Evaluation of the ability of a 2D ionisation chamber array and an EPID to detect systematic delivery errors in IMRT plans

Two clinical intensity modulated radiotherapy plans were selected. Eleven plan variations were created with systematic errors introduced: Multi-Leaf Collimator (MLC) positional errors with all leaf pairs shifted in the same or the opposite direction, and collimator rotation offsets. Plans were measured using an Electronic Portal Imaging Device (EPID) and an ionisation chamber array. The plans were evaluated using gamma analysis with different criteria. The gamma pass rates remained around 95% or higher for most cases with MLC positional errors of 1 mm and 2 mm with 3%/3mm criteria. The ability of both devices to detect delivery errors was similar

Coxiella burnetii in Humans and Ticks in Rural Senegal

Q fever is a zoonotic disease known since 1937. The disease may be severe, causing pneumonia, hepatitis and endocarditis. Q fever agent has been described as a possible biological weapon. Animals—especially domestic cows, goats and sheep—are considered reservoirs for this infection. They are capable of sustaining the infection for long periods and excreting viable bacteria, infecting other animals and, occasionally, humans. Here we studied the distribution of Q fever in a poorly studied region, Senegal. We studied the agent of Q fever both in ticks parasitizing domestic animals and in humans (antibodies in serum, bacteria in feces, saliva and milk). We found from the studied regions the bacterium is highly prevalent in rural Senegal. Up to 37.6% of five different and most prevalent tick species may carry the bacterium. Humans living in such areas, as other mammals, may occasionally excrete Q fever agent through feces and milk

Recreational and occupational field exposure to freshwater cyanobacteria – a review of anecdotal and case reports, epidemiological studies and the challenges for epidemiologic assessment

Cyanobacteria are common inhabitants of freshwater lakes and reservoirs throughout the world. Under favourable conditions, certain cyanobacteria can dominate the phytoplankton within a waterbody and form nuisance blooms. Case reports and anecdotal references dating from 1949 describe a range of illnesses associated with recreational exposure to cyanobacteria: hay fever-like symptoms, pruritic skin rashes and gastro-intestinal symptoms are most frequently reported. Some papers give convincing descriptions of allergic reactions while others describe more serious acute illnesses, with symptoms such as severe headache, pneumonia, fever, myalgia, vertigo and blistering in the mouth. A coroner in the United States found that a teenage boy died as a result of accidentally ingesting a neurotoxic cyanotoxin from a golf course pond. This death is the first recorded human fatality attributed to recreational exposure to cyanobacteria, although uncertainties surround the forensic identification of the suspected cyanotoxin in this case. We systematically reviewed the literature on recreational exposure to freshwater cyanobacteria. Epidemiological data are limited, with six studies conducted since 1990. Statistically significant increases in symptoms were reported in individuals exposed to cyanobacteria compared to unexposed counterparts in two Australian cohort studies, though minor morbidity appeared to be the main finding. The four other small studies (three from the UK, one Australian) did not report any significant association. However, the potential for serious injury or death remains, as freshwater cyanobacteria under bloom conditions are capable of producing potent toxins that cause specific and severe dysfunction to hepatic or central nervous systems. The exposure route for these toxins is oral, from ingestion of recreational water, and possibly by inhalation. A range of freshwater microbial agents may cause acute conditions that present with features that resemble illnesses attributed to contact with cyanobacteria and, conversely, acute illness resulting from exposure to cyanobacteria or cyanotoxins in recreational waters could be misdiagnosed. Accurately assessing exposure to cyanobacteria in recreational waters is difficult and unreliable at present, as specific biomarkers are unavailable. However, diagnosis of cyanobacteria-related illness should be considered for individuals presenting with acute illness following freshwater contact if a description is given of a waterbody visibly affected by planktonic mass development

The Changing Landscape for Stroke\ua0Prevention in AF: Findings From the GLORIA-AF Registry Phase 2

Background GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non\u2013vitamin K antagonist oral anticoagulant (NOAC), became available. Objectives This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. Methods During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients\u2019 baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Results Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patients were from Europe (47.1%), North America (22.5%), Asia (20.3%), Latin America (6.0%), and the Middle East/Africa (4.0%). Most had high stroke risk (CHA2DS2-VASc [Congestive heart failure, Hypertension, Age  6575 years, Diabetes mellitus, previous Stroke, Vascular disease, Age 65 to 74 years, Sex category] score  652; 86.1%); 13.9% had moderate risk (CHA2DS2-VASc = 1). Overall, 79.9% received oral anticoagulants, of whom 47.6% received NOAC and 32.3% vitamin K antagonists (VKA); 12.1% received antiplatelet agents; 7.8% received no antithrombotic treatment. For comparison, the proportion of phase 1 patients (of N = 1,063 all eligible) prescribed VKA was 32.8%, acetylsalicylic acid 41.7%, and no therapy 20.2%. In Europe in phase 2, treatment with NOAC was more common than VKA (52.3% and 37.8%, respectively); 6.0% of patients received antiplatelet treatment; and 3.8% received no antithrombotic treatment. In North America, 52.1%, 26.2%, and 14.0% of patients received NOAC, VKA, and antiplatelet drugs, respectively; 7.5% received no antithrombotic treatment. NOAC use was less common in Asia (27.7%), where 27.5% of patients received VKA, 25.0% antiplatelet drugs, and 19.8% no antithrombotic treatment. Conclusions The baseline data from GLORIA-AF phase 2 demonstrate that in newly diagnosed nonvalvular atrial fibrillation patients, NOAC have been highly adopted into practice, becoming more frequently prescribed than VKA in Europe and North America. Worldwide, however, a large proportion of patients remain undertreated, particularly in Asia and North America. (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients With Atrial Fibrillation [GLORIA-AF]; NCT01468701

Sensitivity of collapsed arc QA method for delivery errors in Volumetric Modulated Arc Therapy (VMAT)

In this paper the sensitivity of an Electronic Portal Imaging Device (EPID) to detecting introduced Volumetric Arc Therapy (VMAT) treatment errors was studied using the Collapsed Arc method. Two clinical Head and Neck (H& N) and Prostate treatment plans had gantry dependent dose and MLC errors introduced to the plans. These plans were then delivered to an Elekta Synergy Linear Accelerator EPID and compared to the original treatment planning system Collapsed Arc dose matrix. With the Collapsed Arc technique the EPID was able to detect MLC errors down to 2mm and dose errors of down to 3% depending on the treatment plan complexity and gamma tolerance used

2-D radiation therapy dosimetry using EPIDs: Dose response variation between 3 siemens electronic portal imaging devices (EPIDs)

Prerequisite for any new clinical dosimeter is a detailed understanding of the detector’s dose response behavior. The purpose of the present study was to investigate the level of variability in dose response characteristics of 3 siemens EPIDs for both 6 and 18 MV photons. Dose response tests for linearity, field size, short- and long-term reproducibilities, ghosting effects and dose rate dependence were undertaken for three different model Siemens EPIDs on three dosimetrically matched linear accelerators. All three EPIDs showed a linear dose response above 20 monitor units. The pixel sensitivity for EPID2 and EPID3 agreed to within 0.5%. EPID1 was 6.3% (6 MV) and 2.3% (18 MV) greater than for EPID2 and EPID3. The field size response and dose rate response agreed within 1% for all three EPIDs. The short-term and long-term reproducibilities for all EPIDs were within 0.5% and 1% respectively. The maximum increase in relative response due to the ghosting effect was 0.5%. The off-axis profiles from uncorrected gain files agreed to within 2% for EPID2 and EPID3 at 6 MV and 18 MV respectively. The off-axis profiles for EPID1 had more pronounced horns. The different dose response behavior of EPID1 is due to a thicker phosphor scintillator compared to EPID2 and EPID3. EPID1 was significantly more sensitive to dose and energy variations and would require separate calibration data for EPID dosimetry. EPIDs with the same phosphor had no significant difference in dose response. Differences in EPID/phosphor design must be considered when commissioning EPIDs for clinical dosimetry

Evaluation of 3D Gamma index calculation implemented in two commercial dosimetry systems

3D Gamma index is one of the metrics which have been widely used for clinical routine patient specific quality assurance for IMRT, Tomotherapy and VMAT. The algorithms for calculating the 3D Gamma index using global and local methods implemented in two software tools: PTW-VeriSoft (R) r as a part of OCTIVIUS 4D dosimeter systems and 3DVH (TM) from Sun Nuclear were assessed. The Gamma index calculated by the two systems was compared with manual calculated for one data set. The Gamma pass rate calculated by the two systems was compared using 3%/3mm, 2%/2mm, 3%/2mm and 2%/3mm for two additional data sets. The Gamma indexes calculated by the two systems were accurate, but Gamma pass rates calculated by the two software tools for same data set with the same dose threshold were different due to the different interpolation of raw dose data by the two systems and different implementation of Gamma index calculation and other modules in the two software tools. The mean difference was -1.3%+/-3.38 (1SD) with a maximum difference of 11.7%

Is a quasi-3D dosimeter better than a 2D dosimeter for Tomotherapy delivery quality assurance?

Delivery quality assurance (DQA) has been performed for each Tomotherapy patient either using ArcCHECK or MatriXX Evolution in our clinic since 2012. ArcCHECK is a quasi-3D dosimeter whereas MatriXX is a 2D detector. A review of DQA results was performed for all patients in the last three years, a total of 221 DQA plans. These DQA plans came from 215 patients with a variety of treatment sites including head-neck, pelvis, and chest wall. The acceptable Gamma pass rate in our clinic is over 95% using 3mm and 3% of maximum planned dose with 10% dose threshold. The mean value and standard deviation of Gamma pass rates were 98.2% +/- 1.98(1SD) for MatriXX and 98.5%+/- 1.88 (1SD) for ArcCHECK. A paired t-test was also performed for the groups of patients whose DQA was performed with both the ArcCHECK and MatriXX. No statistical dependence was found in terms of the Gamma pass rate for ArcCHECK and MatriXX. The considered 3D and 2D dosimeters have achieved similar results in performing routine patient-specific DQA for patients treated on a TomoTherapy unit

EPID sensitivity to delivery errors for pre-treatment verification of lung SBRT VMAT plans

Purpose To study the sensitivity of an Electronic Portal Imaging Device (EPID) in detecting delivery errors for VMAT lung stereotactic body radiotherapy (SBRT) using the Collapsed Arc method. Methods Baseline VMAT plans and plans with errors intentionally introduced were generated for 15 lung SBRT patients. Three types of errors were introduced by modifying collimator angles and multi-leaf collimator (MLC) field sizes (MLCFS) and MLC shifts by ±5, ±2, and ±1° or millimeters. A total of 103 plans were measured with EPID on an Elekta Synergy Linear Accelerator (Agility MLC) and compared to both the original treatment planning system (TPS) Collapsed Arc dose matrix and the no-error plan baseline EPID measurements. Gamma analysis was performed using the OmniPro-I\u27mRT (IBA Dosimetry) software and gamma criteria of 1%/1 mm, 2%/1 mm, 2%/2 mm, and 3%/3. Results When the error-introduced EPID measured dose matrices were compared to the TPS matrices, the majority of simulated errors were detected with gamma tolerance of 2%/1 mm and 1%/1 mm. When the error-introduced EPID measured dose matrices were compared to the baseline EPID measurements, all the MLCFS and MLC shift errors, and ±5°collimator errors were detected using 2%/1 mm and 1%/1 mm gamma criteria. Conclusion This work demonstrates the feasibility and effectiveness of the collapsed arc technique and EPID for pre-treatment verification of lung SBRT VMAT plans. The EPID was able to detect the majority of MLC and the larger collimator errors with sensitivity to errors depending on the gamma tolerances

Sensitivity evaluation of two commercial dosimeters in detecting Helical TomoTherapy treatment delivery errors

Purpose To assess the sensitivity of two commercial dosimetry systems in detecting Helical TomoTherapy (HT) delivery errors. Method Two commercial dosimeters i) MatriXXEvolution and ii) ArcCHECK® were considered. Ten retrospective nasopharynx HT patients were analysed. For each patient, error plans were created by independently introducing systematic offsets in: a) Jaw width error ±1, ±1.5 and ±2 mm, b) Couch speed error ±2%, ±2.5, ±3% and ±4%, and c) MLC Leaf Open Time (MLCLOT) errors (3 separate MLC errors: either leaf 32 open or leaf 42 remains open during delivery, and 4% random reductions in MLCLOT). All error plans, along with the no error plan for each patient, were measured using both dosimeters in the same session. Gamma evaluation (3%/3 mm) was applied to quantitatively compare the measured dose from each dosimeter to the treatment planning system. The error sensitivity was quantified as the rate of decrease in gamma pass rate. Results The gamma pass rate decreases with increase in error magnitude for both dosimeters. ArcCHECK was insensitive for couch speed error up to 2.5% and jaw width error up to −1.5 mm while MatriXXEvolution was found to be insensitive to couch speed error up to 2% and couch speed up to −1 mm. Both of the detectors show similar sensitivity to all the MLCLOT errors that were clinically relevant. Conclusion No statistically significant (p \u3e 0.05) differences exist in detecting the simulated delivery errors between MatriXXEvolution and ArcCHECK dosimeter systems for HT plans. Both dosimeters were able to pick up clinically relevant delivery errors