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Ionizing radiation is emitted by radioactive elements and by equipment such as x-ray and radiation therapy machines.
Types of radiation
Radiation includes
High-energy electromagnetic waves (x-rays, gamma rays)
Particles (alpha particles, beta particles, neutrons)
Alpha particles are energetic helium nuclei emitted by some radionuclides with high atomic numbers (eg, plutonium, radium, uranium); they cannot penetrate skin beyond a shallow depth (< 0.1 mm).
Beta particles are high-energy electrons that are emitted from the nuclei of unstable atoms (eg, cesium-137, iodine-131). These particles can penetrate more deeply into the skin (1 to 2 cm) and cause both epithelial and subepithelial damage.
Neutrons are electrically neutral particles emitted by a few radionuclides (eg, californium-252) and produced in nuclear fission reactions (eg, in nuclear reactors); their depth of tissue penetration varies from a few millimeters to several tens of centimeters, depending on their energy. They collide with the nuclei of stable atoms, resulting in the emission of energetic protons, alpha and beta particles, and gamma radiation.
Gamma radiation and x-rays are electromagnetic radiation (ie, photons) of very short wavelength that can penetrate deeply into tissue (many centimeters). While some photons deposit all their energy in the body, other photons of the same energy may deposit only a fraction of their energy, and others may pass completely through the body without interacting.
Because of these characteristics, alpha and beta particles cause the most damage when the radioactive atoms that emit them are within the body (internal contamination) or, in the case of beta-emitters, directly on the body; only tissue in close proximity to the radionuclide is affected. Gamma rays and x-rays can cause damage distant from their source and are typically responsible for acute radiation syndromes Acute radiation syndromes (ARS) Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more . Acute radiation syndromes can be caused by a sufficient dose of some internally deposited radionuclides that are widely distributed in tissues and organs and have a high specific activity. For example, polonium-210 (Po-210) has a specific activity of 166 terabecquerels per gm (TBq/g), and 1 mcg (about the size of a grain of salt) of Po-210 delivers a whole body dose of 50 Sv (~20 times the median lethal dose).
Measurement of radiation
Conventional units of measurement include the roentgen, rad, and rem. The roentgen (R) is a unit of exposure measuring the ionizing ability of x-rays or gamma radiation in air. The radiation absorbed dose (rad) is the amount of that radiation energy absorbed per unit of mass. Because biologic damage per rad varies with radiation type (eg, it is higher for neutrons than for x-rays or gamma radiation), the dose in rad is corrected by a radiation type quality factor; the resulting equivalent dose unit is the roentgen equivalent in man (rem). Outside the US and in the scientific literature, SI (International System) units are used, in which the rad is replaced by the gray (Gy) and the rem by the sievert (Sv); 1 Gy = 100 rad and 1 Sv = 100 rem. The rad and rem (and hence Gy and Sv) are essentially equal (ie, the quality factor equals 1) when describing x-rays or gamma or beta radiation.
The amount (quantity) of radioactivity is expressed in terms of the number of nuclear disintegrations (transformations) per second. The becquerel (Bq) is the SI unit of radioactivity; one Bq is 1 disintegration per second (dps). The conventional unit, Curie (Ci), is sometimes still used in the US, where one curie is 37 billion Bq. This is equivalent to 37,000 megabecquerels (MBq) or 37 gigabecquerels (GBq).
Types of exposure
Radiation exposure may result from
Radioactive contamination is the unintended contact with and retention of radioactive material, usually as dust or liquid. Contamination may be
External contamination is that on skin or clothing, from which some can fall or be rubbed off, contaminating other people and objects. Internal contamination is unintended radioactive material within the body, which it may enter by ingestion, inhalation, or through breaks in the skin. Once in the body, radioactive material may be transported to various sites (eg, bone marrow), where it continues to emit radiation until it is removed or decays.
Internal contamination is more difficult to remove. Although internal contamination with any radionuclide is possible, historically, most cases in which contamination posed a significant risk to the patient involved a relatively small number of radionuclides, such as phosphorus-32, cobalt-60, strontium-90, cesium-137, iodine-131, iodine-125, radium-226, uranium-235, uranium-238, plutonium-238, plutonium-239, polonium-210, and americium-241.
Irradiation is exposure to radiation but not radioactive material (ie, no contamination is involved). Radiation exposure can occur without the source of radiation (eg, radioactive material, x-ray machine) being in contact with the person. When the source of the radiation is removed or turned off, exposure ends. Irradiation can involve the whole body, which, if the dose is high enough, can result in systemic symptoms and radiation syndromes Acute radiation syndromes (ARS) Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more , or a small part of the body (eg, from radiation therapy), which can result in local effects. People do not emit radiation (ie, become radioactive) following irradiation.
Sources of exposure
Sources may be naturally occurring or artificial (see table Average Annual Radiation Exposure in the US Average Annual Radiation Exposure in the US* ).
People are constantly exposed to low levels of naturally occurring radiation called background radiation. Background radiation comes from cosmic radiation and from radioactive elements in the air, water, and ground. Cosmic radiation is concentrated at the poles by the earth's magnetic field and is attenuated by the atmosphere. Thus, exposure is greater for people living at high latitudes, at high altitudes, or both and during airplane flights. Terrestrial sources of external radiation exposure are primarily due to the presence of radioactive elements with half-lives comparable to the age of the earth (~ 4.5 billion years). In particular, uranium-238 and thorium-232, along with several dozen of their radioactive progeny and a radioactive isotope of potassium (K-40), are present in many rocks and minerals. Small quantities of these radionuclides are in the food, water, and air and thus contribute to internal exposure as these radionuclides are invariably incorporated into the body. The majority of the dose from internally incorporated radionuclides is from radioisotopes of carbon (C-14) and potassium (K-40), and because these and other elements (stable and radioactive forms) are constantly replenished in the body by ingestion and inhalation, there are approximately 7000 atoms undergoing radioactive decay in the body each second.
Internal exposure from the inhalation of radioactive isotopes of the noble gas radon (Rn-222 and Rn-220 ), which are also formed from the uranium-238 decay series, accounts for the largest portion (73%) of the US population's average per capita naturally occurring radiation dose. Cosmic radiation accounts for 11%, radioactive elements in the body for 9%, and external terrestrial radiation for 7%. In the US, people receive an average effective dose of about 3 millisieverts (mSv)/year from natural sources (range ~ 0.5 to 20 mSv/year). However, in some parts of the world, people receive > 50 mSv/year. The doses from natural background radiation are far too low to cause radiation injuries; they may result in a small increase in the risk of cancer, although some experts think there may be no increased risk.
In the US, people receive on average about 3 mSv/year from man-made sources, the vast majority of which involve medical imaging. On a per capita basis, the contribution of exposure from medical imaging is highest for CT and nuclear cardiology procedures. However, medical diagnostic procedures rarely impart doses sufficient to cause radiation injury, although there is a small theoretical increase in the risk of cancer. Exceptions may include certain prolonged fluoroscopically guided interventional procedures (eg, endovascular reconstruction, vascular embolization, cardiac and tumor radiofrequency ablation); these procedures have caused injuries to skin and underlying tissues. Radiation therapy can also cause injury to normal tissues near the target tissue.
A very small portion of average public exposure results from radiation accidents and fallout from nuclear weapons testing. Accidents may involve industrial irradiators, industrial radiography sources, and nuclear reactors. These accidents commonly result from failure to follow safety procedures (eg, interlocks being bypassed). Radiation injuries have also been caused by lost or stolen medical or industrial sources containing large quantities of the radionuclide. People seeking medical care for these injuries may be unaware that they were exposed to radiation.
Unintended releases of radioactive material have occurred, including from the Three Mile Island plant in Pennsylvania in 1979, the Chernobyl reactor in Ukraine in 1986, and the Fukushima Daiichi nuclear power facility in Japan in 2011.
Exposure from Three Mile Island was minimal because there was no breach of the containment vessel as occurred at Chernobyl and no hydrogen explosion as occurred at Fukushima. People living within 1.6 km of Three Mile Island received at most only about 0.08 mSv (a fraction of what is received from natural sources in a month).
By contrast, the 115,000 people who were eventually evacuated from the area around the Chernobyl plant received an average effective dose of about 30 mSv and an average thyroid dose of about 490 mGy. People working at the Chernobyl plant at the time of the accident received significantly higher doses. More than 30 workers and emergency responders died within a few months of the accident, and many more experienced acute radiation sickness. Low-level contamination from that accident was detected as far away as Europe, Asia, and even (to a lesser extent) North America. The average cumulative exposure for the general population in various affected regions of Belarus, Russia, and Ukraine over a 20-year period after the accident was estimated to be about 9 mSv.
The earthquake and tsunami in Japan in 2011 led to the release of radioactive material into the environment from several reactors at the Fukushima Daiichi nuclear power plant. There were no serious radiation-induced injuries to on-site workers. Among nearly 400,000 residents in Fukushima prefecture, the estimated effective dose (based on interviews and dose reconstruction modeling) was < 2 mSv for 95% of the people and < 5 mSv for 99.8%. The World Health Organization estimates were somewhat higher because of intentionally more conservative assumptions regarding exposure. The effective dose in prefectures not immediately adjacent to Fukushima was estimated to be between 0.1 to 1 mSv, and the dose to populations outside of Japan was negligible (< 0.01 mSv).
The most significant radiation exposure to a population occurred following the detonation of two atomic bombs over Japan in August 1945, which caused about 110,000 deaths from the immediate trauma of the blast and heat. A much smaller number (< 1,000) of excess deaths due to radiation-induced cancer have occurred over the ensuing 70 years. Ongoing health surveillance of the survivors remains among the most important sources of estimates of radiation-induced cancer risk.
While several criminal cases of intentional contamination of individuals have been reported, radiation exposure to a population as a result of terrorist activities has not occurred but remains a concern. A possible scenario involves the use of a device to contaminate an area by dispersing radioactive material (eg, from a discarded radiotherapy or industrial source of cesium-137 or cobalt-60). A radiation dispersal device (RDD) that uses conventional explosives is referred to as a dirty bomb. Other terrorist scenarios include using a hidden radiation source to expose unsuspecting people to large doses of radiation, attacking a nuclear reactor or radioactive material storage facility, and detonating a nuclear weapon (eg, an improvised nuclear device [IND], a stolen weapon).
Pathophysiology of Radiation Exposure and Contamination
Ionizing radiation can damage DNA, RNA, and proteins directly, but more often, the damage to these molecules is indirect, caused by highly reactive free radicals generated by radiation's interaction with intracellular water molecules. Large doses of radiation can cause cell death, and lower doses may interfere with endogenous molecular repair systems, homeostasis, and cellular proliferation. Damage to these and other cellular components can result in progressive tissue hypoplasia, atrophy, and eventually fibrosis. However, it is now clear that cell killing alone cannot explain many tissue reactions because those reactions also depend on complex events, including inflammatory, chronic oxidative, and immune reactions, as well as damage to the vasculature and the extracellular matrix. In general, early reactions, such as in the skin and gastrointestinal tract, involve killing of the stem/early progenitor cells that supply the mature functional cells in the tissue, as well as inflammatory reactions. On the other hand, late reactions (eg, in the lung, kidneys, and brain) involve complex and dynamic interactions between multiple cell types in the tissues and organs and include infiltrating immune cells, production of cytokines and growth factors, often in persistent, cyclic cascades, and chronic oxidative stress.
Factors affecting response
Biologic response to radiation varies with
Tissue radiosensitivity
Dose rate
Duration of exposure
Degree of inflammatory response
The age of the patient
Presence of genetic DNA repair defect disorders (eg, ataxia-telangiectasia Ataxia-Telangiectasia Ataxia-telangiectasia results from a DNA repair defect that frequently results in humoral and cellular immunodeficiency; it causes progressive cerebellar ataxia, oculocutaneous telangiectasias... read more , Bloom syndrome, Fanconi anemia Fanconi Syndrome Fanconi syndrome consists of multiple defects in renal proximal tubular reabsorption, causing glucosuria, phosphaturia, generalized aminoaciduria, and bicarbonate wasting. It may be hereditary... read more )
Cells and tissues differ in their radiosensitivity. In general, cells that are undifferentiated and those that have high mitotic rates (eg, stem cells, cancer cells) are particularly vulnerable to radiation. Because radiation preferentially depletes rapidly dividing stem cells over the more resistant mature cells, there is typically a latent period between radiation exposure and overt radiation injury. Injury does not manifest until a significant fraction of the mature cells die of natural senescence and, due to loss of stem cells, are not replaced.
Cellular sensitivities in approximate descending order from most to least sensitive are
Lymphoid cells
Germ cells
Proliferating bone marrow cells
Intestinal epithelial cells
Epidermal stem cells
Hepatic cells
Epithelium of lung alveoli and biliary passages
Kidney epithelial cells
Endothelial cells (pleura and peritoneum)
Connective tissue cells
Bone cells
Muscle, brain, and spinal cord cells
The severity of radiation injury depends on the dose and the length of time over which it is delivered. A high, single, rapid dose is more damaging than the same dose given over weeks or months. Dose-response also depends on the fraction of the body exposed. Significant illness is certain, and death is possible, after a whole-body dose > 4.5 Gy is delivered over a short time interval (minutes to hours); however, 10s of Gy can be well tolerated when delivered over a long period to a small area of tissue (eg, for cancer therapy).
Other factors can increase the sensitivity to radiation injury. Children are more susceptible to radiation injury because they have a higher rate of cellular proliferation. People who are homozygous for the ataxia-telangiectasia Ataxia-Telangiectasia Ataxia-telangiectasia results from a DNA repair defect that frequently results in humoral and cellular immunodeficiency; it causes progressive cerebellar ataxia, oculocutaneous telangiectasias... read more gene exhibit greatly increased sensitivity to radiation injury. Disorders such as connective tissue disorders and diabetes may increase sensitivity to radiation injury. Some medications and chemotherapeutic agents (eg, actinomycin D, doxorubicin, bleomycin, 5-fluorouracil, methotrexate) may also increase sensitivity to radiation injury. Some chemotherapeutic agents (eg, doxorubicin, etoposide, paclitaxel, epirubicin), antibiotics (eg, cefotetan), statins (eg, simvastatin), and herbal preparations can produce an inflammatory skin reaction at the site of prior irradiation (radiation recall) weeks to years after exposure at the same location (1 Pathophysiology reference Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more ).
Carcinogenic, teratogenic, and heritable effects
Radiation-induced genetic damage to somatic cells may result in malignant transformation, while in-utero exposure can lead to teratogenic effects, and damage to germ cells raises the theoretical possibility of transmissible genetic defects.
Protracted whole-body exposure to 0.5 Gy is estimated to increase an average adult's lifetime risk of cancer mortality from approximately 22% to about 24.5%, an 11% relative risk increase but only a 2.5% absolute risk increase. The chance of developing cancer due to commonly encountered doses (ie, from background radiation and typical imaging tests [see Risks of Ionizing Radiation Risks of Medical Radiation Ionizing radiation (see also Radiation Exposure and Contamination) includes High-energy electromagnetic waves (x-rays, gamma rays) Particles (alpha particles, beta particles, neutrons) Ionizing... read more ]) is much less and may be zero. Estimates of increased risk of radiation-induced cancer as a result of the typically low doses experienced by people in the vicinity of reactor incidents such as Fukushima have been made by extrapolating downward from known effects of much higher doses. The very small resultant theoretical effect is multiplied by a large population to give what may appear to be a concerning number of additional cancer deaths. The validity of such extrapolations cannot be confirmed because the hypothesized increase in risk is too small to be detected in epidemiologic studies, and the possibility that there is no increased cancer risk due to this exposure cannot be excluded.
Children are more susceptible because they have a higher number of future cell divisions and a longer life span during which cancer may manifest. CT of the abdomen done in a 1-year-old child is estimated to increase the child's estimated lifetime absolute risk of developing cancer by about 0.1%. Radionuclides that are incorporated into specific tissues are potentially carcinogenic at those sites (eg, the Chernobyl reactor accident resulted in substantial radioactive iodine uptake due to consumption of contaminated milk, and subsequent excess thyroid cancers occurred among exposed children).
The fetus is exceptionally susceptible to high-dose radiation injury. However, at doses < 100 mGy, teratogenic effects are unlikely. The fetal risk from radiation at doses typical of imaging tests that pregnant women are likely to undergo is very small compared with the overall risk of birth defects (2 to 6 % observable at birth) and the potential diagnostic benefit of the examination. The increased risk of developing cancer as a result of in-utero radiation exposure is about the same as that from radiation exposure of children which is about 2 to 3 times the adult risk of 5%/Sv.
The potential risks from radiation exposure mandate giving careful consideration to the need for (or alternatives to) imaging tests involving radiation, optimizing the radiation exposure for body habitus and the clinical question being asked, as well as attention to the use of proper radiation protection procedures, especially in children and pregnant women.
Damage to reproductive cells has been shown to cause birth anomalies in progeny of severely irradiated animals. However, hereditary effects have not been found in children of radiation-exposed humans, including the children of Japanese atomic bomb survivors or the children of cancer survivors treated with radiotherapy. The average dose to the ovaries was ~ 0.5 Gy and to the testes 1.2 Gy.
Pathophysiology reference
1. Balter S, Hopewell JW, Miller DL, et al: Fluoroscopically guided interventional procedures: A review of radiation effects on patients' skin and hair. Radiology 254(2):326-341, 2010. doi:10.1148/radiol.2542082312
Symptoms and Signs of Radiation Exposure and Contamination
Clinical manifestations depend on whether radiation exposure involves the whole body (acute radiation syndrome Acute radiation syndromes (ARS) Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more ) or is limited to a small portion of the body (focal radiation injury Focal radiation injury Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more ).
Acute radiation syndromes (ARS)
After the whole body, or a large portion of the body, receives a high dose of penetrating radiation, several distinct syndromes may occur:
Cerebrovascular syndrome
Gastrointestinal (GI) syndrome
Hematopoietic syndrome
These syndromes have 3 different phases:
Prodromal phase (minutes to 2 days after exposure): Lethargy and GI symptoms (nausea, anorexia, vomiting, diarrhea) are possible.
Latent asymptomatic phase (hours to 21 days after exposure)
Overt systemic illness phase (hours to > 60 days after exposure): Illness is classified by the main organ system affected
Which syndrome develops, how severe it is, and how quickly it progresses depend on radiation dose (see table Effects of Whole-Body Irradiation From External Radiation or Internal Absorption Effects of Whole-Body Irradiation From External Radiation or Internal Absorption ). The symptoms and time course are fairly consistent for a given dose of radiation and thus can help estimate radiation exposure.
The cerebrovascular syndrome, the dominant manifestation of extremely high whole-body doses of radiation (> 30 Gy), is always fatal. The prodrome develops within minutes to 1 hour after exposure. There is little or no latent phase. Patients develop tremors, seizures, ataxia, and cerebral edema and die within hours to 1 or 2 days.
The GI syndrome is the dominant manifestation after whole-body doses of about 6 to 30 Gy. Prodromal symptoms, often marked, develop within about 1 hour and resolve within 2 days. During the latent period of 4 to 5 days, GI mucosal cells die. Cell death is followed by intractable nausea, vomiting, and diarrhea, which lead to severe dehydration and electrolyte imbalances, diminished plasma volume, and vascular collapse. Necrosis of intestine may also occur, predisposing to intestinal perforation, bacteremia, and sepsis. Death is common. Patients receiving > 10 Gy may have cerebrovascular symptoms (suggesting a lethal dose). Survivors also have the hematopoietic syndrome.
The hematopoietic syndrome is the dominant manifestation after whole-body doses of about 1 to 6 Gy and consists of a generalized pancytopenia. A mild prodrome may begin after 1 to 6 hours, lasting 24 to 48 hours. Bone marrow stem cells are significantly depleted, but mature blood cells in circulation are largely unaffected. Circulating lymphocytes are an exception, and lymphopenia may be evident within hours to days after exposure. As the cells in circulation die by senescence, they are not replaced in sufficient numbers, resulting in pancytopenia. Thus, patients remain asymptomatic during a latent period of up to 4.5 weeks after a 1-Gy dose as the impediment of hematopoiesis progresses. Risk of various infections is increased as a result of the neutropenia Neutropenia Neutropenia is a reduction in the blood neutrophil count. If it is severe, the risk and severity of bacterial and fungal infections increase. Focal symptoms of infection may be muted, but fever... read more (most prominent at 2 to 4 weeks) and decreased antibody production. Petechiae and mucosal bleeding result from thrombocytopenia Thrombocytopenia Platelets are circulating cell fragments that function in the clotting system. Thrombopoietin helps control the number of circulating platelets by stimulating the bone marrow to produce megakaryocytes... read more , which develops within 3 to 4 weeks and may persist for months. Anemia develops slowly, because preexisting red blood cells have a longer life span than white blood cells and platelets. Survivors have an increased incidence of radiation-induced cancer, including leukemia Overview of Leukemia Leukemia is a malignant condition involving the excess production of immature or abnormal leukocytes, which eventually suppresses the production of normal blood cells and results in symptoms... read more .
Cutaneous radiation injury is injury to the skin and underlying tissues due to acute radiation doses as low as 3 Gy (see table Focal Radiation Injury Focal Radiation Injury* ). Cutaneous radiation injury can occur with acute radiation syndromes or with focal radiation exposure and ranges from mild transient erythema to necrosis. Delayed effects (> 6 months after exposure) include hyperpigmentation and hypopigmentation, progressive fibrosis, and diffuse telangiectasia. Thin atrophic skin can be easily damaged by mild mechanical trauma. Exposed skin is at increased risk of squamous cell carcinoma Squamous Cell Carcinoma Squamous cell carcinoma is a malignant tumor of epidermal keratinocytes that invades the dermis; this cancer usually occurs in sun-exposed areas. Local destruction may be extensive, and metastases... read more . In particular, the possibility of radiation exposure should be considered when patients present with a painful nonhealing skin burn without a history of thermal injury.
Focal radiation injury
Radiation to almost any organ can have both acute and chronic adverse effects (see table Focal Radiation Injury Focal Radiation Injury* ). In most patients, these adverse effects result from radiation therapy Focal radiation injury . Other common sources of exposure include inadvertent contact with unsecured food irradiators, radiation therapy equipment, x-ray diffraction equipment, and other industrial or medical radiation sources capable of producing high dose rates. Also, prolonged exposure to x-rays during certain interventional procedures done under fluoroscopic guidance can result in cutaneous radiation injury. Radiation-induced sores or ulcers may take months or years to fully develop. Patients with severe cutaneous radiation injury have severe pain and often require surgical intervention.
Diagnosis of Radiation Exposure and Contamination
Symptoms, severity, and symptom latency
Serial absolute lymphocyte counts and serum amylase levels
Diagnosis is by history of exposure, symptoms and signs, and laboratory testing. The onset, time course, and severity of symptoms can help determine radiation dose and thus also help triage patients relative to their likely consequences. However, some prodromal symptoms (eg, nausea, vomiting, diarrhea, tremors) are nonspecific, and causes other than radiation should be considered. Many patients without sufficient exposure to cause acute radiation syndromes may present with similar, nonspecific symptoms, particularly after a terrorist attack or reactor accident, when anxiety is high.
After acute radiation exposure, complete blood count (CBC) with differential and calculation of absolute lymphocyte count is done and repeated 24, 48, and 72 hours after exposure to estimate the initial radiation dose and prognosis (see table Relationship Between Absolute Lymphocyte Count, Radiation Dose, and Prognosis Relationship Between Absolute Lymphocyte Count in the Adult at 48 Hours, Radiation Dose*,†, and Prognosis ). The relationship between dose and lymphocyte counts can be altered by physical trauma, which can shift lymphocytes from the interstitial spaces into the vasculature, raising the lymphocyte count (1, 2 Diagnosis references Ionizing radiation injures tissues variably, depending on factors such as radiation dose, rate of exposure, type of radiation, and part of the body exposed. Symptoms may be local (eg, burns)... read more ). This stress-related increase is transient and typically resolves within 24 to 48 hours after the physical insult. This transient elevation in lymphocyte count may suggest a falsely optimistic prognosis until the lymphocyte count falls. The CBC is repeated weekly to monitor bone marrow activity and as needed based on the clinical course. Serum amylase level rises in a dose-dependent fashion beginning 24 hours after significant radiation exposure, so levels are measured at baseline and daily thereafter. Other laboratory tests are done if feasible:
C-reactive protein (CRP) level: CRP increases with radiation dose; levels show promise to discriminate between minimally and heavily exposed patients.
Blood citrulline level: Decreasing citrulline levels indicate gastrointestinal damage.
Blood fms-related tyrosine kinase-3 (FLT-3) ligand levels: FLT-3 is a marker for hematopoietic damage.
Interleukin-6 (IL-6): This marker of inflammation is increased at higher radiation doses.
Quantitative granulocyte colony-stimulating factor (G-CSF) test: Levels are increased at higher radiation doses.
Cytogenetic studies with overdispersion index: These studies are used to evaluate for partial body exposure.
Radioactive contamination
When contamination is suspected, the entire body should be surveyed with a thin window Geiger-Muller probe attached to a survey meter (Geiger counter) to identify the location and extent of external contamination. Additionally, to detect possible internal contamination, the nares, ears, mouth, and wounds are wiped with moistened swabs that are then tested with the counter. Urine, feces, and emesis should also be tested for radioactivity if internal contamination is suspected.
Diagnosis references
1. Toft P, Tønnesen E, Helbo-Hansen HS, et al: Redistribution of granulocytes in patients after major surgical stress. APMIS 102(1):43-48, 1994. doi: 10.1111/j.1699-0463.1994.tb04843.x
2. DeRijk R, Michelson D, Karp B, et al: Exercise and circadian rhythm-induced variations in plasma cortisol differentially regulate interleukin-1 beta (IL-1 beta), IL-6, and tumor necrosis factor-alpha (TNF alpha) production in humans: high sensitivity of TNF alpha and resistance of IL-6. J Clin Endocrinol Metab82(7):2182-2191, 1997. doi: 10.1210/jcem.82.7.4041
Prognosis for Radiation Exposure and Contamination
Without medical care, the LD-50/60 (dose expected to be fatal to 50% of patients within 60 days) for whole-body radiation is about 3 Gy; exposure to > 6 Gy is nearly always fatal. When exposure is < 6 Gy, survival is possible and is inversely related to total dose. Time to death decreases as the dose increases. Death may occur within hours to a few days in patients with the cerebrovascular syndrome and usually within 2 days to several weeks in patients with the gastrointestinal syndrome. In patients with the hematopoietic syndrome, death may occur within 4 to 8 weeks because of a supervening infection or massive hemorrhage. Patients exposed to whole-body doses < 2 Gy should fully recover within 1 month, although long-term sequelae (eg, cancer) may occur.
With medical care, the LD-50/60 is 6 Gy. Occasional patients have survived exposures of up to 10 Gy. Significant comorbidities, injuries, and burns worsen prognosis.
Treatment of Radiation Exposure and Contamination
Treatment of severe traumatic injuries or life-threatening medical conditions first
Minimization of health care worker radiation exposure and contamination
Treatment of external and internal contamination
Sometimes specific measures for particular radionuclides
Precautions for and treatment of compromised immune system
Minimize inflammatory response
Supportive care
Radiation exposure may be accompanied by physical injuries (eg, from burn, blast, fall). Associated trauma is more immediately life threatening than radiation exposure and must be treated expeditiously (see Approach to the Trauma Patient: Evaluation and Treatment Evaluation and Treatment Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than... read more ). Trauma resuscitation of the seriously injured takes priority over decontamination efforts and must not be delayed awaiting special radiation management equipment and personnel. Standard universal precautions, as routinely used in trauma care, adequately protect the critical care team.
Extensive, reliable information about principles of radiation injuries, including management, is available at the US Department of Health and Human Services Radiation Event Medical Management web site. This information can be downloaded to a personal computer or smartphone in case internet connectivity is lost during a radiation incident. Consensus clinical management guidelines for the optimal management of acute radiation syndromes (ARS) were developed by an international consultancy of experts convened by the World Health Organization to consider the quality of the evidence supporting various treatment guidelines (see table ).
Pearls & Pitfalls
The Joint Commission mandates that all hospitals have protocols and that personnel have training to deal with patients contaminated with hazardous material, including radioactive material. Identification of radioactive contamination on patients should prompt their isolation in a designated area (if practical), decontamination, and notification of the hospital radiation safety officer, public health officials, hazardous material teams, and law enforcement agencies as appropriate to investigate the source of radioactivity.
If practical, treatment area surfaces may be covered with plastic sheeting to aid in facility decontamination. This preparation should never take precedence over provision of medical stabilization procedures. Waste receptacles (labeled "Caution, Radioactive Material"), sample containers, and Geiger counters should be readily available. All equipment that has come into contact with the room or with the patient (including ambulance equipment) should remain isolated until lack of contamination has been verified. An exception is a mass casualty situation Radiological Weapons Ionizing radiation and its effects are discussed in detail elsewhere (see Radiation Exposure and Contamination). Mass casualties due to ionizing radiation can result from the detonation of a... read more , during which lightly contaminated critical equipment such as helicopters, ambulances, trauma rooms, and x-ray, CT, and surgical facilities should be quickly decontaminated to the extent possible and returned to service.
Personnel involved in treating or transporting the patient should follow standard precautions, wearing caps, masks, gowns, gloves, and shoe covers. Used gear should be placed in specially marked bags or containers. Dosimeter badges should be worn to monitor radiation exposure. Personnel may be rotated to minimize exposure, and pregnant personnel should be excluded from the treatment area.
Due to the low exposure rates anticipated from most contaminated patients, medical staff members caring for typical patients are unlikely to receive doses in excess of the occupational limit of 0.05 Sv/year. Even in the extreme case of radiation casualties from the Chernobyl nuclear reactor accident, medical personnel who treated patients in the hospital received < 0.01 Sv. Several authoritative sources suggest that a dose of up to at least 0.5 Gy may be considered an acceptable risk for lifesaving activity.
External decontamination
Typical sequence and priorities are
Removing clothing and external debris
Decontaminating wounds before decontaminating intact skin
Cleaning the most contaminated areas first
Using a radiation survey meter to monitor progress of decontamination
Continuing decontamination until areas are below 2 to 3 times background radiation or there is no significant reduction between decontamination efforts
Clothes are removed carefully to minimize the spread of contamination and placed in labeled containers. Clothing removal eliminates about 90% of external contamination. Foreign objects should be considered contaminated until checked with a radiation survey meter.
Contaminated wounds are decontaminated before intact skin; they are irrigated with saline and gently scrubbed with a surgical sponge. Minimal debridement of wound edges may be done if there is residual contamination after multiple attempts at cleansing. Debridement beyond the wound margin is not required, although embedded radioactive shrapnel can have very high radiation exposure rates and thus should be removed using long forceps or a similar device and placed in a lead container.
Contaminated skin and hair are washed with lukewarm water and mild detergent until radiation survey meter measurements indicate levels below 2 to 3 times normal background radiation or until successive washings do not significantly reduce contamination levels. All wounds are covered during washing to prevent the introduction of radioactive material. Scrubbing may be firm but should not abrade the skin. Special attention is usually required for fingernails and skinfolds. Hair that remains contaminated is removed with scissors or electric clippers; shaving is avoided. Inducing sweating (eg, placing a rubber glove over a contaminated hand) may help remove residual skin contamination.
Burns are rinsed gently rather than scrubbed because scrubbing may increase injury severity. Subsequent dressing changes help remove residual contamination.
Decontamination is not necessary for patients who have been irradiated by an external source and are not contaminated.
Internal decontamination
Ingested radioactive material should be removed promptly by induced vomiting or lavage if exposure is recent. Frequent mouth rinsing with saline or dilute hydrogen peroxide is indicated for oral contamination. Exposed eyes should be decontaminated by directing a stream of water or saline laterally to avoid contaminating the nasolacrimal duct.
The urgency and importance of using more specific treatment measures depend on the type and amount of the radionuclide, its chemical form and metabolic characteristics (eg, solubility, affinity for specific target organs), the route of contamination (eg, inhalation, ingestion, contaminated wounds), and the efficacy of the therapeutic method. The decision to treat internal contamination requires knowledge of the potential risks; consultation with a specialist (eg, Centers for Disease and Control and Prevention [CDC] or Radiation Emergency Assistance Center/Training Site [REAC/TS]) is recommended.
Current methods to remove radioactive contaminants from the body (decorporation) include
Saturation of the target organ (eg, potassium iodide [KI] for iodine isotopes) (see CDC: Potassium Iodide [KI])
Chelation at the site of entry or in body fluids followed by rapid excretion (eg, calcium or zinc diethylenetriamine penta-acetate [DTPA] for americium, californium, plutonium, and yttrium) (see CDC: DTPA )
Acceleration of the metabolic cycle of the radionuclide by isotope dilution (eg, water for hydrogen-3)
Precipitation of the radionuclide in the intestinal lumen followed by fecal excretion (eg, oral calcium or aluminum phosphate solutions for strontium-90)
Ion exchange in the gastrointestinal tract (eg, Prussian blue for cesium-137, rubidium-82, thallium-201) (see CDC: Prussian Blue)
Because a serious nuclear power reactor accident that releases fission products into the environment could expose large groups of people to radioiodine, decorporation using oral potassium iodide has been studied in great detail. Potassium iodide saturates the iodine receptors of the thyroid; this prevents the gland from taking up radioactive iodine, which is the main cause of morbidity. Potassium iodide is > 95% effective when given at the optimal time (1 hour before exposure). However, effectiveness diminishes significantly over time (~80% effective at 2 hours after exposure and administration more than 24 hours after exposure will offer no protection). Potassium iodide can be given either in tablet form or as a supersaturated solution (dosage: adults and children > 68 kg, 130 mg; age 3 to 18 years [< 68 kg], 65 mg; age 1 to 36 months, 32 mg; age < 1 month, 16 mg). The compound is effective only for internal contamination with radioactive iodides and has no benefit in internal contamination with any other radioactive elements. Most other medications used for decorporation are much less effective and reduce the dose to the patient only by 25 to 75%. Contraindications to potassium iodide include iodine allergies and certain skin disorders associated with iodine sensitivity (eg, dermatitis herpetiformis Dermatitis Herpetiformis Dermatitis herpetiformis is an intensely pruritic, chronic, autoimmune, papulovesicular cutaneous eruption strongly associated with celiac disease. Typical findings are clusters of intensely... read more , urticaria vasculitis).
Specific management
Symptomatic treatment is given as needed and includes managing shock and hypoxia, relieving pain and anxiety, and giving sedatives (lorazepam 1 to 2 mg IV as needed) to control seizures, antiemetics (metoclopramide 10 to 20 mg IV every 4 to 6 hours, prochlorperazine 5 to 10 mg IV every 4 to 6 hours, or ondansetron 4 to 8 mg IV every 8 to 12 hours) to control vomiting, and oral antidiarrheal agents (kaolin/pectin 30 to 60 mL with each loose stool or loperamide 4 mg initially, then 2 mg with each loose stool) for diarrhea.
There is no specific treatment for the cerebrovascular syndrome. It is universally fatal; care should address patient comfort.
The gastrointestinal syndrome is treated with aggressive fluid resuscitation and electrolyte replacement. Parenteral nutrition should be initiated to promote bowel rest. In febrile patients, broad-spectrum antibiotics (eg, imipenem 500 mg IV every 6 hours) should be initiated immediately. Septic shock Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more from overwhelming infection remains the most likely cause of death.
Management of the hematopoietic syndrome is similar to that of bone marrow hypoplasia and pancytopenia of any cause. Blood products should be transfused to treat anemia and thrombocytopenia, and hematopoietic growth factors (granulocyte colony-stimulating factor and granulocyte macrophage colony-stimulating factor) and broad-spectrum antibiotics should be given to treat neutropenia and neutropenic fever, respectively (see Treatment of Neutropenia and Lymphocytopenia Treatment Neutropenia is a reduction in the blood neutrophil count. If it is severe, the risk and severity of bacterial and fungal infections increase. Focal symptoms of infection may be muted, but fever... read more ). Patients with neutropenia should also be placed in reverse isolation. With a whole-body radiation dose > 4 Gy, the probability of bone marrow recovery is poor, and hematopoietic growth factors should be given as soon as possible. Filgrastim can be used for the treatment of myelosuppression from radiation. Stem cell transplantation Hematopoietic Stem Cell Transplantation Hematopoietic stem cell (HSC) transplantation is a rapidly evolving technique that offers a potential cure for hematologic cancers ( leukemias, lymphomas, myeloma) and other hematologic disorders... read more has had limited success but should be considered for exposure > 7 to 10 Gy.
Cytokines may be helpful. Recommended medications and dosages are
Filgrastim (G-CSF) 10 micrograms per kilogram of patient weight (10 mcg/kg) daily by subcutaneous injection. Should be administered as soon as possible after suspected or confirmed exposure to radiation doses greater than 2 gray (Gy).
Sargramostim (granulocyte macrophage colony-stimulating factor [GM-CSF]) 5 to 10 mcg/kg subcutaneously once a day or 200 to 400 mcg/m2 subcutaneously once a day
Pegfilgrastim (pegylated G - CSF) 6 mg subcutaneously once
Radiation-induced sores or ulcers that fail to heal satisfactorily may be repaired by skin grafting or other surgical procedures.
Aside from regular monitoring for signs of certain disorders (eg, ophthalmic examination for cataracts, thyroid function studies for thyroid disorders), there is no specific monitoring, screening, or treatment for specific organ injury or cancer.
Prevention of Radiation Exposure and Contamination
Protection from radiation exposure is accomplished by avoiding contamination with radioactive material; by minimizing the duration of exposure; maximizing the distance from the source of radiation, and shielding the source. During some imaging procedures that involve ionizing radiation and during radiation therapy, parts of the body that are near, but not the target of the imaging procedure or therapy, should be shielded to the extent possible with lead.
Although shielding of personnel with lead aprons or commercially available transparent shields effectively reduces exposure to low-energy scattered x-rays from diagnostic and interventional imaging studies, these aprons and shields are almost useless in reducing exposure to the high-energy gamma rays produced by radionuclides that would likely be used in a terrorist incident or be released in a nuclear power plant accident. In such cases, measures that can minimize exposure include using standard precautions, undergoing decontamination efforts, and maintaining distance from contaminated patients when not actively providing care.
All personnel working around radiation sources should wear dosimeter badges if they are at risk for exposures > 10% of the maximum permissible occupational dose (0.05 Sv). Self-reading electronic dosimeters are helpful for monitoring the cumulative dose received during an incident.
Public response
After widespread high-level environmental contamination from a nuclear power plant accident or intentional release of radioactive material, exposure can be reduced either by
Sheltering in place
Evacuating the contaminated area
The better approach depends on many event-specific variables, including
The time elapsed since initial release
Whether release has stopped or is ongoing
Weather conditions
Availability and type of shelter
Evacuation conditions (eg, traffic, transportation availability)
The public should follow the advice of local public health officials as given on emergency alert notification systems. If in doubt, shelter in place is the best option until additional information becomes available. If sheltering is recommended, the center of a concrete or metal structure above or below grade (eg, in a basement) is best. If the event is the detonation of a nuclear weapon, shelter in place as quickly as an effective shelter can be found for the first few hours after the detonation and then follow the advice of local emergency response officials.
Consistent and concise messages from public health officials can help reduce unnecessary panic and reduce the number of emergency department visits from people at low risk, thus keeping the emergency department from being overwhelmed. Such a communication plan should be developed prior to any event. A plan to decrease the demand on emergency department resources by providing an alternative location for first aid, decontamination, and counseling of people without emergent medical problems is recommended.
People living within 16 km (10 miles) of a nuclear power plant should have ready access to potassium iodide tablets. These tablets can be obtained from local pharmacies and some public health agencies.
Preventive medications
Radioprotective medications, such as thiol compounds with radical scavenging properties, have been shown to reduce mortality when given before or at the time of irradiation in patients undergoing chemotherapy and/or radiation therapy. Additional investigations are needed to demonstrate benefit in nonmedical radiation exposures (eg, nuclear power plant accidents).
Amifostine is a powerful injectable radioprotective agent in this category. It is used clinically to prevent xerostomia in patients undergoing radiation therapy. Adverse effects include nausea and vomiting, hypotension, and decreased serum calcium. Exposure of an unborn child to this medication could cause birth defects.
Palifermin, a mucocutaneous epithelial growth factor, is a modified version of a naturally occurring human protein called keratinocyte growth factor (KGF) that is manufactured in a laboratory. It is used to reduce the chances of developing severe mucositis and decrease duration of mucositis in patients who receive high doses of chemotherapy and radiation followed by stem cell rescue. Palifermin can interact with heparin, thus intravenous lines should be rinsed with saline prior to and after palifermin administration. Adverse effects include rash, pancreatitis, fever, and peripheral edema. Exposure of an unborn child to this drug could cause birth defects. Dosage is 60 mcg/kg once per day.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Singh VK, Seed TM: The efficacy and safety of amifostine for the acute radiation syndrome. Expert Opin Drug Saf 18(11):1077-1090, 2019. doi: 10.1080/14740338.2019.1666104
Centers for Disease Control and Prevention, Radiation Emergencies: Information for Clinicians. This resource includes guidelines and links to training resources.
Department of Energy Radiation Emergency Assistance Center/Training Site (REAC/TS): This organization provides 24-hour consultations to US-based people who need it. Weekdays: (865) 576-3131. After-hours and weekends: (865) 576-1005. (Ask for REAC/TS). Email: email@example.com.
US Department of Health and Human Services Radiation Emergency Medical Management: This is an invaluable resource that is maintained with concise and up-to-date, authoritative guidance on the clinical management of radiation injuries for all levels of healthcare providers.
Drugs Mentioned In This Article
Drug Name | Select Trade |
doxorubicin |
Adriamycin, Adriamycin PFS, Adriamycin RDF, Rubex |
bleomycin |
Blenoxane |
fluorouracil |
Adrucil, Carac, Efudex, Fluoroplex, Tolak |
methotrexate |
Jylamvo, Otrexup, Rasuvo, RediTrex, Rheumatrex, Trexall, Xatmep |
etoposide |
Etopophos, Toposar, VePesid |
paclitaxel |
Onxol , Taxol |
epirubicin |
Ellence |
cefotetan |
Cefotan |
simvastatin |
FloLipid, Zocor |
hydrogen peroxide |
CLEAR CARE PLUS with HydraGlyde, ESKATA, HYLAMEND |
potassium iodide |
Pima, SSKI |
lorazepam |
Ativan, Loreev XR |
metoclopramide |
Gimoti, Metozolv, Reglan |
prochlorperazine |
Compazine, Compazine Rectal, Compazine Solution, Compazine Syrup, Compro |
ondansetron |
Zofran, Zofran in Dextrose, Zofran ODT, Zofran Solution, Zuplenz |
loperamide |
Anti-Diarrheal, Imodium A-D, Imodium A-D EZ Chews , K-Pek II, Medique Diamode |
filgrastim |
Neupogen, Nivestym, Releuko, Zarxio |
sargramostim |
Leukine |
pegfilgrastim |
Fulphila, Fylnetra, Neulasta, Nyvepria, Stimufend, UDENYCA, UDENYCA ONBODY, Ziextenzo |
amifostine |
Ethyol |
palifermin |
Kepivance |
heparin |
Hepflush-10 , Hep-Lock, Hep-Lock U/P, Monoject Prefill Advanced Heparin Lock Flush, SASH Normal Saline and Heparin |


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Lecrae Talks of 'Sleepless Nights,' Criticism in Refusing Sacred-Secular Divide
Rapper and Christian evangelist Lecrae Moore recently spoke on some of the difficulty he has had with both Christians and non-Christians in balancing his faith and producing music that has been traditionally considered "worldly."
"There's always somebody saying one or the other about me," said Moore, typically referred to by his first name, commenting on being called "too Christian" or "too pagan." The married father added that he has "definitely had some sleepless nights and some long conversations" in trying to balance his faith and career as a hip-hop artist.
The subject was raised by Eric Geiger, vice president of LifeWay Christian Resources, in an interview with Lecrae broadcast online Monday on Ed Stetzer's "The Exchange," a program featuring in-depth conversations with Christian leaders.
"As far as the world is concerned, it's mostly pre-conceived ideas of what I'm about. So they haven't really investigated enough to know how Christian it is or what it is that's gonna happen," the Atlanta rapper added.
"On the Christian side, there's a sense of like, 'See, Lecrae is falling off, he's getting worldly. I heard him do this song, he's performing at this place ...,'" he explained, giving examples of the kind of criticism he might receive on social media.
Having spoken numerous times on the subject of overcoming the concept some have of a secular-sacred divide — the belief that Christians should avoid certain secular areas and activities — Lecrae shared with Geiger that his model for ministry is the Apostle Paul and his ministry activities as recorded in the Bible.
"I'm a big fan of just looking at Paul in Acts and him in the marketplace, but in the synagogue as well. Him mixing it up out there in the culture and knowing who their modern-day poets were and their speakers and philosophers and being able to integrate their ideals and values in his talks as he tries to preach Christ to them," said Lecrae.
The 33-year-old rapper believes he, and other Christians, can impact culture simply by being engaged and demonstrating what "redemption has done" in a Christian's life, instead of creating sub-cultures or living life in a bubble.
The conversation also touched on a comment Lecrae previously made in response to whether he views himself as a Christian rapper: "I am a Christian. I am a rapper. But Christian is my faith, not my genre."
Saying he knows such a statement "goes against the grain of cultural Christianity," Lecrae told Geiger: "We have to be careful with terms like 'Christian' and 'Gospel.'" He suggested that limiting those labels to simply a genre of music does a "disservice" to the Christian message of salvation in Jesus Christ.
"Christian is an identifying mark. It says I identify myself with Christ, I'm a follower of Christ," he emphasized. "I'd rather you not put the tag or the label 'Christian' on me (simply) because I say so." The rapper added that he welcomes the title "Christian" being applied to him if his character warrants it, but not simply because of the type of music he creates.
As for the kind of responses he has received from mainstream, or non-Christian rappers in the industry, Lecrae said, "I think there are some who respect it. A lot of people respect that I'm willing to be authentic and willing to be real" in keeping elements of his faith in the music.
"I really don't feel like I have anything to lose. I'm being authentic, and my strength is in the Gospel and my strength is in the Lord to allow me to be exactly who I am," he said.
"There's a distaste in the mouths of some, but it's not because I'm obnoxious or because I'm not gracious. It's just because in many people's minds they've just never seen Christ in hip-hop. So some rappers or some people in the hip-hop world are like, 'What are you doing here? I know you've got to be corny or inauthentically hip-hop because we've never seen this before.'"
Lecrae shared that he believes he has impacted some of the secular artists he has been able to work with, and has made "inroads" with those in the industry who have listened to his music.
"There are some albums that have come out this year that are vastly different, and I say it's a testament to myself and my counterparts just being involved in these guys' lives and trying to share our hope with them, our faith with them," he said.
The Atlanta rapper, who also does ministry work through ReachLife Ministries, an extension of Reach Records, became in February the first Christian recording artist to win a Grammy Award in the Best Gospel Album category, due to his 2012 record Gravity.
"To me it's a testament of years of laboring to break down barriers in music and culture," Lecrae told The Christian Post at the time in response to his Grammy win. "Hopefully people will listen and understand what I do creatively and how my faith is a part of who I am, not a genre."
Lecrae's interview on "The Exchange" can be viewed in full online at http://vimeo.com/67132216.

subset: commoncrawl


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" Babar and Zephir" by Jean De Brunhoff was my favorite of all the Babar books, most of which I have tracked down and bought on ebay. What I loved about this book was we got to see where Zephir came from, and go see the fantastic world hanging houses in Monkeyville. Babar books are always interesting to re read as an adult and this one is no exception.
" The Seasons of Fern Hollow" by John Patience. This book is a cute look at the world of Fern Hollow where there is a large cast of animal characters who live in a small idyllic English village. The book itself is sweet, going through village life one season at a time but my favorite thing about this book and the others by the same author was this map of the village. I would lay in bed staring at the map, trying to find different ways to get from one character's house to another. This book inspired my imagination.


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Super Yummy Chocolate Chunk Oatmeal Cookies
Total Time: 35 min
Prep: 15 min
Inactive: 5 min
Cook: 15 min
Yield: 3 dozen cookies
- 2 cups all-purpose flour
- 1 cup rolled oats
- 1 teaspoon baking powder
- 1/2 teaspoon ground cinnamon
- 1/2 teaspoon kosher salt
- 1 cup brown sugar
- 1/2 cup granulated sugar
- 2 sticks unsalted butter, at room temperature
- 2 eggs
- 1 teaspoon vanilla extract
- 12 ounces block dark chocolate, coarsely chopped
- 1 cup walnuts, chopped
- Large flake sea salt, for garnish
- Preheat the oven to 350 degrees F.
- In a small mixing bowl, combine the flour, oats, baking powder, cinnamon and kosher salt.
- In large mixing bowl or the bowl of a stand mixer, combine the brown sugar, granulated sugar and butter. Using an electric beater or the paddle attachment of the stand mixer, beat together the butter and sugar until it they are light and fluffy. Add the eggs one at a time and beat them into the butter and sugar mixture. Add in the vanilla as well.
- With a rubber spatula or with the stand mixer on low, gradually add the flour mixture into the butter/sugar mixture. Mix until just combined. Fold in the chocolate chunks and walnuts.
- Spoon the cookie dough by 2 tablespoon-size balls onto an ungreased cookie sheet. Place the cookie dough balls 2 inches apart on the cookie sheet. Place the cookie sheet in the oven and bake for 12 to 13 minutes.
- When the cookies come out of the oven IMMEDIATELY sprinkle each cookie with a few grains of sea salt. This is really important to do while the cookies are hot.
- Let the cookies cool for 2 to 3 minutes and then transfer them to a cooling rack.


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Zen Gardner
I find it significant that the Sandy Hook issue comes back into public consciousness repeatedly. It's almost as if even the alternative community is baffled how these manipulating bastards were able to pull that highly publicized scam off so slickly, despite it being challenged from the get go and then dissected to bits as time progressed.
I know it's had my attention. The recent interview from a fully qualified law enforcement/school safety expert has certainly done much to revive the issue.
My original post along these mass mind control/trigger lines that immediately followed the Sandy Hook incident was immediately forbidden by the goog and we were forced to remove the article. This was during the initial stages when the media muppets were repeating their boldfaced threats regarding any reports to the contrary to the party line would be treated as subversive. You can easily see why, when it so profoundly exposes the deeper agenda.
Just research all the weird tie-ins to this suspicious event, never mind the usual inconsistencies. It's almost surreal.
Then There's the "Sandy" Trigger
Sandy Hook followed the likewise engineered devastating Hurricane Sandy which was still fresh in everyone's minds. It makes a great psychological tie in to instill greater fear. Is there a significance to the name and its repeated use?
Whether a signal to programmed stooges or general activation signals that the game is on, trigger words are nothing new in the world of mind control and mental manipulation.
See what you think.
The Rise of the Guardians?
Just notice how the name Sandy is repeated and emphasized. It's clear something paranormal is at play. The animation industry specializes in suggestive and subliminal programming and mind manipulation. And the theme of this story is influencing people's dreams, i.e. subconscious.
A little blatant? Just how they like it.
The last line of the trailer is the message the kids will remember: "Everyone needs a guardian." Sure ties in nicely with Obama declaring all kinds of new draconian controls to "prevent something like this from ever happening again" or any one of his mind-numbing draconian statements, doesn't it. Yes, Big Brother, the Protector, Guardian of the people with the outstretched arms of our metastasized State to keep us safe and warm.
By the way, Hurricane Sandy made landfall on October 29th, 2012. This movie was released Nov. 21st, and the shootings took place the middle of the next month. 1-2-3. Actually there was one shooting every month except January and June of that year.
Revealing 1996 CD cover chillingly illustrating the point (Sent in by Neithan)
Trauma Based Mind Control
Sandy Hook is just one instance. You'll find blatant examples of trigger words and phrases used by governments and the media to instigate and justify wars and phony false flag provocations throughout history. Their plans have simply become more insidious. The reason why traumatic experiences are important to mind control is because the human mind is more susceptible to hypnotic command in this state. Trance states of dissociation are the optimum for suggestibility and programming, and on a mass scale they use traumatic images and events via today's worldwide media, and with television they take further advantage, amping the hype and imagery while electronically inducing low alpha waves that relax the brain, making the mind much more suggestible.
If this subject is new to you, there's a link to a quick tutorial below to get you started. They've since gotten much more sophisticated when controlling the masses using a variety of techniques including drugs and technology, but this is the sordid background of the practice and its purpose.
This system of mind control has its origins in Illuminati based black magic practices. Multigenerational Satanic cults and high level Illuminati members have employed mind control for centuries. The basics of this type of mind control slavery was optimized and expanded after World War 2 following the gruesome experiments conducted in the Nazi concentration camps. Dr. Joseph Mengele, (aka, Dr. Green) disappeared from Auschwitz in January of 1945, and was smuggled into the US by the Illuminati. (More HERE)
This mind control influence on the shootings is summarized really well here: (this is to set up the patsy and put the "play" into effect, whatever transpires..)
Rogue intelligence agents and their psychiatrist colleagues have been brainwashing "lone nuts" to commit murder at least since the CIA's MK-Ultra program achieved its objectives circa 1960.Why would such "rogue networks" want to send brainwashed Manchurian Candidates into schools to massacre children? Let's allow one of the terrorists themselves to answer that question.Remember Operation Gladio? The Pentagon, through NATO, organized bombings and shootings in the streets of Europe. When one of the terrorists got caught, he explained at his trial: "You had to attack civilians, the people, women, children, innocent people, unknown people far removed from any political game. The reason was quite simple. They were supposed to force these people, the Italian public to turn to the State to ask for greater security." He later explained the "strategy of tension" to the BBC: "To create tension within the country to promote conservative, reactionary social and political tendencies." Source
Look for the Occult – i.e. Hidden
There's always much more than meets the eye. 9/11 was an occult sacrificial ritual of the highest order while an unsuspecting world watched spellbound and then waltzed willingly into an Orwellian future. Sandy Hook and most of these shooting or bombing events the same. Each succeeding incident builds on the previous one, such as Waco and Oklahoma City. That's how our current police state arrived.
They will and do use anything and everything as a weapon against our awakening and empowerment. Forces outside of our reality are at work, with willing agents amongst us to carry out their plan. That's just the way it is. And we need to be aware of these influences, yet free and clear from them.
The techniques mentioned here are just a few, as far fetched as they may sound. The fact is, it's common knowledge that at the least such things as repeated phrases increase suggestibility and easy entrainment. Obama, for example, keeps repeating certain phrases which are obvious mental implants. Watch for this. His gestures and intonations are measured and designed for a certain response as well.
That's just one obvious, surface level of this technique. It goes much, much deeper.
High In-Your-Face Sorcery
Fundamentally, they are sorcerers. To find connections like this, as well as numerological significance, ley line placements, occult dates, Freemasonry and the like is no surprise. People are still finding clues leading up to 9/11 and discovering all sorts of occult undertones as to what went down that fateful day, as well as to most other staged false flag events.
The dark manipulators like the big stage. The bigger the better, the more bang for their buck. They foreshadowed the hell out of 9/11 with gobs of predictive programming. This continual run up of staged mass killings has been chosen as their false flag du jour for a reason. The barrage of gratuitously violent video games and movies is another surreal part of the now accepted program.
That's the real smoking gun. Our clearly engineered society and who is behind creating it.
They also like to brag about it. In fact flaunt it, and mock our ignorance. But does anybody even notice the programming?
Doesn't seem like too many do. And those who do are hooted down as nut jobs.
As Voltaire wisely said, "To learn who rules over you, simply find out who you are not allowed to criticize."
But also remember what Gandhi stated; "First they ignore you, then they laugh at you, then they fight you, then you win.'
The Awakening Is Real
It's thrilling to see how the alternative community jumped all over the Sandy Hook incident, as we have on so many other clearly staged events. It was covered every which way from Sunday right out of the gate.
It seems pretty bleak when we realize the depths that these creatures sink to and our having to get sullied by their dark reality, but it is important to learn to identify. Recognizing what we're up against is half the battle. Then it's simply deciding we won't accept it and acting, or not acting, accordingly.
That's a big part of awakening.
Be empowered, be confident. We are the true revolution.
Keep on keeping on.


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Layouts for Keynote is a collection of themes created for unique slideshows. Outline your ideas, proposals, contracts, and solutions. Then, enhance them with stylish backgrounds, charts, diagrams, tables, and other data-visualization elements to attain all you have been working for.
Each theme contains 20 master slides, covering everything from basic bullet layouts to complex diagrams and illustrations. All photo slides feature media placeholders to neatly crop a placed image, and most visualization elements can be easily edited.
Most objects in Layouts for Keynote can be easily recolored, reshaped, moved, or removed. You can change the background to a color, gradient, or photo with a simple modification in the Appearance Inspector. Type or paste your own text, add and remove text boxes, and change the fonts if you wish. Edit the charts and diagrams to fit your data. Drag your photos or pictures onto slides to replace the stock images. Use every available tool to make your audience hang on your every word.


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The Blue Bookcase hosts a "Literary Blog Hop" for blogs "that primarily feature reviews of literary fiction, classic literature, and general literary discussion."
Each week, in addition to hopping around and visiting some terrific book blogs, participants answer a bookish question. This week's question comes from Lisa at bibliophiliac:
What literary title (fiction or non-fiction) do you love that has been under-appreciated? We all know about the latest Dan Brown, and James Patterson isn't hurting for publicity. What quiet masterpiece do you want more readers to know?There are plenty of books I've read that I think deserve a wider audience. David Lodge's How Far Can You Go? (reviewed here), The Assistant by Bernard Malamud (reviewed here), and Play It As It Laysby Joan Didion (reviewed here) are just three I can think of off the top of my head.
But if I had to choose one "quiet masterpiece" to champion, it would be The Road Home by Jim Harrison. In general, Harrison is an under-appreciated American treasure, which he has made a career out of. A good part of his memoir, Off to the Side, is his telling of his life on the fringes of literary society.
The Road Home is a sweeping, multi-generational story in "The Great American Novel" tradition. Set in the sandhills of Nebraska, the book takes up where Harrison's prior novel, Dalva, left off, filling in the story of Dalva's family, the formidable Northridges. There are pioneers, farmers, Indians, artists, lovers, and birdwatchers. There is art, literature, food, wine, love, and death. It is wonderful.
My Top 10 list will always include The Road Home. I've read it twice, including reading it out loud to my husband on a long road trip. I will read it again, for sure.


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Emeril's Recipes feature foods and products from his new home in Chelsea market such as Potato Crusted Snapper on Warm Chanterelle and Lump Crabmeat Salad with Fava Bean Cream, Chateaubriand a la Bouquetiere with Marchand de Vin Sauce, Baked Alaska
Hey now...You know how Emeril feels about pork fat. So tonight we're gonna make him happy happy with Bacon Biscuits, Country Pork Ribs and Ham Loaf. In fact we'll use everything but the oink when pork fat rules. Right here on Emeril Live!
Soul food has come a long way from simple greens and sweet potatoes. Today, the modern soul food restaurant is serving kicked up versions of the traditional classics with eye popping presentation. And tonight we'll check out the latest in soul cusine.
Emeril gets so many e-mails from people all over the country, asking him to make their favorite sweets. So what do you crave? Is it ice cream, cookies or maybe a piece of chocolate. You might be surprised at some of the answers Emeril cooks up.
Emeril asks the question, "whats your favorite snack?" Some of your answers will be covered tonight as well as some kicked up snacks of his own.
It's down home country cookin' with recipes like: Sticky Chicken and Rice, corn Oysters, Cracklin' Cornbread and Cinnamon Pound Cake with Stewed Prunes. Special Musical guest Carolyn Dawn Johnson
Tonight Emeril salutes one of his favorite comfort foods...pudding with recipes for Savory Croissant Breakfast Pudding, Nana's Noodle Pudding, Kicked Up, Chocolate Tapioca, Corn & Orange Mango Pudding.
Egg and Lobster Salad with Homemade Tarragon Mayonnaise, Egg Sardou; smoked Salmon Scrambled Egg Packages with Lemon Creme Fraiche; Rum Creme Caramel.
Emeril loves it when it's ooey gooey. Ooey Gooey cheese recipe include Karen's French Harvet Soup, Mashed Potatoes with Cantal, roasted Red Onions Stuffed with mascarpone Mousse, and Asparagus Tart with Vacherin
Grilled Calamari, Grilled Artichokes with Grilled Lemon Mayonnaise, Grilled Tomato Soup with Grilled Pancheltta, Grilled Tuna sandwich, Grilled Pineapple with Coconut Ice Cream and Rum Glaze.
Kicked Up Calamari with Creole Olive Salad; Stuffed Cabbage Rolls; Emeril's Beer Braised Brisket; Emeril's Pink Pig
After a long cold winter, there's only one thing on Emeril's mind...Summer! With special guest Joe Perry of Aerosmith try the recipes for Chi Chi Cocktail, Carpaccio Wrap, Baby Spinach,Grilled Chicken Satay & Grilled Peaches w/Almond Mousse.
Goat Cheese Coated Grapes, Chicken and Andouille Pastry Cups with Sweet BBQ Sauce, Gougeres Stuffed with Ham Mousse, Louisiana Crab Cakes with Corn Relish
They're staple recipes on many backroad kitchen tables, Stuffed Eggplant Pirogues, Brisket Stuffed with Cornbread, Old Time Corn soup with Sausage
Tonight, Emeril is going to show you a few things about salt that you havent thought about before. With recipes for Fresh & Fierce Margaritas, Gravlax, Rosemary & Salt Roasted Shrimp, Duck Pastrami, Apricot and Date Frozen Mousse with Fleur de Sel.
It's a passport to flavor, international soups and stews with recipes like: Jamaican Chiled Avocado Soup with Fresh Ginger and Lime Crema, Swedish Yellow Pea Soup, African Peanut Soup, and Mexican Pozole Verde
Emeril's in the mood for some knee slappin', foot stompin, kicked up country style cooking tonight. Shake 'Em Up Pork Chops, Cheesy Potato Gratin, Bacon Smothered Green Beans, Stuffed Catfish with Cream Gravy, Chocolate Cocoa Buttermilk Cake
Of Course?..Bacon Wrapped Trout with Tomato-Thyme Butter Sauce, Southern Style Green Beans with Bacon and New Potatoes, Root Beer Glazed Pork Chops with Bourbon-Mashed Sweet Potatoes, and Tangerine Glazed Pork belly
Hey now...anyone here like sweets? The sweets Emeril loves most are those home made cookies and cakes that you find at a bake sale. Tonight, Emeril hands down some of his favorite bake sale recipes.
We're making our own ice cream parlor tonight with Strawberry Daiquiri Ice Pops, Chocolate Cherry Ice Cream Bon Bons, Mango Frozen Yogurt and Raspberry parfait, Dulce De Lache Ice Cream Cake.
Chefs come in all sizes...and ages. And with a little help from Mom or Dad, kids can make meals that really sizzle. Join Emeril tonight as he helps get everyone into the kitchen with some kicked up recipes from his new book.
Las Vegas, gambling, show girls and the strip, strip steak that is. Recipes include Sliced Tomato Salad with Herb Vinaigrette and maytag Blue Cheese, Seared Beef Tournedos with Herb-Roasted Potatoes and Sauce au Poivre, Spiny Lobster-Tomato Saffron Stew with Shaved Artichoke and Olive Salad, and Fish House New Orleans Nectar.
Hey kids say the darndest things, but they're really cookin' Tonight we'll answer viewers' mail with Kicked Up No Bake Nachos, Awesome Little Burgers, Ya Gotta Love It Squid Linguine, and Strawberry Banana Trifle. Special musical guests?.Play.
This country is such a melting pot of cultures and cuisines. And we're gonna pass it on with recipes like, Crawfish and Roasted Sweet Potato Salad with Fried Okra and Buttermilk Dressing, Greek Souvlaki Sandwich, Warm Watercress Salad with Stir Fried Beef and Kid Friendly Kim Chi, and Spagheti Bolognese.
Tonight, it's Emeril's family traditions with recipes like, Jillie's Pesto Dip, Marinated Mushroom Salad, Alden's Grandmother's Meat and Potato Casserole, and Jessie's Big Chocolate Chip Cookies
Dishes from Fall River include: Portuguese Tomato and Sausage Soup, Fall River Clam roll, Portuguese Mood Beef, Favas Verde, Ines' Portuguese Biscoitos
Sometimes all it takes to get kids to clean their plates is to make it look fun to eat. We'll do that tonight with recipes like, Dagwood Stacked Sandwiches, Shrek and Donkey's Manly Waffles, Phyllo Wrapped Chicken Mummy, Curious George's Banana Stuffed French Toast
Hold on to your coconuts, because we're having a Polynesian feast with recipes like, Pork and Ginger Dumplings with Sake Soy Dipping Sauce, Tchoup Chop Crunchy Shrimp in Lettuce Cups with Hot and Sour Chili Sauce, Kalua Pork Chow Mein, and Coconut Custard with Coconut Whipped Cream. With Music and dancing by the Lanakela Polynesian Review.
A kicked up brunch - Emeril style. Recipes Include: Emeril's Bloody Mary Mix, Smoked Salmon and Asparagus Frittata, Pecan Waffles with Roasted Pecan and Banana Syrup, Smoked Trout Hash with Choron Sauce, Limoncello Lemon Curd with Mixed Berries
Emeril serves up a romantic meal for an engaged couple. Recipes include: Herbed Flan with Caviar, Hearts of Palm Salad with Citrus Vinaigrette, Grilled Lobster Tails with Lemon Tarragon Butter, Chocolate Amaretto Pave.
It's a manly way to watch the game. Recipes include Grilled Steak Salad, Caesar Style, Sausage Stuffed Portobello Mushrooms, Ultimate Cheesy Crab and Corn Nachos, Ducle de Leche Fondue, and Beer Battered Fried Trout Tacos with Spicy Horseradish Coleslaw.
Emeril and Paula prepare home cookin' at it's best. Chicken Fried Pork Chops with Andouille-Milk Gravy Over Buttermilk Mashed Potatoes; Stuffed Pork Chops; Chicken-Mushroom Fricasse Over Biscuits; Avocado Chicken Salad; Fried Oyster Salad with Buttermilk Dressing and Corn-Jalapeno Relish; Oyster Stew
Emeril and Bobby Flay in a contest to see who can make the best Pub Grub. Smoked Salmon and Watercress Salad with a Lemon Caper Vinaigrette; Smoked Salmon Hash with Dill Vinaigrette; Grilled Lamb T-Bones with a Red Wine Reduction Sauce; Country Style Potatoes; Braised Napa Cabbage with Bacon & Red Wine Vinegar & Mint; Caraway & Fennel Crusted Loin of Lamb with Mustard Sauce; Guiness Battered Onion Rings; Strawberry-Rhubarb Irish Crumble with Irish Whiskey Butter; Oat Cake with Warm Mixed Berry Compote.
Emeril and Michael Lomonico present some comfort food favorites. Wonton Soup; Curried Pea Soup with Frizzed Ginger; Emeril's Knife and Fork Open-Faced Sandwich; Philly Cheese Steak; Peanut Butter Cream Pie; Double Crust Apple Pie
Emeril presents some dishes to kick up a basketball party. Smoked Sausage and White Bean Soup; Chicken Chimichangas with Chipolte Salsa; Emeril's Ultimate Hot Dog Bar; Candy Bar Brownie Sundae
Emeril kicks up some favorite blue plate specials. Kicked Up BLTs; Chicken and Dumplings; Carrot Souffle; Southern-Braised Greens with Bacon; Blueberry Custard Pie
Emeril asks his buddies from Chelsea Market to help him put together some festive ways to say Happy Holidays!
Youre invited to Emerils Holiday Party where the menu is as festive as high heels and a bowtie
Emeril whips up some Firehouse Favorites. Firehouse Crab Boil; Day-After Crab Boil Potato Salad; Urky Lurky; Ugly Cake
Emeril prepares some dishes from his book. Champagne Punch; Helen's Sausage Stuffed French Bread; Emeril's Oven-Briased Osso Buco with Orzo "Risotto"; Devil's Food Cake with Vanilla Buttercream Icing
Emeril prepares the winners recipes. Laotion Grilled Pork Skewers with Papaya Salad and Sticky Rice; Grilled Eggplant Pockets; Ginger-Mango Flank Steak with Fennel Slaw; Mike's Megga Grilled Pizza
Kicked up south of the border favorites. Recipes include: Top Shelf Margarita Grande, Ensalada de Nopalitos, Chorizo tamales with Green Mole Sauce, Shredded Pork Taquitos with Roasted Tomatillo Salsa and Corn and Goat Cheese Queso.
Emeril shows how to make the perfect food/wine pairs. Tuna with a Tomato Caper and Parsley Brown Butter Sauce; Mixed Greens with Prosciutto, Blue Cheese and Dried Fig Vinaigrette; Beef and Wild Mushroom Stew; Lemon Syrup Cake with Strawberries and Mint
Emeril prepares dishes that demonstrate the Portuguese influence all over the world. Piri Piri; Fried Okra with Shrimp (Mozambique); Moqueca (Brazil); Braised Pork with Clams Mariner's Style (Portugal); Banana Fritters (Goa); Caipirinha (Brazil).
Emeril kicks up favorite diner specialties. Everybody's Favorite Malted Shake; Kicked Up Tune Melt; Cheese Fries; New Orleans Style SOS; Peach Fried Pies
Emeril serves up tasty sweet treats with an international twist. Baklava; Frozen Strawberry Lmon-Basil Mousse; Italian Easter Pie; Russian Tea Cakes
Authentic Italian recipes - Emeril Style! Bagna Cauda - Anchovy Garlic Dip for Vegetables; Risotto con Pepperone - Risotto with Sweet Peppers; Brasato al Barolo - Beef Braised in Barolo; Spuma di Cioccolato e Castagne - Chocolate Chestnut Mousse.
Emeril prepares four unique chicken dishes and presents the perfect wine pairings for them. Charlotte's Boursin Roasted Chicken; Chicken Cakes with Tangy Remoulade Sauce; Filipino "Adobo-Style" Chicken Thighs; Chicken Pontalba.
Emeril and special guest Chef Charlie Trotter kick up some favorite dishes. Barbecued Shrimp with Rosemary Biscuits; Duck and Wild Mushroom Gumbo; Chocolate Pudding Cke with Coconut Ice Cream.
Emeril shows some fun and surprising ways to use bread in different recipes. Emeril's Focaccia with Savory and Olives; Stilton Soup Served in a Sourdough Bread Bowl; Fajita Panini with Chipotle Mayonnaise; Apple and Raisin-Challah Stuffed Pork Loin; Ice Cream and Cookies Ice Cream.
Emeril whips up some tasty dishes using butcher shop specialties. Seared Muscovy Duck Breast Salad with Blackberry Vinaigrette; Pasta with Peas and Prosciutto; Asian Style Braised Short Ribs; Pan-Sauteed Dry Aged T-Bone Steak with Potatoes a la Boulangere.
Emeril serves up the winning recipes! Stuffed Chicken with Marsala, Figs, and Goat Cheese; Frank's Italian Sauce (Spaghetti Sauce); Spingi (Italian Donut Fritters), Homemade Chicken-Meatball Soup.
Emeril kicks up an old favorite - the casserole. Lamb and White Bean Casserole; Cowboy Chicken Casserole; Emeril's Favorite Choucroute Casserole; Risotto and Wild Mushroom Casserole.
Emeril shows how to add flavor to add flavor to a meal by cooking with spirits. Long Island Iced Tea; Roasted Corn Salsa with Tequila Lime Dressing; Pan Sauteed Filet Mignon with Caramel Brandy Mushroom Sauce; Steamed Mussels in a Cagnac Cream Sauce; Bourbon Nut Cake


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Nice try!
An obviously faked People magazine cover on which Taylor Lautner supposedly announced that he's "out and proud" ricocheted across the internet Monday, tricking fans and even celebs like Russell Simmons.
RELATED: Taylor Lautner On Gay Pals: "I Think They Know I'm Straight"
The Photoshopped image of the purported Jan. 7, 2012 People issue shows the "Twilight" star announcing he's gay and "tired of the rumors."
The fake cover goes on to fake-quote Lautner as saying his decision to come out has left him feeling "more liberated, and happier than I've ever been."
MORE: What Taylor Lautner Gay Rumors?! Dustin Lance Black Fights Back After GQ
While the internet was abuzz, celebs like Def Jam's Simmons even fell prey to the hoax, tweeting Taylor a congratulatory tweet: "proud of Taylor Lautner for his bravery and his courage."
Once realizing the mistake, Simmons tweeted: "disappointed that people would joke about someone coming out about their sexuality. Let Taylor Lautner be whoever he wants to be...."
CHECK OUT: So True? So False? Guessing Game
A rep for People magazine confirmed the cover a hoax to Gossip Cop, saying the cover is "absolutely fake."
Did you fall for the hoax? Let us know in the comments.
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Dr. Bernard Fisher's Breast Cancer Research Left a Lasting Legacy of Improved Therapeutic Efficacy and Survival
Bernard Fisher, MD, is recognized today for his groundbreaking research in breast cancer, which ultimately ended the standard practice of performing the Halsted radical mastectomy, a treatment that had been in place for more than 75 years. His laboratory and clinical investigations led to more effective therapy, increased survival rates, and improved quality of life for women with breast cancer.
His early medical career, however, was focused primarily on liver regeneration and transplantation. After graduating from the University of Pittsburgh School of Medicine in 1943 and completing a 2-year fellowship in experimental surgery at the University of Pennsylvania, Dr. Fisher returned to the University of Pittsburgh to create a surgical research laboratory, where he began experiments on rats to determine whether their livers would regenerate after large portions were removed. Finding that they did, he began transplanting various organs in rats. In 1955, to increase his knowledge about transplantation, Dr. Fisher served as a research fellow at the London Postgraduate Medical School, Hammersmith Hospital, London.
Novel Approaches to Treatment
When he returned to Pittsburgh the following year, Dr. Fisher received a call from I.S. Ravdin, MD, his mentor at the University of Pennsylvania. That call would permanently alter the course of his scientific and clinical career. Dr. Ravdin, then Chairman of the Clinical Studies Panel of the Cancer Chemotherapy National Service Center at the National Institutes of Health (NIH), asked Dr. Fisher to attend a meeting with 22 other surgeons to discuss the creation of the Surgical Adjuvant Chemotherapy Breast Project, which later became known as the National Surgical Adjuvant Breast and Bowel Project (NSABP), chaired by Dr. Fisher for 30 years.
"I wasn't the least bit interested in breast cancer," said Dr. Fisher. "But since Dr. Ravdin was an army general who had operated on President Eisenhower, when he commanded me to attend the meeting, I did so. At the time of that first meeting in 1956, the idea of using clinical trials to obtain information, and certainly the idea of giving therapy following surgery, were novel approaches to treatment." Although Dr. Fisher was initially hesitant to change the focus of his research from liver regeneration and transplantation to breast cancer and the study of malignant disease, he was intrigued by the question of how tumors metastasize.
The meeting at the NIH resulted in the 1958 launch of the first randomized clinical trial to evaluate the use of systemic therapy following radical mastectomy in the treatment of breast cancer.1,2 More than 800 women treated with the surgery were enrolled in the study and randomly assigned to receive either the alkylating agent thiotepa or a placebo. The study found that while the drug provided a significant benefit in recurrence-free survival in premenopausal women, altering the course of their breast cancer, the fact that the chemotherapy did not benefit all patients and caused some side effects made physicians reluctant to embrace the use of systemic adjuvant therapy.
"Subsequent to that first meeting at the NIH, I discovered how little information there was related to the biology of breast cancer and what a lack of interest there was in understanding the disease. At the meeting, I learned about the need for randomized clinical trials and the use of biostatistics to obtain credible information from those trials," said Dr. Fisher.
Biology of Tumor Metastasis
After that meeting, Dr. Fisher abandoned his research in liver regeneration and transplantation and devoted the next 4 decades to pursuing the biology of breast cancer tumor metastasis and more effective treatments for the disease. His research led him away from the anatomic hypothesis presented by Halsted—that cancer cells, originating from the breast, always passed through the lymph nodes prior to metastatic spread and, therefore, required radical surgery to remove the entire breast, underlying chest muscle, and axillary lymph nodes to halt metastasis.
Instead, Dr. Fisher proposed, breast cancer is a systemic disease in which malignant cells are likely disseminated throughout the body before diagnosis, and radical mastectomies are unlikely to improve overall survival. Breast-sparing surgery such as lumpectomy, in which only the cancerous tumor and a small portion of the surrounding tissue are removed, would probably result in similar outcomes but without the disfigurement caused by total mastectomy, reasoned Dr. Fisher.
Throughout the 1960s and 1970s, Dr. Fisher conducted laboratory investigations of cancer biology and randomized clinical studies evaluating the effectiveness of lumpectomy vs total mastectomy, as well as lumpectomy followed by systemic chemotherapy or radiation therapy in the prevention of disease recurrence. The use of less aggressive, breast-conserving surgical treatment was initially met with resistance from both the medical establishment and the general public—resistance that he looked back on as "extensive and often unpleasant." Dr. Fisher's findings, however, indicated that breast cancer metastasis is not solely determined by anatomic considerations, but is also influenced by biologic activity of both the tumor and the host.
The results from those early studies changed the way breast cancer is treated and are credited with improving breast cancer survival rates. In 1991, Dr. Fisher and his NSABP colleagues began the first breast cancer prevention trial, which tested the efficacy of tamoxifen in preventing breast cancer in high-risk women. The study found that tamoxifen did decrease the incidence of both invasive and noninvasive breast cancer by nearly 50%.3
Six-decade Legacy
Dr. Fisher served as ASCO President from 1992 to 1993 and has received numerous awards for his contributions to breast cancer research and treatment, including the American Association for Cancer Research Award for Lifetime Achievement in Cancer Research, the American Cancer Society Medal of Honor, and the Albert Lasker Clinical Medical Research Award.
When asked what he considers his greatest contributions to medicine and science, Dr. Fisher replied, "That question might be best answered by others who are familiar with my efforts over the past 60 years. However, I do believe that my greatest contribution was carrying out laboratory investigations, beginning in 1950, which have altered our understanding and treatment of breast cancer. The results obtained from those studies led me to form a biologic hypothesis that replaced the Halstedian principles, which governed the treatment of breast cancer for almost a century."
Currently, Dr. Fisher is a Distinguished Service Professor in the Department of Surgery at the University of Pittsburgh, where he is engaged in preserving the accuracy of his life's work. "It is necessary to do so because to be sure where you are, you must know where you have been, and thus be able to better predict what the future is likely to be," said Dr. Fisher. ■
1. NSABP timeline. Available at nsabp.pitt.edu/NSABP_Timeline.pdf. Accessed April 2, 2013.
2. Fisher B, Ravdin RG, Ausman RK, et al: Surgical adjuvant chemotherapy in cancer of the breast: Results of a decade of cooperative investigation. Ann Surg 168:337-356, 1968.
3. Fisher B, Costantino JP, Wickerham DL, et al: Tamoxifen for prevention of breast cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 90:1371-1388, 1998.


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Posted: 12/18/2012 7:15:00 AM
Author: Gil Ronen
Source: This article first appeared on the Arutz 7 website on De. 18, 2012.
Dead Sea Scrolls Online Library Launched
Israel Antiquities Authority and Google launch the Leon Levy Dead Sea Scrolls Digital Library website.
by Gil Ronen
On the occasion of the 65th anniversary of the discovery of the Dead Sea Scrolls, the Israel Antiquities Authority and Google announced on Monday the launch of the Leon Levy Dead Sea Scrolls Digital Library website at www.deadseascrolls.org.il.
The public is invited to experience, view, examine, and explore this collection of over 5000 images of Dead Sea Scrolls, in a quality never seen before.
The library was assembled over the course of two years, in collaboration with Google, using advanced technology first developed by NASA. It includes some 1000 new images of scroll fragments; 3500 scans of negatives from the 1950s; a database documenting about 900 manuscripts, two thousand years old, comprising thousands of scroll fragments; and interactive content pages.
The site enables scholars and millions of users worldwide to reveal and decipher details hence invisible to the naked eye. It displays infra-red and color images at a resolution of 1215 dpi, at a 1:1 scale, equivalent in quality to the original scrolls. Google has provided hosting services and use of Google Maps, image technology and YouTube.
The project was made possible by an exceptionally generous grant from the Leon Levy Foundation, and further contribution by the Arcadia Fund, as well as the support of the Yad Hanadiv Foundation.
One of the earliest known texts is a copy of the Book of Deuteronomy, which includes the Ten Commandments. In addition, the library features a part of chapter 1 of the Book of Genesis, dated to the first century BCE, which describes the creation of the world; a number of copies of Psalms scrolls; tiny texts of tefillin from the Second Temple period; letters and documents hidden by refugees fleeing the Roman army during the Bar Kochba Revolt; and hundreds of additional 2000-year-old texts, shedding light on biblical studies, the history of Judaism and the origins of Christianity.
Shuka Dorfman, Director of the Israel Antiquities Authority, said: "Only five conservators worldwide are authorized to handle the Dead Sea Scrolls. Now, everyone can 'touch' the scrolls on-screen around the globe, and view them in spectacular quality, equivalent to the original!"
The scrolls are considered the most important archaeological discovery of the 20th century.


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I've had several close encounters with libertarians recently and I have to be honest with you, many of them piss me off as much as, if not more, than religious fundamentalists. There is a fairly popular libertarian niche today that is quite outspoken and very ideologically driven, and it seems to have a lot of young people in their ranks. There are also quite a few atheists who are libertarians and I've been noticing them as I go out into my local atheist/philosophical meetups.
Although I am sympathetic to some of the libertarian social views like marijuana and prostitution legalization, when it comes to economics and government I have some sharp disagreements with them. Many libertarians that I've spoken to either want no government at all, or government so small it can be drowned in a bathtub, to paraphrase Grover Norquist. But mostly, they want a total "free market" economy where government regulation is non-existent, and some even want the total privatization of education, law, police, and the military.
Not all libertarians hold to Ayn Rand's Objectivist philosophy, but many do. She's the ideological darling of many on the Right. Her fan boys include Wisconsin Congressman Paul Ryan, who said that her books are "required reading" for his interns. The interesting thing is that Ayn Rand was an outspoken atheist, and it's odd how so many on the Right identify with her, given the Right's close associations with religion. As far as her atheism is concerned, we're on the same page. We both see religion as something irrational and not justified by any good evidence. But Rand's philosophy emphasizes a kind of ethical egoism, whereby she thought that we should never sacrifice anything important to us for the benefit of someone else who was not important to us, like a stranger who was suffering. She thought taxation was theft, but still believed in government doing the three basics: police, law, and military. (This would be financed by voluntary donations according to her.) All the money you make would be yours to keep and there's no concern for any kind of "greater good." Rand's philosophy is a fervent objection to utilitarianism. If fact, recently when I mentioned my concern for the "greater good" when I was debating economics with a libertarian, he literally walked out on me.


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The Dodgers led 4-2 going into the eighth yesterday. They lost. The Marlins led 4-2 going in to the seventh today. They won. WHAT'S UP WITH THAT?
Mike Stanton broke Clayton Kershaw's back today, singling with the bases loaded in the sixth. Okay, so maybe my revolutionary prognostication was wrong. But I did predict James Loney would go 4 for 4 today. What's that, I didn't? Well, I thought about calling Andre Ethier's record-setting 23-game hitting streak. So there.