Oxygen therapy for critically Ill and post-operative patients.

Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.

Pushing the limits of de novo genome assembly for complex prokaryotic genomes harboring very long, near identical repeats.

Generating a complete, de novo genome assembly for prokaryotes is often considered a solved problem. However, we here show that Pseudomonas koreensis P19E3 harbors multiple, near identical repeat pairs up to 70 kilobase pairs in length, which contained several genes that may confer fitness advantages to the strain. Its complex genome, which also included a variable shufflon region, could not be de novo assembled with long reads produced by Pacific Biosciences' technology, but required very long reads from Oxford Nanopore Technologies. Importantly, a repeat analysis, whose results we release for over 9600 prokaryotes, indicated that very complex bacterial genomes represent a general phenomenon beyond Pseudomonas. Roughly 10% of 9331 complete bacterial and a handful of 293 complete archaeal genomes represented this 'dark matter' for de novo genome assembly of prokaryotes. Several of these 'dark matter' genome assemblies contained repeats far beyond the resolution of the sequencing technology employed and likely contain errors, other genomes were closed employing labor-intense steps like cosmid libraries, primer walking or optical mapping. Using very long sequencing reads in combination with assembly algorithms capable of resolving long, near identical repeats will bring most prokaryotic genomes within reach of fast and complete de novo genome assembly.

Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial.

Importance: It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. Objective: To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. Design, Setting, and Participants: Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. Interventions: Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. Main Outcomes and Measures: The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. Results: Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was -0.6 hours (95% CI, -8.3 to 7.2 hours; P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported. Conclusions and Relevance: In patients with septic shock, treatment with intravenous vitamin C, hydrocortisone, and thiamine, compared with intravenous hydrocortisone alone, did not significantly improve the duration of time alive and free of vasopressor administration over 7 days. The finding suggests that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone. Trial Registration: ClinicalTrials.gov Identifier: NCT03333278.

Long-read based de novo assembly of low-complexity metagenome samples results in finished genomes and reveals insights into strain diversity and an active phage system.

BACKGROUND: Complete and contiguous genome assemblies greatly improve the quality of subsequent systems-wide functional profiling studies and the ability to gain novel biological insights. While a de novo genome assembly of an isolated bacterial strain is in most cases straightforward, more informative data about co-existing bacteria as well as synergistic and antagonistic effects can be obtained from a direct analysis of microbial communities. However, the complexity of metagenomic samples represents a major challenge. While third generation sequencing technologies have been suggested to enable finished metagenome-assembled genomes, to our knowledge, the complete genome assembly of all dominant strains in a microbiome sample has not been demonstrated. Natural whey starter cultures (NWCs) are used in cheese production and represent low-complexity microbiomes. Previous studies of Swiss Gruyère and selected Italian hard cheeses, mostly based on amplicon metagenomics, concurred that three species generally pre-dominate: Streptococcus thermophilus, Lactobacillus helveticus and Lactobacillus delbrueckii. RESULTS: Two NWCs from Swiss Gruyère producers were subjected to whole metagenome shotgun sequencing using the Pacific Biosciences Sequel and Illumina MiSeq platforms. In addition, longer Oxford Nanopore Technologies MinION reads had to be generated for one to resolve repeat regions. Thereby, we achieved the complete assembly of all dominant bacterial genomes from these low-complexity NWCs, which was corroborated by a 16S rRNA amplicon survey. Moreover, two distinct L. helveticus strains were successfully co-assembled from the same sample. Besides bacterial chromosomes, we could also assemble several bacterial plasmids and phages and a corresponding prophage. Biologically relevant insights were uncovered by linking the plasmids and phages to their respective host genomes using DNA methylation motifs on the plasmids and by matching prokaryotic CRISPR spacers with the corresponding protospacers on the phages. These results could only be achieved by employing long-read sequencing data able to span intragenomic as well as intergenomic repeats. CONCLUSIONS: Here, we demonstrate the feasibility of complete de novo genome assembly of all dominant strains from low-complexity NWCs based on whole metagenomics shotgun sequencing data. This allowed to gain novel biological insights and is a fundamental basis for subsequent systems-wide omics analyses, functional profiling and phenotype to genotype analysis of specific microbial communities.

Oxygen therapy in acute resuscitation.

PURPOSE OF REVIEW: Avoidance and treatment of hypoxaemia is a cornerstone of acute resuscitation and yet the optimal approach to oxygen therapy in the acute care setting is uncertain. The aim of this review is to appraise recent evidence relating to the provision of supplemental oxygen to adult patients with acute illnesses with a focus on the resuscitation phase. RECENT FINDINGS: Recent findings generally support the notion that exposure to hyperoxaemia is associated with adverse outcomes in acutely ill adults with a range of diseases and raise the possibility that liberal provision of oxygen may cause harm. Several ongoing multicentre randomized trials aim to assess the effects of different oxygen therapy regimens on patient outcomes to provide a foundation for evidence-based recommendations regarding the use of supplemental oxygen in Intensive Care Unit patients. SUMMARY: At present, evidence is lacking to support routine liberal oxygen administration in acutely ill patients and, in most circumstances, a reasonable approach is to titrate supplemental oxygen to achieve an arterial oxygen saturation measured by pulse oximetry (SpO2) of 92-96% with the aim of avoiding both hypoxaemia and hyperoxaemia.

A novel multiplex qPCR targeting 23S rDNA for diagnosis of swine dysentery and porcine intestinal spirochaetosis.

BACKGROUND: A multiplex qPCR targeting a 128 bp region on the 23S rDNA gene was developed for detection of Brachyspira (B.) hyodysenteriae and B. pilosicoli, the agents of swine dysentery (SD) and porcine intestinal spirochaetosis (PIS), together with a triplet of apathogenic Brachyspira spp. (B. innocens, B. intermedia, B. murdochii) in porcine feces. The multiplex qPCR was evaluated against a duplex PCR (La et al., J Clin Microbiol 41:3372-5, 2003). RESULTS: Using DNA extracted from fecal culture, the multiplex qPCR showed excellent agreement with the duplex PCR (κ = 0.943 and 0.933). In addition, thanks to the three probes whereof one detecting the apathogenic Brachyspria spp., a more diversified overview of the brachyspiral flora in porcine fecal samples can be delivered as a part of the routine diagnostic. The multiplex qPCR with a limit of detection of 5-10 genomic equivalents (GE) per reaction (6 × 102 GE per gram) allows reliable detection of Brachyspira species directly from fecal swab DNA. In line with this, analysis of 202 fecal swabs in comparison with culture-based qPCR showed a high agreement for the causative agents of SD (B.hyodysenteriae: κ = 0.853, sensitivity 87% specificity 98%). CONCLUSION: The novel multiplex qPCR is robust and has a high analytical sensitivity and is therefore suitable for high-throughput screening of porcine fecal swabs for the causative agents of SD. This assay can therefore be used for the direct proof of the pathogenic B. spp. in fecal swabs within the scope of a monitoring program.

Combining Monte Carlo methods with coherent wave optics for the simulation of phase-sensitive X-ray imaging.

Phase-sensitive X-ray imaging shows a high sensitivity towards electron density variations, making it well suited for imaging of soft tissue matter. However, there are still open questions about the details of the image formation process. Here, a framework for numerical simulations of phase-sensitive X-ray imaging is presented, which takes both particle- and wave-like properties of X-rays into consideration. A split approach is presented where we combine a Monte Carlo method (MC) based sample part with a wave optics simulation based propagation part, leading to a framework that takes both particle- and wave-like properties into account. The framework can be adapted to different phase-sensitive imaging methods and has been validated through comparisons with experiments for grating interferometry and propagation-based imaging. The validation of the framework shows that the combination of wave optics and MC has been successfully implemented and yields good agreement between measurements and simulations. This demonstrates that the physical processes relevant for developing a deeper understanding of scattering in the context of phase-sensitive imaging are modelled in a sufficiently accurate manner. The framework can be used for the simulation of phase-sensitive X-ray imaging, for instance for the simulation of grating interferometry or propagation-based imaging.

Associations between the intraoperative fraction of inspired intraoperative oxygen administration and days alive and out of hospital after surgery.

Background: There is limited knowledge about the effect of liberal intraoperative oxygen on non-infectious complications and overall recovery from surgery. Methods: In this retrospective cohort study, we investigated associations between mean intraoperative fraction of inspired oxygen (FiO2), and outcome in adults undergoing elective surgery lasting more than 2 h at a large metropolitan New Zealand hospital from 2012 to 2020. Patients were divided into low, medium, and high oxygen groups (FiO2 ≤ 0.4, 0.41-0.59, ≥0.6). The primary outcome was days alive and out of hospital at 90 days (DAOH90). The secondary outcomes were post-operative complications and admission to the ICU. Results: We identified 15,449 patients who met the inclusion criteria. There was no association between FiO2 and DAOH90 when high FiO2 was analysed according to three groups. Using high FiO2 as the reference group there was an adjusted mean (95% confidence interval [CI]) difference of 0.09 (-0.06 to 0.25) days (P = 0.25) and 0.28 (-0.05 to 0.62) days (P = 0.2) in the intermediate and low oxygen groups, respectively. Low FiO2 was associated with increased surgical site infection: the adjusted odds ratio (OR) for low compared with high FiO2 was 1.53 (95% CI 1.12-2.10). Increasing FiO2 was associated with respiratory complications: the adjusted OR associated with each 10% point increase in FiO2 was 1.17 (95% CI 1.08-1.26) and the incidence of being admitted to an ICU had an adjusted OR of 1.1 (95% CI 1.03-1.18). Conclusions: We found potential benefits, and risks, associated with liberal intraoperative oxygen administration indicating that randomised controlled trials are warranted.

Organs-at-risk dose and normal tissue complication probability with dynamic trajectory radiotherapy (DTRT) for head and neck cancer.

We compared dynamic trajectory radiotherapy (DTRT) to state-of-the-art volumetric modulated arc therapy (VMAT) for 46 head and neck cancer cases. DTRT had lower dose to salivary glands and swallowing structure, resulting in lower predicted xerostomia and dysphagia compared to VMAT. DTRT is deliverable on C-arm linacs with high dosimetric accuracy.

Genome sequence data of the strongly antagonistic yeast Pichia kluyveri isolate APC 11.10 B as a foundation for analysing biocontrol mechanisms.

Pichia kluyveri strain APC 11.10 B was isolated from apple bark in Switzerland and exhibited strong antagonistic activity against plant pathogenic fungi in vitro (e.g., Botrytis, Fusarium or Monilinia isolates). In order to identify the mechanisms underlying this antagonism, we have sequenced the genome of this isolate by long- and short-read sequencing technologies. The sequence data were de novo assembled into nine scaffolds and a fully resolved circularized mitogenome. The total genome size was 10.9 Mbp and 7451 potential open reading frames (ORFs) and 202 tRNA genes were predicted. In comparison to two P. kluyveri genomes deposited at the NCBI (of strains X31-10 and CBA6002), the APC 11.10 B strain seemed to represent a hybrid because backmapping of sequencing reads resulted in a high rate of heterozygous and structural variants in the nuclear genome (this was not observed for the mitochondrial genome). The P. kluyveri (APC 11.10 B) draft genome represents a first step and resource for genome mining, comparative and functional genomics (e.g., identifying the biocontrol mode of action), and evolutionary studies. Since the genus Pichia comprises many biotechnologically relevant yeasts, the genome data may be used in a variety of fields and disciplines.

Delivery time reduction for mixed photon-electron radiotherapy by using photon MLC collimated electron arcs.

Objective. Electron arcs in mixed-beam radiotherapy (Arc-MBRT) consisting of intensity-modulated electron arcs with dynamic gantry rotation potentially reduce the delivery time compared to mixed-beam radiotherapy containing electron beams with static gantry angle (Static-MBRT). This study aims to develop and investigate a treatment planning process (TPP) for photon multileaf collimator (pMLC) based Arc-MBRT.Approach. An existing TPP for Static-MBRT plans is extended to integrate electron arcs with a dynamic gantry rotation and intensity modulation using a sliding window technique. The TPP consists of a manual setup of electron arcs, and either static photon beams or photon arcs, shortening of the source-to-surface distance for the electron arcs, initial intensity modulation optimization, selection of a user-defined number of electron beam energies based on dose contribution to the target volume and finally, simultaneous photon and electron intensity modulation optimization followed by full Monte Carlo dose calculation. Arc-MBRT plans, Static-MBRT plans, and photon-only plans were created and compared for four breast cases. Dosimetric validation of two Arc-MBRT plans was performed using film measurements.Main results. The generated Arc-MBRT plans are dosimetrically similar to the Static-MBRT plans while outperforming the photon-only plans. The mean heart dose is reduced by 32% on average in the MBRT plans compared to the photon-only plans. The estimated delivery times of the Arc-MBRT plans are similar to the photon-only plans but less than half the time of the Static-MBRT plans. Measured and calculated dose distributions agree with a gamma passing rate of over 98% (3% global, 2 mm) for both delivered Arc-MBRT plans.Significance. A TPP for Arc-MBRT is successfully developed and Arc-MBRT plans showed the potential to improve the dosimetric plan quality similar as Static-MBRT while maintaining short delivery times of photon-only treatments. This further facilitates integration of pMLC-based MBRT into clinical practice.

Perioperative oxygen administration in patients undergoing major non-cardiac surgery under general anaesthesia in Australia and New Zealand.

The practice of anaesthetists relating to the administration of intraoperative oxygen has not been previously quantified in Australia and New Zealand. The optimal regimen of intraoperative oxygen administration to patients undergoing surgery under general anaesthesia is not known, and international recommendations for oxygen therapy are contradictory; the World Health Organization (WHO) recommend administering an intraoperative fraction of inspired oxygen of at least 0.8, while the World Federation of Societies of Anaesthesiologists, British Thoracic Society, and Thoracic Society of Australia and New Zealand recommend a more restrictive approach. We conducted a prospective observational study to describe the pattern of intraoperative oxygen administration among anaesthetists in Australia and New Zealand and, second, to determine the proportion of anaesthetists who administer intraoperative inspired oxygen in accordance with the WHO recommendations. We identified 150 anaesthetists from ten metropolitan hospitals in Australia and New Zealand and observed the patterns of intraoperative oxygen administration to American Society of Anesthesiologists physical status classification (ASA) 3 or 4 patients undergoing prolonged surgery under general anaesthesia. The median (interquartile range) intraoperative time-weighted mean fraction of inspired oxygen (FiO2) for all participants in the study was 0.47 (0.40-0.55). Three out of 150 anaesthetists (2%, 95% confidence interval 0.4 to 5.7) administered an average intraoperative FiO2 of at least 0.8. These findings indicate that most anaesthetists routinely administer an intermediate level of oxygen for ASA 3 or 4 adult patients undergoing prolonged surgery in Australia and New Zealand, rather than down-titrating inspired oxygen to a target pulse oximetry reading (SpO2) or administering liberal perioperative oxygen therapy in line with the current WHO recommendation.

Elucidation of the Bovine Intramammary Bacteriome and Resistome from healthy cows of Swiss dairy farms in the Canton Tessin.

Healthy, untreated cows of nine dairy herds from the Swiss Canton Tessin were analyzed three times within one year to identify the most abundant species of the intramammary bacteriome. Aseptically collected milk samples were cultured and bacteria identified using MALDI-TOF. Of 256 cows analyzed, 96% were bacteriologically positive and 80% of the 1,024 quarters were positive for at least one bacterial species. 84.5% of the quarters were healthy with somatic cell counts (SCC) < 200,000 cells/mL, whereas 15.5% of the quarters showed a subclinical mastitis (SCC ≥ 200,000 cells/mL). We could assign 1,288 isolates to 104 different bacterial species including 23 predominant species. Non-aureus staphylococci and mammaliicocci (NASM) were most prevalent (14 different species; 73.5% quarters). Staphylococcus xylosus and Mammaliicoccus sciuri accounted for 74.7% of all NASM isolates. To describe the intramammary resistome, 350 isolates of the predominant species were selected and subjected to short-read whole genome sequencing (WGS) and phenotypic antibiotic resistance profiling. While complete genomes of eight type strains were available, the remaining 15 were de novo assembled with long reads as a resource for the community. The 23 complete genomes served for reference-based assembly of the Illumina WGS data. Both chromosomes and mobile genetic elements were examined for antibiotic resistance genes (ARGs) using in-house and online software tools. ARGs were then correlated with phenotypic antibiotic resistance data from minimum inhibitory concentration (MIC). Phenotypic and genomic antimicrobial resistance was isolate-specific. Resistance to clindamycin and oxacillin was most frequently observed (65 and 30%) in Staphylococcus xylosus but could not be linked to chromosomal or plasmid-borne ARGs. However, in several cases, the observed antimicrobial resistance could be explained by the presence of mobile genetic elements like tetK carried on small plasmids. This represents a possible mechanism of transfer between non-pathogenic bacteria and pathogens of the mammary gland within and between herds. The-to our knowledge-most extensive bacteriome reported and the first attempt to link it with the resistome promise to profoundly affect veterinary bacteriology in the future and are highly relevant in a One Health context, in particular for mastitis, the treatment of which still heavily relies on antibiotics.

Next generation biosecurity: Towards genome based identification to prevent spread of agronomic pests and pathogens using nanopore sequencing.

The unintentional movement of agronomic pests and pathogens is steadily increasing due to the intensification of global trade. Being able to identify accurately and rapidly early stages of an invasion is critical for developing successful eradication or management strategies. For most invasive organisms, molecular diagnostics is today the method of choice for species identification. However, the currently implemented tools are often developed for certain taxa and need to be adapted for new species, making them ill-suited to cope with the current constant increase in new invasive species. To alleviate this impediment, we developed a fast and accurate sequencing tool allowing to modularly obtain genetic information at different taxonomical levels. Using whole genome amplification (WGA) followed by Oxford nanopore MinION sequencing, our workflow does not require any a priori knowledge on the investigated species and its classification. While mainly focusing on harmful plant pathogenic insects, we also demonstrate the suitability of our workflow for the molecular identification of bacteria (Erwinia amylovora and Escherichia coli), fungi (Cladosporium herbarum, Colletotrichum salicis, Neofabraea alba) and nematodes (Globodera rostochiensis). On average, the pairwise identity between the generated consensus sequences and best GenBank BLAST matches was 99.6 ± 0.6%. Additionally, assessing the generated insect genomic dataset, the potential power of the workflow to detect pesticide resistance genes, as well as arthropod-infecting viruses and endosymbiotic bacteria is demonstrated.

Semi-classical Monte Carlo algorithm for the simulation of X-ray grating interferometry.

Traditional simulation techniques such as wave optics methods and Monte Carlo (MC) particle transport cannot model both interference and inelastic scattering phenomena within one framework. Based on the rules of quantum mechanics to calculate probabilities, we propose a new semi-classical MC algorithm for efficient and simultaneous modeling of scattering and interference processes. The similarities to MC particle transport allow the implementation as a flexible c++ object oriented extension of EGSnrc-a well-established MC toolkit. In addition to previously proposed Huygens principle based transport through optics components, new variance reduction techniques for the transport through gratings are presented as transport options to achieve the required improvement in speed and memory costs necessary for an efficient exploration (system design-dose estimations) of the medical implementation of X-ray grating interferometry (GI), an emerging imaging technique currently subject of tremendous efforts towards clinical translation. The feasibility of simulation of interference effects is confirmed in four academic cases and an experimental table-top GI setup. Comparison with conventional MC transport show that deposited energy features of EGSnrc are conserved.

Low-Input High-Molecular-Weight DNA Extraction for Long-Read Sequencing From Plants of Diverse Families.

Long-read DNA sequencing technologies require high molecular weight (HMW) DNA of adequate purity and integrity, which can be difficult to isolate from plant material. Plant leaves usually contain high levels of carbohydrates and secondary metabolites that can impact DNA purity, affecting downstream applications. Several protocols and kits are available for HMW DNA extraction, but they usually require a high amount of input material and often lead to substantial DNA fragmentation, making sequencing suboptimal in terms of read length and data yield. We here describe a protocol for plant HMW DNA extraction from low input material (0.1 g) which is easy to follow and quick (2.5 h). This method successfully enabled us to extract HMW from four species from different families (Orchidaceae, Poaceae, Brassicaceae, Asteraceae). In the case of recalcitrant species, we show that an additional purification step is sufficient to deliver a clean DNA sample. We demonstrate the suitability of our protocol for long-read sequencing on the Oxford Nanopore Technologies PromethION® platform, with and without the use of a short fragment depletion kit.

Genome sequence data of the antagonistic soil-borne yeast Cyberlindnera sargentensis (SHA 17.2).

Cyberlindnera sargentensis strain SHA 17.2, isolated from a Swiss soil sample, exhibited strong antagonistic activity against several plant pathogenic fungi in vitro and was highly competitive against other yeasts in soil. As a basis for identifying the mechanisms underlying its strong antagonistic activity, we have sequenced the genome of C. sargentensis (SHA 17.2) by long- and short read sequencing, de novo assembled them into seven contigs/chromosomes and a mitogenome (total genome size 11.4 Mbp), and annotated 5455 genes. This high-quality genome is the reference for transcriptome and proteome analyses aiming at elucidating the mode of action of C. sargentensis against fungal plant pathogens. It will thus serve as a resource for identifying potential biocontrol genes and performing comparative genomics analyses of yeast genomes.

Organ-at-risk sparing with dynamic trajectory radiotherapy for head and neck cancer: comparison with volumetric arc therapy on a publicly available library of cases.

BACKGROUND: Dynamic trajectory radiotherapy (DTRT) extends volumetric modulated arc therapy (VMAT) with dynamic table and collimator rotation during beam-on. The aim of the study is to establish DTRT path-finding strategies, demonstrate deliverability and dosimetric accuracy and compare DTRT to state-of-the-art VMAT for common head and neck (HN) cancer cases. METHODS: A publicly available library of seven HN cases was created on an anthropomorphic phantom with all relevant organs-at-risk (OARs) delineated. DTRT plans were generated with beam incidences minimizing fractional target/OAR volume overlap and compared to VMAT. Deliverability and dosimetric validation was carried out on the phantom. RESULTS: DTRT and VMAT had similar target coverage. For three locoregionally advanced oropharyngeal carcinomas and one adenoid cystic carcinoma, mean dose to the contralateral salivary glands, pharynx and oral cavity was reduced by 2.5, 1.7 and 3.1 Gy respectively on average with DTRT compared to VMAT. For a locally recurrent nasopharyngeal carcinoma, D0.03 cc to the ipsilateral optic nerve was above tolerance (54.0 Gy) for VMAT (54.8 Gy) but within tolerance for DTRT (53.3 Gy). For a laryngeal carcinoma, DTRT resulted in higher dose than VMAT to the pharynx and brachial plexus but lower dose to the upper oesophagus, thyroid gland and contralateral carotid artery. For a single vocal cord irradiation case, DTRT spared most OARs better than VMAT. All plans were delivered successfully on the phantom and dosimetric validation resulted in gamma passing rates of 93.9% and 95.8% (2%/2 mm criteria, 10% dose threshold). CONCLUSIONS: This study provides a proof of principle of DTRT for common HN cases with plans that were deliverable on a C-arm linac with high accuracy. The comparison with VMAT indicates substantial OAR sparing could be achieved.

Monte Carlo implementation, validation, and characterization of a 120 leaf MLC.

PURPOSE: Recently, the new high definition multileaf collimator (HD120 MLC) was commercialized by Varian Medical Systems providing high resolution in the center section of the treatment field. The aim of this work is to investigate the characteristics of the HD120 MLC using Monte Carlo (MC) methods. METHODS: Based on the information of the manufacturer, the HD120 MLC was implemented into the already existing Swiss MC Plan (SMCP). The implementation has been configured by adjusting the physical density and the air gap between adjacent leaves in order to match transmission profile measurements for 6 and 15 MV beams of a Novalis TX. These measurements have been performed in water using gafchromic films and an ionization chamber at an SSD of 95 cm and a depth of 5 cm. The implementation was validated by comparing diamond measured and calculated penumbra values (80%-20%) for different field sizes and water depths. Additionally, measured and calculated dose distributions for a head and neck IMRT case using the DELTA(4) phantom have been compared. The validated HD120 MLC implementation has been used for its physical characterization. For this purpose, phase space (PS) files have been generated below the fully closed multileaf collimator (MLC) of a 40 × 22 cm(2) field size for 6 and 15 MV. The PS files have been analyzed in terms of energy spectra, mean energy, fluence, and energy fluence in the direction perpendicular to the MLC leaves and have been compared with the corresponding data using the well established Varian 80 leaf (MLC80) and Millennium M120 (M120 MLC) MLCs. Additionally, the impact of the tongue and groove design of the MLCs on dose has been characterized. RESULTS: Calculated transmission values for the HD120 MLC are 1.25% and 1.34% in the central part of the field for the 6 and 15 MV beam, respectively. The corresponding ionization chamber measurements result in a transmission of 1.20% and 1.35%. Good agreement has been found for the comparison between transmission profiles resulting from MC simulations and film measurements. The simulated and measured values for the penumbra agreed within <0.5 mm for all field sizes, depths, and beam energies, and a good agreement has been found between the measured and the calculated dose distributions for the IMRT case. The total energy spectra are almost identical for the three MLCs. However, the mean energy, fluence and energy fluence are significantly different. Due to the different leaf widths of the MLCs, the shape of these distributions is different, each representing its leave structure. Due to the increase in width from the inner to the outer HD120 MLC leaves, the fluence and energy fluence clearly decrease below the outer leaves. The MLC80 and the M120 MLC resulted in an increase of the fluence and energy fluence compared with those resulted for the HD120 MLC. The dose reduction can exceed 20% compared with the dose of the open field due to the tongue and groove design of the HD120 MLC. CONCLUSIONS: The HD120 MLC has been successfully implemented into the SMCP. Comparisons between MC calculations and measurements show very good agreement. The SMCP is now able to calculate accurate dose distributions for treatment plans using the HD120 MLC.