program so that whoever is making this measurement for you do it right, okay? So next day you just sign off, okay? Anyway, and the result, if the measurement and the calculation for this particular patient is fine, but first remember when we set up this QC, QA, we need to set up this tolerance level or action level. Remember? So what is the number of, that's the problem. I think at the beginning we can have a very good setup for all the prostate, this is 3.5 for us. Why? Because this picture, okay? We did a lot of tests. This is traditional, this augmented measurement. Like I said, we have a different services. Different services, we try different way of a plan. Different services, we have to tweak the number so that our baseline is somewhere meet our criteria, see what I'm saying? Why we use 3.5 in this? Pediatric services always cause the problem. Head and neck is fine. Nymphoma is fine. For different services have a different type of a plan. So you need to know where is that. This is like one sigma, okay? So most likely if you set this window like 2% or 3%, you're going to have this kind of force alarm to trigger you so that you cannot send off your QA result. You don't want this window too big. That sometimes is not good. But we, pretty soon we realize this 3.5% is not enough. We always have this trigger alarm. We have to go back to do what to do. So for the most services right now, our absolute measurement, 5% is our window. But for head and neck, 3% is the window.  If that's the case, we have to go back, repeat the measurement, find a different point, see whether we can get it within 3%. If within 3%, we sign off. What happened to that 5% difference? We just say, you can all. We just need to do everything we can so that patient can pass. But that's a joke. Anyway, okay, but then you see, we spent a lot of time to do the iron chamber measurement and then we have to tear up the setup, put out another, I didn't show another film at that time, bigger piece, okay? You need to do another film measurement, two step. So it's no good, okay? So quickly we change to this IBA IMRT phantom. Sometimes because our PA said, I am really tired to repeat the measurement, okay? So we do this one phantom to do two measurement at one time, okay? So you can put an iron chamber in there, you can put a film over there, film there, iron chamber over there, okay? So use the iron chamber to do a single point. The best thing is you can only do one point. You cannot move to anywhere. If this point no good, you're in trouble, okay? You have to repeat next day, okay? For the film, we do relative those measurements, those ratio usually is in a corona plan. And then we do gamma analysis. Anyway, have to be real quick. And then we do this traditional QA, we realize we have to use 5%, okay? And so this is 5% over there to do gamma analysis, so that we can pass actual asking for 90%. And this is the film measurement, film measurement. All this film measurement, film, I don't know if somebody talk about it, it's really tricky, I don't really have time. Because this really depends on film processor, that the film itself, by itself, it's just enriching, you know, it's a server, whatever, it's not reproducible. By itself, you have that. And also another thing is once you expose this film, and you have to develop, once you develop, you have to have another film radar to get at this dose and to the analysis. When you see this analysis, but sometimes the setup's wrong or something's wrong, and then the period of this film measure is not good. But which is very late. Or by the time it's doing the analysis the next day, and then you have to come back the next day. See what I'm saying? By the time you get the data, and by the time you analysis the data, usually it takes a long time for the film, that's not good. And for the film, in order to do the analysis, you need to do all this calibration, okay? It's good since you have a spatial resolution, but it is, the film is like a spatial dependent, and also any dependent, you need to do this calibration. For each day, this process could be too warm, could be too cold, the dose is different. You need to change this density to dose correction. This is very, very tedious process. Then you renormalize to get the number right. So it's tough.  We have this kind of sliding window, or we do the VMAT, that the radiation being on during the treatment, then the step shield you can trust each day, but when you do the sliding window, you do need the kind of more information, correct? You need to make sure you get all the information, because all the country angle, dose rate, MLC, they are moving all at the same time. And which one plan may not necessarily the same plan. It's one point may not be enough. So usually you need the more measurement, which is really make people kind of nervous. We have to show our physician, yes, not just one point is enough. We have all these volunteers acceptable, okay? Anyway, so all these end up, we have to have figure out some new detector, new measurement device to figure out VMAT for our physician. Then we just, okay, show you a different way to do this. We have a lot of things, okay? So you need just, you cannot just do one D now. For all the VMAT, all the sliding window, you're supposed to use at least 2D dosimetry. Like this, we have an MRT, matrix X, you have a map check, you have used the iPad. I think the last talk we also discussed a little bit. And then you can use 3D dosimetry, 3D dosimetry, okay? Even some people using the real 3D like a jail fountain, and then use like an MRI or some way to scan, or you have a different way, okay? But this is not quite mature yet, okay? These are commercially available. These two fountain, okay? And we decide to try to use this ARC check, okay? I'm going to use these to show you. But I'm kind of a little bit. This is the 2D fountain, okay? This is for our proton now, okay? This kind of side check real quick. For our proton, we use in this matrix, okay? So we use this either without or with extension, and then in order to make a different depth, you can make a decent fountain. This is really the way we're doing the QA. This is for the proton. It's very, I'm trying to say it's very primitive, but as long as it works, that's the way it is, okay? Even the proton machine is very fancy, or QA has a little bit of problem, okay? Still trying to improve. Huh? Huh? Pardon me? Like a... Compos, compost, IBS program? Yeah, IBS, yeah, yeah. But anyway, in order to make the measurement real quick, we have to repeat the different depths and just add a different build up. Anyway, this is the proton. But then you can use a map check for the QA. We're not using this. I just show you it is possible. In order to make a different depth, you can use their fountain called a map fan, okay? And the list is the detector depth. So many detect this like a matrix. It's like a matrix that you can do, okay? And also you can use the epic. I think he talked about the epic last talk, is that right? So maybe I should pass this. So epic is really good because it's attached to the machine, but it's really bad because it is so hard to calibrate, okay? You need to be very careful. I just give you really quick information about ARC check. When we first switch to the VMAG, the physician asked for more measurement to verify and to a point where to find the different QA fountain to show, and this is what we're going to show them. And this is the specification. Okay, this is the ARC check, we call it ARC check fountain. And you have a different diameter. Okay, the advantage to use the ARC check is basically you can do 3D dose measurement. The bin is always normal to the detector services and it's allow for ion chamber measurement. At this point, we only do the ion chamber measurement when the dial measurement failed. And the next day, we do dial on the chamber at the same time, okay? And then you can do the real-time measurement just real quick if it's not like the film, you have to go process it, do another, you know, film writer, do another film analysis program, okay? And it is usually easy to set up. You can make two measurements at one time and then you can see the composite or each control point that you can separate them. So it gives you more information. Not necessarily good, but for some people, we have to show them this is the way it is, okay? And then you need a commissioning this system. Basically this is the way of commissioning. You need a scan this fountain. Same thing for the ARC fountain, I just show you. You need a scan this fountain, CT scan is for fountain. And then this, which means this fountain is a patient. You're going to treat this patient, okay? Use the plan. So this will be, then after you scan, you verify your scanner, verify the fountain according to whatever the manufacturer specification, okay? You do these measurements. See all this measurement to compare what is the manufacturer saying, what is we have from our CT. And then check whether this is uniform, check this Hansper unit uniformity. See what I'm saying? Because when you calculate in the system, 10 centimeter is the 10 centimeter. You'll have a different attenuation. If your image, your image you come out, instead of 10 centimeter give you 11 or nine centimeter, of course you are not going to measure correctly. See what I'm saying? So you have to make sure this is according to the spec. And then you check for each individual system, you check the house, the dosing linearity, meaning assume your machine is, MU is linear, okay? So make sure give different dose, the response is linear because you may have some patient give 400 a day, some patient give maybe 200 a day, okay? And for this particular detector, maybe see the entrance dose, maybe see the exit dose, the dose may be different. Also this should be dose rate independent, okay? This is different dose rate, like a different MU per minute, see what's the dose rate. We do see this when the dose rate goes very low, you have like a 0.4% away from this expect number, okay? This is where you expect. But for different dose rate, you have a different response. That's the best things for the dial, for the film, for the film now. For the dial, this is the problem, this is the detector issue, okay? And chamber usually independent of dose rate, okay? And then you check all this patient, we compare this arc phantom, check to see this, because we are switching to this new phantom. So when they compare with our old phantom and the new phantom CC, whether they are giving us the same result aspect. So arc check and the previous phantom, we use all the previous measurement, previous plan and the compare, okay? With 25 case and the five-vehicle case, and we don't see really big difference. See, this is where we see, okay? For the gamma analysis, this is where the gamma analysis, or for the in the middle, the ion chamber measurement. But as you can see, the ion chamber measurement jump up and down. So we don't really rely on ion chamber measurement that much, because all these dials supposedly to measure absolute dose for you already, okay? So as long as this peripheral dose is good enough, we just take it, okay? But if it's not, then we do. Then we do this data, we call the error test analysis to have a different dose rate, different location. If we intentionally set up error, see whether this system can pick up this error for us to see how sensitive, okay? And as you can see, it's not quite sensitive, but still good for us, okay? We evaluate, we intentionally change this parameter to see, in principle, we supposed to see this fail, this, but see whether the system tells us this is fail because the setup is wrong, okay? You need to do this kind of test real quick. And then you can see, you can do the analysis, see this called the real time, that when we do that, this look like it's a plus state plan. This is the plus state arc we have from here to here, okay? Usually we have two arcs, we have two arcs. What it's trying to show you, say when this is moving, I don't know if you can see it. When this is moving, see this moving here, this moving, you can see the real time. What do you have, okay? If you see individual cursor here, you have some outliers, see this? The red one, meaning you fail, how many you fail? The green one, how many dials you pass, see it? You can see each individual angle, and they even see the real time, what happened? For this particular arc, it seems here you have a lot of failures, see what I'm saying? Can you see it? This is like a, this going arc like a clockwise, this is like a counterclockwise, from here to all the way to here. So for each individual location, you may see more problem, but the problem is when you add up together, they average out, okay? That's the point. See, then you put all together, and then this gives you, and as you can do like this, the line to see the profile, then they all agree with the other very well, okay? If you just show one, maybe, get your angle at zero, we have a lot of failure. Did you see that? But you see the overall, it's fine. So basically we decide, decide, okay? Take a long time to decide. We are using 3% and the three millimeter gamma analysis for the most cases, okay? So when we report our PA, Physics Assistant, need to show this 3% and 3 millimeter. Where it's more than 90% meaning pass. No question asked, okay? What happened if fail? What happened if fail? Sometimes we see the large fail size because diode is like sensitive to the scatter radiation. We only use 10 by 10 to do the calibration. There's a lot of this issue. Anyway, when it's failed, we use 3%, I mean 3 millimeter and the 5%. If 3 millimeter and 5% pass, usually we pass, okay? Unless physician, particularly the head and neck doctor, say I want to verification, okay? Then we have to do next day. For most other services, 3%, I mean 3 millimeter, 5%, they will just go ahead past, okay? And another thing is sometimes, because this is compared to measurement with the calculations, this measurement, just like the film, you need the conversion, you need the calibration curve so that you can convert the number of your readings to the real dose, relative dose, okay? Even though the manufacturer recommend, probably only need to do this every two or three years. But we do know, I think I have another thing. Okay, maybe this is the last one, okay? Basically, right now we have a two R checks commissioning, we have a two Fenton, we have a two different building when we walk over there, it's like 10, 15 minutes. So there's one PA doing measurement over here, another measurement doing over there, okay? Then, but you need to do this comprehensive analysis, just like I show you, two commissioners Fenton. And then you need to develop the QA program to monitor how it's performed. That's what I'm trying to say. Because the dial is drifting, okay? Even though the manufacturer say you only need to do calibration curve maybe once every year or once every two years, I don't know the number, but pretty soon we realize.  And then suddenly after maybe three months or four months, gradually this number getting worse and worse, and suddenly most of patients getting worse and worse. And what happened is because the dial drifting. So we realize we need to do this calibration more often than they recommend the period, okay? So all we can monitor, now we ask them monitor, see what's the trend. So we decide, okay, now it's time for you to redo the calibration to do this calibration curve, okay? And this happened to us. That's the one time always fail. So we have to go back to repeat again, fail, repeat again because we realize actually it's not a measurement fail. It's the calibration curve, calibration files. No longer valid because the dial response, the sensitivity changed it, okay? And then the issue is also most of the time physician really interest in the high dose volume, but our check, Fenton, only give you prefer, prefer dose and which means usually it's like a low dose region. And sometimes we are saying, oh, for this particular patient I want an additional measurement. They don't satisfy with this prefer dose which is making more measurement, okay? Another problem is the dial response, the sensitivity is really related to this feel of small to big. We realize for the small feel it seems we are fine. But every time we have a large feel like for the pelvis they have this large, you know, feel or the sarcoma case with a large feel, we always fail because there's a lot of scatter, a lot of exit dose cause this problem, okay? And then we don't know how to solve this. It seems like we need two different calibration, two different calibration curve or calibration files, one for the small feel, one for the large feel, okay? Anyway, so this is what, and when we do need the something in between, we put the insert, you can get a different insert there. And the two, we are making this different insert or we have a machine shop so that we can put the un-chamber in different location wherever different, we made ourself, okay? So what I'm, what I just show is we, we do need a QA tool for patient before the treatment so that we know whatever we see on the paper, the treatment plan is what we're going to deliver to patient. However, all the check we have right now is doing, basically it's a homogeneous phantom. That's another thing for the heart check because this dial is not homogeneous, okay? So it's really, that's a different issue. And eventually, gradually we realize we can really not check precise within 2% or 2 millimeter. That's what we are asking for. The, you know, at the beginning, we talk about the religion therapy. See, we want the goals to get within 2%, 2 millimeter, even though eventually the biological dose, we want within 5%, but from a physics point of view, we want within 2%, it's all right? And the 2 millimeter. But whereas we can never get that, okay? So what we are really checking for the MRT QA is probably the patient's safety. The patient's safety is more important. Meaning, as long as it's a reasonable number, we're probably going to take it, okay? If we really were worried, then this pre-check treatment really cannot verify because patient is not homogeneous, okay? If a certain patient, like we treat a total scalp, we treat a total scalp very close to the surface and a lot of bone, and then the physician will prescribe, say, I need the TOD measurement, like in vivo dose. So often times when you have the new technique using the MRT or VMAID, the physician, you need to do this, we call it in vivo dose to verify your plan, yes? Okay, I'm done. This is the last slide, actually. I'm done. So this is the last slide. Sorry. Thank you, sir. Thank you.


Hey everybody forest here ripping 2022 Bowman baseball hobby 12 box case number two random team style You could check out the results anytime of late sports cards calm There's a link in chat for you from a few minutes ago. So let's go ahead and get started everybody It's another pearl pack we have one last case, so maybe we'll see one again Maybe they're running pack. Maybe they're running bunches Something good, that's all I'm thinking We got to get the band together World tour Thanks for sharing Steven Patriots for sure just a feature Hall of Famer last night easy. There'll be none posted tonight Yeah, maybe there'll be some more next week. I would assume there'll be some more next week at some point That's where you check basketball break. So we're scheduled through I think Monday night currently So if any does get listed this weekend it'll be for next week holiday Was a romantic Lunar glow first woman Justin Henry Malloy for the Braves First woman base auto of Jefferson Rojas Cubs First aid of the break Spencer Jones Axel Sench has Braille and Bishop It's a blue chrome coming up true blue as well, and it is a Colton Couser Number 47 150 Baltimore So everybody up to tonight Lot to watch on TV for sports Lakers play tonight, right? I believe they do Jacob Barry Got neon green paper is jet Williams the 399 for the Mets lunar glow Yankees Fernandez Atomic Bowman scouts top 100 Evan Carter Rangers to 150 the workweek starts today Carl You know how I'm sure you're gonna have the bees game on how you're gonna tattoo during the bees game, dude. I Don't know how I'm gonna break during it atomic first woman Roman Anthony Red Sox routine Gonzalez Wagner and Osuna Nah, hopefully there's no game seven. It'd be a lot less fun That's what I'm saying gotta go to gotta go to Carl get some tattoos You dig a rich open up a shop up there That's where you need to go. All right. Nice future lunar crater chase young to 199 Tigers Lunar or lunar glow first woman Axel Sanchez for the Mariners. Oh, is that an orange auto? I think it is. Oh Derniche Valdez true orange first woman auto cubs to 25 Big hit cubbies Orange going into a mag Nice Valdez Hobby only orange That's like essentially. I mean other than super obviously that's that's chase. That's the chase and hobby Super red or cool, but you can only get those here. Got Carol Jones That's what I'm saying. It's got it like the gaming shop gaming shop. It's crazy though That's the only gaming can get that busy Sports shops are cool, but they don't you can't have like tournaments and stuff like that That's what keeps that place pop and they do tournaments every single night. I think You be except Sundays, but even then like I think they do turn on Sundays It's literally every night. They have like regular hours until like seven or so and the tournaments will start like seven or eight It's loony over there first woman lunar glow Anthony Pico Anthony Piquero for the Marlins Atomic first woman D on Jorge Rockies So let's get a football and eminence filled up everybody eminence basketball and contenders optic football. That's all we got left for tonight You're coming narrow Isaac size of kiosks in a mall There's not a lot of big space Massachusetts though Like getting that square footage that rich got for that gaming shop would be really tough to do in a lot of places in Massachusetts Without like building, you know, not being to have like an outrageous lease For me Yeah, food is delicious Geez Carl That's crazy, dude Places like that just last long most likely Which mean you can get things online Yeah You can order from us ship it free Probably get it like two or three days later, man Would you hit Just heat those four boxes in the front as well, so oh There's two Jones, and then there was a gold Gonzalez What has he those four boxes are hot. We're on it. We're on right now. Oh man. Oh, yeah Mervis lunar glows aviar Isaac rays Inemption see Spencer Jones Shay Langley or is your key of the year favorites auto for the A's there Shay Langley or is A's 550 for contenders. Geez, dude. Yeah, man That stinks Blueprint paper to 125 Brady House Nationals We'll say my forearm is a Getting the workout right now With three boxes into this one too Jacob Berry So just two to go in that first half case of contenders optic Carnaval's and Panthers Then random teams it might be sold out Refractors Xavier Isaac first woman raised the 499 with a lunar glow first woman Fray made a lion Red Sox Teen Gonzales got an atomic coming up And it is a Cole Young for the Mariners Spencer Jones base And Nolan Gorman trade some Star Wars toys for some prism That's pretty cool. So we just got contenders optic PYT's and Evan is basketball, that's it for tonight everybody Kyle's live over on drip with personals will be live in the morning with more group breaks as well You got Kyle tomorrow morning. Kenzie tomorrow night And then I'll be here on Sunday for you Yeah, there are no personals tomorrow night to my knowledge It's causing group breaks in the morning. There's no drip tomorrow night And then Kenzie is breaking Saturday night and Sunday morning. So there's no personals tomorrow I'll resume Sunday on this channel So drip is the place to be tonight if you're looking for a personal and this is an endurance break right here These are the real deal lunar glow Michelle. They sound first woman Orioles Blue auto Elijah green 1 18 of 1 to 15 nationals Congrats gnats big card will get the dust back off the bottom we get that magged True blue Elijah green big card. There we go Drew Jones on the base Looks like it would be a dust spec The yellow lunar crater Roman Anthony first bowman 24 of 75 Red Sox nice card Fantastic box here Abel bastidas Cuaca Grego aria al amante Ballesteros Miguel blaze That's pretty interesting be just randomly had some 2021 basketball Lunar glow first woman William Lugo Mets Andres Mesa Wagner Work sleeve got a you under coming arrow with an atomic of young kill Fernandez for the Rockies I'm he's a good prospect too. He's a he's a good prospect and his low number Justin Crawford. He's coming He's coming biased target recently every time I stopped by I grab a I grab a box of like 21-22 series two or something have like 15 bucks Pull like normally two young guns of blaster easy easy times Easiest rip ever right there you can just do Lunar glow first bowman Christian Serda for the D-backs we got an orange shimmer coming up now. I think it's an auto Oh, it is Pretty sure that's mariners colors. See a huge name here. It's a royal. Yep orange shimmer a royal There we go great hit for the Mariners One of 25 first-moment auto sup Alvin. How you doing, man base of royal in there? Blue Rayway first moment of Marcus Lee sang five out of 150 fills Sportsbar near Zellwood. I have no idea So even anything in Zellwood. I think it's getting a little better out there because of Yeah, I don't know I I've I've driven through a cell with like once or twice But that's to get to Mount Dora Spencer Jones, I Was gonna say like does that would have anything I was gonna say you can get to things nearby like you sister Mount Dora, but I don't know I think it's all like chains and stuff right for the most part Chains like biker bars Orange paper Gavin Cross 24 25 Royals Best bet's probably Google honestly Yeah, there's some places in a pocket that are solid it's not the closest but you can drive like Six seven miles probably get to some decent places Garibaldi's is a solid place though Not totally like a sports bar, but you can watch sports there.  So it was behind that Caught yeah again Google Google's your best bet for stuff like that. I don't need I don't even live in a pop I live in winter gardens. So I don't I'm not over here a ton There's an atomic Carlos Jorge first Bowman Reds Then out to months not super far. There's a lot of now tomorrow Aqual Lunar Crater Deon Jorge the 125 Rockies Moving on to the sixth box here Yeah, as far as a pop of yours Garibaldi's unlike The farther east side of a pop it's like right when you get into a pop It's going all right Alvin, you know, it's going Waiting on the Bruins game to start about a little over half an hour NFL Draft coming on a bit few more breaks to fill up. It's been quiet in chat so far Stop Jason. Yes archive six series is a buyback program as a buyback product Manny Top spies back the cards because the players assigned on the stands with the six series Seeing the show that it's from that product and not like actual pack pulled then puts them out like that You can find six series stuff on eBay Well, yeah, they're tough to calm especially low-numbered and a guy like Jesse winger that doesn't sell probably a ton Lunar glow first woman Gabriel Martinez blue Jays Nice Glader figure a oh lunar blue lunar crater first woman auto 112 by the 150 Rangers That's figure a oh that figure a oh Spencer Jones spotlight of Alvarez Julian Bishop Lazarus Romantes Hector Rodriguez First woman Aqua shimmer Max Wagner Orioles the 125 Lunar glow first woman Kyle Harris and Giants Rano Perez and Ben Cosme What happened to Will Lewis you fell that happens every year purple print Nolan Aronado number to 199 Cardinals Jacob Barry Atomic first moment Pedro Amir as For the Cubs Patrick Dreyfinger for funsies I Like I like the pets draft pick I'll be opposed to the patch drafting I'm just so just five teams total left on contenders optic and eminence that everybody got to get those filled up Yeah, I was kind of surprised they were able to trade back and still get them Katelyn Carter He's gonna be pretty good He goes they will Washington's kept trying to roll a Sam Howell they're trying to see what they got in him will ever I would just not go to the draft Oh The corner I Think Washington's got that ahead of them. Yeah, who to Washington take forget now flight blue paper rookie eggy Rosario to 499 Padres post rate the Paula first woman base Lava Colsom Montgomery to 399 White Sox Lunar glow first woman Deanna Jorge Rockies Speckle first bowman auto going to the Mariners is Gabriel Gonzalez 29 out of 299 Congrats Mariners Autos are hitting big time in this case Get that magged just a Crawford White blue paper first moment. I've able to see that's the 499 Tigers Next year is like football products. Yeah, I mean it'll be good I think Bryce Young is gonna be the real deal everyone else. We shall see Panthers could actually be like a pretty good team this year. I think they were sneaky towards the end of last year. They got a Decent old line. I think Bryce Young is really good Made some good pick up some free agency. I think they're gonna be pretty good next year, especially considering that division visions Falcons took a running back in the top 10 B John's awesome, but he's not gonna help you win football games next year Maybe that's your plan where the plan is to lose a lot of games next year Draft near the top Lunar glow first woman Austin Charles Royals Yeah, we were just talking about that illegal. We should give him to come to the shop For sure. Yeah. Yeah, APK. He's a blue darter. Blue darter Yeah, we're like literally like literally just now Atomic first woman Alejandro Osuna for the Rangers Yeah, the the Philadelphia Bulldogs do they draft all the Georgia players now smart. Yeah, he was killed. Are we heading in there? J-Spoen Arielle Almonte Josh Young All right. Well, the Giants take a center So dusty in here. Oh See the you see Shaq Yeah, dude Love to get him up love to show everybody Probably one of the fair all you had to do was throw football over the mountains and you got the sloth, so I'm the only person that did it. Let's go Thanks playing collect Maybe it's a tackle maybe who do the Raiders taking the first time they take an offensive tackle, right? I Can't remember the Tennessee kid, right? Oh DT. Yes, which I was right It's a Daniel Martinez routine Gonzalez Lunar glow first-moment one almost Royals First moment refractor auto Red Sox branded Walter to 499 finally cool off in here Purple print one Brito first moment Rockies color matched to 199 Yeah, that was a big dude Yeah, Carl got that I got this got the stuff sloth Was the they don't they don't have actual steel tip darts there anymore Or like throwing like hacky sacks or whatever So then soft he's got a it made it too easy.  She's parking for the aquamar It's good as good rides or they should they rattle your brain a good amount as a drew Jones got an atomic on Hellsend now first woman for the Guardians All those rides they shake your head a little too much that brain shake We start to get Colby Thomas Lou shimmer first woman Leandra Arias one eleven of 150 for the Orioles Lunar glowed JC on tigers 66271 Again looks like a complete chisel beast Pretty scary. Yes very scary Which products blaze Jordan basically every bowman product since 2021 Bowman 2020 Bowman is his first but basically every product since then that's a Bowman product He has basin. I think he has base in this too 2021 Bowman is his first bowman auto Hopefully blaze Jordan is good. Let's see as he moves up through the Red Sox system No, no more not not yet today DJ. We did pull a pearl pack though Lane pulled a Christian right as super fracter in the in the 10 case or earlier Maybe maybe the rest of the case will have one. Hey, I hope so too DJ if I don't pull it here I hope it's in your case tomorrow. Let's make me like dizzy. They sell like Concessions at this at this you just show up or like, oh, there's definitely sessions They're gonna get that money. I was gonna say like it's a gigantic field for the people Yeah, they're definitely So I'd be wondering about like where am I gonna get a beer and like a sandwich Superfactor Blake it dude if you pull the Blake super I'm telling you guys I will lose it Lose my mind not lose the super fracter And I'll just tell tell rich Yeah Lunar glow Jason Dominguez Yankees Gold Carlos Jorge first bowman auto for the Reds Congrats Reds get that mag for you true gold the odd has been crazy in this case Hobby's been good man. There's definitely more balance between hobby and jumbo this year on what up getting that breakers claw What up on? in that breakers claw Cossus Spencer Jones First woman lava is Javier Osorio to 399 for the Tigers Maybe I'll just go to the fair again tomorrow. I don't know. I don't know if I do any rides I probably just go get some food and play some games Edward Julian for the end connoisseur Lunar glow first bowman Daniel Montecino. No, I didn't see those man to be I know how to do it this year Which I guess makes it more fair because when they used to sell it You could buy like the one of one it would sell out like immediately if like anything So at least it's more fair this year to split it up. Maybe we're pissed about that But like get more people a chance to do something like that Blind green paper neon green paper sorry Kenny Gomez to 399 for the Astros Atomic or hey board goes first bowman guardians These hobby cases are a beast the rip. I'm pretty taken napping for this one. Yeah, you're probably right about that Manny That yeah, if I pull the Blake, I am gonna be like a what-not breaker Pulling a base or fracture of like wanderfrog over something.   I'm like I'm getting like dead arm Came motion over and over Well, let's hope the Bruins we can just switch over and watch the leakers game and happiness appreciate that Manny Appreciate you man I'll be worth it when you get a Franz one of one neon green paper CJ Abrams of 399 the Nats Lunar glow first moment Kennedy Corona Astros First woman base auto Nick vote Padres No, man. He not not like at all. I'm just leaning on my left arm right now though Because my left my left arm is just staying still coming arrow base This is like something you could break in your sleep, dude. That's a 299 Eric Brown jr. Pink paper Brewer's Aqua Lunar crater Deon Jorge to 125 first moment for the Rockies That yeah, yeah, well legal is actually right.  Yeah, I have Luke Skywalker's arm. Yeah, sounds like it Do we short some coffee post weight the Paula first woman base Lunar glow Ryan Clifford first woman Astros Crawford well von I mean Wouldn't they get it because it's the 32nd pick like is that not how it works? That's how it should be Atomic Oscar Coloss white socks. Oh nice. It already started back up. Oh goes by a round pick.   Of course the NFL would do it that way. Oh, we don't the teams give out more money We'll go get upset They can't afford it. Do you imagine owning like a sport like a Big four sports franchise in the United States and be like, well, it's tough, you know, it's don't make a ton of money. Oh That's that's good That's all the MLB owners tried to say during the lockout. I'm gonna make that much money. Oh, that's funny That's hilarious They're like that that uh, what is it the woody hair or something or not? So I would hear somebody's like crying wiping his tears of the money. That's the MLB owners are doing too bad illegal It's the Steelers you you you don't want it You don't want the Steelers to have to pay more to this player that's about to get drafted 30 second overall What is Donnie talking about now? Hey Donnie got any good questions. Oh, thank you Don't worry guys, he'll come back with a question Don't you worry We'll get him we'll get him. Oh, here we go Steelers pick. They're gonna take Will Levis. Oh, they did it. They took Joey Porter, Jr They did it They did it. That's awesome.  Yeah, Dolphin's legend Joey Porter Lunar globe Peyton Graham Tigers. What's that? That was a No, do you know what a first woman based on a Rockies you're thinking of James Harrison? Yes That's gotta be a crazy moment for that family Nero purple paper first woman one burrito Rockies to 250 Personals over on drip tonight. They're not full get your link in a second. Justin Crawford That shot. There's actually a Lincoln. Shoot your chat right now So only on drip tonight next time the person's here be Sunday morning Mervis Murphy to turn Matt Murphy. Yeah Lunar globe first woman Ronnie Simone raise Do not love it when they they show up the stats of on the screen Got an orange Khalil Watson on the Bowman Scouts top 100 inserted 25 nice card for the for the Marlins.  That's all they do. So you have bad team is Do you should chrome first woman Gabriel Martinez the 199 there go blue jays? What's a Jags next pick Vaughn? Atomic first woman or William Sedanio Padres? There's a late in sports cars drip personals Hello late in sports cars your personals Rookie if you should paper DL hauled to 99 Orioles Yeah, awesome great. Yeah, she's back. Yeah, just Top 10 so far Yeah, the atomics are pretty sick. It's atomic in Bowman and then sapphire is just the Product itself, but yeah same design probably draft the running bag. Maybe I'll take levis You think you think this is where levis gets drafted right here Levis girlfriends and Eagles fan, yes, they're gonna break up. We should go break at the draft next year That'd be cool, that'd be cool, right? Just set us up to the side of the stage We'll be there they'll be sign of their first cards over there with us All right last box of the case. Good luck everybody Jacob Barry first bowman Booner glow first bowman jace bowman pirates Purple first bowman auto astros Andrew Taylor to 250 Let's get these breaks filled up you guys. You've got contenders optic PYT's and we've got eminence football Blue ray wave first woman Andres Mesa to 150 there you go Rangers. That's interesting got a how you Lee Lunar glow first one you offer Solano for the Marlins Joshua Dobbs. Yeah, dude. He's the goat atomic James Wood for the Nationals Not a very eventful last box here. Those are Drew Jones Got lava Javier Asorio fuchsia Gabriel Martinez fuchsia lunar crater Jase young Atomic Evan Carter insert blue ray wave Andres Mesa blue shimmer Leandro Arias There's a ray wave of Marcus Lee and a true blue Colton Couser Aqua shimmer Max Wagner Aqua lunar crater Deon Jorge twice there Yellow Lunar crater Roman Anthony Orange Cleil Watson bowman scouts top 100 Autos of Deon Jorge and they vote Jefferson Arias. Sorry Jefferson Rojas refractor Brandon Walter Purple Andrew Taylor a Shea Langle ears are key to your favorites insert auto for the A's Speckle Auto Gabriel Gonzalez Mariners at 299 Blue Lunar crater Auto Glator Figueroa Figueroa to 150 for the Rangers true blue Elijah green to 150 Nationals gold first woman auto Carlos Jorge Reds Orange don't each a Valdez first woman auto and orange shimmer Michael Arroyo first woman auto Thanks again everybody moving on


Hello, my name is Anping Chen. I'm a post-doc working in Dr. Michael Romer's lab at American Clinic, the Department of Physiology and Biomedical Engineering. Today it is my honor to have the chance to talk about our current result of the functional analysis for the coding SNPs in human SLC 2689 gene, which published in Human Mutation recently. SNC 2689 is not a chloride channel, but also a chloride bicarbonate exchanger. The non-codomized of SNC 2689 show decreased gastric acid secretion. SNC 2689 is also suggested to be a novel candidate gene associated with inner ear development, as well as in antipsychotic responses. Interestingly, SNC 2689 is localized to absciliar of the stomach and the lung. These are also tissues and members which the CFTR is located. CFTR is a chloride channel which mutants cause cystic fibrosis. Moreover, a recent G1 analysis of cystic fibrosis patients indicated that some SNPs of human SNC 2689 is associated with cystic fibrosis phenotypes. So the question is, how about the SNPs of the SNC 2689 show their respectively effect for the function of the SNC 2689? To answer this question, we performed the functional analysis for those SNPs. Now, let's talk about our funding in our experiments. This is the title for our paper in Human Mutation. This is a predicted topological model of SNC 2689 protein. It has 12 transmembrary regions, with one set of plastic C terminals with stastaman. When we started our project on 2010, there are eight SNPs in the database of NCBI. There are 170N located in N terminals, T 127N located in TM3 region, I 384T located in intracellular loop, R 575W P606R V622R is located in the stastaman variable loop, the V744M H748R SNPs located labeling to the stastaman. Hi, I'm Dr. Michael Efremero and the Mayo Clinic in Physiology and Biomedical Engineering. I'd like to give you a bit of insight into some really interesting work that Anping Chen in my lab has been working on for the past couple of years that's just been published in Human Mutations. What Anping has found is if we look at the naturally, when he looks at the naturally occurring human mutations of SNC 2689, which in my lab, being a physiology lab, we know is both a channel and a chloride bicarbonate exchanger, the wild type transporter shown in green has a certain amount of function, this is just current on the y-axis, but one mutation has a lot more function than the wild type Y70N and there are three others shown in red here that have decreased function. Yet the protein amount seems to be relatively same and all of these proteins make it out to the plasma membrane. Why do we even care about this? Well, if we think about where this protein is located in the gut and in the pancreas, it's in the apical membrane and it has these different roles. It can interact with the chloride channel that's mutated in cystic fibrosis or CFTR and rather than activating function, it inhibits function. So what's even more interesting is there's a recent study, a GWAS study, that just came out from Sun and All in Nature Genetics that shows that this SLC26A9 gene is genetically associated with the gut phenotypes in cystic fibrosis. And so the really important factor of Dr. Anping Chen's findings is that not only is CFTR changing the function of the bicarbonate and chloride transport in the epithelia, but if you layer on top of that this chloride channel and transporter, SLC26A9 in the naturally occurring SNPs, you can either increase or decrease function. And so this in part accounts for the variability that we think are seen in the cystic fibrosis phenotypes. Thank you very much.


Good morning everyone. Okay, good morning everyone. I'm Neve Eastwood from Release in the UK. We are delighted to welcome you to this official HR 19 press conference, which we hope will give you a insight into some of the key findings from the conference this week. The press conference is being streamed live, so for those of you who are watching online, welcome. Before I introduce my colleagues sitting with me today, let me touch briefly on a few points. As my colleague Naomi Burke Shine reiterated last night at the opening ceremony, we are deeply privileged to be here in Portugal to learn about the health advances that have been achieved under the Portuguese decriminalization model. As Naomi remarked yesterday, there has been huge advances in this country, and the world still looks to Portugal for leadership on this issue, but more can be done. And I think we ought not underestimate what kind of impact these reforms have had on health. Portugal in the late 80s and 90s was experiencing skyrocketing rates of hepatitis C and HIV. Twenty years later, after decriminalization, it has one of the lowest rates of blood-borne viruses and of drug-related deaths in Europe. The same cannot be said for other European countries, where the criminalization of people who use drugs creates an environment of fear and stigma and contributes to record levels of drug-related deaths. The UK and Sweden are countries that continue to arrest and punish those who use drugs. The rates of drug-related deaths in the UK are 77 per million. In Sweden, it is 88 per million. Compare that to the Czech Republic and to Portugal, where we are today, which have both scaled up harm reduction and decriminalized personal possession of drugs, and where the rate of drug-related deaths is 4 per million. The evidence on decriminalization and harm reduction is in, and as we will hear from our speakers today, that evidence continues to grow and throw up new responses to the growing opioid overdose epidemic in Canada and the US. So, I am going to hand over to our esteemed panel, but first a bit of housekeeping. We will hear some brief remarks from our speakers, and then I will open to the floor for questions. Once the press conference has ended, you can approach a number of our speakers for one-on-one interviews or arrange to speak with them later on this week. I believe everybody is available at the end of the conference to meet with you. Our first speaker is Jane Buxton. Jane is an epidemiologist and the harm reduction lead at the British Columbia Centre for Disease Control in Vancouver, Canada. Jane will talk to a fascinating presentation she will give later this week on changing drug use behaviour around fentanyl. We think it's really exciting research, and we're really looking forward to hearing your comments. Thank you. So, for those of you that don't know, British Columbia is the most western province in Canada. It, like many of our regions in North America, has a high and increasing death rate from illicit drug deaths. So, in BC, we used to, before 2011, we had about 250 illicit drug deaths per year. Last year, 2018, we had 1,500, so six times that amount. And, of course, this, as many people will know in North America, has been attributed to fentanyl. Fentanyl is a very potent toxic opioid, and the discussion that has been in the media have been around fentanyl poisoning, people unknowingly taking fentanyl when they think they're taking something else like heroin. So, what I'm going to give you is a little bit of a description of how fentanyl and how the landscape changed, and what our most recent study showed. So, we first had this real wake-up call in October of 2014, when we were told there were 30 overdoses occurring at InSight at a weekend. Not deaths, there'd been no deaths at any of our supervised consumption sites, but there were 30 overdoses. The police came and took a substance that people thought they were using was heroin, and in fact, it was fentanyl. There was no heroin at all, it was pure fentanyl with caffeine. Following that, we thought we'd better find out where fentanyl's occurring. We did a study where we asked people throughout BC at harm reduction distribution sites, what drugs they'd used in the past three days, and would they give us a sample of their urine, and we used the fentanyl pest strips to identify if there was fentanyl there. Over time, we've seen fentanyl presence in deaths increasing. It was about 4% in 2012. It went up to 25% in 2014. In 2018, it was 87% of illicit drug overdoses had fentanyl. Because of the awareness, because of the alerting that goes out, and also having identified analogues such as car fentanyl, which is even more toxic, we thought we needed to assess again, and having done a survey for four years, we did another one in 2018. We again asked people what substances they'd used in the past three days, and then we sent the urine off for full analysis. What has happened over time with the analogues appearing, the fentanyl test strips don't always pick up things like car fentanyl, so we needed to have it properly done at a laboratory. So what did the results show? Well, in 2015, when we were first seeing fentanyl appearing, people weren't realizing they were using it, 13% of people said that they had used fentanyl. In fact, when we looked at the samples, 29% had, so that 73% were using substances and unaware that they were using fentanyl. In 2018, 39% said they were using fentanyl. When we looked at the urine analysis, 64% of people knew that they had taken fentanyl. It was only 36 that didn't. So what we've seen over time is that people are knowingly taking fentanyl. That's what the predominant down is. No longer it's really hard to find heroin and heroin alone, so people know what they're taking. But it's still so, so dangerous. But the actual dialogue has changed that it's not unintentional poisoning. It's people know what they're getting. And until we have decriminalization, until we have better regulated supply of opioids, it's going to continue to cause deaths. And our 1500 deaths that we saw last year looks as though it's going to be similar for 2019. Thank you. Thank you, Jane. I'll move straight on to our second speaker, Barrett Lambden. Barrett is a senior epidemiologist, an implementation scientist with the Community Health and Implementation Research Program at RTI International in the US. I know there's a lot of expectation around Barrett's presentation on the new data being released on an unsanctioned consumption room in the US. Barrett, what are you about? Good morning, everybody. So I'm going to be presenting this week a proof-of-concept evaluation of the first four and a half years of operation of an unsanctioned supervised injection facility in the United States. In September of 2014, an unnamed organization in an unnamed location in the United States opened a supervised injection site to address the overdose crisis that was occurring in the surrounding community. What this looked like was that there were two large rooms dedicated solely to injection and then hanging out post-drug use. Six stainless steel stations with mirrors and a table for assisted injections were within the site. Access to clean needles and syringes. Naloxone was on site. To be able to use a site, people had to be invited to use it. As you can imagine, the illegal nature of the site requires controls on making sure that other participants and the staff of the site are protected. And there's a staff person stationed in the injection room at all times. So to date, the site has observed over 9,000 different injections, events. This has effectively resulted in the prevention of nearly 8,400 public injection events. These are injection events that would have occurred in the surrounding communities. That includes parks, sidewalks, bathrooms of local businesses. Over 85% of people from the site report that when they're not using at the site, they're having to rush their injections. That has big implications as we all know for overdose, for infectious disease transmission, abscesses, wounds, etc. During the period of the study, we observed over a 540% increase in the overdose rate occurring at the site. So in 2015, 2016, what that looked like was just under one overdose per 1,000 injections. And in the first part of 2019, what that looks like is about 6 overdoses per 1,000 injections. So when you translate that, that effectively means that for every 167 injections that occur at the site, there's an overdose event. And if that, what we see at the site was reflective of what's occurring in the community, you can imagine the level of response that's needed to respond to that, those overdose events in the community. But despite this rapidly increasing overdose rate, all overdoses at the site have been reversed with naloxone, so the overdose death rate has remained zero at the site, even in spite of a rapidly increasing overdose rate. Our preliminary findings suggest that we need to consider this tool to address the overdose crisis in the United States. It is not too difficult to imagine that if we could take a substantial portion of the injections that are occurring in unsafe locations and move them into safer locations as this site has done, then we could expect to see community level impacts in overdose death rates. Thank you. Thank you, Barrett. That's such important work in the context of the US at the moment. Our third speaker is Lindsay McKay. Lindsay is a family physician from Canada. She will be speaking on her presentation on the use of hydromorph as a fentanyl substitute in British Columbia in Canada. This research really does demonstrate where we've arrived with the opioid overdose epidemic. So, it's important work again. Lindsay. Thank you for the invitation to the conference and for this audience today. I'd like to take this opportunity to discuss a solution to the opioid overdose crisis that we at PHS Community Services Society, a non-profit based in Vancouver, Canada that provides housing service and advocacy in the downtown East Side, have adopted to compassionately combat opioid poisoning. Many of you might be aware that the Public Health Agency of Canada issued a report that revealed that over 10,300 Canadians died of opioid-related deaths between 2016 and 2018. The opioid crisis stems from many converging issues, from policy issues including housing, poverty and health care, to matters of social justice, such as colonization, the denial of indigenous sovereignty, gender-based violence and social isolation. This number, 10,300, is an absolutely harrowing figure and can never serve to quantify the loss experienced by family members, friends, neighbors, coworkers and community members. But within the story, there's hope. There's a different way to address opioid use. Last year, across our three PHS supervised consumption sites, we saw over 331,000 visits and reversed almost 3,500 overdoses. And within the 15 years of insight, the first of these consumption sites being available to the drug-using community, there has never been an overdose-related death. Not there and not at the peer-led overdose prevention sites either. And so, we learned that this intervention has been an oasis of ingenuity and hope in the crisis. Community-based health centers like this were keeping people connected, and they were sparing folks from the stigma that killed others who were using a loan and dying. There are countless literature, reports and news coverage talking about fentanyl and how it has compromised the street drug market. But outside of medical care, the street market has been the only supplier of accessible opiates to people in the downtown East Side community for decades. So, how do we go about disrupting the system in a manner where drug users retain their agency are not stigmatized and can work with their physician towards a goal of safety? There is robust evidentiary base for providing opioid users with observed injectable opioids in order to address their substance use. Our clinical team at PHS decided we needed to supply the opioids to those who needed them. We worked with Vancouver's drug-using community to start our tablet and injectable opiate agonist therapy programs, or IOT. We knew how this program was situated in the community would determine its success, so we went to where the community was best supported and had established resilience and harm reduction practices, the supervised consumption sites and overdose prevention sites. Here, we seamlessly integrated into the continuum of services that community members were already accessing, and we were able to engage with and enlist opioid users who would most benefit from the program. A nurse, a community health worker, and a peer worker staff our overdose prevention site injectable program. The program is open every day. The injectable or tablet hydromorphone is paired with flexible doses of oral opiate agonist therapy. Patients have the option to come twice daily for the injectable and up to five times daily for the tablet program. Transitions within the program are patient-led and patients have the option to transition between programs based on what works best for them. Since the program was made available in 2016, we have been operating a 50-person capacity for the injectable program with an additional 50 people in the tablet program since early 2019. We also have three housing-based programs that can have up to eight people at a time. More than 300 different clients have engaged with our various programs over the past two years. Our IOD and tablet programs have allowed us to connect participants to primary care services and has led to some incredible outcomes that are synonymous with patient-centered care. People report less anxiety around managing their substance use and engage in less criminal activity to finance access to illicit substances. To this date, there have been no overdoses inside of our program. In closing, I want to share with you the words of Paul Skiback, who was one of our first clients after IOD's initial launch. He says, On the fourth day of the program, I stopped feeling anxiety. Then I think it was the seventh day I started to think, what am I going to do with my time? I had all the spare time because I wasn't hunting dope, so I got a job. Three weeks ago, I was trying to figure out what I was going to do every morning for my fix, and now I'm working, and I haven't worked in 10 years. Thank you for your time. Thank you, Lindsay, and thank you for sharing Paul's story. Our fourth speaker is Kirsten Horsper. Kirsten is the strategy coordinator with the Scottish Drugs Forum. She will give us today a European perspective on some of the groundbreaking work being carried out by law enforcement agencies in Scotland. Kirsten. That's quite a statement to start with. Scotland has the unenviable position of having the highest rates of accidental and preventable overdose deaths in the whole of Europe. So in 2017, we lost 934 people, and in 2018, it's expected that there will be well over 1,000 people having lost their lives. So it's incredible rates. Scotland is absolutely in the midst of a public health crisis, and at times of crisis, we need to rely on other people who might not be our instant assumptions of those who would help in such crisis. The majority of overdose deaths involve opioids such as heroin and methadone, normally in combination with other drugs such as benzodiazepines and alcohol, and certainly over the last few years, Tizolam has been one of the main benzodiazepines involved in our drug deaths. But the majority of cases involve opioids. Naluxone is a medication that reverses the effects of an opioid-related overdose, and we have had a national Naluxone programme in Scotland since 2011. It was introduced by the Scottish Government and it was fully funded for five years, and then it has just continued to be funded by the Health Service and by local authority areas since then. Since the start of the programme, we've provided over 50,000 Naluxone kits to people who use drugs, staff working in drug services and others who are likely to witness an overdose. The priority of the national programme is absolutely to make sure that Naluxone is in the hands of those who are most likely to witness an overdose, which is people who use drugs, and it can be an absolute lifesaver if it is in the right place at the right time. However, we do also accept that other people are quite often in the presence of those who might overdose. There are other first responders. One group of first responders is prison officers. So in the Scottish Prison Service, overnight in the prisons, there is no nursing cover, so if there's a medical emergency, the prison officers are required to phone an ambulance, and obviously that can take some time. So in partnership with the Scottish Prison Service headquarters, Scottish Drugs Forum worked with the staff to provide training to around 300 night staff prison officers over the course of a few months. It's quite challenging training, but the ultimate outcome of that was that now in prison service across Scotland, Naluxone is available overnight to be used in an emergency by prison officers. The chances of an overdose occurring overnight in the prison service is fairly low. It's not something that they experience frequently, however it is the principle of having Naluxone available, which is a safe and effective medication that can be used by anyone for the purpose of saving a life. The other group who are more likely to be first responders are police officers, and we find that police officers in Scotland are quite often first on the scene at an overdose. They have been partners in the Naluxone programme in the eight years since it has been running, and we have worked with them throughout those eight years to try and enhance their role so that they are then in a position to actually administer Naluxone in an emergency and to carry it. I had hoped that by the time that this conference came around that we would be in the position where frontline police were piloting the carriage of Naluxone among officers, however just when you think you're getting to the next level, the final level, another level appears, so we are still working with them to achieve that. At the minute though the safer communities department within Police Scotland has a rolling programme to train new recruits, so we deliver training to probationers, and the outcome of that eventually will be that Naluxone training will be part of the annual officer safety training programme. So it's definitely something that we're nearer to than we ever have been before. It's likely that when we do pilot police carrying Naluxone it will be an intranasal version rather than an injectable one, but ultimately we do not envisage or desire a situation where police are leading in the efforts to prevent drug deaths, but we have to acknowledge that they are very often first on the scene and could potentially be saving lives with Naluxone. So just to finish, to be honest we don't care who you are, you could be a police officer, a prison officer, a person who uses drugs, a family member, friend, a member of the general public. If you are somebody who is likely to witness an overdose you should absolutely be carrying Naluxone just in case. Final speaker for today is Jasmine Tyler. Jasmine is the advocacy director for the US programme at Human Rights Watch, and she will reflect briefly on the human rights aspects of the opioid crisis. Good morning, thank you. Every 25 seconds in the United States someone is arrested for drug possession, and you could time in the amount of time this panel has even been going on how many people have been arrested. I haven't done that right now, I probably should have, but it's a crisis. Criminalization of drug use in the United States is a crisis, it's a crisis around the world as well, but the other crisis is that we have a lack of healthcare infrastructure and access to community-based services for individuals who are in need. The panel that I'll be on here at the harm reduction conference is called drug courts, hard lessons from implementing countries. And my colleagues on this panel will be examining and exploring research that has proven that drug courts are not actually the answer to those two problems, the problems of public health infrastructure and criminalization. In fact, drug courts challenge and violate international standards with respect to the right to health, the right to self-determination and proportionality in sentencing. There are a number of specific challenges that have been uncovered when it comes to the drug court model. Namely, the largest issue is that these courts tend to practice medicine without any medical practitioners involved. For instance, it seems to me and in the research to be a completely crazy idea to determine someone has a health condition, substance use disorder, but then instead of providing them services within a medical context, continuing to send them through a court process that again doesn't have medical staff involved and has a number of legal consequences because it is within the legal, criminal legal system. Some of those consequences around the criminal legal system also undermine the goal of not using or the purported goal of not using the criminal justice system as a lever for drug addiction, but the reality is that's the only lever the court has for individuals who may not be able to comply with the terms like sobriety and going to appointments on time, things like that, and what we've seen as many times individuals end up serving more time because of violations that they've experienced in drug courts than they would have maybe if they had just taken their original case to trial or to plead. It's important to also understand that the resources that drug courts are using actually take resources from community opportunities for individuals, so many times you'll have someone in a community call for drug treatment for themselves or for a loved one and they will be put on a wait list for access to services that could be anywhere from days to months because those drug courts have priority over the slots of treatment in those community-based treatment programs. So it's counterintuitive that a person who needs help and wants to get it, right, they're self-determining their desire to get help, gets stalled because people have to be criminalized in order to access that care. And so we see here that because of the use of incarceration as punishment and coupled with the lack of its own resources and taking from community resources that these programs really don't demonstrate the cost-effective solution that is also purported to be gained by implementing them. In fact, the government accountability office in the United States, Congress's research body, has determined that the cost-effectiveness in U.S. drug courts is just unfounded.  And so while drug court seems like an option for individuals, it really continues to perpetuate the criminalization because many times you have to enter a guilty plea in order to participate. And so you forfeit not only your rights as a criminal defendant to work with your lawyer in privacy, but you also then adopt those sort of scarlet letter challenges of being a convicted felon for a drug offense. So you can't access public housing, you can't access public benefits for accessing food, you cannot vote. And there are a host of ways in which communities have been disempowered and obviously or maybe not obviously, but in the United States the war on drugs is largely a war on people of color. And so there are extreme disparities in what we see between the ways white people and black and brown people sort of play out in the criminal justice system. So drug courts also is another area in which there are preferences for people who are whiter, who are more affluent, who are likely to be successful anyway using these resources that could be perhaps seen as real cost savings opportunities and impactful interventions if used on a different risk population. Right now they're used on sort of lowest risk, lowest need, including marijuana offenses, possession for marijuana. But if we thought about using a drug court like intervention for more violent offenses, people who pose public safety threats, then we might actually see that cost benefit because we would see programming impact people's lives and we wouldn't have to pay for them to be incarcerated for years and years and years. So really looking forward to being a part of this panel, I hope you'll come, but also very excited to be here in Portugal to learn from the lessons of nonpartisan decriminalization and to of course be here with the international harm reduction crew for the conference. Okay, time for questions. When I call on you, could you please state your name and what media outlet you are associated with? Please keep your questions brief and indicate who you are directing the question to. So opening to you guys. Yes. No, I'm not. Yeah, so we asked a question, basically, if you were not using this site today, where would you be using your drugs? And people could choose different public environments or residences or locations, other locations that they could be using in. That's right. As far as I understand, yes. Question to the panel then. Could you tell us, Jean, the research that you did obviously shows that people are looking to use fentanyl, choosing to use fentanyl. Did you look behind what the drivers were, what their experiences were? Could you share some of that with us? Sure. I mean, this was very much a quantitative, what did you use, what do you think you used and then analyzing what exactly people used. I think what we see is that if somebody wants to use down or an opioid, fentanyl is what you get. The alternative pure heroin is not available as it had been in the past. So it's not necessarily a choice. That was what people would prefer. But we found that that is what people are using and knowingly using as well. And for the others on the panel, I mean, Kirsten and I are from the UK and drug related deaths are at a record high in both England and even more so in Scotland. Is there any lessons that we can maybe learn from your jurisdictions, your countries? Probably Canada more than the US at the minute. But if there's anything that you could suggest in terms of innovation around harm reduction. This isn't a suggestion. It's an observation. And I think one of the ways we were able to get police in BC all carry intranasal naloxone was because people were concerned about their own and their colleagues health and exposure to fentanyl. And that was a reason for implementing it so that people carry it for occupational reasons, but also very willing to use it on members of the public that they do come across who have overdosed. So it's a bit of a sad reflection on the state that we have in Canada. And just on that Jane, I guess we did some training with the Scottish police authority who are all the in the toxicology department. And we have equipped them with naloxone and it was for those exact reasons that, you know, they were concerned about if they were to get any fentanyl packages in that there would be potential exposure to their staff. And I guess whilst we recognised that the risk of that was slim to absolute none. Again, the principle of having the naloxone available was important, but I think what was noted throughout the training that we've done with prison officers and with police officers, and it's what you're hinting at there as well, is that there is a much broader need and an essential need to really challenge the stigma that exists within these groups and training is essential to do that whilst it's quite difficult and it is challenging. We can't not erase those issues and those need to be challenged for sure. Talk about innovation in terms of us working towards solving this crisis. It's really important to involve the community advocates and the people with lived experience because at the end of the day those are the people who know what they need and they're often best situated to be able to come up with those solutions. And we've seen some incredible innovation come out of the downtown Eastside in Vancouver and most of that is thanks to the people with lived experience. Just one more thing to add. I think what we see certainly in NBC is that it's not just the urban centres and that's why our survey was throughout the province and it was the same rate of fentanyl use because fentanyl was everywhere. And I totally agree in talking with people with lived experience and with substance use what their needs are and what's acceptable. There's no point us going in and saying hey we've got this good idea if it's not going to be acceptable. So having overdose prevention services which has had hundreds of thousands of injections throughout the province so that people can use close to where they are. Yeah and we heard from the plenary this morning about how important it is because we're saying how important it is to make sure that people who use drugs are part of the policy development law reform engaged at every aspect. Any more questions from? Yes. So could you say where you're from and who you are? Columbia. I have to admit to not knowing a lot about injection in Latin America but I do know that there's a lot of harm reduction efforts underway to build out harm reduction opportunities. One thing that I do know though is that much of our drug policy in the U.S. but also around the world tends to focus on what's happening right at the moment as opposed to thinking more comprehensively about how to deal with drugs in our societies. And I think the fact that you know every decade or set of years you can see like the focus of particularly U.S. drug policy sort of shifting on to a drug and trying to figure out how to deal with that drug. Then we've missed sort of how to deal with drugs in general and keep people as healthy as possible. On an array of treatment options so for instance you hear all of us talking or many people on this panel talking about naloxone and responding to opioid overdose. But we don't really hear anybody talking about response to stimulant overdose which is also a problem maybe not at the crisis level but still a problem in which people need to have a way to address it. My own brother died of a cocaine induced heart attack on his 37th birthday. I was 27 at the time. So this is a real challenge that people have so I'm not sure it's an answer directly to your question but it is an answer sort of about what we need to be doing better. I think on that note we'll wrap up. Thank you very much to all of the speakers. They will be available to talk to you after we've concluded so do come up and ask them any questions if you have some. All right thanks.