Objective:To retrieve, evaluate, and integrate the best evidence for prevention of hemodialysis catheter thrombosis, so as to provide evidence-based basis for catheter thrombosis prevention in hemodialysis patients.Methods:Guidelines, clinical decisions, evidence summaries, systematic reviews, and expert consensus on the prevention of hemodialysis catheter thrombosis were systematically searched on Guidelines International Network, Scottish Intercollegiate Guidelines Network, Agency for Healthcare Research and Quality, Registered Nurses' Association of Ontario, National Institute for Health and Clinical Excellence, UpToDate, British Medical Journal (BMJ) Best Practice, Joanna Briggs Institute Evidence-Based Health Care Center Database, European Renal Association, National Kidney Foundation, UK Kidney Association, Canadian Society of Nephrology, Japanese Society for Dialysis Therapy, Medlive, Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang Data and Chinese Biomedical Database. The search period was from database establishment to March 31, 2023. Investigators conducted quality evaluations separately and extracted and summarized evidence based on the theme.Results:A total of 16 articles were included, including five clinical decisions, four guidelines, two evidence summaries, and five expert consensuses. Finally, 15 best pieces of evidence were formed, including four themes of indwelling dialysis catheters, anticoagulation strategies, flushing and sealing techniques, and daily management.Conclusions:Nursing staff should choose the best evidence for preventing thrombosis in hemodialysis catheters based on clinical situations, reduce the occurrence of catheter thrombosis, extend the usage time of catheters, and improve patient outcomes.

Objective:To analyze the safety of reduced clinical target volume (CTV) irradiation of suspicious positive lymph nodes in IIa region in patients with N 0-N 1 nasopharyngeal carcinoma (NPC) and the protective effect of submandibular gland and long-term resting dry mouth, and to explore the diagnostic value of multimodal imaging for suspicious cervical lymph nodes. Methods:Clinical data of T 0-4N 0-1M 0 stage NPC patients admitted to Jiangsu Cancer Hospital from July 2015 to April 2017 were retrospectively analyzed. Clinical, radiation therapy planning, multimodal imaging and other relevant data were collected. All patients were treated with an optimized regimen of IMRT with a prophylactic radiation dose of 50.4 Gy (named as CTV50) for IIa region. Imaging characteristics and treatment response of suspicious lymph nodes were monitored by MRI, MRI-DWI, PET-CT and repeated enhanced positioning CT, etc. The dosimetry of the submandibular gland between optimized and standard dose plans (CTV50 vs. CTV60) was compared by paired t-test. The long-term dry mouth degree of the patients was evaluated using advanced radiation injury from Radiation Therapy Oncology Group (RTOG), Jiangsu Cancer Hospital Multi-dimensional Dry Mouth Evaluation Scale and summated xerostomia inventory (SXI). The difference of dry mouth degree was analyzed by rank-sum test. Results:A total of 106 patients were included in this study, including 149 cervical lymph node negative sides, 73 sides of which had ≤3 recognizable lymph nodes, and 76 of which were>3 in Ⅱa region. Among patients with N 1 stage, 63 patients underwent contralateral single neck area optimization, and 43 patients (N 0 stage and N 1 stage patients with retropharyngeal lymph node metastasis) underwent double-neck area optimization. A total of 109 suspicious lymph nodes with a short diameter of >5 mm were found on the largest cross section, of which 105 had clear portal structure. The ratio of long to short diameter was ≥1.5 in 93 cases, and the maximum standardized uptake value (SUV max) in PET-CT was ≥2.5 in 76 cases. No lymph node recurrence was found in the CTV optimized area. There was no significant difference in the average dose of GTV in tumor target area after optimization ( P>0.05), and the D mean and V 39 Gy in submandibular gland were significantly lower than those in unoptimized plan (both P<0.01). There was no significant difference in long-term dry mouth and resting dry mouth between patients with unilateral and bilateral optimization of submandibular gland (both P>0.05). Conclusions:The optimal program of CTV50 reduction irradiation in Ⅱa area of N 0-N 1 NPC patients is safe and effective. The submandibular gland has obvious dosimetric advantages, and patients have a good subjective response to resting dry mouth. The multimodal imaging tools such as enhanced CT, MRI-DWI and PET-CT should be performed to deliver individual evaluation and treatment for suspicious lymph nodes.

Objective:To investigate the treatment strategy and prognostic factors of nasopharyngeal necrosis after the first radical radiotherapy for nasopharyngeal carcinoma.Methods:Clinical data of 1020 patients with nasopharyngeal carcinoma undergoing radical intensity-modulated radiotherapy in Jiangsu Cancer Hospital from January 2013 to January 2022 were retrospectively analyzed. Nasopharyngeal necrosis was confirmed by nasopharyngeal MRI, electronic nasopharyngoscopy and biopsy. Patients with nasopharyngeal necrosis were treated with electronic nasopharyngoscope irrigation debridement, combined with systemic anti-infection and nutritional support therapy. Kaplan-Meier method was used to calculate the survival, and Cox regression analysis was used to analyze the relationship between clinical factors and patients' survival.Results:Nasopharyngeal necrosis occurred in 20 cases of 1020 nasopharyngeal carcinoma patients after the first radical intensity-modulated radiotherapy, with an incidence rate of 1.96%. Odd smell and headache were common in nasopharyngeal necrosis patients. All patients had locally advanced nasopharyngeal carcinoma at initial treatment, including 2 (10%) cases of T 3 stage and 18 (90%) cases of T 4 stage. Nasopharyngeal necrosis occurred in the primary nasopharyngeal lesions. According to the stages of nasopharyngeal necrosis, there were 6 (30%) cases of stage I, 14 (70%) cases of stage II and no stage III. The occurrence time of nasopharyngeal necrosis was from 2 to 24 months after radiotherapy, and the median time was 5 months. All 16 cases of nasopharyngeal necrosis were cured clinically after debridement and irrigation under nasopharyngoscope, systemic anti-infection and symptomatic support treatment. Among them, 9 cases had no necrotic cavity and complete healing and 7 cases had residual necrotic cavity. Four patients died of massive nasopharyngeal hemorrhage or due to the inability to nasopharyngeal irrigation. The 5-year survival rates were 37.5% and 85.7% in patients with and without internal carotid artery involvement ( P=0.008), and 25.0% and 77.8% in patients with and without diabetes mellitus ( P=0.016). Univariate Cox regression analysis showed that necrotic lesions involving internal carotid artery ( HR=5.80, 95% CI=1.14-29.38, P=0.034) and diabetes mellitus ( HR=10.24, 95% CI=1.19-88.04, P=0.034) were the influencing factors of overall survival. Conclusions:Nasopharyngoscope irrigation debridement combined with anti-inflammation and nutritional support treatment are effective interventions for nasopharyngeal necrosis after the first radical intensity-modulated radiotherapy in patients with nasopharyngeal carcinoma. The necrosis involving the internal carotid artery and diabetes mellitus are important factors affecting the survival of patients. Vascular invasion caused by vascular rupture is the main cause of death.

Objective:To investigate the feasibility of individualized primary clinical target volume (CTV) delineation in intensity-modulated radiotherapy for nasopharyngeal carcinoma (NPC).Methods:Clinical data of 87 consecutive patients newly diagnosed with lateralized NPC in Jiangsu Cancer Hospital between October 2016 and February 2018 were retrospectively analyzed. Lateralized NPC is defined as tumor invasion not exceeding the contralateral wall. According to the tumor spread, the primary CTV was optimized as follows: CTV2 only covered the medial part of the contralateral pterygopalatine fossa, whereas the contralateral foramen oval was not included; on the level of parapharyngeal space, the contralateral side of CTV only covered the posterior lateral lymph nodes, whereas the contralateral internal jugular vein was not regularly covered. Failure patterns and 5-year survival [local control rate (LCR), progression-free survival (PFS) and overall survival (OS)] were evaluated by Kaplan-Meier method. Paired t-test and rank-sum test were used to analyze the dose variation in the optimized region and adverse reactions. Results:The median follow-up time was 59.5 months. The 5-year LCR, PFS, and OS were 98.9%, 86.5% and 92.1%, respectively. There was no local recurrence in the optimized area of CTV. Dosimetric comparison results showed that the doses of parotid gland, temporal lobe, cochlea and middle ear on the contralateral side were reduced by 13.45%, 9.14%, 38.83%, and 29.36%, respectively. Four cases (4.6%) developed grade 3 hearing loss, all on the ipsilateral side. The optimized scheme significantly alleviated the hearing loss on the contralateral side compared to that on the ipsilateral side ( P<0.001). Other grade 3 late adverse reactions included cranial nerve injury, subcutaneous fibrosis in the neck and visual impairment, with 1 case each. Conclusion:Individualized primary CTV for lateralized NPC is feasible and safe, with obvious dosimetric advantages and reduced adverse reaction rate, which is worthy of clinical promotion.

Objective:To observe the analgesic effect of local anesthesia combined with nerve block anesthesia on golden microneedles for improving facial aging.Methods:Between December 2018 and December 2019 in Burn and Plastic Surgery of Nanchong Central Hospital, sixty female patients (between 30 and 58 years old, with an average of 45.2 years old) with natural facial skin aging were randomly divided into two groups: Group A: surface anesthesia group (30 cases); Group B: local anesthesia combined with nerve block anesthesia (30 cases). Intraoperative and postoperative pain scores, length of operation, and incidence of adverse reactions were compared between groups A and B.Results:Pain score during surgery was (6.90±0.96) points in Group A, (3.63±0.72) points in Group B. The difference between the two groups was statistically significant ( t=14.93, P<0.05); Pain score at 30 minutes after operation was (2.03±0.62) in Group A, (0.77±0.73) in Group B, the difference between the two groups was statistically significant ( t=7.28, P<0.05). There was no statistically significant difference between the two groups in the pain score at 24 hours after operation ( P>0.05); The operation process in group B was simplified, and the treatment time was significantly shortened. The difference between the two groups was statistically significant ( t=17.93, P<0.05). Conclusions:The method of local anesthesia combined with nerve block anesthesia is used in the treatment of gold microneedles to improve the analgesic effect in facial aging, which significantly shortens the treatment time and has fewer adverse reactions. This method is worth popularizing.

Objective:To summarize the clinical characteristics, imaging features, diagnosis, treatment and prognosis of pulmonary actinomycosis in children.Methods:The clinical data of a child with pulmonary actinomycosis who was hospitalized in Children′s Hospital, Zhejiang University School of Medicine in December 2019 was retrospectively analyzed. The related literature published from January 1975 to January 2020 was retrieved from Wanfang, CNKI and PubMed databases with "pulmonary" or "thoracic" and "actinomycosis" and "pediatric" or "children" or "child" as the keywords. And the characteristics of pediatric pulmonary actinomycosis were summarized based on the literature review.Results:The patient was a boy aged 12 years and 6 months. He was admitted due to cough and chest pain for more than 20 days, with fever on the first three days. The chest CT scan in local hospital found inflammatory lesions in the right middle lobe, which was also suspected to be cavitation. The flexible bronchoscopy showed congestion and edema of bronchial mucosa in the right middle lobe, and bronchoalveolar lavage fluid smear was positive for acid-fast bacilli DNA, although both purfied protein derivatives tuberculin test and T-spot were negative. During the hospitalization, the child had persistent cough and chest pain, but no fever. Pathogen metagene sequencing of the bronchoalveolar lavage fluid detected Actinomyces (sequence number: 222) and Grevini Actinomycetes (sequence number: 185). The boy received intravenous cefoperazone sulbactam sodium for 2 weeks followed by oral amoxicillin clavulanate potassium for 6 weeks. Until April 2020, his clinical symptoms completely relieved, and the pulmonary lesions were significantly absorbed on the latest chest CT scan. Eight articles and 62 children with pulmonary actinomycosis were reported, but no related reports were retrieved from CNKI and Wanfang databases. The youngest case was 27 months old. The clinical presentations of this disease were nonspecific. The main symptoms included chest wall masses (8 cases), cough (23 cases), pain (chest, back, shoulders and armpits) (24 cases), fever (25 cases), weight loss (26 cases), etc.Conclusions:The clinical manifestations and imaging features of pediatric pulmonary actinomycosis are nonspecific, therefore it could easily be misdiagnosed. For children with pneumonia of unknown etiology and failing to respond to routine antibiotics, the pathogen metagene sequencing of the bronchoalveolar lavage fluid will be helpful for diagnosis. With appropriate course of antibiotic treatment, the prognosis is good in most cases.

Objective To explore the clinical value of magnetic resonance diffusion-weighted imaging ( MR-DWI ) in the early diagnosis of cervical lymph node recurrence after radiotherapy of nasopharyngeal carcinoma, aiming to provide reference for targeted diagnosis and treatment of these patients. Methods The MR-DWI features of 17 patients with recurrent cervical lymph nodes after radiotherapy from 2005 to 2016 were retrospectively analyzed. The results of diagnosis and treatment after lymph node recurrence were summarized. Results The recurrent lymph nodes of 17 patients showed a high signal or mixed signal on MR-DWI images. The sensitivity of MR-DWI and T2WI fat suppression sequence was 100% and 60%. Positron emission tomography-computed tomography ( PET-CT) or biopsy was performed to validate the diagnosis in patients with highly suspected single cervical recurrence. Besides, surgical treatment yielded better clinical prognosis. Conclusions MR-DWI is highly sensitive to recurrent cervical lymph nodes of nasopharyngeal carcinoma after radiotherapy, especially for the small lymph nodes of 5-10 mm in diameter, which are easily ignored. PET-CT examination should be performed, the nature of the lymph nodes should be confirmed by multi-modality imaging diagnosis, and timely operation has important clinical significance in improving the therapeutic effect and quality of life for patients with cervical lymphnode recurrence.

Objective: To investigate the high-risk factors for parotid lymph node (PLN) metastasis from nasopharyngeal carcinoma (NPC) and evaluate the feasibility of local intensity-modulated radiotherapy (IMRT) in patients with high-risk NPC. Methods: Clinical data of 440 NPC patients admitted to Department of Radiotherapy of Jiangsu Cancer Hospital from May, 2011 to March, 2017 were collected. The imaging features, treatment strategies and clinical prognosis of PLN metastasis were retrospectively analyzed. The whole group adopts the technique of intensity modulated radiotherapy. Total parotid or partial parotid irradiation, selective PLN irradiation, X-Ray and/or electronic line supplementation, dose 45-60 Gy. The χ² test or Fisher′s accurate probability method test and single factor analysis, Logistic regression model multi-factor analysis. Kaplan-Meier survival analysis, log-rank test differences. Results: PLN was observed in the parotid of 230 cases. At the end of follow-up, 11 patients (2.5%, 11/440) were diagnosed with PLN metastases. Among 11 cases, 9 patients (81.8%) had PLN size ≥5 mm. Multivariate analysis demonstrated that extracapsular spread of level Ⅱ was an independent risk factor for PLN metastasis. The patients with PLN size ≥5 mm or extracapsular spread of level Ⅱ were assigned into the high-risk PLN metastasis group. The patients in the high-risk group were further divided into the radiotherapy and non-radiotherapy subgroups. Survival analysis demonstrated that for 230 patients with PLN metastasis, the local recurrence-free survival (LRFS) significantly differed, whereas the overall survival (OS), disease metastasis-free survival (DMFS) and progression-free survival (PFS) did not considerably differ between the radiotherapy and non-radiotherapy subgroups in the high-risk PLN metastasis patients. Conclusions The PLN metastasis rate of NPC is low. Extracapsular spread of level Ⅱ is an independent risk factor. Radiotherapy of the parotid region is considered for patients with PLN size≥5 mm or those with PLN size<5 mm complicated with extracapsular spread of level Ⅱ.

Objective To clarify the diagnostic value of diffusion-weighed imaging ( DWI) in the medial group of retropharyngeal lymph nodes in nasopharyngeal carcinoma, understand the clinical characteristics of retropharyngeal lymph nodes and explore the feasibility of optimizing the target volume of CT V60. Methods Clinical data of 437 patients with clinical stage Ⅰ-IVa nasopharyngeal carcinoma admitted to Jiangsu Cancer Hospital from 2011 to 2017 were retrospectively analyzed. All patients underwent magnetic resonance imaging (MRI),DWI (1 000 s/mm2) and enhanced CT scans to analyze the clinical characteristics of retropharyngeal lymph nodes and investigate the dosimetric advantage and safety of CT V60 lower margin on the upper margin of C2. Results The medial lymph nodes with a transverse diameter of 2. 0-19. 0 mm were detected 13 of 437 patients,and 53. 8% of the lymph nodes were measured 2-5 mm in transverse diameter. The medial lymph nodes were distributed between the superior margin of C1and 1/3 of C3.Its occurrence was related to N stage,double cervical lymph node metastases,especially the transverse diameter of cervical lymph node＞ 3 cm.The sensitivity of DWI,T2and enhanced CT were 100%,61. 5% and 23. 1%.After the special cases were excluded,the lower margin of CT V60on the superior margin of C2was separated. The radiation dose and volume of the swallowing structures were significantly decreased. The 5-year survival rate was 80% without recurrence in the optimized region. Conclusions The incidence of the medial group of retropharyngeal lymph nodes is low with a diameter of less than 5 mm. DWI possesses advantages in displaying the medial group of retropharyngeal lymph nodes. Isolating the lower margin of CT V60from the superior margin of C2is safe and feasible and has dosimetric advantages for protecting swallowing structure.

Objective To investigate the relationship between the incidence of radiation-induced brain stem injury after intensity-modulated radiotherapy (IMRT) and the radiation dose volume in patients with nasopharyngeal carcinoma.Methods A retrospective analysis was performed on the data of 258 patients newly diagnosed with nasopharyngeal carcinoma who received IMRT in our group from 2005 to 2013.The radiation dose per unit volume of brain stem was analyzed.The relationship between the incidence of brain stem injury induced by IMRT and the radiation dose volume was studied.The survival rate was calculated using the Kaplan-Meier method.The factors influencing the radiation-induced brain stem injury were analyzed using the Cox regression model.Results Two patients with stage T3 disease and three patients with T4 disease had radiation-induced brain stem injury.The 3-and 5-year injury incidence rates were 1.6％ and 2.4％,respectively.The latency ranged between 9 and 58 months,with a median latency of 19 months.The median D1％ and Dmax for the brain stem were 54.24 and 59.22 Gy in all patients,54.31 and 59.45 Gy in patients with stage T3 disease,and 61.29 and 66.37 Gy in patients with stage T4 disease,respectively.In the five patients with brain stem injury,the D1％ and Dmax were larger than 60 and 63 Gy,respectively.The univariate analysis showed that the incidence of radiation-induced brain stem injury was correlated with D1％,Dmax,D0.1 cm3,D0.5 cm3,and D1.0 cm3 (all P=0.01).The incidence of radiation-induced brain stem injury was significantly lower in patients with D1％,Dmax,D0.1 cm3,D0.5 cm3,and D1.0 cm3 no larger than 60,63,60,58,and 56 Gy,respectively (all P =0.00).Conclusions The incidence of radiation-induced brain stem injury after IMRT is relatively low in patients with nasopharyngeal carcinoma.Strict control of the dose to the brain stem may help to reduce the incidence of brain stem injury and improve the long-term quality of life.