Effectiveness of SplashGuard Caregiver prototype in reducing the risk of aerosol transmission in intensive care unit rooms of SARS-CoV-2 patients: a prospective and simulation study

BACKGROUND

The contagiousness of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is known to be linked to the emission of bioaerosols. Thus, aerosol-generating procedures (AGPs) could increase the risk of infection among healthcare workers (HCWs).

AIM

To investigate the impact of an aerosol protection box, the SplashGuard Caregiver (SGGC) with suction system, by direct analysis of the presence of viral particles after an AGP, and by using the computational fluid dynamics (CFD) simulation method.

METHODS

This prospective observational study investigated HCWs caring for patients with SARS-CoV-2 admitted to an intensive care unit (ICU). Rooms were categorized as: SGCG present and SGCG absent. Virus detection was performed through direct analysis, and using a CFD model to simulate the movement dynamics of airborne particles produced by a patient's respiratory activities.

FINDINGS

Of the 67 analyses performed, three samples tested positive on quantitative polymerase chain reaction: one of 33 analyses in the SCCG group (3%) and two of 34 analyses in the non-SGCG group (5.9%). CFD simulations showed that: (1) reduction of the gaps of an SGCG could decrease the number of emitted particles remaining airborne within the room by up to 70%; and (2) positioning HCWs facing the opposite direction to the main air flow would reduce their exposure.

CONCLUSIONS

This study documented the presence of SARS-CoV-2 among HCWs in a negative pressure ICU room of an infected patient with or without the use of an SGCG. The simulation will help to improve the design of the SGCG and the positioning of HCWs in the room.

Hemodynamic assessment in children after cardiac surgery: A pilot study on the value of infrared thermography

Introduction

Low cardiac output syndrome in the postoperative period after cardiac surgery leads to an increase in tissue oxygen extraction, assessed by the oxygen extraction ratio. Measurement of the oxygen extraction ratio requires blood gases to be taken. However, the temperature of the skin and various parts of the body is a direct result of blood flow distribution and can be monitored using infrared thermography. Thus, we conducted a prospective clinical study to evaluate the correlation between the thermal gradient obtained by infrared thermography and the oxygen extraction ratio in children at risk for low cardiac output after cardiac surgery.

Methods

Children aged 0 to 18 years, having undergone cardiac surgery with cardio-pulmonary bypass in a pediatric intensive care unit were included in the study. One to 4 thermal photos were taken per patient using the FLIR One Pro thermal imaging camera. The thermal gradient between the central temperature of the inner canthus of the eye and the peripheral temperature was compared to the concomitant oxygen extraction ratio calculated from blood gases.

Results

41 patients were included with a median age of 6 months (IQR 3-48) with median Risk Adjustment for Congenital Heart Surgery-1 score was 2 (IQR 2-3). Eighty nine thermal photos were analyzed. The median thermal gradient was 2.5 °C (IQR 1,01-4.04). The median oxygen extraction ratio was 35% (IQR 26-42). Nine patients had an oxygen extraction ratio ≥ 50%. A significant but weak correlation was found between the thermal gradient and the oxygen extraction ratio (Spearman's test p = 0.25, p = 0.016). Thermal gradient was not correlated with any other clinical or biologic markers of low cardiac output. Only young age was an independent factor associated with an increase in the thermal gradient.

Conclusion

In this pilot study, which included mainly children without severe cardiac output decrease, a significant but weak correlation between thermal gradient by infrared thermography and oxygen extraction ratio after pediatric cardiac surgery was observed. Infrared thermography is a promising non-invasive technology that could be included in multimodal monitoring of postoperative cardiac surgery patients. However, a clinical trial including more severe children is needed.

Optical thermography infrastructure to assess thermal distribution in critically ill children

The temperature distribution at the skin surface could be a useful tool to monitor changes in cardiac output. Goal: The aim of this study was to explore infrared thermography as a method to analyze temperature profiles of critically ill children. Methods: Patients admitted to the pediatric intensive care unit (PICU) were included in this study. An infrared sensor was used to take images in clinical conditions. The infrared core and limb temperatures (θ_c & θ_l) were extracted, as well as temperatures along a line drawn between these two regions. Results: The median [interquartile range] θ_c extracted from the images was 33.88°C [32.74-34.19] and the median θ_l was 30.21°C [28.89-33.13]. There was a good correlation between the θ_c and the clinical axillary temperature (rho = 0.39, p-value = 0.016). There was also a good correlation between the θ_c and θ_l (rho = 0.66, p-value = 1.2 e⁻⁰⁵). Conclusion: Thermography was found to be effective to estimate the body temperature. Correlation with specific clinical conditions needs further study.

Fluorescence-based tools for single-cell approaches in food microbiology

The better understanding of the functioning of microbial communities is a challenging and crucial issue in the field of food microbiology, as it constitutes a prerequisite to the optimization of positive and technological microbial population functioning, as well as for the better control of pathogen contamination of food. Heterogeneity appears now as an intrinsic and multi-origin feature of microbial populations and is a major determinant of their beneficial or detrimental functional properties. The understanding of the molecular and cellular mechanisms behind the behavior of bacteria in microbial communities requires therefore observations at the single-cell level in order to overcome "averaging" effects inherent to traditional global approaches. Recent advances in the development of fluorescence-based approaches dedicated to single-cell analysis provide the opportunity to study microbial communities with an unprecedented level of resolution and to obtain detailed insights on the cell structure, metabolism activity, multicellular behavior and bacterial interactions in complex communities. These methods are now increasingly applied in the field of food microbiology in different areas ranging from research laboratories to industry. In this perspective, we reviewed the main fluorescence-based tools used for single-cell approaches and their concrete applications with specific focus on food microbiology.

Biofilm-associated persistence of food-borne pathogens

Microbial life abounds on surfaces in both natural and industrial environments, one of which is the food industry. A solid substrate, water and some nutrients are sufficient to allow the construction of a microbial fortress, a so-called biofilm. Survival strategies developed by these surface-associated ecosystems are beginning to be deciphered in the context of rudimentary laboratory biofilms. Gelatinous organic matrices consisting of complex mixtures of self-produced biopolymers ensure the cohesion of these biological structures and contribute to their resistance and persistence. Moreover, far from being just simple three-dimensional assemblies of identical cells, biofilms are composed of heterogeneous sub-populations with distinctive behaviours that contribute to their global ecological success. In the clinical field, biofilm-associated infections (BAI) are known to trigger chronic infections that require dedicated therapies. A similar belief emerging in the food industry, where biofilm tolerance to environmental stresses, including cleaning and disinfection/sanitation, can result in the persistence of bacterial pathogens and the recurrent cross-contamination of food products. The present review focuses on the principal mechanisms involved in the formation of biofilms of food-borne pathogens, where biofilm behaviour is driven by its three-dimensional heterogeneity and by species interactions within these biostructures, and we look at some emergent control strategies.

Realistic representation of Bacillus subtilis biofilms architecture using combined microscopy (CLSM, ESEM and FESEM)

In this contribution, we used a set of microscopic techniques including confocal laser scanning microscopy (CLSM), environmental scanning electron microscopy (ESEM) and field emission scanning electron microscopy (FESEM) to analyze the three-dimensional spatial arrangement of cells and their surrounding matrix in Bacillus subtilis biofilm. The combination of the different techniques enabled a deeper and realistic deciphering of biofilm architecture by providing the opportunity to overcome the limits of each single technique.

Anisotropic nutrient transport in three-dimensional single species bacterial biofilms

The ability for a biofilm to grow and function is critically dependent on the nutrient availability, and this in turn is dependent on the structure of the biofilm. This relationship is therefore an important factor influencing biofilm maturation. Nutrient transport in bacterial biofilms is complex; however, mathematical models that describe the transport of particles within biofilms have made three simplifying assumptions: the effective diffusion coefficient (EDC) is constant, the EDC is that of water, and/or the EDC is isotropic. Using a Monte Carlo simulation, we determined the EDC, both parallel to and perpendicular to the substratum, within 131 real, single species, three-dimensional biofilms that were constructed from confocal laser scanning microscopy images. Our study showed that diffusion within bacterial biofilms was anisotropic and depth dependent. The heterogeneous distribution of bacteria varied between and within species, reducing the rate of diffusion of particles via steric hindrance. In biofilms with low porosity, the EDCs for nutrient transport perpendicular to the substratum were significantly lower than the EDCs for nutrient transport parallel to the substratum. Here, we propose a reaction-diffusion model to describe the nutrient concentration within a bacterial biofilm that accounts for the depth dependence of the EDC.

Resistance of bacterial biofilms to disinfectants: a review

A biofilm can be defined as a community of microorganisms adhering to a surface and surrounded by a complex matrix of extrapolymeric substances. It is now generally accepted that the biofilm growth mode induces microbial resistance to disinfection that can lead to substantial economic and health concerns. Although the precise origin of such resistance remains unclear, different studies have shown that it is a multifactorial process involving the spatial organization of the biofilm. This review will discuss the mechanisms identified as playing a role in biofilm resistance to disinfectants, as well as novel anti-biofilm strategies that have recently been explored.

Comparative biocidal activity of peracetic acid, benzalkonium chloride and ortho-phthalaldehyde on 77 bacterial strains

Despite numerous reports on biocide activities, it is often difficult to have a reliable and relevant overview of bacterial resistance to disinfectants because each work challenges a limited number of strains and tested methods are often different. The aim of this study was to evaluate the bactericidal activity of three different disinfectants commonly used in industrial or medical environments (peracetic acid, benzalkonium chloride and ortho-phthalaldehyde) against 77 bacterial strains from different origins using one standard test method (NF EN 1040). Results highlight the existence of high interspecific variability of resistance to disinfectants and, contrary to widespread belief, Gram-positive strains generally appeared more resistant than Gram-negative strains. Resistance was also variable among strains of the same species such as Bacillus subtilis to peracetic acid, Pseudomonas aeruginosa to benzalkonium chloride and Staphylococcus aureus to ortho-phthalaldehyde.

Thyroid volume measurement in external beam radiotherapy patients using CT imaging: correlation with clinical and anthropometric characteristics

The aim of this study is to define criteria for accurate representation of the thyroid in human models used to represent external beam radiotherapy (EBRT) patients and evaluate the relationship between the volume of this organ and clinical and anthropometric characteristics. From CT images, we segmented the thyroid gland and calculated its volume for a population of 188 EBRT patients of both sexes, with ages ranging from 1 to 89 years. To evaluate uncertainties linked to measured volumes, experimental studies on the Livermore anthropomorphic phantom were performed. For our population of EBRT patients, we observed that in children, thyroid volume increased rapidly with age, from about 3 cm(3) at 2 years to about 16 cm(3) at 20. In adults, the mean thyroid gland volume was 23.5 ± 9 cm(3) for males and 17.5 ± 8 cm(3) for females. According to anthropometric parameters, the best fit for children was obtained by modeling the log of thyroid volume as a linear function of body surface area (BSA) (p < 0.0001) and age (p = 0.04) and for adults, as a linear function of BSA (p < 0.0001) and gender (p = 0.01). This work enabled us to demonstrate that BSA was the best indicator of thyroid volume for both males and females. These results should be taken into account when modeling the volume of the thyroid in human models used to represent EBRT patients for dosimetry in retrospective studies of the relationship between the estimated dose to the thyroid and long-term follow-up data on EBRT patients.

The biofilm architecture of sixty opportunistic pathogens deciphered using a high throughput CLSM method

This study proposes a high throughput method based on Confocal Laser Scanning Microscopy (CLSM) combined with the use of 96-wells microtiter plates compatible with high resolution imaging for the study of biofilm formation and structure. As an illustration, the three-dimensional structures of biofilms formed by 60 opportunistic pathogens were thus observed and quantified. The results revealed the diversity of biofilm architectures. Specific spatial arrangement such as the mushroom-like structures already described for Pseudomonas aeruginosa was observed. Other features, such as hollow voids in microcolonies of Salmonella enterica strain Agona, were identified for the first time. The combined use of microplates and confocal imaging proved to be a good alternative to the other high throughput methods commonly used as it enables the direct, insitu, qualitative and quantitative characterization of biofilm architecture. This high content method should lead to a clearer understanding of the structure-function relationships implicated in biofilms traits.

[Quality control of dosing delivered by in vivo measurements for head and neck radiotherapy]

PURPOSE

Measurement of absorbed dose in target volume is widely considered to be an important tool for quality assurance in external radiotherapy. The aims of this work were to measure the entrance dose for patient treated for head and neck tumors and to compare this measured dose with the dose calculated.

PATIENTS AND METHODS

Twenty patients were evaluated. Initially, the measurements were performed on a polystyrene phantom in order to calibrate diodes in terms of entrance dose and to determinate appropriate correction factors. In vivo entrance dosimetry check was performed for these patients treated for head and neck tumors in (60)Co gamma-rays.

RESULTS

For the entrance dose evaluation over 100 field measurements, the mean deviation between the measured dose and the calculated dose was equal to 0.12% and the standard deviation was 1.84%. The deviation was less than 3% in 95% of measurements. Large deviation (more than 5%) was observed in one case.

CONCLUSION

Simple in vivo dose measurements are an additional safeguard against major set-up errors and calculation or transcription errors that were missed during pretreatment chart check.

Multichannel dosemeter and Al2O3:C optically stimulated luminescence fibre sensors for use in radiation therapy: evaluation with electron beams

This article proposes an innovative multichannel optically stimulated luminescence (OSL) dosemeter for on-line in vivo dose verification in radiation therapy. OSL fibre sensors incorporating small Al(2)O(3):C fibre crystals (TLD(500)) have been tested with an X-ray generator. A reproducible readout procedure should reduce the fading-induced uncertainty ( approximately - 1% per decade). OSL readouts are temperature-dependent [ approximately 0.3% K(-1) when OSL stimulation is performed at the same temperature as irradiation; approximately 0.16% K(-1) after thermalisation (20 degrees C)]. Sensor calibration and depth-dose measurements with electron beams have been performed with a Saturne 43 linear accelerator in reference conditions at CEA-LNHB (ionising radiation reference laboratory in France). Predosed OSL sensors show a good repeatability in multichannel operation and independence versus electron energy in the range (9, 18 MeV). The difference between absorbed doses measured by OSL and an ionisation chamber were within +/-0.9% (for a dose of about 1 Gy) despite a sublinear calibration curve.

Épidermolyse staphylococcique et impétigo bulleux chez des jumeaux nouveau-nés contaminés par le lait maternel

Staphylococcus aureus is often responsible for late septic infections, more rarely of toxinic ones, occurring in neonatal period. We report a case of staphylococcal scalded skin syndrome and bullous impetigo in newborn twins infected by breast milk from their asymptomatic mother. This transmission was confirmed by molecular biology method. This case emphasizes the potential part of the mother in staphylococcal nosocomial infections and the complexity of toxinic mechanisms.

Impact of PSA decrease at the end of radiotherapy for localized prostate cancer on clinical recurrence and specific cause survival

15501

Background: The objective was to identify early predictors of outcome in a large retrospective series of patients treated by external beam radiotherapy only (without androgen deprivation). All the patients had a PSA at the 6th week (PSA6wRT) in the course of RT. Methods: From 1990 to 2004, 409 pts with localized prostate cancer were treated by RT. Median pretreatment PSA (PSApreRT) was 13 ng/mL (0.5–133). Clinical stage was T1 (26%), T2 (60%), and T3 (14%). Gleason score was 4–6 (59%), 7 (31%) and 8–10 (10%). Prognosis was classified as low risk (24%), intermediate (39%) and high risk (37%). The prostate received 65 Gy (2.5 Gy/day) (34%) or 70 Gy (2 or 2.5 Gy/day) (66%). Results: The median follow-up was 57 months (6–190). The median ratio of : PSA6wRT / PSApreRT was 71% (1–374). The 5-year biochemical disease free survival (DFS) rates (RTOG-ASTRO 2006) by PSA6wRT / PSApreRT < 71% or ≥ 71% were: 66% (95% CI: 58–74) and 56% (95% CI: 48–64), respectively (Log rank, p=0.048),. The 5-year clinical (local or metastases) DFS rates by PSA6wRT / PSApreRT < 71% or ≥ 71% were: 96% (95% CI: 93–99) and 85% (95% CI: 79–91), respectively (p=0.03). In multivariate analysis, the prognostic values of PSA6wRT / PSApreRT (as a continuous variable) on biochemical DFS, clinical DFS and cause specific survival are shown in the table . Conclusions: The PSA6wRT / PSApreRT predicts for biochemical DFS, clinical DFS and cause specific survival in localized prostate cancer. This factor could be used to propose adjuvant treatment after radiotherapy, in case of high: PSA6wRT / PSApreRT.

[Table: see text]

No significant financial relationships to disclose.

Recommandations pour un protocole d’assurance de qualité de la radiothérapie conformationnelle avec modulation d’intensité des cancers de la tête et du cou

Head and neck tumors represent very interesting targets for IMRT techniques because of the complex shape of the structures and the organs at risk close by. The use of this kind of techniques requires a quality assurance protocol. The physicists of the GORTEC group shared their experience to define some recommendations in order to draw up a QA protocol. The dosimetric verification of the treatment plans (in terms of absolute and relative dose), the control of the reproducibility of the patient positioning and the use of a record and verify system to control the different parameters form the main parts of these recommendations. Each chapter comprises a description of the different methods, recommendations concerning the equipment, the adopted tolerances, the frequency of controls. At the end of each chapter, a table summarizes the main actions to carry out. These recommendations will allow to harmonize our practices whatever the softwares and the accelerator that are being used. They will simplify the task of the teams that wish to implement IMRT for head and neck tumors.

[Influence of thermoplastic masks on the absorbed skin dose for head and neck tumor radiotherapy]

The influence of thermoplastic masks used in clinical routine for patient immobilization in head and neck radiotherapy treatment on the absorbed skin dose has been investigated at Gustave-Roussy Institute. The measurements were performed in 60Co gamma-rays, 4 and 6MV X-rays and in 8 and 10MeV electron beams. Initially, the measurements were performed with thermoluminescent dosimeters (LiF) and a NACP chamber on a polystyrene phantom in order to study the influence of physical parameters (distance, field size, energy...) on first millimeters depth variation dose. The study was completed with in vivo measurements on 14 patients using various dosimeters (thermoluminescent detectors, diodes) in order to assess the increase of dose on first millimeters depth and to verify the delivered dose during treatment sessions (quality control). In treatment conditions, masks lead to an important increase of dose on the first millimeter in 60Co gamma-rays beams (dose value normalized to maximum of dose increase from 57.1% to 77.7% for 0.5 mm-water depth and from 78.5% to 88% for 1 mm-water depth); its contribution is less important in 4 and 6 MV X-rays beams (dose value normalized to maximum of dose increase from 49.5% to 63.2% for 0.5 mm-water depth and from 59% to 70.1% for 1 mm-water depth). Concerning 8 and 10 MeV electron beams, the normalized dose value increase respectively from 78.4% to 81.7% and from 82.2% to 86.1% for 0.5 mm-water depth. In vivo dosimetry enabled the quality control of delivered dose during treatment. Measured dose is in agreement within +/- 5% with the prescribed dose for 92.3% of cases. In routine, in vivo dosimetry allowed to quantify the increase of skin dose induced by thermoplastic masks for various energies of photon and electron beams as well as quality control.

Influence of high-energy photon beam irradiation on pacemaker operation

In this paper, we determine the influence of high-energy photon beam irradiation used for external radiotherapy on pacemakers, at different doses and dose rates. Ninety-six pacemakers of various origins and ages underwent in vitro high-energy photon irradiation under technical conditions close to external radiotherapy, using a linear accelerator delivering photons of high energy (18 MV). Various dose levels (up to 200 Gy for certain particularly resistant pacemakers) were delivered to pacemakers located in a water-equivalent phantom with several dose rates (from 0.05 to 8 Gy min(-1)). Observed failures were sorted into eight classes of progressive harmfulness, some of them possibly lethal. One irradiated pacemaker exhibited an important defect at a dose rate of 0.2 Gy min(-1), for a cumulative dose of 0.15 Gy. Two pacemakers showed an important defect at a cumulative dose of 1 Gy, while nine pacemakers failed at a cumulative dose lower than or equal to 2 Gy and 13 failed at a cumulative dose lower than or equal to 5 Gy. The most important failure probability (70% of irradiated pacemakers) is observed for 8 Gy min(-1), whereas no pacemakers failed at a dose rate lower than or equal to 0.2 Gy min(-1). In conclusion, warnings given by manufacturers about the maximum tolerable cumulative radiation doses for safe operation of irradiated pacemakers (5 Gy), even reduced to 2 Gy, are not reliable. The spread of cumulative doses inducing failures is very large since our observations show an important failure at 0.15 Gy, while ten pacemakers withstood more than 140 Gy of cumulative dose. The safe operation of pacemakers under irradiation depends mainly on type and model. It depends also on dose rate. From our observations, for the safe operation of pacemakers, a recommendation of a maximum dose rate of 0.2 Gy min(-1) rejecting direct irradiation of the pacemaker at a standard dose rate for tumour treatment (2 Gy min(-1)) is made.

[Definition of volumes in external radiotherapy: ICRU reports 50 and 62]

Prescribing and achieving radiotherapy require accurate definitions of the target volumes and of the dose to be delivered in them. The need for the availability of a coherent vocabulary, recognized from local to international levels, has justified the publication, by the ICRU, of two reports related to external radiotherapy, the Report 50 (1993) and the Report 62 (1999). This paper presents the main propositions of the ICRU for the definition of the volumes, as well as comments and recommendations for their use.

The ESTRO-EQUAL Quality Assurance Network for photon and electron radiotherapy beams in Germany

BACKGROUND

In 1998 an ESTRO Quality Assurance Network for radiotherapy (EQUAL) has been set up for 25 European countries for photon and electron beams in reference and non-reference conditions.

MATERIAL AND METHODS

Measurements are done using LiF powder (DTL937-Philitech, France) that is processed with the PCL3 automatic reader (Fimel-PTW). The participating centers irradiate the TLDs with an absorbed dose of 2 Gy according to the clinical routine.

RESULTS

Until September 2000 EQUAL has checked 135 photon beams (including the beams rechecked) from 51 radiotherapy centers in Germany out of 86 accepted centers. The results show that 2% of the beam outputs in reference conditions and 3% of the percentage depth doses are outside the tolerance level (deviation > +/- 5%). 6% of the beam output variations and of the wedge transmission factors show deviations > +/- 5%. The global analysis of results shows deviations > +/- 5% in at least one parameter for 18 beams out of the 135 beams checked. Five rechecked beams present one "real dosimetric" problem in one or more parameters, corresponding to 4% of the 114 beams for which the deviations cannot be attributed to set-up errors.--The EQUAL network has checked 89 electron beams in Germany. The results show that all beam outputs checked are within the tolerance level. The standard deviation for the beam output in reference conditions is 2.0% and 2.2% for the beam output for the others field sizes. The percentage of deviations > 3% and < or = 5% for the reference beam output is higher for electron beams than for photon beam checks. Therefore the electron beam calibration and the TPS algorithms should be improved to increase the accuracy of the patient dosimetry for radiotherapy.

CONCLUSION

EQUAL program demonstrates a consistency in radiotherapy dosimetry for photon and electron beams resulting in a satisfying accuracy of the dosimetry in Germany.

[Method of radiotherapy planning for head and neck tumors using simulated CT images and radiographic data, developed at the Gustave Roussy Institute]

The paper deals with the recent improvements introduced in the most usual method applied in the Institut Gustave Roussy radiotherapy department for obtaining the anatomical data of patients treated for head and neck tumors. For each of these patients, five to seven transverses slices and a lateral radiographic film are taken from a Mecaserto simulator-CT. The anatomical representation of the patient sagittal plane is carried out from the digitalisation of the radiographic film on a Vidar Vxr-12 Plus film scanner and integrated into the Dosigray dose calculation programme in order to be used as a support for the laying out of the dose distribution in reference to the treatment. The sagittal anatomical representation obtained from the radiographic film digitalisation is compared with the one resulting from the interpolation between a limited number of irregularly-spaced transverse slices taken on the simulator-CT. The method using the simulator-scanner transverse slices and the radiographic film digitalisation represents an interesting alternative for obtaining an anatomy simulation representative of the patient in hospitals where a scanner is not available full-time for the needs of the radiotherapy process.

Energy correction factors of LiF powder TLDs irradiated in high-energy electron beams and applied to mailed dosimetry for quality assurance networks

Absorbed dose determination with thermoluminescent dosimeters (TLDs) generally relies on calibration in 60Co gamma-ray reference beams. The energy correction factor fCo(E) for electron beams takes into account the difference between the response of the TLD in the beam of energy E and in the 60Co gamma-ray beam. In this work, fCo(E) was evaluated for an LiF powder irradiated in electron beams of 6 to 20 MeV (Varian 2300C/D) and 10 to 50 MeV (Racetrack MM50), and its variation with electron energy, TLD size and nature of the surrounding medium was also studied for LiF powder. The results have been applied to the ESTRO-EQUAL mailed dosimetry quality assurance network. Monte Carlo calculations (EGS4, PENELOPE) and experiments have been performed for the LiF powder (rho = 1.4 g cm3) (DTL937, Philitech, France), read on a home made reader and a PCL3 automatic reader (Fimel, France). The TLDs were calibrated using Fricke dosimetry and compared with three ionization chambers (NE2571, NACP02, ROOS). The combined uncertainties in the experimental fCo(E) factors determined in this work are less than about 0.4% (1 SD), which is appreciably smaller than the uncertainties up to 1.4% (1 SD) reported for other calculated values in the literature. Concerning the Varian 2300C/D beams, the measured fCo(E) values decrease from 1.065 to 1.049 +/- 0.004 (1 SD) when the energy at depth in water increases from 2.6 to 14.1 MeV; the agreement with Monte Carlo calculations is better than 0.5%. For the Racetrack MM50 pulsed-scanned beams, the average experimental value of fCo(E) is 1.071 +/- 0.005 (1 SD) for a mean electron energy at depth Ez ranging from 4.3 to 36.3 MeV: fCo(E) is up to 2% higher for the MM50 beams than for the 2300C/D beams in the range of the tested energies. The energy correction factor for LiF powder (3 mm diameter and 15 mm length) varies with beam quality and type (pulsed or pulsed-scanning), cavity size and nature of the surrounding medium. The fCo(E) values obtained for the LiF powder (3 mm diameter and 15 mm length) irradiated in water, have been applied to the EQUAL external audit network, leading to a good agreement between stated and measured doses, with a mean value of 1.002 +/- 0.022 (1 SD), for 170 beam outputs checked (36 electron beam energies) in 13 'reference' radiotherapy centres in Europe. Such fCo(E) data improve the accuracy of the absorbed dose TLD determination in electron beams, justifying their use for quality control in radiotherapy.

[Validation of biological dosimetry in patients conditioned with total body irradiation: conventional cytogenetics and in situ hybridization(FISH)]

PURPOSE

Validation of biological dosimetry versus physical dosimetry in malignant haemopathy patients conditioned by total body irradiation (TBI) before bone marrow transplantation (BMT).

PATIENTS AND METHODS

The scoring of chromosomal aberrations in peripheral lymphocytes irradiated in vivo was used to perform the biological dosimetry. The data were compared to those obtained with healthy volunteers' total blood exposed to in vitro irradiation with linear accelerator doses (0.2, 0.5, 0.75, 1, 2, 3, 4 and 5 Gy) for dose-response curves. In experimental animal models, can in vivo and in vitro responses be considered as being the same? All the published human data are based on retrospective dose evaluation with very large uncertainties on the dose precisely delivered to the subject. TBI before BMT was taken as a model where the dose calculation results from the physical method, with homogeneous beam and dose delivered precisely along the entire organism. In vivo response allows us to validate biological dosimetry in 15 adult patients (female + male), before (D = 0 Gy) and after the first fraction of 1.8 Gy, delivered by a linear accelerator (18 MV, dose-rate of 15.8 cGy/min-1). Two methods, conventional cytogenetics (CCG) and fluorescent in situ hybridization (FISH painting) of chromosome 4 were respectively used to analyze the unstable chromosome aberrations and stable chromosome aberrations.

RESULTS

Healthy volunteer lymphocytes, before irradiation, yielded 0.1% dicentrics and 0.3% translocations of chromosome 4, with 2.5% for the whole genome. Patients before irradiation had 2% dicentrics and 11.48% chromosome 4 translocations for the whole genome. In the 15 patients, for a physical dose of 1.8 Gy, the evaluated biological dose was 1.93 Gy (95% CI: 1.85-2.05 Gy) with conventional cytogenetics and 2.06 Gy (95% CI: 1.75-2.15 Gy) with FISH.

CONCLUSION

These results, in which the biologically estimated dose is in complete agreement with the dose calculated by physical dosimetry in the homogeneous irradiation model, suggest the validation of biological dosimetry in TBI conditioning.

The ESTRO-QUALity assurance network (EQUAL)

BACKGROUND AND PURPOSE

ESTRO has set up a Quality Assurance network (EQUAL) to check the dose delivered on axis in reference and non-reference conditions for external radiotherapy. The external audits covered by the network are based on measurements made with mailed thermoluminescent dosimeters (TLD).

MATERIAL AND METHODS

The TLD consist of LiF powder type DTL 937 read with a PCL 3 automatic TLD reader. The participating centres are instructed to deliver to the TLDs absorbed doses of 2 Gy calculated with the Treatment Planning System used in clinical routine. A maximum of three photon energies by participating centre have been checked with 10 on-axis points per beam. The quantities checked include the reference beam output, beam output variation with collimator opening, depth dose data and wedge transmission factor.

RESULTS

During the 1998 EQUAL programme 102 centres have been checked corresponding to 235 beams (28 (60)Co beams and 207 X-ray beams). About 3% of the outputs in reference conditions show deviations outside tolerance level (>+/-5%). A similar rate of deviation is noted for the percentage depth doses. A rate of deviation (6%) has been observed for the beam output variation (open and wedged beams) and the wedge transmission factor. The analysis of the results shows that for 24 out of the 102 centres, a deviation outside tolerance level is observed at least in one point, mainly for the large and rectangular field sizes and for the wedged beams.

CONCLUSIONS

The results for the EQUAL programme show the importance of a quality assurance network in Radiotherapy especially for the non reference points even if they are only located on the beam axis (In order to participate in this network, please contact EQUAL secretariat or download the attached application form ESTRO web site: Dr I.H. Ferreira or Mrs Aline Mechet, EQUAL-ESTRO, Physics Department, Institut Gustave-Roussy 39 Rue Camille Desmoulins, F-94805 Villejuif Cedex, France. e-mail:equal@igr.fr or http://www.estro.be/).

A comparative description of three multipurpose phantoms (MPP) for external audits of photon beams in radiotherapy: the water MPP, the Umeå MPP and the EC MPP

AIM

To present a technical description and intercomparison of three multipurpose phantoms (MPP) developed for mailed dosimetry checks of therapeutic photon beams in reference and non-reference conditions.

MATERIALS

The W-MPP is a water MPP, whereas the Umeâ-MPP, made of perspex (PMMA, Plexiglas), and the EC-MPP, made of polystyrene, are solid MPPs. The W-MPP uses only thermoluminescent dosimeters (TLD) for dosimetry checks, the EC MPP uses film and TLD; the Umeâ phantom uses film and TLD, and offers in addition the possibility for ionization chamber measurements. Either using TLD or films, the MPPs have been designed to check on-axis and off-axis the following irradiation conditions: square and rectangular fields, asymmetric fields, wedged beams, oblique incidence and, for the solid MPPs, also the influence of inhomogeneities.

RESULTS AND DISCUSSION

The MPPs have been compared for different aspects going from their dosimetric performance (number of dosimetric parameters that can be checked) to some practical consideration in the use of the different MPPs (set-up time, stability, instruction sheets, etc.). From a comparison between the solid multi-purpose phantoms, it turns out that the EC-MPP is capable of checking the largest number of dosimetric parameters per beam, but has the longest set-up time ( approximately 2 h) per beam according to the users. The Umeå-MPP has a smaller number of set-ups (hence a smaller average time) and also includes some parameters not checked with the EC-MPP (e.g. SSD accuracy). The major drawback however of the Umeå-MPP is considered to be its high density (>1.1 g/cm(3)) which increases the difficulty of the analysis with the treatment planning system. The W-MPP checks the smallest number of parameters, but is the fastest in set-up time, the easiest for mailing, and is water equivalent, which is advantageous for the TPS checks. The major drawback of this MPP is however the inability to check complete dose distribution (film) or inhomogeneities.

Prospective randomized comparison of single-dose versus hyperfractionated total-body irradiation in patients with hematologic malignancies

PURPOSE

Fractionated total-body irradiation (HTBI) is considered to induce less toxicity to normal tissues and probably has the same efficacy as single-dose total-body irradiation (STBI) in patients with acute myeloid leukemia. We decided to determine whether this concept can be applied to a large number of patients with various hematologic malignancies using two dissimilar fractionation schedules.

PATIENTS AND METHODS

Between December 1986 and October 1994, 160 patients with various hematologic malignancies were randomized to receive either a 10-Gy dose of STBI or 14.85-Gy dose of HTBI.

RESULTS

One hundred forty-seven patients were assessable. The 8-year overall survival rate and cause-specific survival rate in the STBI group was 38% and 63.5%, respectively. Overall survival rate and cause-specific survival rate in the HTBI group was 45% and 77%, respectively. The incidence of interstitial pneumonitis was similar in both groups. However, the incidence of veno-occlusive disease (VOD) of the liver was significantly higher in the STBI group. In the multivariate analysis with overall survival as the end point, the female sex was an independent favorable prognostic factor. On the other hand, when cause-specific survival was considered as the end point, the multivariate analysis demonstrated that sex and TBI were independent prognostic factors.

CONCLUSION

The efficacy of HTBI is probably higher than that of STBI. Both regimens induce similar toxicity with the exception of VOD of the liver, the incidence of which is significantly more pronounced in the STBI group.

Biological dosimetry after total body irradiation (TBI) for hematologic malignancy patients

PURPOSE

Biological dosimetry based on scoring chromosomal aberrations in peripheral lymphocytes was compared to physical dosimetry done for total body irradiation (TBI) before bone marrow transplantation (BMT) in patients with hematologic malignancies.

PATIENTS AND METHODS

Fifteen patients undergoing TBI were included in the study. A total dose of 12 Gy in 2.5 days was fractionated into 2 or 3 daily doses of 1.8 Gy delivered by a 18 MV linear accelerator (dose rate: 15.8 cGy x min(-1)). Blood samples were obtained from patients before irradiation and after the first fraction of 1.8 Gy. A standard dose-effect curve was established by in vitro irradiation of healthy volunteer lymphocytes. Chromosomal aberrations were scored by the conventional cytogenetics (CCG) method for unstable anomalies and by fluorescent in situ hybridization (FISH) for stable anomalies.

RESULTS

Healthy donor lymphocytes before irradiation yielded 0.1% dicentrics and 0.3% translocations of chromosome 4 (Chr. 4), that is 2.5% for the whole genome. Patients before irradiation had 2% of dicentrics and 1.1% of chromosome 4 translocations. The biologically estimated dose of the 15 patients after exposure to 1.8 Gy was 1.93 Gy (95% CI: 1.85-2.05) according to CCG, and 2.06 Gy (95% CI: 1.75-2.15) by FISH.

CONCLUSION

The dose estimated by biological dosimetry, in this case of homogeneously distributed radiation of TBI agrees well with the absorbed radiation dose calculated by physical dosimetry.

Monte Carlo calculations of the ionization chamber wall correction factors for 192Ir and 60Co gamma rays and 250 kV x-rays for use in calibration of 192Ir HDR brachytherapy sources

As in the method for the calibration of 192Ir high-dose-rate (HDR) brachytherapy sources, the ionization chamber wall correction factor A(w), is needed for 192Ir and 60Co gamma rays and 250 kV x-rays. This factor takes into account the variation in chamber response due to the attenuation of the photon beam in the chamber wall and build-up cap and the contribution of scattered photons. Monte Carlo calculations were performed using the EGS4 code system with the PRESTA algorithm, to calculate the A(w) factor for 51 commercial ionization chambers and build-up caps exposed to the typical energy spectrum of 192Ir and 60Co gamma rays and 250 kV x-rays. The calculated A(w) correction factors for 192Ir and 60Co sources and 250 kV x-rays agree very well to within 0.1% with published experimental data (the statistical uncertainty is less than 0.1% of the calculated correction factor value). For the 192Ir sources, A(w) varies from 0.973 to 0.993 and for the 250 kV x-rays the minimum value of A(w) for all chambers studied is 0.983. The calculated A(w) correction factors can be used to calculate the air kerma calibration factor of HDR brachytherapy sources, when interpolative methods are considered, contributing to the reduction in the overall uncertainties in the calibration procedure.

Perturbation corrections for flat and thimble-type cylindrical standard ionization chambers for 60Co gamma rays: Monte Carlo calculations

The use of an ionization chamber for absorbed dose determinations in a medium requires one to take into account perturbation corrections due to the presence of the chamber cavity in the medium. Evaluation of these corrections for perturbation and their variation with depth in the medium has been performed for a flat cylindrical and a cylindrical (thimble-type) ionization chamber placed in a graphite phantom irradiated by a 60Co gamma beam using Monte Carlo calculations (EGS4 system with correlated sampling variance reduction technique). The results of these calculations agree with published experimental and theoretical data to better than 0.18%, with a statistical uncertainty of less than 0.17%.

Proton dosimetry comparison involving ionometry and calorimetry

A comparison of the absorbed dose to tissue determined by various ionization chambers, Faraday cups, and an A-150 plastic calorimeter was performed in the 200 MeV proton beam of Orsay, France. Four European proton-therapy centers (Clatterbridge, UK, Louvain la Neuve, Belgium, and Nice and Orsay, France) participated in the comparison. An agreement of better than 1% was observed in the absorbed dose to A-150 measured with the different chambers of the participating groups. The mean ratio of the absorbed dose to A-150 determined with the calorimeter to that determined by the different ionization chambers in the different irradiation conditions was found to be 0.952 +/- 0.007 [1 standard deviation (SD)] according to the code of practice used by all the participating centers, based on Janni's tables of stopping powers and a value of 35.2 J/Coulomb for (W(air)/e)p. A better agreement in the mean ratio calorimeter/chamber, 0.985 +/- 0.007 (1 SD) is observed when using the proton stopping power ratio values recently published by the International Commission on Radiation Units and Measurements in Report no. 49. The mean ratio of these doses determined in accordance with the American Association of Physicists in Medicine protocol and using the new recommended stopping power tables becomes 1.002 +/- 0.007 (1 SD). Two Faraday cups agree in measured charge to within 0.8%; however, the calculation of dose is underestimated by up to 17%; compared with ion chamber measurements and seems to be very sensitive to measurement conditions, particularly to the distance to the collimator.

An experimental approach to the design of a scattering system for a proton therapy beam line dedicated to ophthalmological applications

PURPOSE

The development of a scattering system for a proton therapy beam line dedicated to ophthalmological applications.

METHODS AND MATERIALS

A protontherapy beam line has been developed for the treatment of uveal melanoma at the Orsay synchrocyclotron. The original 200 MeV proton beam is degraded to 76 MeV and the final beam characteristics (range, modulation, flatness, collimation) are obtained with beam modifiers in the treatment room. A passive scattering system is used to obtain a uniform dose distribution in the beam cross-section throughout 30 mm in diameter, with minimal losses in energy and dose rate. We have used an experimental approach for the scattering study.

RESULTS

An elliptical ring shaped from 0.1-mm thick lead is the solution we have adopted for the scattering system. For a modulated beam, a flatness of 1% is obtained on transverse profiles. The energy loss introduced by this scatterer is only 0.5 MeV, with no appreciable change in the range over the treatment field. For an unmodulated beam, 21% of intensity is lost when the scatterer is used. The distal and the lateral dose fall-off (90-10%) for a modulated beam are 2.6 mm. These last values are independent of the range and the modulation currently used for the ophthalmic applications.

CONCLUSION

A specific passive scattering system can be adapted to a particular beam emittance. A systematic experimental approach can easily be undertaken to obtain the scatterer adapted for small irradiation fields in proton therapy.