home Drugs Radiation sickness: signs, symptoms and consequences. Radiation skin lesions

Radiation sickness: signs, symptoms and consequences. Radiation skin lesions

In 14 patients suffering from malignant skin tumors complicated by radiation ulcers, a 0.25% Derinat solution for external use was used as the main treatment. “Derinat” was used to moisten sterile napkins that were used to cover ulcerative defect skin twice a day, a course of 10-24 procedures. Complete effect was obtained in 9 patients (64%), partial - in 2 (14%), stabilization of the process - in 2 (14%), no effect - in 1 (8%).

The incidence of malignant skin tumors has remained very low for many years. high level both in developed Western countries and the Russian Federation, ranking 1-3 in frequency. In a complex of therapeutic measures malignant tumors Radiation therapy plays an important role. However, along with the positive effects of this treatment, there are side effects. Radiation reactions are an inevitable companion to radiation treatment. According to M.S. Bardycheva et al. , late radiation damage to the skin and underlying tissues occur in 41.5% of patients after radiation therapy. The incidence of radiation ulcer is 3.5% of cases. In the treatment of primary malignant neoplasms of the oral mucosa, radiation ulcers account for 15.0%, recurrent and residual tumors in 33.0% of cases.

A common complication of radiation therapy for skin cancer is radiation ulcers, the treatment of which is incredibly difficult and takes many months and even years. Radiation ulcers are persistent and require long-term treatment. Difficulties in therapy are caused by disruption of metabolic and proliferative processes in tissues, changes in the state of tissue and regional circulation in the area of radiation damage. Developing early and late radiation injuries lead to social disability active persons and significantly reduce their quality of life. Therefore, it is necessary to search and implement new methods of treatment and rehabilitation of this category of cancer patients, taking into account cost-effectiveness.

In our work we Special attention turned to the use of "Derinat" for visible localizations of malignant neoplasms due to the fact that the assessment of the therapeutic effect can be visual, objective and easily documented. In addition, tumors of the named localization are among the most common. Thus, in the Republic of Moldova, the incidence of skin cancer ranks 1-2 among other malignant tumors. This is true for other regions as well.

Patients and methods.

We used external use of Derinat in 14 patients suffering from malignant skin tumors. The study included 14 men and women. The age of the patients participating in the study ranged from 58 to 92 years. All patients included in the study showed signs of trophic disturbances in the affected area (where the primary lesion was previously localized) in the form of hyperpigmentation, areas of soft tissue necrosis, fibrin deposits, peeling skin, cyanosis and the presence of ulcers. Average duration Treatment period for a patient with Derinat in a clinical study was 6.7 weeks. Patients underwent a course of 10-24 procedures of external administration of the drug “Derinat” into the skin of the area of trophic disorders.

A sterile solution of Derinat (0.25%) was used externally, moistening sterile napkins with it to cover the ulcerative skin defect. To keep the napkins in a damp state, they were covered with an insulating material such as parchment paper for 1-2 hours (no more, to eliminate the possibility of the greenhouse effect). Dressings were performed in the dressing room twice a day - morning and evening. The dosage depended on the area of the problem area and could include from 2.0 to 5.0 ml of the drug.

The effectiveness of the drug "Derinat" was assessed using standard clinical and instrumental research methods before the start of use, in the middle (2 weeks from the start of treatment) and at the end of the course (4-5 weeks) from the moment of use of the drug.

Data on patients are presented in Table 1.

Table 1

Distribution of patients who received external treatment with Derinat by gender, nosology and stage

	Diagnosis	Qty	Gender: m/f
1.	Stage I-II basal cell skin cancer, complicated by radiation ulcer	9	4/5
2.	Basal cell skin cancer stage III.	1	1/0
3.	Basal cell skin cancer stage IV.	1	1/0
3.	Squamous cell skin cancer stage I-II. against the background of a trophic ulcer after a thermal burn	2	0/2
4.	Soft tissue sarcoma complicated by prolonged non-healing of the wound after surgical excision	1	1/0

Clinical examples.

Observation #1. Patient N., 92 years old, three years ago received radiation treatment(close-focus radiotherapy) for stage I basal cell skin cancer of the right temporal region. at a dose of 56 Gray. Over the past 8 months. at the site of the cancerous tumor there is an ulcer with a diameter of 2.5 cm, which gradually increases in size. The ointment treatment provided no effect. The diagnosis was made: “Basal cell skin cancer of the right temporal region, stage I.” II class group. Condition after radiation therapy (in 2003). Radiation ulcer." There was no evidence of cancer recurrence. An objective picture of the pathological process at the time of treatment is presented in Fig. 1. Figures 2 and 3 show changes in a radiation ulcer due to topical application of Derinat.

Fig.1. Patient N., 92 years old. Three years after close-focus radiotherapy for basal cell carcinoma of the skin of the right temple at a dose of 56 Gy, a radiation ulcer with a diameter of 2.5 cm appeared at the site of the cancerous tumor after 2 years

Fig.2. 2 weeks after topical application of Derinat, the bottom of the ulcer began to clear of necrotic plaque

Fig.3. After 3 months, complete healing of the radiation ulcer occurred

It should be noted that a similar effect for radiation ulcers with traditional methods treatment (ointment dressings, local application rosehip or sea buckthorn oils, hormonal ointments etc.) is impossible to achieve. The average healing time for radiation ulcers using these treatment methods is more than 12 months.

Clinical observation No. 2. Use of derinat for prolonged non-healing postoperative wound after radical excision of soft tissue sarcoma of the posterior thigh followed by radiation therapy in terms of combination treatment at a dose of 70 Gy in a 48-year-old man.

Fig.4. Appearance wounds after 3 months. after surgery

Fig.5. After local treatment the wound has cleared of purulent plaque, but the depth of the wound has not decreased - there is no tendency to heal. Treatment with Derinat was started on an outpatient basis

Fig.6, 7. After 2 months. After using Derinat, the wound decreased by 50% and became superficial. Active epithelization can be seen

Research results and discussion.

Of the 14 patients listed, complete effect was obtained in 9 (64%), partial effect - in 2 (14%), stabilization of the process - in 2 (14%), no effect - in 1 (8%).

So, our first experience of using Derinat for malignant neoplasms of visible localizations complicated by radiation ulcers, when applied topically, revealed a high therapeutic effect of the drug. Although the relatively small amount of clinical material does not allow us to draw far-reaching conclusions at this stage, it does provide an opportunity to discuss the likely mechanisms of drug effectiveness.

Of course, local use of Derinat ensures its direct contact with epithelial cells of the epidermis, as well as with immune system through the lymphoid tissue located at the site of inflammation. This is a condition for the onset of the immunomodulatory properties of the drug, which can be manifested by a decrease in the level of pro-inflammatory cytokines, a decrease in the level of adhesive function of cells and their apoptosis, a significant increase in the activity of tissue macrophages, these “cells for all occasions”, responsible for the completion of reparative processes. In addition, the literature describes positive influence"Derinata" on microcirculation in trophic ulcers, reducing antioxidant deficiency, as well as suppressing the infectious factor.

Our experience shows that Derinat has a very great healing potential, which is obviously due to its ability to penetrate cells by pinocytosis without compromising the integrity of membranes, stimulating metabolic and reparative processes. Therefore, it is able to support the restoration and differentiation of skin cells.

It is also necessary to note the obvious feasibility of using Derinat as a universal metabolic modulator based on nucleic acids already in early period acute radiation injuries of the skin. Since it is during this period that, due to both direct and indirect effects of radiation, damage to biomacromolecules and disruption of the synthesis of nucleic acids occurs, changes in immunity and the intensity of proliferation and transformation processes. Already on these early stages When irradiated, the metabolism of nucleic acids undergoes significant changes, so the issue of protecting and restoring biosynthesis is one of the most important in pathogenetic therapy.

In addition, it is known that activation of cells during regeneration by tissue decay products occurs through nucleic acid metabolism. Therefore, it seems reasonable to include “Derinat” in the composition complex therapy at all stages of treatment of such patients.. We did not specifically use the combined technique of combined administration of Derinat (combination of intramuscular injections of Derinat with outer shape) since it is obvious that the effect would be significantly higher.

Our work has shown that even external use of the drug makes it possible to apply this drug directly to the ulcer as monotherapy and effectively stimulate regenerative processes. results clinical trial The external use of the drug "Derinat" in patients with malignant tumors of external localizations and radiation ulcers demonstrates a good therapeutic effect.

The method of external use of the drug “Derinat” can be used in oncology for the purpose of treatment, prevention and correction of external skin damage, including radiation ulcers.

Conclusions:

1. For external use of the drug "Derinat" side effects was not observed.

2. The study revealed the safety of using the drug “Derinat”.

3. External use of the drug "Derinat" leads to accelerated healing trophic changes in tissue and radiation ulcers.

4. After a course of external use of the drug "Derinat" there is a significant improvement in the repair processes, resulting in complete healing even severe forms radiation damage to the skin in almost 65%.

M.T. Kulaev, G.G. Meltsaev, S.A. Shchukin

Mordovian Republican Oncology Dispensary

Saransk Medical Institute, Moscow State University. N.P. Ogareva

Kulaev Mikhail Timofeevich - candidate medical sciences, Associate Professor, Head of the Department of Oncology, Medical Institute of Moscow State University. N.P. Ogareva.

Literature:

1. Kaplina E.N., Weinberg Yu.P. "Derinat" is a natural immunomodulator for children and adults. M., 2007.

2. Zhavrid E.A., Khodina T.V. Report on clinical study hemostimulating properties of the drug "Derinat". Research Institute of Oncology and Medical Radiology of the Ministry of Health of the Republic of Belarus, 1994.

3. Tarelkina M.N. The use of the drug "Derinat" in the complex treatment of cancer patients. Report from the Research Institute of Emergency Medicine named after. I.I. Dzhanelidze. St. Petersburg, 2002.

4. Pluzhnikov N.N. "Experimental study of the effectiveness of the drug "Derinat" as a means of early treatment of radiation injuries." research institute Military medicine Ministry of Defense of the Russian Federation, St. Petersburg, 1997.

5. Sinkov A.A. Complex treatment of trophic ulcers lower limbs venous origin with the use of the drug "Derinat". Department of Medicine 2005; 1(13): 104-109

6. Guidelines by application medicinal product— immunomodulator “Derinat” in the complex treatment of burn disease (patients over 15 years old). Ministry of Health of the Russian Federation, Voronezh regional clinical Hospital No. 1, Voronezh, 2004.

7. G.A. Panshin. Report on clinical trials the drug "Derinat" in the complex treatment of cancer patients. Moscow Research Institute of Diagnostics and Surgery, Ministry of Health of the Russian Federation, 1998.

8. Karaskov A.M., Weinberg Yu.P., Volkov A.M., Kazanskaya G.M. Efficiency of application sodium salt native DNA in myocardial infarction. Military Medical Journal 1995; 2: 64-65.

9. Bardychev M.S., Tsyb A.F. Local radiation damage. M., “Medicine”, 1985, 240 p.

10. Bardychev M.S. Treatment of local radiation damage. Attending Physician 2003; 5:78-79

11. Lelyuk V.G., Filin S.V. Possibilities and first results of using a comprehensive study of blood flow in the subcutaneous vessels in patients with consequences of local radiation injuries using laser flowmetry and duplex scanning. Flowmetry methodology, 1997, p. 35-44

12. Korovina M.A., Levshova N.V., Oltarzhevskaya N.D. Textile materials for the treatment of trophic ulcers. Textile Chemistry;1(20): 67-72.

Natural and artificial radioactive isotopes have found wide application in almost all industries, agriculture, medicine, especially in carrying out scientific research. Careless handling of them, use of significant doses with therapeutic purpose, as well as industrial accidents can lead to local and general radiation with the development of painful manifestations in the oral cavity in the form of burns, ulcerative, necrotic and aphthous stomatitis with impaired oral function.

The effects of ionizing radiation can be detected immediately or after a certain period of time.

Course of acute radiation sickness divided into 4 periods. The first period occurs several hours after irradiation. On the background common symptoms(dizziness and general weakness) dry mouth, a dull tint of the mucous membrane and pinpoint hemorrhages appear in it.

The second period is imaginary well-being. All symptoms observed in the first period disappear, there are no changes in the oral cavity.

The third period is the height of the disease. It is characterized by the appearance of a number of symptoms from the oral mucosa, which becomes pale and dry. The gingival papillae, especially their edges, become swollen, and a pink border appears in the form of a fringe. The mucous membrane of the gums bleeds. Reduced content platelets in the blood and increased permeability of the vascular wall lead to the appearance of extensive hemorrhages, especially in the area of the floor of the oral cavity. The swelling of the oral mucosa increases, and tooth marks are visible on the mucous membranes of the cheeks and tongue. The mucous membrane is covered with whitish viscous mucus mixed with blood with an unpleasant odor.

Against the background of a pale and edematous mucous membrane, areas of limited tissue necrosis appear in the form of white spot, primarily in places adjacent to metal fillings and prostheses. After the necrotic epithelium is rejected, an ulcer is formed, the bottom of which has uneven elevations, is covered with a gray-dirty coating and has reddened edges. The edges of the ulcer without sharp boundaries merge into the surrounding tissue.

In case of infection, more extensive necrosis is formed on the mucous membrane of the gums, cheeks, and at the root of the tongue, sometimes reaching the bone. The papillae of the tongue swell, the tongue becomes rough, and cracks appear.

The interdental bone septa dissolve, the teeth become loose and fall out. All this is accompanied by painful phenomena. On the 8-10th day of illness, the submandibular lymph nodes enlarge and become painful.

The fourth period- recovery. All symptoms slowly begin to disappear, but a recurrence of stomatitis is possible, which stops with general recovery.

Metal dentures and fillings worsen the condition of the oral cavity during radiation sickness. Ulcers formed on the mucous membrane in places adjacent to metal fillings and dentures do not heal until the dentures and fillings are removed.

At chronic course ulcers resemble aphthae, which appear on the vestibular surface in the area of transitional folds, gums and lower lip. The tongue swells and deep furrows appear on it. In some patients, glossalgia persists. After 5-7 days, these phenomena may disappear, and then reappear for a long time.

The diagnosis is made on the basis of anamnesis, the general condition of the blood picture and the clinical picture.

Treatment is mostly general. Due to the significantly reduced protective function of the body and the possibility of secondary infection, it is necessary to carefully care for the oral cavity. The mucous membrane is irrigated with a weak solution of potassium permanganate, furatsilin, applications are made with antibiotic solutions (200,000 units of penicillin in 10 ml of 0.5% novocaine, water solution biomycin - 100,000 units in 20 ml of distilled water). Prescribe a gentle diet, milk, a large amount of vitamins, raw egg white(lots of lysozyme). Partial sanitation of the oral cavity is performed.

Tooth extraction and the use of cauterizing substances are contraindicated.

The prognosis is always serious.

Prevention. Carrying out preventive measures to prevent gingivitis, stomatitis and other manifestations of the disease in the oral cavity play an important role in the process of curing radiation sickness.

Persons in contact with X-rays must be constantly under the supervision of a doctor and at least once every 3 months must come for examination and sanitation by the dentist. All workers with radioactive isotopes must be familiarized with personal preventive measures.

Persons who, due to the nature of their diseases, require radiation therapy, in order to prevent complications from the oral cavity, must be appropriately prepared. Necessary:

1) undergo complete sanitation of the oral cavity;

2) don't wear removable dentures at the time of irradiation;

3) remove metal prostheses and fillings;

4) do not use a toothbrush to avoid injury to the mucous membrane during radiation therapy; perform morning oral hygiene with a cotton ball moistened with a solution of hydrogen peroxide;

5) eat food that does not irritate the oral mucosa; do not smoke or drink alcohol;

6) rinse your mouth thoroughly before a radiation therapy session.

Irrigation of the oral cavity with a solution of adrenaline (1:1000) in physiological solution (2:100) with the addition of 3 ml of a 40% glucose solution significantly reduces the sensitivity of the mucous membrane to radium rays.

Radiation sickness occurs when the human body is affected by radioactive radiation and its range exceeds the dose that the immune system can handle. The course of the disease is accompanied by damage to the endocrine, skin, digestive, hematopoietic, nervous and other systems.

Throughout our lives, each of us is exposed to minor doses of ionizing radiation to one degree or another. It comes from and, which enter the body through food, drink or breathing, and accumulate in the cells of the body.

Normal background radiation, in which human health does not suffer, is in the range of 1-3 m3v/year. The International Commission on Radiological Protection has established that exceeding the rate of 1.5 3V/year, as well as with a single exposure to 0.5 3V/year, there is a risk of developing radiation sickness.

Causes and features of radiation sickness

Radiation damage occurs in two cases:

short-term, single high-intensity irradiation,
prolonged exposure to low doses of radiation.

The first type of damage occurs when man-made disasters occur in nuclear energy, during the use or testing of nuclear weapons, or during total irradiation in hematology, oncology, and rheumatology.

Health workers in radiation therapy and diagnostic departments, as well as patients who are often subjected to radionuclide and x-ray examinations, are exposed to prolonged exposure to low doses of radiation.

The damaging factors are:

neutrons,
gamma rays,
X-rays.

In some cases, simultaneous exposure to several of these factors occurs—mixed exposure. So, if it happened external influence gamma and neutrons, this will definitely cause radiation sickness. However, alpha and beta particles can cause damage only if they enter the body with food, through breathing, skin or mucous membranes.

Radiation damage is a damaging effect on the body at the cellular and molecular level. Complex biochemical processes occur in the blood, the result of which are products of pathological nitrogen, carbohydrate, fat, water-salt metabolism, causing radiation toxemia.

First of all, such changes affect actively dividing cells of neurons, brain, intestinal epithelium, lymphoid tissue, skin, endocrine glands. Based on this, toxemic, hemorrhagic, bone marrow, intestinal, cerebral and other syndromes that are part of the pathogenesis (mechanism of origin) of radiation disease develop.

The insidiousness of radiation injury is that at the moment of direct exposure a person often does not feel anything, be it heat, pain or anything else. Also, the symptoms of the disease do not make themselves felt immediately; there is a certain latent, hidden period when the disease is actively developing.

There are two types of radiation injury:

acute, when the body is exposed to sudden and strong radiation,
chronic, resulting from prolonged exposure to low doses of radiation.

The chronic form of radiation injury will never turn into acute, and vice versa.

Based on the specific effects on health, radiation injuries are divided into three groups:

immediate consequences - acute form, burns,
long-term consequences - malignant tumors, leukemia, reduction in viability time, accelerated aging of organs,
genetic – birth defects, hereditary diseases, deformities and other consequences.

Symptoms of acute radiation injury

Most often, radiation sickness occurs in the bone marrow form and has four stages.

First stage

It is characterized by the following signs of radiation exposure:

If the radiation dose exceeded 10 Gy, the following symptoms are added to those listed:

diarrhea,
fever,
arterial hypotension,
fainting.

Against the backdrop of all this, this arises:

skin erythema (abnormal redness) with a bluish tint,
reactive leukocytosis (excess of white blood cells), followed after a day or two by lymphopenia and leukopenia (decreased number of lymphocytes and leukocytes, respectively).

Second stage

At this stage, clinical well-being is observed, when all the above symptoms disappear and the patient’s well-being improves. But when diagnosing, the following is observed:

lability (instability) of pulse and blood pressure,
lack of coordination
decreased reflexes,
EEG shows slow rhythms,
approximately two weeks after irradiation, baldness begins,
leukopenia and other abnormal blood conditions worsen.

If the radiation dose exceeds 10 Gy, then the first stage may be immediately replaced by the third.

Third stage

This is the phase of pronounced clinical symptoms when syndromes develop:

The patient's condition is seriously deteriorating, and the symptoms of the first stage return and intensify. Also observed:

hemorrhages in the central nervous system,
gastrointestinal bleeding,
nosebleeds,
bleeding gums,
ulcerative-necrotizing gingivitis,
gastroenteritis,
pharyngitis,
stomatitis,
gingivitis.

The body is easily susceptible to infectious complications, such as:

angina,
pulmonary abscess,
pneumonia.

If the radiation dose was very high, radiation dermatitis develops, when primary erythema appears on the skin of the elbows, neck, groin, and axillary areas, followed by swelling of these areas of the skin and the formation of blisters. With a favorable outcome, radiation dermatitis resolves with the formation of scars, pigmentation, and compaction of the subcutaneous tissue. If dermatitis affects the blood vessels, skin necrosis and radiation ulcers occur.

Hair falls out over the entire area of the skin: on the head, face (eyelashes, eyebrows including), pubic area, chest, legs. The work of the endocrine glands is inhibited, the ones that suffer the most are thyroid, adrenal glands, gonads. There is a risk of developing thyroid cancer.

Defeat gastrointestinal tract appears as:

colitis,
hepatitis A,
gastritis,
enteritis,
esophagitis.

Against this background we observe:

From the outside nervous system there are such manifestations:

meningeal symptoms (headaches, photophobia, fever, uncontrollable vomiting),
increasing loss of strength, weakness,
confusion,
increased tendon reflexes,
decreased muscle tone.

Fourth stage

This is the recovery phase, which is characterized by a gradual improvement in well-being and the restoration of impaired functions, at least partially. The patient remains anemic for quite a long time, he feels weak and exhausted.

Complications include:

Symptoms of chronic radiation injury

Mild degree

Pathological effects in this case do not unfold so quickly. Among them, the leading ones are violations metabolic processes, disruptions in the gastrointestinal tract, endocrine, cardiovascular and neurological systems.

IN mild degree Chronic radiation injury produces nonspecific and reversible changes in the body. It feels like:

weakness,
headache,
decreased endurance, performance,
sleep disturbance,
emotional instability.

The constant signs are:

poor appetite
chronic gastritis,
intestinal digestion disorder,
biliary dyskinesia,
decreased libido,
impotence in men,
in women - a violation of the monthly cycle.

A mild degree of chronic radiation sickness is not accompanied by serious hematological changes, its course is not complicated and recovery usually occurs without consequences.

Average degree

When the average degree of radiation damage is recorded, the patient suffers from asthenic manifestations and more serious vegetative-vascular disorders. His condition states:

emotional instability,
weakening of memory,
fainting,
nail deformation,
baldness,
dermatitis,
decrease in blood pressure,
paroxysmal tachycardia,
multiple ecchymoses (small bruises), petechiae (spots on the skin),
bleeding gums, nose.

Severe degree

Severe chronic radiation injury is characterized by dystrophic change in organs and tissues, and it is not replenished by the regenerative capabilities of the body. That's why clinical symptoms progress and are accompanied by infectious complications and intoxication syndrome.

Often the course of the disease is accompanied by:

sepsis,
endless headaches,
weakness,
insomnia,
bleeding,
multiple hemorrhages,
loosening, tooth loss,
total baldness,
ulcerative-necrotic lesions of the mucous membranes.

With an extremely severe degree of chronic radiation, pathological changes occur quickly and steadily, leading to inevitable death.

Diagnosis and treatment of radiation sickness

IN this process The following specialists take part:

therapist,
hematologist,
oncologist.

Diagnosis is based on the study of clinical signs manifested in the patient. The dose of radiation he received is determined using chromosome analysis, carried out on the first day after irradiation. Thus it is possible:

competent preparation of treatment tactics,
analysis of quantitative parameters of radioactive influence,
forecasting acute form diseases.

For diagnosis, an established set of studies is used:

laboratory blood tests,
consultations with various specialists,
bone marrow biopsy,
grade circulatory system via sodium nucleate.

The patient is prescribed the following diagnostic procedures:

CT scan,
electroencephalography,

Dosimetric tests of urine, feces, and blood are additional methods in diagnosis. Only after all these procedures is a specialist able to correctly assess the patient’s condition and prescribe appropriate treatment.

What should be done first when a person has received radiation?

take off his clothes,
wash his body in the shower,
rinse your nose, mouth, eyes,
rinse the stomach with a special solution,
give an antiemetic.

In the hospital such a person will undergo antishock therapy, will give detoxification, cardiovascular, sedatives, as well as drugs that block gastrointestinal symptoms.

If the degree of radiation is not severe, the patient’s nausea and vomiting are stopped and dehydration is prevented by administering saline. In severe cases of radiation injury, surgical detoxification therapy and drugs to prevent collapse are necessary.

Next, it is necessary to prevent infections of external and internal types; for this, the patient is placed in an isolation room where sterile air is supplied, and all care items, medical materials and food are also sterile. A routine treatment of the visible mucous membrane and skin with antiseptics is carried out. The patient is given non-absorbable antibiotics to suppress activity intestinal flora, along with this he also takes antifungal drugs.

For infectious complications, large doses are prescribed antibacterial agents administered intravenously. Sometimes biological drugs with targeted action are used.

Literally after a couple of days the patient feels positive action antibiotics. If this is not observed, the medicine is changed to another, and a blood test, urine test, and sputum culture results are taken into account.

When a severe degree of radiation injury is diagnosed and depression of hematopoiesis and a severe drop in immunity are observed, doctors recommend a bone marrow transplant. However, this is not a panacea, since modern medicine does not have effective measures to prevent the rejection of foreign tissue. Many rules are followed to select bone marrow, and the recipient is also subject to immunosuppression.

Prevention and prognosis for radiation injury

To prevent radiation injury, people who are or often are in areas of radio radiation are given the following advice:

use personal protective equipment,
take radioprotective drugs,
include a hemogram in your regular medical examination.

The prognosis for radiation sickness correlates with the dose of radiation received, as well as the time of its damaging effect. If the patient has survived the critical period of 12-14 weeks after radiation injury, he has every chance of recovery. However, even with non-lethal radiation, the victim may develop malignant tumors, hematological malignancies, and his subsequent children may develop genetic abnormalities of varying severity. Radiation sickness. Stages and types, methods of its treatment and prognosis.

RADIATION SICKNESS. Acute radiation sickness is an independent disease that develops as a result of the death of predominantly dividing cells of the body under the influence of short-term (up to several days) exposure to ionizing radiation on large areas of the body. The cause of acute radiation sickness can be either an accident or total irradiation of the body for therapeutic purposes - during bone marrow transplantation, in the treatment of multiple tumors. In the pathogenesis of acute radiation sickness, cell death in the immediate lesions plays a decisive role. No significant primary changes are observed in organs and systems that were not directly exposed to radiation. Under the influence of ionizing radiation, primarily dividing cells in the mitotic cycle die, but unlike the effect of most cytostatics (with the exception of myelosan, which acts at the level of stem cells), resting cells also die, and lymphocytes also die. Lymphopenia is one of the early and the most important signs acute radiation injury. Fibroblasts in the body are highly resistant to radiation. After irradiation, they begin to grow rapidly, which in areas of significant damage contributes to the development of severe sclerosis. The most important features of acute radiation sickness include the strict dependence of its manifestations on the absorbed dose of ionizing radiation. The clinical picture of acute radiation sickness is very diverse; it depends on the radiation dose and the time elapsed after irradiation. In its development, the disease goes through several stages. In the first hours after irradiation, a primary reaction appears (vomiting, fever, headache immediately after irradiation). After a few days (the sooner, the higher the radiation dose), bone marrow depletion develops, agranulocytosis and thrombocytopenia develop in the blood. Various infectious processes, stomatitis, hemorrhages. Between the primary reaction and the height of the disease, at radiation doses of less than 500-600 rad, a period of external well-being is observed - the latent period. The division of acute radiation sickness into periods of primary reaction, latent, height and recovery is inaccurate: purely external manifestations of the disease do not determine the true situation. When the victim is close to the radiation source, the reduction in the radiation dose absorbed throughout the human body is very significant. The part of the body facing the source is irradiated significantly more than its opposite side. The unevenness of irradiation may also be due to the presence of low-energy radioactive particles, which have little penetrating ability and cause predominantly damage to the skin, subcutaneous tissue, mucous membranes, but not to the bone marrow and internal organs.

It is advisable to distinguish four stages of acute radiation sickness: mild, moderate, severe and extremely severe. Mild cases include cases of relatively uniform exposure to a dose of 100 to 200 rad, moderate - from 200 to 400 rad, severe - from 400 to 600 rad, and extremely severe - over 600 rad. When exposed to a dose of less than 100 rad, they speak of radiation injury. The division of radiation according to severity is based on a clear therapeutic principle. Radiation injury without the development of disease does not require special medical supervision in a hospital. In mild cases, patients are usually hospitalized, but no special treatment is given, and only in rare cases, at doses approaching 200 rads, is it possible to develop short-term agranulocytosis with all the infectious complications and consequences requiring antibacterial therapy. With moderate severity, agranulocytosis and deep thrombocytopenia are observed in almost all patients; treatment in a well-equipped hospital, isolation, and powerful antibacterial therapy during the period of hematopoiesis depression are necessary. In severe cases, along with bone marrow damage, a picture of radiation stomatitis and radiation damage to the gastrointestinal tract is observed. Such patients should be hospitalized only in a highly specialized hematological and surgical hospital, where there is experience in managing such patients. With uneven irradiation, it is not at all easy to distinguish the severity of the disease, focusing only on dose loads. However, the task is simplified if we proceed from therapeutic criteria: radiation injury without the development of the disease - there is no need for special observation; mild - hospitalization mainly for observation; medium - all victims require treatment in a regular multidisciplinary hospital; severe - help needed specialized hospital(in terms of hematological lesions or deep skin or intestinal lesions); extremely severe - in modern conditions the prognosis is hopeless. The dose is rarely set physically; as a rule, this is done using biological dosimetry. The special system of biological dosimetry developed in our country now makes it possible not only to accurately determine the fact of overexposure, but also to reliably (within the described degrees of severity of acute radiation sickness) determine the radiation doses absorbed in specific areas of the human body. This provision is valid for cases of immediate, i.e., within the next 24 hours after irradiation, the victim’s admission for examination. However, even after several years after irradiation, it is possible not only to confirm this fact, but also to establish the approximate radiation dose by chromosomal analysis of peripheral blood lymphocytes and bone marrow lymphocytes. The clinical picture of the primary reaction depends on the radiation dose; it varies with different degrees gravity. The recurrence of vomiting is determined mainly by irradiation of the chest and abdomen. Irradiation lower half body, even a very large and heavy one, is usually not accompanied essential features primary reaction. During the next few hours after irradiation, patients experience neutrophilic leukocytosis without noticeable rejuvenation of the formula. It appears to be due to the mobilization of mainly the vascular granulocyte reserve. The height of this leukocytosis, in the development of which the emotional component may also play an important role, is not clearly related to the radiation dose. During the first 3 days. In patients, there is a decrease in the level of lymphocytes in the blood, apparently due to the interphase death of these cells. This indicator has a dose dependence 48-72 hours after irradiation.

After the end of the initial reaction, a gradual drop in the level of leukocytes, platelets and reticulocytes in the blood is observed. Lymphocytes remain close to the level of their initial drop. The leukocyte curve and generally similar curves of platelets and reticulocytes characterize regular, rather than random, changes in the level of these cells in the blood (blood tests are done daily). Following the initial increase in the level of leukocytes, a gradual decrease develops, associated with the consumption of the bone marrow granulocyte reserve, consisting mainly of mature, radiation-resistant cells - band and segmented neutrophils. The time to reach minimum levels and these levels themselves in the initial decrease in leukocytes have a dose dependence (see Table 10). Thus, if the radiation dose in the first days of the disease is unknown, it can be determined with sufficient accuracy for treatment after 1-1.5 weeks.

At radiation doses above 500-600 rads per bone marrow, the initial decrease in suffocation will lead to a period of agranulocytosis and deep thrombocytopenia. At lower doses, following the initial fall, there will be a slight rise in leukocytes, platelets and reticulocytes. In some cases, white blood cells can reach normal levels. Then leukemia and thrombocytopenia will occur again. So, agranulocytosis and thrombocytopenia during bone marrow irradiation in doses of more than 200 rad will occur the sooner the more dose, but not earlier than the end of the first week, during which the bone marrow granulocyte reserve is consumed and platelets “survive.” The period of agranulocytosis and thrombocytopenia in its clinical manifestations is identical to those of other forms of cytostatic disease. In the absence of blood transfusions, hemorrhagic syndrome in acute human radiation sickness is not expressed if the period of deep thrombocytopenia does not exceed 1.5-2 weeks. The depth of cytopenia and the severity of infectious complications are not strictly related to the radiation dose. Recovery from agranulocytosis occurs the sooner the earlier it began, i.e., the higher the dose. The period of agranupocytosis ends with the final restoration of the level of leukocytes and platelets. There are no relapses of deep cytopenia in acute radiation sickness. Recovery from agranulocytosis is usually quick - within 1-3 days. It is often preceded by a 1-2 day rise in platelet levels. If during the period of agranulocytosis there was heat body, then sometimes its fall is 1 day ahead of the rise in leukocyte levels. By the time of recovery from agranupocytosis, the level of reticulocytes also increases, often significantly exceeding normal - reparative reticulocytosis. At the same time, it is at this time (after 1-1.5 months) that the level of red blood cells reaches its minimum value. Damage to other organs and systems during acute radiation sickness is partly reminiscent of hematological syndrome, although the timing of their development is different.

When the oral mucosa is irradiated at a dose above 500 rad, the so-called oral syndrome develops: swelling of the oral mucosa in the first hours after irradiation, a short period of weakening of the swelling and its intensification again, starting from the 3-4th day; dry mouth, impaired salivation, the appearance of viscous saliva that provokes vomiting; development of ulcers on the oral mucosa. All these changes are caused by local radiation damage; they are primary. Their occurrence usually precedes agranulocytosis, which can exacerbate the infection of oral lesions. Oral syndrome occurs in waves with a gradual weakening of the severity of relapses, sometimes dragging on for 1.5-2 months. Starting from the 2nd week after the injury, at radiation doses of less than 500 rads, swelling of the oral mucosa is replaced by the appearance of dense whitish plaques on the gums - hyperkeratosis, which looks like thrush. Unlike her, these plaques are not removed; Microscopic analysis of the print from the plaque, which does not detect the mycelium of the fungus, also helps in differentiation. Ulcerative stomatitis develops when the oral mucosa is irradiated at a dose above 1000 rad. Its duration is about 1-1.5 months. Restoration of the mucous membrane is almost always complete; only with irradiation salivary glands at a dose above 1000 rad, a permanent suppression of salivation is possible.

At radiation doses above 300-500 rad, the intestinal area may develop signs of radiation enteritis. With irradiation up to 500 rad, slight bloating of the abdomen is noted in the 3-4th week after irradiation, infrequent mushy stupors, and an increase in body temperature to febrile levels. The time of appearance of these signs is determined by the dose: the higher the dose, the earlier the intestinal syndrome will appear. With more high doses a picture of severe enteritis develops: diarrhea, hyperthermia, abdominal pain, bloating, splashing and rumbling, pain in the ileocecal area. Intestinal syndrome can be characterized by damage to the colon (in particular, the rectum with the appearance of characteristic tenesmus), radiation gastritis, radiation esophagitis. The time of formation of radiation gastritis and esophagitis occurs at the beginning of the second month of the disease, when the bone marrow lesion is usually already eliminated. Even later (after 3-4 months) radiation hepatitis develops. His clinical characteristics differs in some features: jaundice occurs without a prodrome, bilirubinemia is low, the level of aminotransferases is increased (within 200-250 units), skin itching is pronounced. Over the course of several months, the process goes through many “waves” with a gradual decrease in severity. “Waves” are characterized by increased itching, a slight increase in bilirubin levels and pronounced activity of serum enzymes. The immediate prognosis for liver lesions should be considered good, although no specific therapeutic agents have yet been found (prednisolone worsens the course of hepatitis). In the future, the process can progress and after many years leads the patient to death from cirrhosis of the liver.

A typical manifestation of acute radiation sickness is damage to the skin and its appendages. Hair loss is one of the most striking external signs disease, although it has the least influence on its course. Hair from different parts of the body has different radiosensitivity: hair on the legs is the most resistant, hair on the scalp and face is the most sensitive, but eyebrows belong to the group of very resistant ones. Final (without restoration) hair loss on the head occurs with a single dose of radiation above 700 rad. The skin also has unequal radiosensitivity of different areas. The most sensitive areas are the armpits, inguinal folds, elbows, and neck. The areas of the back and extensor surfaces of the upper and lower extremities are significantly more resistant. Skin damage - radiation dermatitis - goes through the corresponding development phases: primary erythema, edema, secondary erythema, development of blisters and ulcers, epithelization. Between primary erythema, which develops at a skin irradiation dose above 800 rad, and the appearance of secondary erythema, there is a certain period, which is shorter the higher the dose, is a kind of latent period for skin lesions. It must be emphasized that the latent period itself in case of damage to specific tissues should not at all coincide with latent period damage to other tissues. In other words, such a period when the complete external well-being of the victim is noted cannot be observed with radiation doses above 400 rad for uniform irradiation; it is practically not observed with uneven irradiation, when the bone marrow is irradiated at a dose of more than 300-400 rad. Secondary erythema can result in peeling of the skin, mild atrophy, pigmentation without compromising the integrity of the skin, if the radiation dose does not exceed 1600 rad. At higher doses (starting from 1600 rad) bubbles appear. At doses above 2500 rad, primary erythema is replaced by swelling of the skin, which after a week turns into necrosis or blisters filled with serous fluid. The prognosis of skin lesions cannot be considered sufficiently definite: it depends on the severity of not only the skin changes themselves, but also on damage to the skin vessels and large arterial trunks. The affected vessels undergo progressive sclerotic changes over many years, and previously well-healed skin radiation ulcers over a long period of time can cause repeated necrosis, lead to amputation of a limb, etc. Outside of vascular damage, secondary erythema often ends with the development of pigmentation at the site of the radiation “burn” with compaction of subcutaneous tissue. In this area, the skin is usually atrophic, easily vulnerable, and prone to the formation of secondary ulcers. At the sites of the blisters, after their healing, nodular skin scars are formed with multiple angiectasias on atrophic skin. Apparently, these scars are not prone to cancerous degeneration.

The diagnosis of acute radiation sickness is currently not difficult. The characteristic picture of the primary reaction, its temporal characteristics of changes in the levels of lymphocytes, leukocytes, and platelets make the diagnosis not only error-free, but also accurate in relation to the severity of the process. Chromosomal analysis of cells, bone marrow and blood lymphocytes makes it possible to clarify the dose and severity of damage immediately after irradiation and retrospectively, months and years after irradiation. When this area of the bone marrow is irradiated at a dose of more than 500 rad, the frequency of cells with chromosomal abnormalities is almost 100%; at a dose of 250 rad, it is about 50%. Treatment of acute radiation sickness strictly corresponds to its manifestations. Treatment of the primary reaction is symptomatic: vomiting is stopped with the use of antiemetics medicines, administration of hypertonic solutions (in case of uncontrollable vomiting), and in case of dehydration, administration of plasma substitutes is necessary. To prevent exogenous infections, patients are isolated and aseptic conditions are created (boxes, ultraviolet air sterilization, use of bactericidal solutions). Treatment of bacterial complications should be urgent. Before identifying the causative agent of infection, so-called empirical therapy with broad-spectrum antibiotics is carried out according to one of the following regimens:

I. Penicillin - 20,000,000 units/day, streptomycin - 1 g/day.

II. Kanamycin - 1 g/day, ampicillin - 4 g/day.

III. Tseporin - 3 g/day, gentamicin -160 mg/day.

IV. Rifadin (benemicin) - 450 mg orally per day, lincomycin - 2 g / day. Daily doses of antibiotics (except rifadin) are administered intravenously 2-3 times a day.

When the infectious agent is seeded, antibacterial therapy becomes targeted. Treatment of necrotizing enteropathy: complete starvation until its elimination clinical manifestations(usually about 1-1.5 weeks), drink only water (but not juices!); if necessary long fasting – parenteral nutrition; careful care of the oral mucosa (rinsing); intestinal sterilization (kanamycin -2 g, polymyxin M - up to 1 g, ristomycin - 1.51; nystatin - 10,000,000 - 20,000,000 units/day). To combat thrombocytopenic hemorrhagic syndrome, transfusions of platelets obtained from a single donor are necessary. It is necessary to warn once again about the inappropriateness of transfusion of red blood cells in case of acute radiation sickness, if there are no clear indications for this in the form of severe anemia and the resulting respiratory and heart failure. In other words, if the hemoglobin level is above 83 g/l without signs of acute blood loss, there is no need to transfuse erythromass, as this can further aggravate radiation damage to the liver, increase fibrinolysis, and provoke severe bleeding.

Forecast. After eliminating all pronounced manifestations acute radiation sickness (bone marrow, intestinal, oral syndromes, skin lesions) patients recover. With mild and moderate lesions, recovery is usually complete, although moderate asthenia may persist for many years. After suffering a severe degree of illness, severe asthenia usually persists for a long time. In addition, such patients are at risk of developing cataracts. Its appearance is caused by a dose of exposure to the eyes of more than 300 rads. At a dose of about 700 rads they develop heavy defeat retina, hemorrhages in the fundus, increased intraocular pressure, possibly with subsequent loss of vision in the affected eye. After acute radiation sickness, changes in the blood picture are not strictly constant: in some cases stable moderate leukopenia and moderate thrombocytopenia are observed, in other cases this is not the case. There is no increased susceptibility to infectious diseases in such patients. The appearance of gross changes in the blood - pronounced cytopenia or, conversely, leukocytosis - always indicates the development of a new pathological process (aplastic anemia as an independent disease, leukemia, etc.). Changes in the intestines and oral cavity are not subject to any relapses. Chronic radiation sickness is a disease caused by repeated irradiation of the body in small doses, totaling more than 100 rad. The development of the disease is determined not only by the total dose, but also by its power, i.e., the period of exposure during which the radiation dose was absorbed in the body. In the conditions of a well-organized radiological service, there are currently no new cases of chronic radiation sickness in our country. Poor control over radiation sources and violation of safety regulations by personnel when working with X-ray therapy units have in the past led to cases of chronic radiation sickness. The clinical picture of the disease is determined primarily by asthenic syndrome and moderate cytopenic changes in the blood. Changes in the blood themselves are not a source of danger for patients, although they reduce their ability to work. The pathogenesis of asthenic syndrome remains unclear. As for cytopenia, it is apparently based not only on a decrease in the bridgehead of hematopoiesis, but also on redistribution mechanisms, as in these. patients in response to infection, the administration of prednisopon develops a distinct leukocytosis. Pathogenetic treatment There is no chronic radiation sickness. Symptomatic therapy is aimed at eliminating or weakening asthenic syndrome.

Forecast. Chronic radiation sickness itself does not pose a danger to the lives of patients, its symptoms do not tend to progress, and at the same time, complete recovery apparently does not occur. Chronic radiation sickness is not a continuation of the acute one, although the residual effects of the acute form partly resemble the chronic form. With chronic radiation sickness, tumors very often arise - hemoblastosis and cancer. With a well-organized clinical examination, a thorough oncological examination once a year and blood tests twice a year, it is possible to prevent the development of running forms cancer, and the life expectancy of such patients is approaching normal. Along with acute and chronic radiation sickness, a subacute form can be distinguished, which occurs as a result of repeated repeated irradiation in medium doses over several months, when the total dose for a relatively short term reaches more than 500-600 rad. The clinical picture of this disease resembles acute radiation sickness. Treatment for the subacute form has not been developed, since similar cases not found at present. Apparently the main role is played by replacement therapy blood components for severe aplasia and antibacterial therapy for infectious diseases.

Radiation damage to the skin, often called a radiation burn, can have a variety of clinical manifestations.

Radiation damage to the skin (development of radiation burns). Rice. 5. Erythema. Rice. 6 - 8. Development of bubbles. Wet radioepidermitis. Rice. 9. Erosion. Rice. 10. Scar; dyschromia, telangiectasia and a border of hyperpigmentation are visible.

Erythema - temporary redness of the skin at the site of irradiation; develops on the 13-14th day after single and 2-6 weeks after fractional irradiation.
Long lasting hair removal develops with single or fractional irradiation of the scalp. Dry epidermitis develops 7-10 days after a single dose or 2-3 weeks after fractional irradiation. Clinically manifested by erythema, swelling of the skin followed by lamellar peeling. Recovery of irradiated skin is incomplete. The skin remains atrophied, dry, epilated. Later, telangiectasia and uneven pigmentation appear.
Wet radioepidermitis is accompanied by sharp redness and swelling of the skin, the appearance of blisters filled with a clear yellowish liquid, which quickly open, exposing the basal layer of the epidermis. After 1-2 days, epithelization begins.
Wet epidermitis ends with permanent atrophy hair follicles, sebaceous and sweat glands, significant thinning of the skin, loss of elasticity, depigmentation (dyschromia), and the appearance of telangiectasia. Later, hyperkeratosis (excessive keratinization) and sclerosis of the underlying subcutaneous fatty tissue may become apparent. After irradiation with hard X-ray or amma radiation, 6-9 months later. and later slowly progressive atrophy is revealed muscle tissue and bone osteoporosis. The most severe degree of muscle atrophy and bone growth retardation are observed in children.
When treating malignant tumors, moist radioepidermitis is permissible only in small irradiation fields.
Radiation ulcer can develop acutely in the coming days and weeks after intense single irradiation, subacutely after 6-10 weeks, and also several years after irradiation. Acute course characterized by intense redness of the skin shortly after irradiation, accompanied by severe swelling, severe pain, a violation of the general condition. On edematous skin with congestive hyperemia, large blisters often appear with hemorrhagic cloudy contents. Upon rejection of the epidermis, a necrotic surface is exposed, covered with a permanent plaque, in the center of which an ulcer forms. Over a long period of time, necrotic tissue is rejected, flaccid and unstable granulations form, and the ulcer undergoes epithelization. Often healing does not occur. Subacutely developing radiation ulcer is often the outcome of long-term wet epidermitis. In the tissues surrounding the ulcer within the irradiated field, pronounced radiation atrophy develops over the next few months.
Late radiation ulcer usually develops against the background of sharply atrophied tissue at the site of irradiation. The formation of an ulcer occurs according to the type of acute radiation necrosis of tissue in the area of the entire irradiation field, involving not only the skin, but also the underlying tissues, subcutaneous tissue, muscles, and bones. In some cases, superficial excoriation (abrasion) appears on atrophied skin, which gradually deepens and increases in size, turning into a deep ulcer.
Radiation skin atrophy and radiation ulcer often result in the development of radiation cancer.
The result of radiation exposure to the skin and subcutaneous fatty tissue is often indurative tissue edema.
Indurative edema develops as a result of damage not only to the blood vessels, but also lymphatic vessels, which leads to impaired lymph outflow, swelling and sclerosis of the skin and subcutaneous tissue. The skin and subcutaneous tissue of the irradiated field gradually become dense and rise above the level normal skin, when pressed, a hole remains. The skin is hyperpigmented, covered with telangiectasia, or acquires a reddish-bluish tint and becomes painful. Under the influence of trauma or for no apparent reason, skin necrosis may occur in the area of inductive edema, leading to the formation of deep radiation ulcers.

Erythema does not require special treatment; All you need is protection from any type of skin irritation: solar insolation, thermal, chemical and mechanical effects, washing, especially with soap. All of these irritants contribute to an increase in the degree of damage.
It is allowed to lubricate reddened skin surfaces with indifferent fat, oils, and prednisolone ointment.
Wet epidermitis treated in an open manner, without a bandage. The wet surface is treated daily or every other day. alcohol solution gentian violet. If necessary, apply dressings with aloe liniment, tesan emulsion, sea buckthorn oil, fish oil. Epithelization ends after 1 - 2 weeks.
Treatment of radiation ulcer consists of radical surgical removal of the ulcer and surrounding tissues altered by radiation exposure. Non-radical intervention, i.e. leaving part of the irradiated tissue, leads to divergence of the sutures and the formation of an initially non-healing defect, which later turns into an ulcer again. After excision of small ulcers, it is possible to apply sutures without additional plastic surgery. For large ulcers, the operation ends with plastic surgery using flaps from surrounding tissues or Filatov flaps.
Before the operation, long-term preparation is necessary, which consists of fighting the infection, for which antibiotics are used; to cleanse the ulcer from necrotic tissue, use a 5-10% solution of dibunol in linethol, peloidin, vinylin (Shostakovsky balm); To stimulate the formation of granulations, metacil ointment, fish oil, linol, and aloe liniment are used. To improve blood supply to the tissues surrounding the ulcer and increase its mobility in relation to the underlying tissues, as well as improve nerve trophism, a circular novocaine blockade with a 0.25% solution is used.