SSRMP Recommendations No 9: Reference dosimetry in low and medium energy x-ray beams.

The SSRMP recommendations on reference dosimetry in kilovolt beams as used in radiation therapy were revised to establish current practice in Switzerland. The recommendations specify the dosimetry formalism, reference class dosimeter systems and conditions used for the calibration of low and medium energy x-ray beams. Practical guidance is provided on the determination of the beam quality specifier and all corrections required for converting instrument readings to absorbed dose to water. Guidance is also provided on the determination of relative dose under non-reference conditions and on the cross calibration of instruments. The effect of lack of electron equilibrium and influence of contaminant electrons when using thin window plane parallel chambers at x-ray tube potentials higher than 50kV is elaborated in an appendix. In Switzerland the calibration of the reference system used for dosimetry is regulated by law. METAS and IRA are the authorities providing this calibration service to the radiotherapy departments. The last appendix of these recommendations summarise this calibration chain.

Low dose radiation therapy for severe COVID-19 pneumonia: a randomized double-blind study.

PURPOSE: The morbidity and mortality of patients requiring mechanical ventilation for coronavirus disease 2019 (COVID-19) pneumonia is considerable. We studied the use of whole-lung low dose radiation therapy (LDRT) in this patient cohort. METHODS AND MATERIALS: Patients admitted to the intensive care unit (ICU) and requiring mechanical ventilation for COVID-19 pneumonia were included in this randomized double-blind study. Patients were randomized to 1 Gy whole-lung LDRT or sham irradiation (sham-RT). Treatment group allocation was concealed from patients and ICU clinicians, who treated patients according to the current standard of care. Patients were followed for the primary endpoint of ventilator-free days (VFDs) at day 15 post-intervention. Secondary endpoints included overall survival, as well as changes in oxygenation and inflammatory markers. RESULTS: Twenty-two patients were randomized to either whole-lung LDRT or sham-RT between November and December 2020. Patients were generally elderly and comorbid, with a median age of 75 years in both arms. No difference in 15-day VFDs was observed between groups (p = 1.00), with a median of 0 days (range, 0-9) in the LDRT arm, and 0 days (range, 0-13) in the sham-RT arm. Overall survival at 28 days was identical at 63.6% (95%CI, 40.7-99.5%) in both arms (p = 0.69). Apart from a more pronounced reduction in lymphocyte counts following LDRT (p < 0.01), analyses of secondary endpoints revealed no significant differences between the groups. CONCLUSIONS: Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

Low-Dose Radiation Therapy for Severe COVID-19 Pneumonia: A Randomized Double-Blind Study.

PURPOSE: The morbidity and mortality of patients requiring mechanical ventilation for coronavirus disease 2019 (COVID-19) pneumonia is considerable. We studied the use of whole-lung low-dose radiation therapy (LDRT) in this patient cohort. METHODS AND MATERIALS: Patients admitted to the intensive care unit and requiring mechanical ventilation for COVID-19 pneumonia were included in this randomized double-blind study. Patients were randomized to 1 Gy whole-lung LDRT or sham irradiation (sham-RT). Treatment group allocation was concealed from patients and intensive care unit clinicians, who treated patients according to the current standard of care. Patients were followed for the primary endpoint of ventilator-free days at day 15 postintervention. Secondary endpoints included overall survival, as well as changes in oxygenation and inflammatory markers. RESULTS: Twenty-two patients were randomized to either whole-lung LDRT or sham-RT between November and December 2020. Patients were generally elderly and comorbid, with a median age of 75 years in both arms. No difference in 15-day ventilator-free days was observed between groups (P = 1.00), with a median of 0 days (range, 0-9) in the LDRT arm and 0 days (range, 0-13) in the sham-RT arm. Overall survival at 28 days was identical at 63.6% (95% confidence interval, 40.7%-99.5%) in both arms (P = .69). Apart from a more pronounced reduction in lymphocyte counts after LDRT (P < .01), analyses of secondary endpoints revealed no significant differences between the groups. CONCLUSIONS: Whole-lung LDRT failed to improve clinical outcomes in critically ill patients requiring mechanical ventilation for COVID-19 pneumonia.

Technical Note: Alternating clinical usage of the integral quality monitor transmission detector.

PURPOSE: The purpose of the study was the implementation of a method to use the integral quality monitor (IQM) transmission detector for occasional, alternating usage during patient treatment with intensity modulated radiotherapy. Due to attenuation, the transmission detector must be taken into account during the planning process. The proposed workflow is based on determining a dynamic transmission factor (dTF) required to scale the total number of MU of the original radiotherapy (RT) plan. Thus a very similar radiation therapy plan is obtained that can be used with the IQM detector. METHODS: Ten clinically applied volumetric modulated arc therapy plans were delivered at two beam qualities. A dTF is calculated from each RT plan for which a collapsed RT plan was created for verification using a two-dimensional array with and without the IQM detector. The total number of MU of the original RT plan was scaled by the inverse of the dTF to obtain the modified RT plan for clinical use with the IQM detector. Validation was performed with an electronic three-dimensional phantom and via gamma analysis using strict criteria of 1%/1 mm. RESULTS: Except for one outlier, the gamma pass rate between the original RT plan without IQM and the modified RT plan with IQM was always above 99.5%. The variations of the dTF were smaller than 1% for all tested RT plans. CONCLUSIONS: The results show that the proposed workflow can be used clinically. Thus the IQM transmission detector can also be used occasionally for online verification of RT plans.

Use of EORTC target definition guidelines for dose-intensified salvage radiation therapy for recurrent prostate cancer: results of the quality assurance program of the randomized trial SAKK 09/10.

PURPOSE: Different international target volume delineation guidelines exist and different treatment techniques are available for salvage radiation therapy (RT) for recurrent prostate cancer, but less is known regarding their respective applicability in clinical practice. METHODS AND MATERIALS: A randomized phase III trial testing 64 Gy vs 70 Gy salvage RT was accompanied by an intense quality assurance program including a site-specific and study-specific questionnaire and a dummy run (DR). Target volume delineation was performed according to the European Organisation for the Research and Treatment of Cancer guidelines, and a DR-based treatment plan was established for 70 Gy. Major and minor protocol deviations were noted, interobserver agreement of delineated target contours was assessed, and dose-volume histogram (DVH) parameters of different treatment techniques were compared. RESULTS: Thirty European centers participated, 43% of which were using 3-dimensional conformal RT (3D-CRT), with the remaining centers using intensity modulated RT (IMRT) or volumetric modulated arc technique (VMAT). The first submitted version of the DR contained major deviations in 21 of 30 (70%) centers, mostly caused by inappropriately defined or lack of prostate bed (PB). All but 5 centers completed the DR successfully with their second submitted version. The interobserver agreement of the PB was moderate and was improved by the DR review, as indicated by an increased κ value (0.59 vs 0.55), mean sensitivity (0.64 vs 0.58), volume of total agreement (3.9 vs 3.3 cm(3)), and decrease in the union volume (79.3 vs 84.2 cm(3)). Rectal and bladder wall DVH parameters of IMRT and VMAT vs 3D-CRT plans were not significantly different. CONCLUSIONS: The interobserver agreement of PB delineation was moderate but was improved by the DR. Major deviations could be identified for the majority of centers. The DR has improved the acquaintance of the participating centers with the trial protocol.

Pacing Strategy and Change in Body Composition during a Deca Iron Triathlon.

We investigated the timeline of performances in the three races of the 'World Challenge Deca Iron Triathlon', held in 2006, 2007 and 2009, where the athletes completed one Ironman triathlon daily on 10 consecutive days. The association of anthropometric characteristics such as body fat estimated using bioelectrical impedance analysis and previous experience in ultra-triathlon with race time was investigated using multiple linear regression analysis. Forty-nine athletes participated in these three races; 23 (47%) participants completed the race within 8,817 (1,322) min. Day 1 was the fastest with 762 (86) min; the slowest was Day 10 with 943 (167) min (P<0.05). The time per Ironman increased during the race (P<0.05). Body mass and fat mass decreased whereas lean body mass increased (P<0.05). Race time was related to both the number of finished Triple Iron triathlons (P=0.028) and the personal best time in a Triple Iron triathlon (P<0.0001). We concluded that performance in a Deca Iron triathlon decreased throughout the competition, with the fastest race on Day 1 and the slowest on Day 10. The number of finished Triple Iron triathlons and the personal best time in a Triple Iron triathlon, but not anthropometry, were related to race time. To conclude, athletes need to have a high number of previously completed Triple Iron triathlons, as well as a fast personal best time in a Triple Iron triathlon, in order to finish a Deca Iron triathlon successfully.

The effect of 1,000 km nonstop cycling on fat mass and skeletal muscle mass.

We evaluated the change in body mass including fat mass and skeletal muscle mass in one ultracyclist whilst cycling 1,000 km in 48 hours at a constant intensity of ∼48% VO(2)max, corresponding to a heart rate frequency of ∼105 ± 5 bpm. A 1 kg fat mass decrease resulted, with the largest decrease occurring between the 12th and the 24th hour. No steady state in metabolism was observed and no regular decrease of subcutaneous adipose tissue resulted. This result is backed up by the nuclear magnetic resonance (NMR) urine analysis. Body water increase with simultaneous dehydration is possibly due to endocrine-induced renal water retention, in order to maintain metabolism processes that are required for energy supply and blood flow during very prolonged exercise. Both applied methods, the anthropometric and the bioelectrical impedance analysis, analyse fluid accumulation--especially in the skinfolds of the lower extremities--apparently incorrectly as an increase in body mass and not as an increase in fluids.

Prevalence of exercise-associated hyponatremia in male ultraendurance athletes.

OBJECTIVE: The prevalence of exercise-associated hyponatremia (EAH) has mainly been investigated in marathoners and Ironman triathletes. The aim of this study was to investigate the prevalence of EAH in male ultraendurance athletes in other disciplines, such as ultraswimming, ultracycling, and ultramarathon running. DESIGN: Observational field study. SETTING: "Marathon Swim" in Lake Zurich, the "Swiss Cycling Marathon," the "Swiss Bike Masters," the "100-km Lauf Biel," and the "Swiss Jura Marathon." PARTICIPANTS: Fifteen ultraswimmers, 28 ultra-road cyclists, 37 ultra-mountain bikers, 95 ultramarathoners, and 25 mountain ultramarathoners. MAIN OUTCOME MEASURES: Changes in body mass, plasma sodium, urinary specific gravity, and hematocrit were measured. The athletes recorded their intake of fluids. RESULTS: Two swimmers (13%), 3 road cyclists (10.7%), no mountain bikers (0%), 5 ultramarathoners (5%), and 2 mountain ultramarathoners (8%) developed EAH. In the mountain bikers (r = -0.41) and the 100-km ultramarathoners (r = -0.52), fluid intake was significantly and negatively related to race time. In the mountain ultramarathoners, fluid consumption increased during the race. CONCLUSIONS: The prevalence of EAH was no higher in ultraendurance athletes compared with existing reports on marathoners and Ironman triathletes. Of the 200 investigated ultraendurance athletes, 12 finishers (6%) developed EAH.

Study of a European male champion in 10-km road races in the age group >85 years.

An 86-year-old man became a double champion in the European championship for road running in 2009. He won the 10-km road run with a time of 58:01 minutes, setting a new European record for men aged 85 and older. Two days later, he became a European champion in the same age group for the half-marathon, with a time of 2:17 hours. He started his running career at the age of 64 years and has trained for about an hour three times a week every year since. During these 22 years, he has performed several road runs each year, ranging from 2.5 to 10 km, and also completed a number of half-marathons. Although his running speeds had progressively slowed since the age of 64, there was an increased rate of decline at the age of 82. This man's outstanding performance should encourage other master runners to continue running and competing past the age of 85.

An ironman triathlon does not lead to a change in body mass in female triathletes.

In 16 female nonprofessional Ironman triathletes, body mass, percent body fat, and skeletal muscle mass were determined before and after an Ironman race in order to detect changes. Selected hematological and urinary variables as well as percent total body water were measured in order to quantify a change in hydration status. Body mass, skeletal muscle mass, percent body fat, and percent body water did not change (p > 0.05). Plasma volume increased significantly by 8.1 (13.7) % (p < 0.05). The significant increase in plasma volume, plasma urea concentration, and urinary specific gravity after the race was associated with a significant fall in hematocrit and plasma sodium concentration (p < 0.05). In contrast to studies of male Ironman triathletes, we could not detect a decrease in body mass in female Ironman triathletes. The statistically insignificant loss of 0.6 kg in body mass was smaller than reported in studies of male athletes.

The energetically optimal cadence decreases after prolonged cycling exercise.

This study investigated the change in the energetically optimal cadence after prolonged cycling. The energetically optimal cadence (EOC) was determined in 14 experienced cyclists by pulmonary gas exchange at six different cadences (100-50 rpm at 10 rpm intervals). The determination of the EOC was repeated after a prolonged cycling exercise of 55 min duration, where cadence was fixed either at high (>95 rpm) or low (<55 rpm) pedalling rates. The EOC decreased after prolonged cycling exercise at a high as well as at a low fixed cadence (P < 0.01). According to the generalized muscle equations of Hill, this indicates that most likely more type I muscle fibres contribute to muscular power output after fatiguing cycling exercise compared to cycling in the beginning of an exercise bout. We suggest that the determination of EOC might be a potential non-invasive method to detect the qualitative changes in activated muscle fibres, which needs further investigation.

Body mass and circumference of upper arm are associated with race performance in ultraendurance runners in a multistage race--the Isarrun 2006.

In the present study, we investigated the association of anthropometric parameters with race performance in ultraendurance runners in a multistage ultraendurance run, in which athletes had to run 338 km within 5 consectitive days. In 17 male successful finishers, calculations of body mass, body height, skinfold thicknesses, extremity circumference, skeletal muscle mass (SM), and percentage body fat (%BF) were performed before the race to correlate anthropometric parameters with race performance. A positive association was shown between total running time and both body mass (r2 = .29, p < .05) and upper arm circumference (r = .23, p < .05). In contrast, body height, skinfold thicknesses, extremity circumference, SM, and %BF showed no association with race performance (p > .05). We concluded that in a multistage ultraendurance run, body mass and upper arm circumference were nega tively associated with race performance in well experienced ultraendurance runners. In contrast, body height, skinfold thicknesses, circumferences of the other extremities, SM, and %BF showed no association with race performance.

Body composition, energy, and fluid turnover in a five-day multistage ultratriathlon: a case study.

A multistage ultraendurance triathlon over five times the Ironman distance within five consecutive days leads in one ultraendurance triathlete to minimal changes in body mass (BM; -0.3 kg), fat mass (FM; -1.9 kg), skeletal muscle mass (SM; no change), and total body water (TBW; +1.5 l). This might be explained by the continuously slower race times throughout the race every day and the positive energy balance (8,095 kcal), although he suffered an average energy deficit of -1,848 kcal per Ironman distance. The increase of TBW might be explained by the increase of plasma volume (PV) in the first 3 days. The increase of PV and TBW could be a result of an increase of sodium, which was increased after every stage. We presume that this could be the result of an increased activity of aldosterone.

No change of body mass, fat mass, and skeletal muscle mass in ultraendurance swimmers after 12 hours of swimming.

We evaluated whether ultraendurance swimmers suffer a change of body mass, fat mass, skeletal muscle mass, total body water and specific gravity of urine during a 12-hr swim in 12 male Caucasian ultraswimmers. Proton nuclear magnetic resonance of urine samples before and after the race was performed to detect alanine, lactate, and 3-hydroxybutyrate. The 12 swimmers achieved an average distance of 29.4 km (SD = 5.1). No statistically significant changes in body mass, fat mass, skeletal muscle mass, and total body water could be determined (p > .05), but urine gravity decreased significantly (p < .001). Two participants showed increased signals of ketone bodies after the race. In these samples, the hydroxybutyrate-creatinine ratio increased more than tenfold.

The effects of running 1,200 km within 17 days on body composition in a female ultrarunner-Deutschlandlauf 2007.

We describe the changes of body composition in the female overall winner of the Deutschlandlauf 2007 over 17 stages from the northeast to the southwest of Germany with average daily running stages of 70.9 km to cover the total distance of 1,200 km. Determined by bioelectrical impedance analysis, body mass (BM) increased, percent body fat (% BF) decreased, and percent body water as well as lean body mass (LBM) increased. Skeletal muscle mass and % BF as determined by an anthropometric method showed no changes. This data show, that this female runner achieved an excellent performance and that it is possible for a woman to beat all the men. This type of analysis provides a unique opportunity to gain insight into the physiological changes during multiday running in ultraendurance athletes.

Vitamins, minerals and race performance in ultra-endurance runners--Deutschlandlauf 2006.

We investigated the effect of pre-race intake of vitamins and minerals, in the form of supplementation, before a multi-stage ultra-endurance run and their effect on race performance. At the Deutschlandlauf 2006 in Germany, where athletes had to run across Germany from the north (Kap Arkona-Rügen) to the south (Lörrach) over 1,200 km within 17 consecutive stages, twenty male ultra runners (46.2+/-9.6 years, 71.8+/-5.2 kg, 179+/-6 cm, BMI 22.5+/-1.9 kg/m2) completed a questionnaire about their intake of vitamin and mineral supplements in the four weeks before the race. Race performance of athletes with- and athletes without regular intake of these supplements were compared. In the four weeks before the run, nine runners (45%) ingested vitamin- and twelve athletes (60%) mineral supplements. Athletes with an intake of vitamins (152.8+/-14.1 h versus 160.6+/-14.6 h, p>0.05) and minerals (151.6+/-14.5 h versus 165.3+/-10.8 h, p>0.05) finished the race no faster than athletes without an intake of vitamins and minerals. We concluded that in the Deutschlandlauf 2006 of over 1,200 km within 17 consecutive stages, athletes with a regular intake of vitamin and mineral supplements in the four weeks before the race finished the competition no faster than athletes without an intake of vitamins and minerals.

An ultratriathlon leads to a decrease of body fat and skeletal muscle mass--the Triple Iron Triathlon Austria 2006.

We investigated the effects on body composition in triathletes at the Triple Iron Triathlon Austria in 2006, where athletes had to perform 11.6 km swimming, 540 km cycling, and 126.6 km running within 58 h. In 16 male triathletes, body mass (BM), skinfold thicknesses, and circumferences of extremities were measured before and after the competition in order to calculate body mass index (BMI), percent body fat (%BF), fat mass (FM), and skeletal muscle mass (SM). Body mass, BMI, %BF, FM, and SM decreased statistically significantly (p < 0.01). The loss of BM is associated neither with the decrease of %BF (p > 0.05, r(2)= 0.00) nor with the decrease of SM (p> 0.05, r(2)= 0.06). There is no association between total race time and the loss of BM (r(2) = 0.06), %BF (r(2) = 0.10), and SM (r2 = 0.11). No significant correlation (p > 0.05, r(2)= 0.43) was found between the initial SM and loss of SM.

No correlation of anthropometry and race performance in ultra-endurance swimmers at a 12-hours-swim.

BACKGROUND: In swimmers, the effects of the anthropometric factors, upper extremity length, hand length and body height, on performance over 100 m have been shown, but no data exist about the influence of anthropometric factors on performance in ultra-endurance swimmers. SUBJECTS AND METHODS: Twelve male Caucasian ultra-swimmers participated in our study at the 9th edition in 2007 of the 12-hours-swim in Zurich, Switzerland. We determined body mass, length of arms and legs, body height, circumferences of extremities, skeletal muscle mass and fat mass in order to correlate with the covered distance and to find an effect on race performance. RESULTS: The 12 swimmers achieved an average distance of 29.4 +/- 5.1 km, varying from 22.8 km to 39.1 km during these 12 hours. There was no correlation between body mass, length of arms and legs, body height, circumferences of extremities, skeletal muscle mass and fat mass to race performance. CONCLUSION: In these 12 male ultra-endurance swimmers no effect of the anthropometric parameters body mass, body height, BMI, circumferences of extremities, length of arms and legs, skeletal muscle mass and fat mass, on performance in a 12-hours-swim has been found.

A Multi-Stage Ultra-Endurance Run over 1,200 KM Leads to a Continuous Accumulation of Total Body Water.

We determined whether ultra-runners in a multi-stage ultra- endurance run lose body mass, fat mass, skeletal muscle mass or total body water in a descriptive field study at the 'Deutschlandlauf' 2007 a 1,200 km run within 17 consecutive days with 10 male non-professional Caucasian ultra-runners (mean ± SD, 43.8 ± 6.2 years, 73.8 ± 6.0 kg body mass, 1.77 ± 0.05 m body height, BMI 23.3 ± 1.8 kg·m(-2)). Body mass, fat mass, skeletal muscle mass, lean body mass and percent total body water were determined using bioelectrical impedance analysis and the anthropometric method before the race and after each stage. In addition, urinary specific gravity was measured in order to quantify hydration status. Fat mass (bioelectrical impedance analysis) decreased by 3.9 kg (p < 0.05), skeletal muscle mass (anthropometric method) decreased by 2.0 kg (p < 0.05) whereas percent total body water increased by 6.1 % (p < 0.05) by the end of the race. Ultra-runners in a multi-stage ultra-endurance event over 1,200 km, with 17 consecutive stages, showed a cumulative increase in percent total body water, a decrease in skeletal muscle mass and a decrease in fat mass, depending upon the method used. We presume that the eccentric component of running leads to damage of skeletal muscle, leading to rhabdomyolysis, with impaired renal function. Key pointsUltra-runners in a multi-stage ultra-endurance run over 1,200 km in 17 consecutive stages suffered a decrease in fat mass, skeletal muscle mass and an increase in total body water, whereas overall body mass showed no change.

Simultaneous separation of intracellular and extracellular lactate NMR signals of human erythrocytes.

Intracellular/extracellular lactate (Lac) distribution has been determined before in human and animal erythrocytes (red blood cells [RBCs]) with various methods. However, all previous methods determine intra- and extracellular Lac separately or indirectly. Now, (13)C-NMR spectroscopy has been used to monitor intra- and extracellular Lac simultaneously in intact RBCs. Isolated human RBCs were incubated with [3-(13)C]-Lac, [3-(13)C]-pyruvate (Pyr), and [1-(13)C]-glucose (Gluc). A distortionless enhancement by polarization transfer (DEPT) sequence was used (TR = 3.3 s, N = 128) to monitor the (13)C-NMR resonances in both compartments. The intra- and extracellular methyl group resonances of Lac and Pyr were clearly separated by 9.6 Hz and 7.0 Hz, respectively, under normoxic conditions due to the RBC chemical-shift effect. The results show that the chemical-shift effect of RBCs is convenient to monitor intra- and extracellular Lac simultaneously in intact RBCs under normoxic conditions.