Objective:To analyze the efficacy and safety of nalbuphine for analgesia in patients with non-mechanical ventilation in intensive care unit (ICU).Methods:From December 2018 to August 2021, a multicenter randomized controlled clinical study was conducted to select non-mechanical ventilation patients with analgesic needs admitted to ICU of four hospitals in Henan Province and Guizhou Province. Patients were randomly assigned to nalbuphine group and fentanyl group. The nalbuphine group was given continuous infusion of nalbuphine [0.05~0.20 mg/(kg·h)], and the fentanyl group was given continuous infusion of fentanyl [0.5~2.0 μg/(kg·h)]. The analgesic target was critical-care pain observation tool (CPOT) score<2. The observation time was 48 hours. The primary endpoint was CPOT score, the secondary endpoints were Richmond agitation-sedation score (RASS), ICU length of stay, adverse events, and proportion of mechanical ventilation. The quantitative data of the two groups were compared by t test or Mann-Whitney U test. The enumeration data were compared by chi square test or Fisher exact probability method. The data at different time points between groups were compared by repeated measures analysis of variance. Results:A total of 210 patients were enrolled, including 105 patients in the nalbuphine group and 105 patients in the fentanyl group. There was no significant difference in baseline data between the two groups (all P>0.05). There was no significant difference in CPOT score between nalbuphine group and fentanyl group at each time point after medication ( P>0.05), the CPOT score of both groups at each time point after medication was significantly lower than that before medication, and the analgesic target could be achieved and maintained 2 hours after medication. There was no significant difference in RASS between the two groups at each time point after medication ( P>0.05), which was significantly lower than that before medication, and the target sedative effect was achieved 2 hours after medication. There was no significant difference in ICU length of stay between nalbuphine group and fentanyl group [5.0(4.0,7.5) d vs. 5.0(4.0,8.0) d, P=0.504]. The incidence of delirium, nausea and vomiting, abdominal distension, pruritus, vertigo and other adverse events in the nalbuphine group was lower than that in the fentanyl group (all P<0.05). There was no significant difference in the incidence of other adverse events such as deep sedation, hypotension and bradycardia between the two groups (all P>0.05). The incidence of respiratory depression in nalbuphine group was not significantly different from that in fentanyl group ( P>0.05), but the proportion of mechanical ventilation was significantly lower than that in the fentanyl group [1.9% (2/105) vs. 8.6%(9/105), P=0.030]. Conclusions:Nalbuphine could be used for analgesia in ICU patients with non-mechanical ventilation. The target analgesic effect could be achieved within 2 hours, and it had a certain sedative effect with a low incidence of adverse reactions.

Objective To present and discuss beam characteristics of the first Mevion S250i gantry-mounted accelerator pencil beam scanning proton therapy system in China.Methods The output dose was measured using a parallel-plate ionization chamber.The integrated depth dose was measured with a large-radius Bragg peak ionization chamber,covering 19 energy levels ranging from 227 MeV to 28 MeV,to analyze the proton beam characteristics.The spots in the air were measured with Phoenix flat panel detector on the beam central axis,and the precision of the delivery position was verified by measuring the multi-spot beam map.The interleaf leakage and penumbra reduction of adaptive aperture were measured to characterize its performance.Results The proton system was calibrated for a maximum energy of 227 MeV,with a(10×10)cm2uniform field delivering 1 Gy dose at a depth of 5 cm underwater.The system effectively modulated the proton beam range to the patient's surface,maintaining a constant 80%-80%Bragg peak width of 8.6 mm at all energy levels.The spot size of the highest energy beam at the isocenter was about 4 mm in the air,and the spot delivery position error was less than 1 mm.The interleaf leakage rate of the adaptive aperture for the highest energy beam was below 1.5%,and the penumbra was significantly reduced.Conclusion Mevion S250i proton therapy system demonstrates unique design and beam characteristics,which is reflected in the Bragg peak shape,spot size variation with energy,and penumbra sharpening of adaptive aperture;and these differences should be considered in treatment planning system modeling and planning for precision treatment.

Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

Objective:To evaluate the clinical application value of the adaptive aperture by comparing intensity-modulated proton radiotherapy(IMPT) plans using and not using the aperture for brain tumors.Methods:A total of twenty patients treated with postoperative radiotherapy for brain tumors were enrolled in this study. IMPT plans were developed for each patient using and not using the adaptive aperture under the same optimization conditions. The target conformal index (CI) value, target homogeneity index (HI) value, and the dose to normal tissues of the two sets of plans were compared.Results:The IMPT plans designed using the adaptive aperture significantly increased the mean CI value from 0.58 to 0.66, while decreasing the mean 50% prescription dose volume from 797.70 cm 3 to 638.15 cm 3. These plans also reduced the irradiation doses to the cochlea, brainstem, optic chiasm, optic nerve, and lens ( t = 2.06, 3.02, 2.11, 2.58, 2.67, P < 0.05). Additionally, there was no significant difference in the HI value of the target volumes and the machine jumps (MU) between the two sets of plans ( P > 0.05). Conclusions:The adaptive aperture can significantly reduce the irradiation dose to normal tissues outside the target volumes, positively impacting the protection of organs at risk (OARs) around the target values. This demonstrates its great potential for clinical application.

Objective:To measure and assess relevant radiation doses at the radiotherapy site of the first domestic single-vault proton therapy system.Methods:The radiation levels of the therapy system during and after beam irradiation were measured, and annual effective doses were assessed for personnel at the site.Results:During beam irradiation, the highest radiation dose was detected at the shielded door of the equipment floor, with a gamma radiation level of 2.140 μSv/h and a neutron radiation level of 0.850 μSv/h. Neutron radiation disappeared immediately once the beams stopped. In contrast, the radiation activated originated mostly from gamma rays. A longer time after beams stopped was associated with lower induced radiation intensity at the same location. Furthermore, a farther distance from the irradiated object corresponded to lower induced radiation intensity at the same time. The assessment result reveal that the annual effective doses to the personnel were at the safe level, with physicists exposed to the highest dose of 2.138 mSv.Conclusions:The radiation level at the studied proton therapy site meets the safety requirement, and the treatment can be performed safely at this site.

Objective:To verify and calibrate the CT modeling curves of three CT devices in RayStation proton treatment planning system (TPS).Methods:CT-mass density (CT-MD) curves were established by CT Hounsfield units of different tissue substitute materials obtained by scanning the model with CT equipment. CT-stopping power (CT-SP) curves were established by calculation based on the chemical composition of various human tissues. The equivalent water thickness of tissue substitute modules was calculated with different CT modeling curves in TPS. The actual equivalent water thickness of various modules was measured by a Bragg peak detector, and compared with the calculated values of TPS to verify the accuracy of different CT models.Results:The differences of CT modeling curves were significantly different under different tube voltage scanning protocols. Compared with CT-MD curves, CT-SP curves based on the stoichiometric calibration were more suitable for proton dose calculation. However, the values of stopping power corresponding to high CT values still needed to be optimized, and the calculation error after calibration was less than 3%.Conclusion:The method of verifying and calibrating CT unit curves of proton TPS is described, proving that the CT-SP curves after stoichiometric calculation are more suitable for proton dose calculation.

The debate on the merits of proton radiotherapy and photon radiotherapy has lasted for more than 20 years, mainly reflected in the comparison of dose distribution and clinical outcomes. Because dosimetric advantages do not always translate to better clinical outcomes, several phase Ⅲ comparative clinical studies are being conducted in Western countries. However, it is highly questionable that these studies will bring great value to the advancement of radiation therapy or settle the debate. This is because the effectiveness of the treatment depends not only on the type of radiation, but also on the technology used. Therefore, the focus of the research should not be which type of radiation is superior, but how to avoid its disadvantages while taking full advantage of the dose characteristics of each type of radiation. Both proton therapy and photon therapy will play an important role in cancer treatment in the future, and limited resources should be applied to maximize the effectiveness of each. With the rapid development of radiotherapy technology and systemic therapies including immunotherapy, reducing treatment fractions in the form of stereotactic radiosurgery and stereotactic body radiotherapy (SRS/SBRT) will be the inevitable trend. The need for dose focusing will drive photon therapy toward 4π radiotherapy using more non-coplanar fields, while higher geometric accuracy requirements will cause wide adoption of artificial intelligence-based online adaptive radiotherapy.

Objective To analyze the daily quality assurance(QA)measurement results of IBA Sphinx Compact device on the Mevion compact pencil beam scanning proton therapy system for evaluating its clinical application value in proton therapy.Methods The daily QA measurement of Mevion S250i proton therapy system was carried out with Sphinx Compact device for 30 consecutive days,and the measurement results were analyzed.Results The average deviation between the positioning laser and the image center was(0.42±0.27)mm in 30 days.All of the proximal and distal depth errors of the high-and low-energy pencil beams were within 0.50 mm.The position deviation of all the spots measured did not exceed 1.00 mm,and the size deviation was less than 7.5%.The deviation between the image center and the beam center was not more than 0.75 mm.The relative deviation of the flatness of the rectangular field was about 0.5%.The deviation of the output dose of the square field was within 1.0%.Conclusion The proton system daily QA measurement items recommended by AAPM TG-224 report can be accurately and rapidly measured with Sphinx Compact device.The device is a practical and efficient daily QA tool with high practical value in clinic.

Objective:To retrospectively study the curative effect of Vbeam 595nm pulsed dye laser(PDL)in treating the mid-term infantile hemangiomas(IHs),and analyze and explore the possible influencing factors of that.Methods:A total of 219 IHs patients who underwent PDL treatment in Tangshan Maternal and Child Health Care Hospital from January 2020 to December 2022 were selected,and they received follow-up at least 6 months.The relationship between the treatment effect and the month age,location,thickness of hemangioma and the number of treatments was analyzed.Results:The median month age of the 219 pediatric children was 7 months,and the average month age of them was(4-10)months,and there was a total of 219 lesions.There were no statistically significant differences in the general data such as month age and the characteristics of lesion between different genders(P＞0.05).The overall effective rate of treatment was 92.7%,and the median number of treatments was 3 times,and the average number of treatments was(2-4)times.There were no statistically significant differences in the comparisons of gender,the number of treatments and the treatment outcome(P＞0.05).The curative effects of 6 pediatric children were poor,whose month age was 13(8,19)months.The curative effects of 10 pediatric children were general,whose month age was 13(8,14)months.The curative effects of 31 pediatric children were favorable,whose month age was 8(4,10)months.The curative effects of 172 pediatric children were excellent,whose month age was 6(4,9)months.The difference of month age of pediatric children among different curative effect was significant(Z=24.863,P＜0.001),and the pediatric children with better curative effect had smaller month age.The treatment outcome of pediatric children with hemangioma was correlated with the thickness of lesion,the area size of lesion and the number of treatment(r=-0.32,-0.46,-0.46,P＜0.05),respectively.The effective treatment mainly focused on the treatments of the 2nd-4th times.The adverse reaction caused by treatment was skin erythema,and the rate of the total residual after six months of the complication was 5.48%.Conclusion:The treatment of 595nm PDL combined with dynamic cooling device(DCD)can provide a safe and effective treatment for IHs.Early intervention for IHs can improve the curative effect,and reduce the course of treatment,and further reduce the possibility of corresponding complications.

Objective:To discuss the acceptance test of beam performance and mechanical precision of the first Mevion type S250i proton therapy system in China,and verify the stability and reliability of that in clinical treatment.Methods:According to the requirements of acceptance report of manufacturer,the output and range of machine unit(MU),the accuracy and stability of size and position of beam spot,the penumbra and position accuracy of adaptive aperture(AA)of Mevion type S250i proton therapy system,as well as the tests of mechanical properties and functions of the requirement of clinical use,were checked and tested for acceptance.Results:The maximum deviation of MU output was 1.3%,and the maximum deviation of the range was 0.037 g/cm2,and the maximum distal fall-off was 0.465 cm,and the minimum range of energy modulation was 0.21 g/cm2.The maximum deviations of the size of beam spot and the maximum deviation of the position were respectively 0.07 cm and 0.05 cm.The maximum AA penumbra was 0.007 cm,and the AA position accuracy was less than 0.1 cm.Conclusion:The acceptance test of the Mevion type S250i proton therapy system indicates that the parameters of the beam performance and mechanical precision can meet the requirements of the acceptance contract and AAPM-TG224 report of manufacturer,which has verified the machine has better favorable stability and reliability.