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Hess CB, Eng TY, Nasti TH, Dhere VR, Kleber TJ, Switchenko JM, Weinberg BD, Rouphael N, Tian S, Rudra S, Taverna LS, Daisson AP, Ahmed R, Khan MK. Whole-lung low-dose radiation therapy (LD-RT) for non-intubated oxygen-dependent patients with COVID-19-related pneumonia receiving dexamethasone and/or remdesevir. Radiother Oncol 2021; 165:20-31. [PMID: 34653525 PMCID: PMC8511870 DOI: 10.1016/j.radonc.2021.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/30/2021] [Accepted: 10/03/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Low-dose radiotherapy (LD-RT) has produced anti-inflammatory effects in both animal models and early human trials of COVID-19-related pneumonia. The role of whole-lung LD-RT within existing treatment paradigms merits further study. METHODS A phase II prospective trial studied the addition of LD-RT to standard drug treatments. Hospitalized and oxygen-dependent patients receiving dexamethasone and/or remdesevir were treated with 1.5 Gy whole-lung LD-RT and compared to a blindly-matched contemporaneous control cohort. RESULTS Of 40 patients evaluated, 20 received drug therapy combined with whole-lung LD-RT and 20 without LD-RT. Intubation rates were 14% with LD-RT compared to 32% without (p = 0.09). Intubation-free survival was 77% vs. 68% (p = 0.17). Biomarkers of inflammation (C-reactive protein, p = 0.02) and cardiac injury (creatine kinase, p < 0.01) declined following LD-RT compared to controls. Mean time febrile was 1.4 vs 3.3 days, respectively (p = 0.14). Significant differences in clinical recovery (7.5 vs. 7 days, p = 0.37) and radiographic improvement (p = 0.72) were not detected. On subset analysis, CRP decline following LD-RT was predictive of recovery without intubation compared to controls (0% vs. 31%, p = 0.04), freedom from prolonged hospitalizations (21+ days) (0% vs. 31%, p = 0.04), and decline in oxygenation burden (56% reduction, p = 0.06). CRP decline following 1st drug therapy was not similarly predictive of outcome in controls (p = 0.36). CONCLUSIONS Adding LD-RT to standard drug treatments reduced biomarkers of inflammation and cardiac injury in COVID-19 patients and may have reduced intubation. Durable CRP decline following LD-RT predicted especially favorable recovery, freedom from intubation, reduction in prolonged hospitalization, and reduced oxygenation burden. A confirmatory randomized trial is now ongoing. CLINICAL TRIAL REGISTRATION NCT04366791.
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Affiliation(s)
- Clayton B Hess
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; Department/Division of Microbiology and Immunology, Emory University, Atlanta, United States
| | - Tony Y Eng
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States
| | - Tahseen H Nasti
- Department/Division of Microbiology and Immunology, Emory University, Atlanta, United States
| | - Vishal R Dhere
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States
| | - Troy J Kleber
- School of Medicine, Emory University, Atlanta, United States
| | - Jeffrey M Switchenko
- School of Biostatistics and Bioinformatics, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States
| | | | - Nadine Rouphael
- School of Infectious Disease, Emory University, Atlanta, United States
| | - Sibo Tian
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States
| | - Soumon Rudra
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States
| | - Luisa S Taverna
- Undergraduate Scholarly Inquiry and Research Experience (SIRE), Emory University, Atlanta, United States
| | - Alvaro Perez Daisson
- Undergraduate Scholarly Inquiry and Research Experience (SIRE), Emory University, Atlanta, United States
| | - Rafi Ahmed
- Department/Division of Microbiology and Immunology, Emory University, Atlanta, United States
| | - Mohammad K Khan
- Department/Division of Radiation Oncology, Emory University, Atlanta, United States; School of Medicine, Emory University, Atlanta, United States; Winship Cancer Institute, Emory University, Atlanta, United States.
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Kapoor R, Welsh JS, Dhawan V, Javadinia SA, Calabrese EJ, Dhawan G. Low-dose radiation therapy (LDRT) for COVID-19 and its deadlier variants. Arch Toxicol 2021; 95:3425-3432. [PMID: 34302492 PMCID: PMC8308081 DOI: 10.1007/s00204-021-03124-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/20/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT USA
| | - James S. Welsh
- Edward Hines Jr VA Hospital, Hines, IL USA
- Stritch School of Medicine, Loyola University Chicago, Maywood, IL USA
| | - Vikas Dhawan
- COVID 19 Facilities, Command Hospital (Western Command), Chandimandir, Panchkula, Haryana India
| | - Seyed Alireza Javadinia
- Clinical Research Development Unit, Hospital Research Development Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Edward J. Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA USA
| | - Gaurav Dhawan
- Sri Guru Ram Das University of Health Sciences, Amritsar, India
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Oakley PA, Betz JW, Harrison DE, Siskin LA, Hirsh DW. Radiophobia Overreaction: College of Chiropractors of British Columbia Revoke Full X-Ray Rights Based on Flawed Study and Radiation Fear-Mongering. Dose Response 2021; 19:15593258211033142. [PMID: 34421439 PMCID: PMC8375354 DOI: 10.1177/15593258211033142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - International Chiropractors Association Rapid Response Research Review Subcommittee
- Private Practice, Newmarket, ON, Canada
- Private Practice, Boise, ID, USA
- CBP NonProfit, Inc, Eagle, ID, USA
- Private Practice, Green Brook, NJ, USA
- Private Practice, Laurel, MD, USA
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Calabrese EJ, Kozumbo WJ, Kapoor R, Dhawan G, Lara PC, Giordano J. Nrf2 activation putatively mediates clinical benefits of low-dose radiotherapy in COVID-19 pneumonia and acute respiratory distress syndrome (ARDS): Novel mechanistic considerations. Radiother Oncol 2021; 160:125-131. [PMID: 33932453 PMCID: PMC8080499 DOI: 10.1016/j.radonc.2021.04.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 04/12/2021] [Accepted: 04/20/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
| | | | - Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, USA
| | - Gaurav Dhawan
- Sri Guru Ram Das University of Health Sciences, Amritsar, India.
| | - Pedro C Lara
- Department of Radiation Oncology, Hospital Universitario San Roque, Universidad Fernando Pessoa Canarias, Las Palmas Gran Canaria, Spain.
| | - James Giordano
- Departments of Neurology and Biochemistry, Georgetown University Medical Center, Washington, DC, USA.
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Oakley PA, Harrison DE. 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. Dose Response 2021; 19:1559325820984626. [PMID: 33628151 PMCID: PMC7883173 DOI: 10.1177/1559325820984626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/04/2020] [Accepted: 12/05/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Kumar A, Dey AD, Behl T, Chadha S, Aggarwal V. Exploring the multifocal therapeutic approaches in COVID-19: A ray of hope. Int Immunopharmacol 2020; 90:107156. [PMID: 33189613 PMCID: PMC7608010 DOI: 10.1016/j.intimp.2020.107156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/24/2020] [Accepted: 10/21/2020] [Indexed: 12/28/2022]
Abstract
COVID-19 is caused by severe acute respiratory syndrome coronavirus. Current knowledge about the treatment protocol is still limited. COVID-19, poses significant challenges to the healthcare system.
The ongoing global pandemic of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is marked as one of the most challenging infectious diseases in the history of mankind with affliction of ~29,737,453 confirmed cases globally. Looking at the present scenario where there is a parallel increment in curve with time, there is an utmost emergency to discover a perennial solution to this life-threatening virus which has led the Human race in an unusual state of affair. The entire health care fraternity is engaged in endeavouring an ultimate way out to hit this pandemic but no such research made till now has been approved yet, to have the potential to bring an end to this fatal situation. Although a few possible treatment choices exist at the moment yet the requirement to search for a still better therapeutic option remains persistent. Global laboratories are working day and night in search for an effective vaccine, many are undergoing clinical trials but their commercialization is no less than a year away. The present review highlights the current potential therapies viz., vaccines, immunotherapies, convulsant plasma therapies, corticosteroids, antithrombotic, intravenous immunoglobulins, nocturnal oxygen therapy etc. that may prove beneficial in attenuating the pandemic situation. However, comparison and presentation of collective data on the therapeutic advancements in mitigating the pandemic situation needs further clinical investigations in order to prove boon to mankind.
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Affiliation(s)
- Arun Kumar
- Chitkara College of Pharmacy, Chitkara University, Punjab, India.
| | - Asmita Deka Dey
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Tapan Behl
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Swati Chadha
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Vishal Aggarwal
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
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Ghahramani-Asl R, Porouhan P, Mehrpouyan M, Welsh JS, Calabrese EJ, Kapoor R, Dhawan G, Javadinia SA. Feasibility of Treatment Planning System in Localizing the COVID-19 Pneumonia Lesions and Evaluation of Volume Indices of Lung Involvement. Dose Response 2020; 18:1559325820962600. [PMID: 33088245 PMCID: PMC7545774 DOI: 10.1177/1559325820962600] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Ruhollah Ghahramani-Asl
- Department of Medical Physics and Radiation Sciences, Faculty of Paramedicine, Sabzevar University of Medical Sciences, Sabzevar, Iran.,Clinical Research Development Unit, Hospital Research Development Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Pejman Porouhan
- Department of Radiation Oncology, Vasei Educational Hospital, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - Mohammad Mehrpouyan
- Department of Medical Physics and Radiation Sciences, Faculty of Paramedicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
| | - James S Welsh
- Loyola University Chicago, Edward Hines Jr., VA Hospital, Stritch School of Medicine, Department of Radiation Oncology, Maywood, IL, USA
| | - Edward J Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | | | - Seyed Alireza Javadinia
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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8
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Oakley PA, Navid Ehsani N, Harrison DE. 5 Reasons Why Scoliosis X-Rays Are Not Harmful. Dose Response 2020; 18:1559325820957797. [PMID: 32963506 PMCID: PMC7488912 DOI: 10.1177/1559325820957797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Oakley PA, Harrison DE. X-Ray Hesitancy: Patients' Radiophobic Concerns Over Medical X-rays. Dose Response 2020; 18:1559325820959542. [PMID: 32994755 PMCID: PMC7503016 DOI: 10.1177/1559325820959542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/20/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022] Open
Abstract
All too often the family physician, orthopedic surgeon, dentist or chiropractor is met with radiophobic concerns about X-ray imaging in the clinical setting. These concerns, however, are unwarranted fears based on common but ill-informed and perpetuated ideology versus current understanding of the effects of low-dose radiation exposures. Themes of X-ray hesitancy come in 3 forms: 1. All radiation exposures are harmful (i.e. carcinogenic); 2. Radiation exposures are cumulative; 3. Children are more susceptible to radiation. Herein we address these concerns and find that low-dose radiation activates the body's adaptive responses and leads to reduced cancers. Low-dose radiation is not cumulative as long as enough time (e.g. 24 hrs) passes prior to a repeated exposure, and any damage is repaired, removed, or eliminated. Children have more active immune systems; the literature shows children are no more affected than adults by radiation exposures. Medical X-rays present a small, insignificant addition to background radiation exposure that is not likely to cause harm. Doctors and patients alike should be better informed of the lack of risks from diagnostic radiation and the decision to image should rely on the best evidence, unique needs of the patient, and the expertise of the physician-not radiophobia.
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10
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Dhawan G, Kapoor R, Dhawan R, Singh R, Monga B, Giordano J, Calabrese EJ. Low dose radiation therapy as a potential life saving treatment for COVID-19-induced acute respiratory distress syndrome (ARDS). Radiother Oncol 2020; 147:212-216. [PMID: 32437820 PMCID: PMC7206445 DOI: 10.1016/j.radonc.2020.05.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Gaurav Dhawan
- Human Research Protection Office, University of Massachusetts, Amherst, United States.
| | - Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, United States
| | - Rajiv Dhawan
- Radiotherapy Department, Government Medical College, Amritsar, India
| | - Ravinder Singh
- MedSurg Urgent Care, Gilbertsville, Pennsylvania, United States
| | - Bharat Monga
- Division of Hospital Medicine, Mount Sinai Morningside Hospital, New York, United States
| | - James Giordano
- Department of Neurology and Biochemistry and Chief, Neuroethics Studies Program, Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, United States; Program in Biosecurity, Technology, and Ethics, US Naval War College, Newport, United States
| | - Edward J Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, United States
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11
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Lara PC, Nguyen NP, Macias-Verde D, Burgos-Burgos J, Arenas M, Zamagni A, Vinh-Hung V, Baumert BG, Motta M, Myint AS, Bonet M, Popescu T, Vuong T, Appalanaido GK, Trigo L, Karlsson U, Thariat J. 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. Aging Dis 2020; 11:489-493. [PMID: 32489696 PMCID: PMC7220282 DOI: 10.14336/ad.2020.0506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Pedro C Lara
- Department of Radiation Oncology, Hospital Universitario San Roque, Fernando Pessoa Canarias Las Palmas University, Las Palmas, Spain.
| | - Nam P Nguyen
- Department of Radiation Oncology, Howard University, Washington D.C., USA.
| | - David Macias-Verde
- Department of Radiation Oncology, Hospital Universitario San Roque, Fernando Pessoa Canarias Las Palmas University, Las Palmas, Spain.
| | - Javier Burgos-Burgos
- Department of Radiation Oncology, Hospital Universitario San Roque, Fernando Pessoa Canarias Las Palmas University, Las Palmas, Spain.
| | - Meritxell Arenas
- Department of Radiation Oncology, Sant Joan de Reus University, University Rovira I Virgili, Tarragona, Spain.
| | - Alice Zamagni
- Radiation Oncology Center, Department of Experimental, Diagnostic and Specialty Medicine, Sant’Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
| | - Vincent Vinh-Hung
- Department of Radiation Oncology, University Hospital of Martinique, Martinique, France.
| | - Brigitta G Baumert
- Institute of Radiation Oncology, Cantonal Hospital Graubuenden, Chur, Switzerland.
| | - Micaela Motta
- Department of Radiation Oncology, ASST Papa Giovanni XXIII, Bergamo, Italy.
| | - Arthur Sun Myint
- Department of Radiation Oncology, Clatterbridge Cancer Center, Liverpool, United Kingdom.
| | - Marta Bonet
- Department of Radiation Oncology, Arnau de Vilanova University Hospital, Lleida, Spain.
| | - Tiberiu Popescu
- Department of Radiation Oncology, Prof. Dr. Ion Chricuta Oncology Institute, Cluj-Napoca, Romania.
| | - Te Vuong
- Department Of Radiation Oncology, McGill University, Montreal, Canada.
| | | | - Lurdes Trigo
- Department of Radiation Oncology, Instituto Portuges de Oncologia Porto Francisco Gentil E.P.E, Porto, Portugal.
| | - Ulf Karlsson
- Department of Radiation Oncology, International Geriatric Group, Washington D.C., USA.
| | - Juliette Thariat
- Department of Radiation Oncology, Baclesse Cancer Center, Caen, France.
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Oakley PA, Harrison DE. Are Restrictive Medical Radiation Imaging Campaigns Misguided? It Seems So: A Case Example of the American Chiropractic Association's Adoption of "Choosing Wisely". Dose Response 2020; 18:1559325820919321. [PMID: 32425722 PMCID: PMC7218311 DOI: 10.1177/1559325820919321] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/12/2020] [Accepted: 03/20/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Oakley PA, Harrison DE. Death of the ALARA Radiation Protection Principle as Used in the Medical Sector. Dose Response 2020; 18:1559325820921641. [PMID: 32425724 PMCID: PMC7218317 DOI: 10.1177/1559325820921641] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Cuttler JM. Application of Low Doses of Ionizing Radiation in Medical Therapies. Dose Response 2020; 18:1559325819895739. [PMID: 31933547 PMCID: PMC6945458 DOI: 10.1177/1559325819895739] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 01/08/2023] Open
Abstract
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.
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Oakley PA, Ehsani NN, Harrison DE. Repeat Radiography in Monitoring Structural Changes in the Treatment of Spinal Disorders in Chiropractic and Manual Medicine Practice: Evidence and Safety. Dose Response 2019; 17:1559325819891043. [PMID: 31839759 PMCID: PMC6900628 DOI: 10.1177/1559325819891043] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Dhawan G, Kapoor R, Dhamija A, Singh R, Monga B, Calabrese EJ. Necrotizing Fasciitis: Low-Dose Radiotherapy as a Potential Adjunct Treatment. Dose Response 2019; 17:1559325819871757. [PMID: 31496924 PMCID: PMC6716184 DOI: 10.1177/1559325819871757] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 12/27/2022] Open
Abstract
Necrotizing fasciitis (NF) is a rapidly spreading bacterial infection causing extensive tissue necrosis and destruction. Despite appropriate therapy, the disease results in significant morbidity/mortality and substantial treatment costs. Several studies published in the early 1900s demonstrated the effective use of low-dose X-ray radiotherapy (RT) for the treatment of many diverse inflammatory conditions and diseases (eg, gas gangrene, sinus infections, arthritis, tendonitis, and serious inflammatory lung conditions). The mechanism by which therapeutic RT doses produce positive patient outcomes is related at least in part to its capacity to induce tissue-based anti-inflammatory responses. This action is due to the polarization of macrophages to an anti-inflammatory or M2 phenotype via optimized low-dose RT. Low-dose RT has the potential to significantly reduce debilitating surgeries and aggressive treatments required for NF, providing a 3-prong benefit in terms of patient mortality, length of hospitalization stays, and cost of health care (both short term and long term). Low cost and easy availability of low-dose RT makes it a potentially useful option for patients of every age-group. In addition, low-dose RT may be a particularly useful option in countries treating many patients who are unable to afford surgeries, antibiotics, and hyperbaric oxygen.
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Affiliation(s)
- Gaurav Dhawan
- Human Research Protection Office, University of Massachusetts, Amherst, MA, USA
| | - Rachna Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | | | | | - Bharat Monga
- Division of Hospital Medicine, Mount Sinai St Luke's Hospital, New York, NY, USA
| | - Edward J Calabrese
- Department of Environmental Health Sciences, School of Public Health and Health Sciences, University of Massachusetts, Amherst, MA, USA
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Calabrese EJ, Dhawan G, Kapoor R, Kozumbo WJ. Radiotherapy treatment of human inflammatory diseases and conditions: Optimal dose. Hum Exp Toxicol 2019; 38:888-898. [DOI: 10.1177/0960327119846925] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
During the early part of the past century, hundreds of clinical studies involving more than 37,000 patients were conducted that showed radiotherapy (RT) to be a successful and safe alternative to drug therapy for the treatment of many diverse inflammatory conditions and diseases (e.g. tendonitis, bursitis, arthritis, and serious inflammatory lung conditions). Data from these studies were collected and analyzed with the intent of estimating an optimal dosing range for RT that would induce an efficacious treatment response. RT was reported to be frequently effective after only a single treatment, with a rapid (within 24 h) and often long-lasting (from months to years) relief from symptoms. Over a two-decade span from the 1920s to the 1940s, the therapeutic responses to a single RT treatment consistently improved as the dosing for multiple ailments decreased over time to between 30 roentgen (r) and 100 r. These findings are significant and in agreement with a number of contemporary reports from Germany where RT has been commonly and successfully employed in treating ailments with an inflammatory origin. A proposed mechanism by which RT mitigates inflammation and facilitates healing is via the polarization of macrophages to an anti-inflammatory or M2 phenotype.
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Affiliation(s)
- EJ Calabrese
- Department of Environmental Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - G Dhawan
- Mass Venture Center, Research Compliance, University of Massachusetts, Hadley, MA, USA
| | - R Kapoor
- Saint Francis Hospital and Medical Center, Hartford, CT, USA
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Calabrese EJ, Giordano JJ, Kozumbo WJ, Leak RK, Bhatia TN. Hormesis mediates dose-sensitive shifts in macrophage activation patterns. Pharmacol Res 2018; 137:236-249. [DOI: 10.1016/j.phrs.2018.10.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/09/2018] [Accepted: 10/09/2018] [Indexed: 02/07/2023]
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Abstract
X-ray therapy was used to treat pertussis/whooping cough during a 13-year period from 1923 to 1936 in North America and Europe. Twenty studies from clinicians in the United States reported that approximately 1500 cases of pertussis were treated by X-ray therapy usually with less than 0.5 erythema dose. Young children (<3 years) comprised about 70% to 80% of the cases, with the age of cases ranging from as young as 1 month to 50 years. In general, symptoms of severe coughing, vomiting episodes, and spasms were significantly relieved in about 85% of cases following up to 3 treatments, while about 15% of the cases showed nearly full relief after only 1 treatment. The X-ray therapy was also associated with a marked reduction in mortality of young (<3 years) children by over 90%. Despite such reported clinical success from a wide range of experienced researchers, the use of X-rays for the treatment of pertussis in young children was controversial, principally due to concerns of exposure to the thymus and thyroid even with the availability of lead shielding. By the mid-1930s, the treatment of pertussis cases via vaccine therapy came to dominate the therapeutic arena, and the brief era of a radiotherapy option for the treatment of pertussis ended.
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Affiliation(s)
- Edward J Calabrese
- Environmental Health Sciences, University of Massachusetts, Amherst, MA, USA
| | - Gaurav Dhawan
- Research Compliance, University of Massachusetts, Mass Venture Center, Hadley, MA, USA
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Calabrese EJ, Dhawan G, Kapoor R. The Use of X Rays in the Treatment of Bronchial Asthma: A Historical Assessment. Radiat Res 2015. [PMID: 26207685 DOI: 10.1667/rr14080.1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This article provides a historical assessment of the role of X-ray therapy in the treatment of bronchial asthma. This analysis revealed that X-ray therapy in the treatment of bronchial asthma spanned the first six decades of the 20th century, and involved nearly 6,000 patients in published clinical case studies. Patients selected typically had at least moderate to severe asthma and were refractory to other commonly employed treatments. The results of more than 60 studies indicated that about 70% of patients had rapid and marked reductions in clinical symptoms with about half of these patients showing complete symptom relief. The duration of the beneficial responses was variable but was approximately 1-6 months for about 50% of the benefited patients, and between 1 to 4 years for the upper 25% of benefited patients. The use of X rays to treat such patients fell into disfavor during the 1950s due to mounting concerns over possible enhanced risks of cancer that coincided with the discoveries and use of antihistamine medications, antibiotics and the methyl xanthine bronchodilators aminophylline and theophylline.
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Affiliation(s)
| | | | - Rachna Kapoor
- b Public Health, University of Massachusetts, Amherst, Massachusetts, 01003
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Use of X-rays to treat shoulder tendonitis/bursitis: a historical assessment. Arch Toxicol 2014; 88:1503-17. [DOI: 10.1007/s00204-014-1295-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
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Calabrese EJ, Dhawan G. How radiotherapy was historically used to treat pneumonia: could it be useful today? THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2013; 86:555-70. [PMID: 24348219 PMCID: PMC3848110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
X-ray therapy was used to treat pneumonia during the first half of the 20th century. Fifteen studies report that approximately 700 cases of bacterial (lobar and bronchopneumonia), sulfanilamide non-responsive, interstitial, and atypical pneumonia were effectively treated by low doses of X-rays, leading to disease resolution, based on clinical symptoms, objective disease biomarkers, and mortality incidence. The capacity of the X-ray treatment to reduce mortality was similar to serum therapy and sulfonamide treatment during the same time period. Studies with four experimental animal models (i.e., mice, guinea pig, cat, and dog) with bacterial and viral pneumonia supported the clinical findings. The mechanism by which the X-ray treatment acts upon pneumonia involves the induction of an anti-inflammatory phenotype that leads to a rapid reversal of clinical symptoms, facilitating disease resolution. The capacity of low doses of X-rays to suppress inflammatory responses is a significant new concept with widespread biomedical and therapeutic applications.
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Affiliation(s)
- Edward J. Calabrese
- To whom all correspondence should be
addressed: Edward J. Calabrese, PhD, Professor of Toxicology, Department of
Public Health, Environmental Health Sciences, Morrill I, N344, University of
Massachusetts, Amherst, MA 01003; Tele: 413-545-3164; Fax: 413-545-4692;
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Calabrese EJ. Low doses of radiation can enhance insect lifespans. Biogerontology 2013; 14:365-81. [PMID: 23793937 DOI: 10.1007/s10522-013-9436-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Accepted: 05/30/2013] [Indexed: 01/14/2023]
Abstract
This paper assesses the capacity of ionizing radiation to extend the lifespans of experimental insect models based on the peer-reviewed literature. Ionizing radiation biphasically affects the lifespans of adult males and females for a broad range of insect models with high doses reducing lifespan whereas lower doses can enhance lifespan, typically in the 20-60 % range. The average adult insect lifespan can be increased when ionizing radiation exposure is administered during early developmental stages or during the adult stage. The effective dose inducing the average adult insect lifespan enhancement may vary considerably depending upon which life stage is exposed. Recent findings have identified specific genes affecting anti-oxidant defenses, DNA repair, apoptosis and heat shock proteins as well as several cell signaling pathways that mediate the longevity enhancing hormetic response.
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Affiliation(s)
- Edward J Calabrese
- Department of Public Health, Division of Environmental Health Sciences, University of Massachusetts, Amherst, 01003, USA.
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Abstract
Approximately 160,000 people evacuated the area around the Fukushima Dai-ichi NPP shortly after it was damage by the earthquake and tsunami. The evacuation order applied to 70,000 of them, while the other 90,000 left voluntarily and returned soon afterward. After more than two years, most of the 70,000 are still not allowed to return to their homes. The 1100 disaster-related deaths caused by the evacuation order show that this pre-cautionary action, taken to minimize cancer risks, was not "conservative." In this paper, recent studies are reviewed on the consequences of the radioactive releases and on the benefits of many medical treatments with low doses of radiation that were carried out until the 1950s, before the radiation scare was created. Recent research has shed light on the high rate of spontaneous double-strand breaks in DNA and the adaptive protections in cells, tissues and humans that are up-regulated by low radiation. These defences prevent, repair, remove and replace damage, from all causes including external agents. Cancer mortality is reduced. The ICRP's concept of radiation risk is wrong. It should revert to its 1934 concept, which was a tolerance dose of 0.2 roentgen (r) per day based on more than 35 years of medical experience.
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