Sweden, the first country to achieve the Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) 90-90-90 continuum of HIV care targets.

OBJECTIVES: The Joint United Nations Programme on HIV/AIDS (UNAIDS)/World Health Organization (WHO) 90-90-90 goals propose that 90% of all people living with HIV should know their HIV status, 90% of those diagnosed should receive antiretroviral therapy (ART), and 90% of those should have durable viral suppression. We have estimated the continuum of HIV care for the entire HIV-1-infected population in Sweden. METHODS: The Swedish InfCare HIV Cohort Study collects viral loads, CD4 counts, and viral sequences, along with demographic and clinical data, through an electronic clinical decision support system. Almost 100% of those diagnosed with HIV infection are included in the database, corresponding to 6946 diagnosed subjects living with HIV-1 in Sweden by 31 December 2015. RESULTS: Using HIV surveillance data reported to the Public Health Agency of Sweden, it was estimated that 10% of all HIV-infected subjects in Sweden remain undiagnosed. Among all diagnosed patients, 99.8% were linked to care and 97.1% of those remained in care. On 31 December 2015, 6605 of 6946 patients (95.1%) were on ART. A total of 6395 had been on treatment for at least 6 months and 6053 of those (94.7%) had a viral load < 50 HIV-1 RNA copies/mL. CONCLUSIONS: The 2014 UNAIDS/WHO 90-90-90 goals for HIV care means that > 73% of all patients living with HIV should be virologically suppressed by 2020. Sweden has already achieved this target, with 78% suppression, and is the first country reported to meet all the UNAIDS/WHO 90-90-90 goals.

Influence of HyCoSy on spontaneous pregnancy: a randomized controlled trial.

BACKGROUND: The aim of the study was to test whether the use of sonography contrast could enhance the chance of spontaneous clinical pregnancy in women undergoing subfertility investigation. METHODS: Couples with at least 1 year of infertility who were scheduled for a consultation including a hysterosalpingo contrast sonography (HyCoSy) were invited to participate in the study. We compared flushing with water-soluble contrast medium (WSCM) versus no flushing. Randomization sequence was computer generated, stratified for age and group allocation was concealed. Primary outcome was clinical pregnancy defined as a sonographically visible fetal sac, detected within 6 months from randomization. Secondary outcomes were spontaneous miscarriage and birth. Exclusion criteria were female age >or=40 years, severe male infertility, previously known severe tubal infertility and suspected anovulation. RESULTS: The mean age of the study population (n = 334) was 31.9 years. Duration of infertility was 2.1 years. The clinical pregnancy rate was 29.2% in the HyCoSy group and 26.5% in the non-flushing group, the difference being 2.7% (95% confidence interval -6.9 to 12.3%, P = 0.63). CONCLUSION: The clinical impression of an enhanced pregnancy rate after performing HyCoSy could not be confirmed. Tubal investigation with sonography using water-soluble contrast has a function as a diagnostic procedure but not in terms of increasing pregnancy rates in subfertile patients. TRIAL REGISTRATION NUMBER: ISRCTN20715945.

Nanodosimetry in a clinical neutron therapy beam using the variance-covariance method and Monte Carlo simulations.

Nanodosimetric single-event distributions or their mean values may contribute to a better understanding of how radiation induced biological damages are produced. They may also provide means for radiation quality characterization in therapy beams. Experimental nanodosimetry is however technically challenging and Monte Carlo simulations are valuable as a complementary tool for such investigations. The dose-mean lineal energy was determined in a therapeutic p(65)+Be neutron beam and in a (60)Co gamma beam using low-pressure gas detectors and the variance-covariance method. The neutron beam was simulated using the condensed history Monte Carlo codes MCNPX and SHIELD-HIT. The dose-mean lineal energy was calculated using the simulated dose and fluence spectra together with published data from track-structure simulations. A comparison between simulated and measured results revealed some systematic differences and different dependencies on the simulated object size. The results show that both experimental and theoretical approaches are needed for an accurate dosimetry in the nanometer region. In line with previously reported results, the dose-mean lineal energy determined at 10 nm was shown to be related to clinical RBE values in the neutron beam and in a simulated 175 MeV proton beam as well.

Photon and neutron dose discrimination using low pressure proportional counters with graphite and A150 walls.

A graphite-walled proportional counter with low neutron sensitivity was used in combination with a tissue-equivalent proportional counter (TEPC) to separate the photon and neutron components in mixed radiation fields. Monte Carlo (MCNP4C) simulations of the photon and neutron responses of the two detectors were done to obtain correction factors for the sensitivity differences. In an alternative method the radiation components were determined using constant-yD-values for typical photon and neutron energy distributions. The results show no significant difference between the two methods and the measured neutron dose-equivalent agrees within +/-50% with Bonner sphere determined values. The experimental data were obtained in measurement campaigns organised within the EVIDOS-project.

Nanodosimetric measurements and calculations in a neutron therapy beam.

A comparison of calculated and measured values of the dose mean lineal energy (y(D)) for the former neutron therapy beam at Louvain-la-Neuve is reported. The measurements were made with wall-less tissue-equivalent proportional counters using the variance-covariance method and simulating spheres with diameters between 10 nm and 15 microm. The calculated y(D)-values were obtained from simulated energy distributions of neutrons and charged particles inside an A-150 phantom and from published y(D)-values for mono-energetic ions. The energy distributions of charged particles up to oxygen were determined with the SHIELD-HIT code using an MCNPX simulated neutron spectrum as an input. The mono-energetic ion y(D)-values in the range 3-100 nm were taken from track-structure simulations in water vapour done with PITS/KURBUC. The large influence on the dose mean lineal energy from the light ion (A > 4) absorbed dose fraction, may explain an observed difference between experiment and calculation. The latter being larger than earlier reported result. Below 50 nm, the experimental values increase while the calculated decrease.

Determinations of H(10) and its dose components onboard aircraft.

Aircrew is in general receiving a higher average annual dose than other occupationally exposed personnel, and about half of the effective dose is deposited by high-LET neutron secondaries. A recent investigation of the cancer incidence following the atomic bombs at Hiroshima and Nagasaki has put forward the possibility that the relative biological efficiency for neutrons could be underestimated. If so, the effective dose to aircrew from this component would increase and the estimation of this component will become even more important. Different ambient dose equivalent measurement techniques and calculation methods have recently been compared on a dedicated flight. The experimental results are compared with calculations made with the codes EPCARD 3.2 and an updated version of FLUKA and different galactic proton spectra. The aircraft circulated within the target areas at two constant altitudes with a flight route variation of only about 1 degrees in longitude and latitude to reduce the influence from variations in atmospheric and geomagnetic shielding. The instrumentation consisted of tissue-equivalent proportional counters (TEPC) and a silicon diode spectrometer. Measurements were performed for 2 h to reduce the statistical uncertainties in the results. The TEPCs were evaluated either according to single-event analysis techniques or the variance-covariance method. Besides the total ambient dose equivalent, the instruments can be evaluated to reveal the low- and high-LET components. The EPCARD and FLUKA simulations can determine the contribution from each type of particle directly. The ratio between the calculated and the measured average value of the ambient dose equivalent rate was 1.00 +/- 0.08 with all instruments included for EPCARD and 0.97 +/- 0.07 when FLUKA was used. The measured high-LET component and the calculated neutron component are not quite identical, but should be similar. The agreement was always within 20%. The high-LET component contributed with about 57% at N57 E8 and 48% at N42 E12.

Evaluation of individual dosimetry in mixed neutron and photon radiation fields (EVIDOS). Part II: Conclusions and recommendations.

The paper presents the main conclusions and recommendations derived from the EVIDOS project, which is supported by the European Commission within the 5th Framework Programme. EVIDOS aims at evaluating state of the art neutron dosimetry techniques in representative workplaces of the nuclear industry with complex mixed neutron-photon radiation fields. This analysis complements a series of individual papers which present detailed results and it summarises the main findings from a practical point of view. Conclusions and recommendations are given concerning characterisation of radiation fields, methods to derive radiation protection quantities and dosemeter results.

Evaluation of individual dosimetry in mixed neutron and photon radiation fields (EVIDOS). Part I: Scope and methods of the project.

Supported by the European Commission, the EVIDOS project started in November 2001 with the broad goal of evaluating state of the art dosimetry techniques in representative workplaces of the nuclear industry. Seven European institutes joined efforts with end users at nuclear power plants, at fuel processing and reprocessing plants, and at transport and storage facilities. A comprehensive programme was devised to evaluate capabilities and limitations of standard and innovative personal dosemeters in relation to the mixed neutron-photon fields of concern to the nuclear industry. This paper describes the criteria behind the selection of dosimetry techniques and workplaces that were analysed, as well as the organisation of the measurement campaigns. Particular emphasis was placed on the evaluation of a variety of electronic personal dosemeters, either commercially available or previously developed by the partners. The estimates provided by these personal dosemeters were compared to reference values of dose equivalent quantities derived from spectrometry and fluence-to-dose equivalent conversion coefficients. Spectrometry was performed both with conventional multisphere and with some original instrumentation providing energy and direction resolution, based on silicon detectors and superheated drop detectors mounted on or in spherical moderators. The results were collected in a large, searchable database and are intended to be used in the harmonisation of dosimetric procedures for mixed radiation fields and for the approval of dosimetry services in Europe.

Direction distributions of neutrons and reference values of the personal dose equivalent in workplace fields.

Within the EC project EVIDOS, double-differential (energy and direction) fluence spectra were determined by means of novel direction spectrometers. By folding the spectra with fluence-to-dose equivalent conversion coefficients, contributions to H*(10) for 14 directions, and values of the personal dose equivalent Hp(10) and the effective dose E for 6 directions of a person's orientation in the field were determined. The results of the measurements and calculations obtained within the EVIDOS project in workplace fields in nuclear installations in Europe, i.e., at Krümmel (boiling water reactor and transport cask), at Mol (Venus research reactor and fuel facility Belgonucléaire) and at Ringhals (pressurised reactor and transport cask) are presented.

Achievements in workplace neutron dosimetry in the last decade: lessons learned from the EVIDOS project.

The availability of active neutron personal dosemeters has made real time monitoring of neutron doses possible. This has obvious benefits, but is only of any real assistance if the dose assessments made are of sufficient accuracy and reliability. Preliminary assessments of the performance of active neutron dosemeters can be made in calibration facilities, but these can never replicate the conditions under which the dosemeter is used in the workplace. Consequently, it is necessary to assess their performance in the workplace, which requires the field in the workplace to be fully characterised in terms of the energy and direction dependence of the fluence. This paper presents an overview of developments in workplace neutron dosimetry but concentrates on the outcomes of the EVIDOS project, which has made significant advances in the characterisation of workplace fields and the analysis of dosemeter responses in those fields.

Characterisation of mixed neutron photon workplace fields at nuclear facilities by spectrometry (energy and direction) within the EVIDOS project.

Within the EC project EVIDOS, 17 different mixed neutron-photon workplace fields at nuclear facilities (boiling water reactor, pressurised water reactor, research reactor, fuel processing, storage of spent fuel) were characterised using conventional Bonner sphere spectrometry and newly developed direction spectrometers. The results of the analysis, using Bayesian parameter estimation methods and different unfolding codes, some of them especially adapted to simultaneously unfold energy and direction distributions of the neutron fluence, showed that neutron spectra differed strongly at the different places, both in energy and direction distribution. The implication of the results for the determination of reference values for radiation protection quantities (ambient dose equivalent, personal dose equivalent and effective dose) and the related uncertainties are discussed.

Summary of personal neutron dosemeter results obtained within the EVIDOS project.

Within the EC project EVIDOS ('Evaluation of Individual Dosimetry in Mixed Neutron and Photon Radiation Fields'), different types of active neutron personal dosemeters (and some passive ones) were tested in workplace fields at nuclear installations in Europe. The results of the measurements which have been performed up to now are summarised and compared to our currently best estimates of the personal dose equivalent Hp(10). Under- and over-readings by more than a factor of two for the same dosemeter in different workplace fields indicate that in most cases the use of field-specific correction factors is required.

Neutron area survey instrument measurements in the EVIDOS project.

Neutron survey instruments have been exposed at all the measurement locations used in the EVIDOS project. These results have an important impact in the interpretation of the results from the project, since operationally the survey instrument will be used for an initial assessment of and routine monitoring of the ambient dose equivalent dose rate. Additionally, since the response of these instruments is in some cases very well characterised, their systematic deviations from the reference quantities provide an important verification of the determination of those quantities.

Application of workplace correction factors to dosemeter results for the assessment of personal doses at nuclear facilities.

Ratios of H(p)(10) and H*(10) were determined with reference instruments in a number of workplace fields within the nuclear industry and used to derive workplace-specific correction factors. When commercial survey meter results together with these factors were applied to the results of the locally used personal dosemeters their results improved and became within 0.7 and 1.7 of the reference values or better depending on the response of the survey meter. A similar result was obtained when a correction was determined with a prototype reference instrument for H(p)(10) after adjustment of its response. Commercially available survey instruments both for photon and neutron H*(10) measurements agreed with the reference instruments in most cases to within 0.5-1.5. Those conclusions are derived from results reported within the EC supported EVIDOS contract.

Evaluation of individual monitoring in mixed neutron/photon fields: mid-term results from the EVIDOS project.

EVIDOS is an EC sponsored project that aims at an evaluation and improvement of radiation protection dosimetry in mixed neutron/photon fields. This is performed through spectrometric and dosimetric investigations during different measurement campaigns in representative workplaces of the nuclear industry. The performance of routine and, in particular, novel personal dosemeters and survey instruments is tested in selected workplace fields. Reference values for the dose equivalent quantities, H(*)(10) and H(p)(10) and the effective dose E, are determined using different spectrometers that provide the energy distribution of the neutron fluence and using newly developed devices that determine the energy and directional distribution of the neutron fluence. The EVIDOS project has passed the mid-term, and three measurement campaigns have been performed. This paper will give an overview and some new results from the third campaign that was held in Mol (Belgium), around the research reactor VENUS and in the MOX producing plant of Belgonucléaire.

Electronic neutron personal dosemeters: their performance in mixed radiation fields in nuclear power plants.

This work describes spectral distributions of neutrons obtained as function of energy and direction at four workplace fields at the Krümmel reactor in Germany. Values of personal dose equivalent H(p)(10) and effective dose E are determined for different directions of a person's orientation in these fields and readings of personal neutron dosemeters--especially electronic dosemeters--are discussed with respect to H(p)(10) and E.

Influence of microdosimetric quantities on observed dose-response relationships in radiation therapy.

The steepness of dose-response curves in radiation therapy depends to a large extent on the statistics of cell killing. This is so if the last few clonogenic tumor cells have to be hit or eradicated by other means to cure the patient. The steepness is dependent on the number of clonogenic cells in the tumor and the possible variation in their sensitivity. However, the uniformity of the dose distribution is also important and a decreased slope may result when the delivery of the dose is nonuniform or statistically uncertain. The variance in the energy imparted at the microdosimetric level to individual cell nuclei constitutes the ultimate limit of the variance in delivered dose at a given mean tumor dose. Considering all dosimetric variances it is shown that for low-LET beams the conventional microdosimetric variance will dominate, while in neutron and high-LET beams in general the microdosimetric variance may contribute significantly to the observed dose-response relationship. As a result the normalized slope of the dose-response curve for tumor control and normal tissue complications with neutrons and other high-LET beams will be reduced compared to that with photons. This conclusion is found to be in quantitative agreement with available data from clinical trials with neutron therapy. Finally, it is pointed out that for beams with a very high RBE and LET it may be favorable to deliver a fraction of the total dose in the form of conventional low-LET radiation. This addition of low-LET radiation may be desirable to ensure a dose to all clonogenic tumor cell nuclei that is sufficiently high and uniform to achieve a high probability of tumor control.

Microdosimetry of pulsed radiation fields employing the variance method.

The relationship between dose mean lineal energy and relative variance has been exploited previously to derive yD from the calculated variance in current measurements in steady and uniform radiation fields. Recently Kellerer and Rossi made the observation that utilization of two detectors can make the variance technique practicable in time-varying fields. We report here the first measurements of yD for 10 MeV X rays and 9 and 18 MeV electrons from a pulsed linear accelerator using the variance method. Two independent analog-to-digital converters were used to obtain data from two spherical proportional counters in synchrony with the beam pulse. The method is described in detail and results are reported for site diameters of 1/2, 1, and 2 microns. Data for an accurate determination of yD can be obtained with this technique in less than 1 min, making possible an essentially "on line" determination of yD or zD in a clinical situation.

On the calibration of plane-parallel ionization chambers for electron beam dosimetry.

The procedure recommended by different dosimetry protocols for the determination of the absorbed dose to air chamber factor, ND,pp, of plane-parallel chambers, comparing absorbed dose determinations in a high-energy electron beam with a reference cylindrical chamber having a known ND,cyl factor, has been investigated. Attention has been focused on the case that the chamber serving as reference has a solid aluminium central electrode. It has been found that using a wide spread Farmer-type chamber (NE 2571), together with recommendations which specifically take into account central electrode corrections for electron beam dosimetry, kcelpcel = pcel-global(IAEA) = 1.008, yields inconsistent results compared with those obtained from a fully homogeneous ionization chamber; for the NE 2571 chamber, a value kcelpcel = pcel-global(IAEA) congruent to 1.0 has been obtained. Analytical calculations of kmkatt for Farmer-type cylindrical chambers and experimental determinations of the product kmkattkcelpcel in electron beams agree within experimental uncertainties, with no evidence of statistical significance for the commonly used assumption pcel = 1, which yields a 0.8% correction (due to kcel only) for the effect of the NE 2571 aluminium electrode in electron beam dosimetry. The use of a 'NACP-chamber' specific factor (kpp or kmkatt) to obtain ND,pp from NK,pp in NACP plane-parallel chambers has been found unsatisfactory, and direct experimental determinations of ND,pp are recommended instead. It is suggested that Standard Dosimetry Laboratories provide ND,pp calibration factors in 60Co beams.

Cosmic radiation measurements on-board aircraft with the variance method.

The microdosimetric variance-covariance method has been used for cosmic radiation measurements on-board aircraft. Two independent methods of data analysis are presented; the first based on a high energy neutron calibration and the second on identification of single high LET events in the measured multiple event spectrum. Reduced dose levels at high geomagnetic latitudes are observed on one flight in a period of enhanced solar activity as indicated by a reduced ground-level neutron fluence rate. It is shown that with a reduced 137Cs-calibration factor, a Geiger-Mueller tube can be used as a low LET monitor, and that the wall thickness of a tissue-equivalent proportional counter is not crucial for flight measurements. No covariance is observed on any flight indicating it is sufficient to base dose determinations on variance measurements with only one detector. The uncertainties involved are also discussed in some detail.