Necrotizing Fasciitis: Low-Dose Radiotherapy as a Potential Adjunct Treatment

Giant Ulcer with Necrosis on Right Vulva, Groin, and Thigh-- A Case of Necrotizing Fasciitis Associated with Erythematous Pemphigus

Necrotizing fasciitis is a rare, severe, rapidly progressing disease with a high mortality rate. We report a case of a 72-year female with erythematous pemphigus who developed erythema, swelling and ulceration on right vulva, groin, and thigh. The early clinical manifestations of the patient were nonspecific and easily misdiagnosed as cellulitis. However, upon the occurrence of ulceration and necrosis, deep fungal infection, pyoderma gangrenosum or lymphoproliferative disorders were considered. The pathology suggested IgG4-related diseases, plasmacytoma et al. But at last, surgical exploration and postoperative pathology confirmed the diagnosis of necrotizing fasciitis. The patient recovered after multiple aggressive surgical debridement procedures and antibiotic therapy and the patient has been followed up for 2 years without recurrence. Clinicians should be vigilant about the possibility of necrotizing fasciitis in patients with erythema, pain, rapid ulceration of skin and soft tissue, particularly in immunocompromised individuals with long-term use of immunosuppressive agents. It is crucial for saving life by early multi-disciplinary consultation, prompt diagnosis, and aggressive treatment.

The effect of hyperbaric oxygen therapy on the clinical outcomes of necrotizing soft tissue infections: a systematic review and meta-analysis

BACKGROUND

To determine the efficacy of hyperbaric oxygen therapy (HBO) in the treatment of necrotizing soft tissue infections (NSTI), we conducted a meta-analysis of the available evidence.

METHODS

Data sources were PubMed, Embase, Web of Science, Cochrane Library, and reference lists. The study included observational trials that compared HBO with non-HBO, or standard care. The primary outcome was the mortality rate. Secondary outcomes were the number of debridement, amputation rate and complication rate. Relative risks or standardized mean differences with 95% confidence intervals were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

A total of retrospective cohort and case-control studies were included, including 49,152 patients, 1448 who received HBO and 47,704 in control. The mortality rate in the HBO group was significantly lower than that in the non-HBO group [RR = 0.522, 95% CI (0.403, 0.677), p < 0.05]. However, the number of debridements performed in the HBO group was higher than in the non-HBO group [SMD = 0.611, 95% CI (0.012, 1.211), p < 0.05]. There was no significant difference in amputation rates between the two groups [RR = 0.836, 95% CI (0.619, 1.129), p > 0.05]. In terms of complications, the incidence of MODS was lower in the HBO group than in the non-HBO group [RR = 0.205, 95% CI (0.164, 0.256), p < 0.05]. There was no significant difference in the incidence of other complications, such as sepsis, shock, myocardial infarction, pulmonary embolism, and pneumonia, between the two groups (p > 0.05).

CONCLUSION

The current evidence suggests that the use of HBO in the treatment of NSTI can significantly reduce the mortality rates and the incidence rates of complications. However, due to the retrospective nature of the studies, the evidence is weak, and further research is needed to establish its efficacy. It is also important to note that HBO is not available in all hospitals, and its use should be carefully considered based on the patient's individual circumstances. Additionally, it is still worthwhile to stress the significance of promptly evaluating surgical risks to prevent missing the optimal treatment time.

A Case of Necrotizing Fasciitis Mimicking a Burn in an Elderly Patient

Necrotizing fasciitis travels along the fascial plane and surrounding soft tissue, leading to ischemia and necrosis. Fournier's gangrene is a type of necrotizing fasciitis invading the deep and superficial planes of the perineal/genital region. It is rapidly progressive in nature and may have life-threatening consequences. Fournier's often exhibits a misleading clinical presentation and can be mistaken for other conditions, such as hematoma, phlebitis, cellulitis, or septic arthritis. Since the ramifications of delayed diagnosis can be clinically significant, recognition of potential mimics is important to prevent morbidity or mortality. We report a case of Fournier's gangrene mimicking a second-degree burn, an exceedingly rare presentation.

A rare case of fully recovered necrotizing fasciitis

Necrotizing fasciitis (NF) is a severe soft tissue infection caused by bacterial fascia invasion and quick spreading to the muscle and subcutaneous tissues. Treatments of NF should be conducted by extensive debridement and antibiotic therapies. This report presented a 53-year-old woman with diabetes mellitus (DM) and hypothyroid who was referred to our medical center with lower limb pain and significant swelling after mild trauma. The patient was diagnosed with NF due to E. coli. She underwent surgical interventions for debridement and long-term antibiotic therapy. The patient recovered successfully without complications or range of motion (ROM) restriction in the hip and knee. It is recommended that immediate actions be taken in NF cases to preserve the remaining tissues and provide better outcomes.

Low-dose radiation therapy (LDRT) for COVID-19 and its deadlier variants

Coronavirus variants are gaining strongholds throughout the globe. Despite early signals that SARS-CoV-2 coronavirus case numbers are easing up in the United States and during the middle of a (not so easy) vaccination roll out, the country has passed a grim landmark of 600,000 deaths. We contend that these numbers would have been much lower if the medical community undertook serious investigations into the potential of low doses of radiation (LDRT) as a mainstream treatment modality for COVID-19 pneumonia. LDRT has been posited to manifest anti-infectious and anti-inflammatory properties at doses of 0.3-1.0 Gy via the activation of the Nrf-2 pathway. Although some researchers are conducting well-designed clinical trials on the potential of LDRT, the deep-rooted, blind, and flawed acceptance of the Linear No-Threshold (LNT) model for ionizing radiation has led to sidelining of this promising therapy and thus unimaginable numbers of deaths in the United States.

Low Dose Ionising Radiation-Induced Hormesis: Therapeutic Implications to Human Health

The concept of radiation-induced hormesis, whereby a low dose is beneficial and a high dose is detrimental, has been gaining attention in the fields of molecular biology, environmental toxicology and radiation biology. There is a growing body of literature that recognises the importance of hormetic dose response not only in the radiation field, but also with molecular agents. However, there is continuing debate on the magnitude and mechanism of radiation hormetic dose response, which could make further contributions, as a research tool, to science and perhaps eventually to public health due to potential therapeutic benefits for society. The biological phenomena of low dose ionising radiation (LDIR) includes bystander effects, adaptive response, hypersensitivity, radioresistance and genomic instability. In this review, the beneficial and the detrimental effects of LDIR-induced hormesis are explored, together with an overview of its underlying cellular and molecular mechanisms that may potentially provide an insight to the therapeutic implications to human health in the future.

Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering

Fears over radiation have created irrational pressures to dissuade radiography use within chiropractic. Recently, the regulatory body for chiropractors practicing in British Columbia, Canada, the College of Chiropractors of British Columbia (CCBC), contracted Pierre Côté to review the clinical use of X-rays within the chiropractic profession. A "rapid review" was performed and published quickly and included only 9 papers, the most recent dating from 2005; they concluded, "Given the inherent risks of radiation, we recommend that chiropractors do not use radiographs for the routine and repeat evaluation of the structure and function of the spine." The CCBC then launched an immediate review of the use of X-rays by chiropractors in their jurisdiction. Member and public opinion were gathered but not presented to their members. On February 4, 2021, the College announced amendments to their Professional Conduct Handbook that revoked X-ray rights for routine/repeat assessment and management of patients with spine disorders. Here, we highlight current and historical evidence that substantiates that X-rays are not a public health threat. We also point out critical and insurmountable flaws in the single paper used to support irrational and unscientific policy that discriminates against chiropractors who practice certain forms of evidence-based X-ray-guided methods.

Nrf2 activation putatively mediates clinical benefits of low-dose radiotherapy in COVID-19 pneumonia and acute respiratory distress syndrome (ARDS): Novel mechanistic considerations

Novel mechanistic insights are discussed herein that link a single, nontoxic, low-dose radiotherapy (LDRT) treatment (0.5-1.0 Gy) to (1) beneficial subcellular effects mediated by the activation of nuclear factor erythroid 2-related transcription factor (Nrf2) and to (2) favorable clinical outcomes for COVID-19 pneumonia patients displaying symptoms of acute respiratory distress syndrome (ARDS). We posit that the favorable clinical outcomes following LDRT result from potent Nrf2-mediated antioxidant responses that rebalance the oxidatively skewed redox states of immunological cells, driving them toward anti-inflammatory phenotypes. Activation of Nrf2 by ionizing radiation is highly dose dependent and conforms to the features of a biphasic (hormetic) dose-response. At the cellular and subcellular levels, hormetic doses of <1.0 Gy induce polarization shifts in the predominant population of lung macrophages, from an M1 pro-inflammatory to an M2 anti-inflammatory phenotype. Together, the Nrf2-mediated antioxidant responses and the subsequent shifts to anti-inflammatory phenotypes have the capacity to suppress cytokine storms, resolve inflammation, promote tissue repair, and prevent COVID-19-related mortality. Given these mechanistic considerations-and the historical clinical success of LDRT early in the 20th century-we opine that LDRT should be regarded as safe and effective for use at almost any stage of COVID-19 infection. In theory, however, optimal life-saving potential is thought to occur when LDRT is applied prior to the cytokine storms and before the patients are placed on mechanical oxygen ventilators. The administration of LDRT either as an intervention of last resort or too early in the disease progression may be far less effective in saving the lives of ARDS patients.

Radiophobic Fear-Mongering, Misappropriation of Medical References and Dismissing Relevant Data Forms the False Stance for Advocating Against the Use of Routine and Repeat Radiography in Chiropractic and Manual Therapy

There is a faction within the chiropractic profession passionately advocating against the routine use of X-rays in the diagnosis, treatment and management of patients with spinal disorders (aka subluxation). These activists reiterate common false statements such as "there is no evidence" for biomechanical spine assessment by X-ray, "there are no guidelines" supporting routine imaging, and also promulgate the reiterating narrative that "X-rays are dangerous." These arguments come in the form of recycled allopathic "red flag only" medical guidelines for spine care, opinion pieces and consensus statements. Herein, we review these common arguments and present compelling data refuting such claims. It quickly becomes evident that these statements are false. They are based on cherry-picked medical references and, most importantly, expansive evidence against this narrative continues to be ignored. Factually, there is considerable evidential support for routine use of radiological imaging in chiropractic and manual therapies for 3 main purposes: 1. To assess spinopelvic biomechanical parameters; 2. To screen for relative and absolute contraindications; 3. To reassess a patient's progress from some forms of spine altering treatments. Finally, and most importantly, we summarize why the long-held notion of carcinogenicity from X-rays is not a valid argument.

Enzymatic Responses to Low-Intensity Radiation of Tritium

The present study considers a possible role of enzymatic reactions in the adaptive response of cells to the beta-emitting radionuclide tritium under conditions of low-dose exposures. Effects of tritiated water (HTO) on the reactions of bacterial luciferase and NAD(P)H:FMN-oxidoreductase, as well as a coupled system of these two reactions, were studied at radioactivity concentrations ≤ 200 MBq/L. Additionally, one of the simplest enzymatic reactions, photobiochemical proton transfer in Coelenteramide-containing Fluorescent Protein (CLM-FP), was also investigated. We found that HTO increased the activity of NAD(P)H:FMN-oxidoreductase at the initial stage of its reaction (by up to 230%); however, a rise of luciferase activity was moderate (<20%). The CLM-FP samples did not show any increase in the rate of the photobiochemical proton transfer under the exposure to HTO. The responses of the enzyme systems were compared to the 'hormetic' response of luminous marine bacterial cells studied earlier. We conclude that (1) the oxidoreductase reaction contributes significantly to the activation of the coupled enzyme system and bacterial cells by tritium, and (2) an increase in the organization level of biological systems promotes the hormesis phenomenon.

Feasibility of Treatment Planning System in Localizing the COVID-19 Pneumonia Lesions and Evaluation of Volume Indices of Lung Involvement

Background and purpose

To assess the feasibility of a treatment planning system in localizing, contouring, and targeting lung lesions along with an evaluation of volume indices of lung involvement in patients with COVID-19 pneumonia.

Methods

We evaluated 10 patients with PCR-confirmed COVID-19 pneumonia. The CT images were imported into the ISOgray® treatment planning system to anatomically define and contour the volumes of the pulmonary lesions, the lungs, and other nearby organs.

Results

The ratio of lung lesion volume to lung volume in this study was 0.11 ± 0.13 (11.13%). The highest mean biosynthesis ratio of lung lesions was 0.36. The ratio of lesion volume in the left lung of patients with the highest volume of involvement, was 0.44, and the ratio of lesion volume in the right lung of these patients was 0.27 (approximately 1.5 times more in the left lung than the right lung). On average, CTDIvol and DLP for all patients studied in our study were 11.22 ± 2.47 mGy and 354.20 ± 65.11 mGy.cm.

Conclusion

We reported the feasibility of using a treatment planning system in localizing COVID-19 pulmonary lesions and its validity in the volumetric assessment of infected lung regions.

5 Reasons Why Scoliosis X-Rays Are Not Harmful

Radiographic imaging for scoliosis screening, diagnosis, treatment, and management is the gold standard assessment tool. Scoliosis patients receive many repeat radiographs, typically 10-25 and as many as 40-50, equating to a maximum 50 mGy of cumulative exposure. It is argued this amount of radiation exposure is not carcinogenic to scoliosis patients for 5 main reasons: 1. Estimated theoretical cumulative effective doses remain below the carcinogenic dose threshold; 2. Scoliosis patient x-rays are delivered in serial exposures and therefore, mitigate any potential cumulative effect; 3. Linear no-threshold cancer risk estimates from scoliosis patient cohorts are flawed due to faulty science; 4. Standardized incidence/mortality ratios demonstrating increased cancers from aged scoliosis cohorts are confounded by the effects of the disease entity itself making it impossible to claim cause and effect resulting from low-dose radiation exposures from spinal imaging; 5. Children are not more susceptible to radiation damage than adults. Radiophobia concerns from patients, parents, and doctors over repeat imaging for scoliosis treatment and management is not justified; it adds unnecessary anxiety to the patient (and their parents) and interferes with optimal medical management. X-rays taken in the evidence-based management of scoliosis should be taken without hesitation or concern about negligible radiation exposures.

Low dose radiation therapy as a potential life saving treatment for COVID-19-induced acute respiratory distress syndrome (ARDS)

The new coronavirus COVID-19 disease caused by SARS-CoV-2 was declared a global public health emergency by WHO on Jan 30, 2020. Despite massive efforts from various governmental, health and medical organizations, the disease continues to spread globally with increasing fatality rates. Several experimental drugs have been approved by FDA with unknown efficacy and potential adverse effects. The exponentially spreading pandemic of COVID-19 deserves prime public health attention to evaluate yet unexplored arenas of management. We opine that one of these treatment options is low dose radiation therapy for severe and most critical cases. There is evidence in literature that low dose radiation induces an anti-inflammatory phenotype that can potentially afford therapeutic benefit against COVID-19-related complications that are associated with significant morbidity and mortality. Herein, we review the effects and putative mechanisms of low dose radiation that may be viable, useful and of value in counter-acting the acute inflammatory state induced by critical stage COVID-19.

Whole-lung Low Dose Irradiation for SARS-Cov2 Induced Pneumonia in the Geriatric Population: An Old Effective Treatment for a New Disease? Recommendation of the International Geriatric Radiotherapy Group

A cytokine storm induced by SARS-Cov2 may produce pneumonitis which may be fatal for older patients with underlying lung disease. Hyper-elevation of Interleukin1 (IL-1), Tumor necrosis factor-1alfa (TNF-1 alfa), and Interleukin 6 (IL-6) produced by inflammatory macrophage M1 may damage the lung alveoli leading to severe pneumonitis, decreased oxygenation, and potential death despite artificial ventilation. Older patients may not be suitable candidates for pharmaceutical intervention targeting IL-1/6 blockade or artificial ventilation. Low dose total lung (LDTL) irradiation at a single dose of 50 cGy may stop this cytokine cascade, thus preventing, and/or reversing normal organs damage. This therapy has been proven in the past to be effective against pneumonitis of diverse etiology and could be used to prevent death of older infected patients. Thus, LDRT radiotherapy may be a cost-effective treatment for this frail patient population whom radiation -induced malignancy is not a concern because of their advanced age. This hypothesis should be tested in future prospective trials.

Are Restrictive Medical Radiation Imaging Campaigns Misguided? It Seems So: A Case Example of the American Chiropractic Association's Adoption of "Choosing Wisely"

Since the 1980s, increased utilization of medical radiology, primarily computed tomography, has doubled medically sourced radiation exposures. Ensuing fear-mongering media headlines of iatrogenic cancers from these essential medical diagnostic tools has led the public and medical professionals alike to display escalating radiophobia. Problematically, several campaigns including Image Gently, Image Wisely, and facets of Choosing Wisely propagate fears of all medical radiation, which is necessary for the delivery of effective and efficient health care. Since there are no sound data supporting the alleged risks from low-dose radiation and since there is abundant evidence of health benefits from low-doses, these imaging campaigns seem misguided. Further, thresholds for cancer are 100 to 1000-fold greater than X-rays, which are within the realm of natural background radiation where no harm has ever been validated. Here, we focus on radiographic imaging for use in spinal rehabilitation by manual therapists, chiropractors, and physiotherapists as spinal X-rays represent the lowest levels of radiation imaging and are critical in the diagnosis and management of spine-related disorders. Using a case example of a chiropractic association adopting "Choosing Wisely," we argue that these campaigns only fuel the pervasive radiophobia and continue to constrain medical professionals, attempting to deliver quality care to patients.

Death of the ALARA Radiation Protection Principle as Used in the Medical Sector

ALARA is the acronym for "As Low As Reasonably Achievable." It is a radiation protection concept borne from the linear no-threshold (LNT) hypothesis. There are no valid data today supporting the use of LNT in the low-dose range, so dose as a surrogate for risk in radiological imaging is not appropriate, and therefore, the use of the ALARA concept is obsolete. Continued use of an outdated and erroneous principle unnecessarily constrains medical professionals attempting to deliver high-quality care to patients by leading to a reluctance by doctors to order images, a resistance from patients/parents to receive images, subquality images, repeated imaging, increased radiation exposures, the stifling of low-dose radiation research and treatment, and the propagation of radiophobia and continued endorsement of ALARA by regulatory bodies. All these factors result from the fear of radiogenic cancer, many years in the future, that will not occur. It has been established that the dose threshold for leukemia is higher than previously thought. A low-dose radiation exposure from medical imaging will likely upregulate the body's adaptive protection systems leading to the prevention of future cancers. The ALARA principle, as used as a radiation protection principle throughout medicine, is scientifically defunct and should be abandoned.

Application of Low Doses of Ionizing Radiation in Medical Therapies

The discovery of X-rays and radioactivity in 1895/1896 triggered a flood of studies and applications of radiation in medicine that continues to this day. They started with imaging fractures/organs and progressed to treating diseases by exposing areas to radiation from external and internal sources. By definition, low-dose treatments stimulate damage control (or adaptive protection) systems that remedy diseases. Publications are identified on low-dose ionizing radiation (LDIR) therapies for different cancers, infections, inflammations, and autoimmune and neurodegenerative diseases. The high rate of endogenous DNA damage, due to leakage of oxygen from aerobic metabolism, and the damage control systems that deal with this are discussed. Their stimulation and inhibition by radiation are described. The radium dial painter studies revealed the radium ingestion threshold for malignancy and the dose threshold for bone sarcoma. The radiation scare that misled the medical profession and the public is a barrier to LDIR therapies. Many studies on nasal radium irradiation demonstrated that children are not unduly radiation sensitive. Omissions in the medical textbooks misinform physicians about the effects of LDIR therapy, which blocks clinical trials to determine optimal doses, efficacy, and thresholds for onset of harm. Information from many recent case reports on LDIR therapies, including successes with radon therapy, is provided.

Repeat Radiography in Monitoring Structural Changes in the Treatment of Spinal Disorders in Chiropractic and Manual Medicine Practice: Evidence and Safety

There is substantial evidence for normal relationships between spine and postural parameters, as measured from radiographs of standing patients. Sagittal balance, cervical lordosis, thoracic kyphosis, lumbar lordosis, pelvic tilt, and the more complex understanding of the interrelations between these essential components of normal stance have evolved to where there are known, established thresholds for normalcy. These spinal parameters are reliably measured from X-ray images and serve as goals of care in the treatment of spine and postural disorders. Initial and follow-up spinal imaging by X-ray is thus crucial for the practice of contemporary and evidence-based structural rehabilitation. Recent studies have demonstrated that improvement in the spine and posture by nonsurgical methods offers superior long-term patient outcomes versus conventional methods that only temporarily treat pain/dysfunction. Low-dose radiation from repeated X-ray imaging in treating subluxated patients is substantially below the known threshold for harm and is within background radiation exposures. Since alternative imaging methods are not clinically practical at this time, plain radiography remains the standard for spinal imaging. It is safe when used in a repeated fashion for quantifying pre-post spine and postural subluxation and deformity patterns in the practice of structural correction methods by chiropractic and other manual medicine practices.