MANAGEMENT OF THE SIDE EFFECTS OF RADIATION THERAPY IN CHILDREN: SIDE EFFECTS OF THORACIC IRRADIATION

I. EARLY EFFECT
Esophagitis A. Prevention
1.    Sucralfate (Carafate) slurry, starting on the 1st day of irradiation, has been suggested to decrease incidence and severity.
a.    Dose: 10-20 mg/kg per dose PO q.i.d.
b.    Available: suspension: 100 mg/mL
2.    Ranitidine HC1 (Zantac) has also been suggested to decrease severity.
a.    Dose: Infants and children: 4-5 mg/kg/day, divided, b.i.d. or t.i.d.
b.    Available
Tablet: 75 (OTC), 150 or 300 mg Syrup: 15 mg/mL
B. Presentation
Symptoms include substernal pain on swallowing, sensation of lump in throat, and sore throat.
Symptoms begin about 2 weeks into the course of thoracic radiation therapy.
Symptoms usually ease after radiation to esophagus stops or even decrease when oblique fields start.
a. Treatment
i.    Treat the same as oral mucositis.
ii.    If dysphagia persists or there is evidence of oral can-
didiasis, start candidal treatment (See above,
“Section IB under “Side Effects of Head and Neck
Irradiation”).
iii.    If the dysphagia is severe, the patient may need a
break from radiation treatment.
II. INTERMEDIATE EFFECTS
Radiation pneumonitis
A. Presentation
This presents either during radiation therapy or up to about 6 months after treatment is completed; it is very rare with doses <3000 cGy
Symptoms are shortness of breath, dyspnea on exertion, and cough
Fever is rare.
Radiographic changes seen in most patients are infiltrates within the irradiated volume of lung.
Decreased vital capacity and diffusing capacity are present.
Actinomycin D and Adriamycin may reactivate.
Abrupt steroid withdrawal may reactivate.
B. Treatment
Bedrest
Prednisone
a.    Dose: 0.5-2 mg/kg/day (maximum 80 mg/day), divided
t.i.d. to q.i.d.
b.    Available
Tablet: 1, 2.5, 5, 10, 20, or 50 mg Syrup: 1 mg/mL (5/6 alcohol)
III. LATE EFFECTS
A. Cardiac complications
1.    Late cardiac complications
a.    Acute myocardial infarction
b.    Acute pericarditis
c.    Constrictive pericarditis
d.    Valvular disease
2.    Risk factors
a.    Complications are dose, volume, and exact target
dependent.
i.    Proximal coronary arteries tend to be in high-dose
mediastinal fields.
ii.    Pericardial problems require that most of the heart
be in treatment volume; this is rare today.
b.    Age dependent: Risk decreases as child’s age at treatment increases.
c.    Acute pericarditis may be precipitated by abrupt
steroid withdrawal.
d.    Malignant hypertension can exacerbate arteriosclerosis in irradiated vessels, precipitating myocardial
infarction in patients at risk.
e.    Previous treatment with doxorubicin enhances the
risk.
3.    Presentation
a.    Acute myocardial infarction
Remember this risk in patients who present with chest pain or congestive failure after chest irradiation.
b.    Acute pericarditis
Pain
c. Constrictive pericarditis
Chest pain, poor tolerance of exercise, and normal heart size
B. Pulmonary fibrosis Presentation
Radiographs: scarring in field of radiation, sometimes with retraction
Rarely symptomatic
Reduced diffusing capacity
*47\168\2*

OTHER CAUSES OF LUNG CANCER: GENETICS

Ideas about the cause of lung cancer have been so dominated by recognition of the effect of smoking for the last forty years that it is sometimes easy to forget that there may be other important causal factors and that lung cancer still occurs in non-smokers. The effect of smoking is so strong that it can be quite difficult to unravel other causes, because the presence of a few smokers in any group will so alter the statistics. However, there are undoubtedly other factors at work in the development of lung cancer and many of them can now be judged.
Lung cancer is not inherited in any simple way and in Scandinavia, studies of identical twins have shown that it is smoking that determines any difference in risk of lung cancer. Identical twins have identical genes and if there were a simple relationship between inherited genes and lung cancer, we would expect the incidence of cancer to be the same in identical twins, regardless of any differences which we might find in the smoking habits of each twin in a pair. This is not the case. If one of a pair of twins smokes, the risk of lung cancer in that twin is greater. While, however, there is no simple link between genetic inheritance and the incidence of lung cancer, the fact remains that some non-smokers get cancer and some smokers do not. This raises the possibility that genetic inheritance may be influential in some subtle way and provide at least part of the explanation for this odd fact. One of the teasing questions which biologists now have to tackle is the part played by innate genetic make-up in protecting some smokers from cancer and disposing some non-smokers to the disease. One suggestion that is being studied is that there may be genetic differences in the way in which the body handles the chemicals produced in cigarettes so as to detoxify them. If research along these, or similar, lines produces answers, we shall be able to identify the patients whose genetic make-up puts them at special risk.
*46\194\4*

VITAMIN C: PRODUCTION OF ANTI-BODIES

Ascorbic acid is necessary for the production of anti-bodies formed in the body against infections by bacteria and viruses. Unless it is present in the blood, immunization or vaccination against infectious disease causes marked reactions. Diphtheria, tetanus and whooping cough vaccines (triple antigen injected into babies), influenza vaccine, smallpox and rubella vac­cines can cause fever and severe symptoms if the reci­pient is deficient in Vitamin C.

This is why doctors are advised in the leaflets ac­companying the vaccines not to immunize a child suf­fering from a cold or other infection. Infections quickly use up all the Vitamin C in the blood and tissues and, unless it is specially supplied before immunization, there is none to produce antibodies against the introduced organisms, whether they be living or killed.

This danger of immunization has been brought out by the experiences of Dr Archie Kalokerinos with aboriginal children in Collarenabri (N.S.W.). The constant infections of nasal passages, ears, chest and bowels from which so many aboriginal children suffer, use up all the scanty supply of Vitamin C they obtain from their food. They have little natural immunity in their make up and, with no Vitamin C to produce antibodies, injections of triple antigen have caused such severe reactions that some of them have become severely sick with pneumonia, others have died of shock.

Ascorbic acid is thus one of the best and safest bul­warks we have against infections of all kinds, whether by bacteria or viruses. It enables the body to produce anti-bodies against them’— and without it antibodies cannot be formed to combat these invaders, nor the poisons they produce.

It has been actually shown, for example, that shots of ‘flu vaccine have a far greater protective effect when Vitamin C is given at the same time. Similar results have been achieved by Vitamin C controlling the germs causing whooping cough and tetanus.

In practice it is, of course, unwise — even dangerous — to give an immunizing injection to any child who has ‘flu or a cold or other infection. Should immunization be urgent, large doses of Vitamin C should be given before and for several days after the injection.

Even babies can take Vitamin C as Rose Hip Syrup or vitamin drops (orange juice is not enough and oranges differ widely in their Vitamin C content).

Even in a perfectly well child or adult the value of immunization injections of any kind is improved by taking at least 1000 mg to 1500 mg of Vitamin C on the day before and for several days after.
*6/21/7*
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FUNCTIONS OF VITAMIN C IN COLLAGEN FORMATION

One of the most important functions of Vitamin C is the formation and maintenance of a protein-like sub­stance in the body called ‘collagen’. Collagen cannot be formed without ascorbic acid.

Collagen is the actual cement substance that holds the body together. It forms one third of the total amount of body protein. Collagen forms the kind of meshwork in which the calcium of the bones is laid down, much like the ‘reinforcement’ in a concrete wall.

Ligaments that join bone to bone in the joints, the tendons of muscles, indeed, the connective tissue net­work in which the muscle cells lie are formed of colla­gen. It enters into the substance of the teeth and is the cement that holds the teeth firmly in the gums. Even a mild deficiency over the years causes the teeth to be­come loose in their sockets, and, as the cement sub­stance disappears, pockets are formed in which food and germs accumulate with the resulting pyorrhoea that comes on about middle age.

As Vitamin C is not so well absorbed by the elderly, pyorrhoea and loosened teeth become more prevalent as the years advance. Very few elderly people still have their own teeth and healthy gums.

Collagen is most important in the walls and linings of the blood vessels. It forms the firm connective tissue in the walls of both arteries and veins, and when weakened aneurisms or bubbles can form on the artery walls, and veins become flaccid, bulgy and ‘varicose’ where pressure is greatest. This is seen mostly in the legs and round the anus — forming piles or haemor­rhoids.

It is the collagen substance that actually joins the cells lining the blood vessels. The walls of the capil­laries where the fluid nourishment in the blood actu­ally seeps through to the tissues are only one cell thick. If the cement that holds them together is weak or lost, as in scurvy, the capillaries become like a leaking sieve and the red blood corpuscles themselves escape into the tissues and we have a bruise or blood mark under the skin.

Easy bruising and those tiny patches of haemor­rhage so often seen under the skin on the hands and forearms of elderly people are early but certain signs of Vitamin C deficiency.

In scurvy the whole condition is intensified. Blood seeps into the joints, between muscles and round the teeth.

It is the C dependent collagen in the tissues that keeps the skin youthful, soft, firm, supple and free of wrinkles. In fact, poor collagen maintenance is inti­mately connected with the whole ageing process. Adequate strong collagen throughout the body main­tains health, flexibility and a youthful appearance.

Viewed under the high powered microscope this collagen substance is marked by bands of firmer ma­terial in the jelly-like matrix, much like the reinforce­ment in concrete. But there are no strengthening bands in vitamin deficient collagen. It is soft, friable and easily dislodged and broken, allowing the blood to seep out of the capillaries, the teeth to become loose in their sockets, the lining of joints to become pitted and painful and the expanding tissues in the body to lose their elasticity and become like old spent elastic.

This is almost certainly what happens to the pads of fibrous elastic tissue between the vertebrae of the spine — the inter-vertebral discs. With a low Vitamin C con­tent of the tissues, the discs degenerate and cause a condition prevalent in many people.

For many young people, but more so as the years advance, the discs, made largely of collagen, lose their firmness and elasticity and squash out between the vertebrae thinning and protruding so that they press on the sensitive nerves, emerging between the bones, causing intense pain.

The bodies of the vertebrae themselves are only too often softened through lack of firm collagen matrix in which the calcium particles are enmeshed. They tend to give under the weight of the body and become wedge-shaped — causing further pressure on nerves. Here we have all the makings of the low back pain that plagues so many and the bent backs and dwindling height so prevalent in the elderly.

This is what we see so often in old age — deteriora­tion not due to age alone, but to a shortage of Vitamin C over the years. We need much more than the mere Recommended Daily Allowance, and yet there are only 50 mg tablets now allowed for pensioners as a pharmaceutical benefit.

The old 500 mg tablets were much more effective. Two or three of these a day kept many pensioners, who could not afford much fresh fruit, healthy, active and free from colds and chest infections and backache.

There are, indeed, many people both young and old even in this fruit-growing country who suffer from a Vitamin C deficiency, not recognized and not ac­knowledged by doctors or health authorities.

If their symptoms were called early or incipient scurvy — which it is — perhaps we would all take more notice and seek to remedy the deficiency.
*5/21/7*
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FOOD ACCEPTANCE AND HABITS: HUNGER AND APPETITE

THE AIROLA DIET: COLD-PRESSED VEGETABLE OILS AND HONEY

CHILD’S HEALTH/SKIN DISORDERS: ATHLETE’S FOOT (TINEA PEDIS)

Athlete’s foot is the name given to a common fungal infection of the feet which is usually more common in teenagers.

Cause

Warm, sweaty skin is the ideal breeding ground for this fungus called tinea. It commonly occurs in summer, or in people (such as athletes) who always wear shoes and tend to get sweaty feet.

Clinical features

The rash usually appears as itchy, red, peeling areas, mainly between the toes. Cracks may appear in the skin which may weep or bleed. Small scales or tiny dots may appear on the sole of the feet, and sometimes can be mistaken for warts. The feet usually have a distinctive, musty odour.

Make sure the area between the toes is dried well after bathing. An antifungal powder or cream (available on prescription and in some cases over the counter from your chemist) should be applied twice a day, for at least 3 weeks, until the rash has cleared completely. Discourage scratching, as this will only make matters worse. Make sure only cotton socks are worn, and that they are changed twice a day. It is preferable to go barefoot or wear sandals, so that the feet are kept dry and exposed to the air. If shoes must be worn, leather is preferable to synthetic or rubber shoes, as they tend to ‘breathe’ more.

When to see your doctor

• if the feet are painful;

• if there is pus oozing from the rash;

• if the rash is spreading despite taking the above measures;

• if the rash does not start to improve a week after starting treatment.

Prevention

There is no proof that tinea is picked up from public swimming pools or showers but some people feel safer if they wear thongs or sandals in these places. The main way to prevent tinea is to keep the feet dry and change socks and shoes frequently, going barefoot or wearing open shoes as much as possible.

*291\90\8*

SENIOR CITIZEN SEX EDUCATION: FEW QUESTIONS ABOUT MENOPAUSE

“Do men have menopause?”

A very small percentage of men over age sixty experience what some doctors call the male climacteric, and this relatively rare condition is related to a decrease in a certain hormone in the blood. If the doctor tries to provide the hormone and the symptoms don’t disappear or reduce, it is probably not the male climacteric that is causing the problem.

The symptoms of male climacteric usually include a combination of loss of appetite, distractibility, decrease in sexual urge or interest, edginess, fatigue, and some problems with erection. Of course, these problems happen to everyone sometime, so don’t be too quick to jump to conclusions about male climacteric. My experience teaches that this is a very rare condition that is not at all the same thing as menopause in women.

“Does menopause mean loss of sex interest?”

No. Menopause is just the reverse of a process that started early in your life as you developed fertility. Menopause is not a thing, but a process of several years, so fertility does not just stop one day. Menopause definitely does not end sexual interest or ability to want to and to be able to enjoy sex.

*327\97\8*

YOUR MARITAL HEALTH/WIVES’ SEXUALITY: DO YOU KNOW YOUR WIFE’S TYPE?

The Figurine

I’m just not as strong as he is. I need him. He takes care of me like no one ever could.

WIFE

This is the fragile wife. The husband feels he is protecting her, and she assumes this role by acting weak, even physically sick or emotionally insecure. Sexually, she conveys an image of breakability, holding back her own assertive and expressive tendencies for fear of “blowing her cover,” for fear of letting her husband see that she is not as fragile as he thinks or perhaps needs her to be.

The Searcher

I have watched every time a talk show has anybody on about sex. I have tried everything. My women’s support group says my husband is just a sexist pig. Maybe they’re right, but I’m not going to tell him. I’m used to him that way. I call him Mr. Piggy.

WIFE

This wife has sensed that something is not well sexually and has turned to talk shows and sex manuals for direction. She talks more with friends about her sexual problems than she does with her husband. Most of her sexual knowledge is derived from friends, books, romantic novels. She assumes the role of Scarlett from Gone with the Wind, provoking, teasing, trying new techniques to encourage her husband to be Rhett and sweep her off her feet, up the stairs, and into bed. Unfortunately, some of these husbands continue not to “give a damn.”

The Super Wife

I never knew how strong I was as a person until I learned how strong we were as a couple.

WIFE

This is the model of the wife in a super sex marriage. She is aware of her sexual physiology, the forms and formation of her love map, understands the fourth perspective of sex, and integrates sex, love, and loving into her own unique and ever-changing role as a self-representing love partner.

*154\97\8*

THE DESEXUALIZATION OF THE AMERICAN MARRIAGE: THE MIMS TEST (MARRIAGE INVESTMENT MINUTES)

Over a seven-day week, add the minutes you estimate you spend in the following activities:

1. Talking with your spouse with absolutely no one else around, not even the dog.

2. Discussing things related only to the two of you, excluding for now the kids, your parents, work, money, or other daily activities.     

3. Time spent just looking at one another, not talking, doing, fixing, or fussing—just looking.        

4. Time spent having fun together, playing together in a non-goal-directed activity, without another couple or the kids. (Not getting ready to play, but actually in mutually enjoyable recreation.)    

5. Time spent during the week making love, kissing, hugging, touching in privacy without interruption. This counts for only consecutive time, not a kiss here, a hug there.    

6. Time spent talking about the future of the marriage. This means your future together, not retirement funds, retirement home, and insurance plans.        

7. Time spent discussing world affairs, politics, issues of the day (this means actually discussing, not just one partner complaining or lecturing and the other serving as audience).    

8. Time spent just sitting together while each of you is doing something else, such as reading, sewing, listening to music (do not count TV-watching time, which is typically mutual hypnosis, not mutual relaxation).

9. Time spent eating quietly together alone, with no kids or pets or phones or TV.        

10. Time spent spiritually together, such as praying, contemplating, meditating, attending religious services as a couple.        

To promote discussion of MIMs, I estimate that total available time for relating is a maximum of thirty hours per week, or 1,800 available MIMs. Of course, no one gets even close to that amount in our complex and ‘ ‘hurry illness” society, but the 1,800 available MIMs provide a starting point when time for sleep and work is subtracted from minutes in the week.

Now, a penalty subtraction. Subtract the time you spend per week, either alone or with your spouse, watching TV. This TV addiction is one of the most detrimental influences on American marriage. It is a shared addiction, which is the worst type, because it sometimes covertly robs the relationship of available time for intimacy while both partners take unknowing part in the theft.

*14\97\8*